PassMed GP

Question 1

which lab findings would you expect for osteoporosis

Answer 1

Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)

Question 2

You are seeing a 38-year-old female patient in your morning clinic who complains of persistent vertigo associated with some nausea, but no vomiting.

This started 16 days ago following a ‘nasty cold’ and seems fairly constant. She has not noticed any other symptoms. She had spoken to a pharmacist who gave her 3 days of prochlorperazine. Unfortunately, her symptoms have not improved.

She has no significant past medical history and is a non-smoker. There is no significant family history. She takes no regular medication.

On examination, she has normal hearing, normal upper and lower limb power and sensation as well as normal reflexes. Her gait is normal. You do note marked horizontal nystagmus, but normal pupillary reflexes.

What would be the most appropriate next step?

Answer 2

Vestibular rehabilitation exercises are the preferred treatment for vestibular neuronitis

Question 3

A 28-year-old Caucasian male presents with itchy red spots on is abdomen, back and arms, which he reports appeared quite suddenly. He has no significant past medical history, but states he had a sore throat a few weeks ago. On examination, you notice he has a white pus-like discharge over his palatine tonsils. He states that he a similar rash last winter, when he had a sore throat.

Which of the following is the most likely diagnosis?

Answer 3

guttate psoriasis

Question 4

A 15-year-old female presents to ambulatory care with a painful pruritic rash that has rapidly worsened over the last 10 hours. Her past medical history includes atopic dermatitis treated with emollients and hayfever.

On examination, she has a monomorphic rash with punched out erosions over her cheeks and bilateral dorsal wrists. She is admitted for IV antivirals and observation.

Which of the following is the most likely implicated pathogen?

Answer 4

Eczema herpeticum is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly coxsackievirus

Question 5

DEXA scan for osteoporosos

Answer 5

T score -2.5 or less on DEXA scan= osteoporosis

-1- 2.5 = osteopenia (low bone mineral density)

Question 6

in young adults with septic arthritis, what is the most commmon cause

Answer 6

Neisseria gonorrhoeae is the most common organism found in yioung adults (SEXUALLY ACTIVE)

Staphylococcus aureus is the most common overall cause of septic arthritis, but not in young adults.

Question 7

A 55-year-old man presents to his GP with a gradual onset of back pain over the past 8 months. The back pain is worse on activity and walking causes bilateral pain and weakness in his calves. The back pain is relieved by sitting or leaning forward.

On examination, no neurological findings are present. He has no relevant past medical history, smokes socially and drinks a glass of wine with dinner each night. He is currently a builder and is concerned because his back is starting to interfere with his ability to work.

What is the most likely diagnosis?

Answer 7

Spinal stenosis is often relieved by sitting down or leaning forward

Question 8

A 34-year-old woman visits her GP with concerns about her current medication. She was diagnosed with system lupus erythematous 18 months ago and is currently taking azathioprine 130mg/day, in divided doses. Three days ago she took a home pregnancy test which was positive.

What is the best course of management for her medication?

Answer 8

Azathioprine is safe to use in pregnancy

Question 9

A 20-year-old male who was playing a rugby match when he suddenly felt a ‘pop’ in his left foot while attempting a tackle. This was followed by significant pain and an inability to properly weight bear on the affected side. He is driven to the emergency department. During the examination, he is asked to lay face down with his feet hanging off the edge of the examination bed. On squeezing the calf on the affected leg, there was no movement of his foot.

What would be the initial imaging modality for confirming the most likely diagnosis?

Answer 9

Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture

Question 10

A 54-year-old woman attends the GP with a one-day history of hearing loss in her right ear. There is no discharge or pain. She has no history of dizziness or tinnitus.

Assessment by otoscopy shows wax in the right ear with no other obvious changes to the external auditory meatus or tympanic membranes bilaterally. Weber test lateralises to the left side. Rinne test shows air conduction louder than bone conduction bilaterally.

What is the most appropriate next step?

Answer 10

Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI

Question 11

An 80-year-old man is taken to the Emergency Department after falling at home. He manages to walk into the department but is complaining of left hip pain. His daughter notes that he fell onto his left side. An x-ray is taken of the pelvis:

Answer 11

This x-ray shows advanced osteoarthritic changes at the left hip joint; loss of joint space and subchondral sclerosis are prominent.

Question 12

A 44-year-old man is seen in the rheumatology clinic after being diagnosed with rheumatoid arthritis 4 months ago. He was initially started on methotrexate, however, was unable to tolerate its side effects. The consultant is considering starting the patient on hydroxychloroquine.

What should occur before the patient commences treatment?

Question 12

A 44-year-old man is seen in the rheumatology clinic after being diagnosed with rheumatoid arthritis 4 months ago. He was initially started on methotrexate, however, was unable to tolerate its side effects. The consultant is considering starting the patient on hydroxychloroquine.

What should occur before the patient commences treatment?

Question 12

A 44-year-old man is seen in the rheumatology clinic after being diagnosed with rheumatoid arthritis 4 months ago. He was initially started on methotrexate, however, was unable to tolerate its side effects. The consultant is considering starting the patient on hydroxychloroquine.

What should occur before the patient commences treatment?

Answer 12

Patients that will be taking hydroxychloroquine long-term now require baseline ophthalmologic examination at the outset of treatment

Question 13

A 45-year-old male presents to his GP with a 12-day history of frontal facial pain that is exacerbated by leaning forward. His baseline observations (heart rate, respiratory rate and temperature) are all normal. The GP suspects a diagnosis of sinusitis. The patient has no relevant past medical history.

Given the duration of the patient’s symptoms, and the absence of any relevant medical history, which of the following drugs may the GP begin today?

Answer 13

Intranasal steroids should only be considered for sinusitis if symptoms have persisted for 10 days or more

NICE guidelines only recommend treatment with intra-nasal corticosteroids if the symptoms of sinusitis are severe or have lasted for a period of 10 days or more.

Antibiotics are only advised if individuals are systemically unwell or have significant co-morbidities that pre-dispose them complications (for example chronic severe COPD). This explains why amoxicillin and phenoxymethylpenicillin are incorrect.

NICE suggest that the following treatments should NOT be offered for sinusitis:
Oral corticosteroids (option 3)
Steam inhalation (option 5)
Antihistamines (unless there is co-existing allergic rhinitis)
Complementary and alternative medicine

Mucolytics

Question 14

A 41-year-old female presents with lethargy and pain all over her body. This has been present for the past six months and is often worse when she is stressed or cold. Clinical examination is unremarkable other than a large number of tender points throughout her body. A series of blood tests including an autoimmune screen, inflammatory markers and thyroid function are normal. Given the likely diagnosis, which one of the following is most likely to be beneficial?

Answer 14

fibromyalgia

CBT

Question 15

A 69-year-old woman presents to her general practitioner with a 48-hour history of headache and blurred vision. She reports suffering from migraines every few months since her teens, though this episode feels different. It came on over a few hours, is aggravated by chewing, and has been constant since its onset. She describes the headache as ‘throbbing’.

On examination, the patient’s scalp is very tender, though it does not feel boggy or appear bruised. Her dentition is poor with multiple caries, though the examination is otherwise unremarkable.

Given this information, what is the most likely diagnosis?

Answer 15

Constant throbbing headache, pain on chewing, and tender scalp indicates temporal arteritis

Question 16

A 52-year-old woman presents to her general practitioner complaining of joint pain. She has been having severe pain in her left foot and right wrist for six months. The pain is worse in the morning but gets better during the day. Ibuprofen does not help with the symptoms. She had a sore throat the week preceding the beginning of her symptoms. She remembers having a skin condition as a kid, which improved growing up.

On examination, she has swollen distal interphalangeal joints in her right hand, accompanied by pain on movement of her wrist. Her left ankle is swollen and tender.

What is the most likely diagnosis?

Answer 16

An asymmetrical presentation suggests psoriatic arthritis rather than rheumatoid

Question 17

A 62-year-old man presents 2 days after receiving a punch to his head on the right side. Since the injury, he feels his hearing has been muffled on the right side. On examination there is no bruising. Both his ears are obscured by a thin translucent layer of wax. On the right, Rinne’s test demonstrates the tuning fork is easier to hear when pressed on the mastoid bone. On Weber’s test the sound is heard best on the right hand side. What is the most likely diagnosis?

Answer 17

Tympanic membrane perforation is a relatively common complication of trauma to the skull. It is important to distinguish this from sensorineural hearing loss resulting from a base of skull fracture.

Question 18

Which of the following extra-intestinal manifestations of ulcerative colitis are related to the activity of the colitis?

Answer 18

Episcleritis

Erythema nodosum

Question 19

The flexible sigmoidoscopy shows features suggestive of Ulcerative colitis. What would is the most important step in initial treatment?

Answer 19

IV hydrocortisone

Question 20

NICE guidance recommends the use of intravenous………… for patients who are not responding to intravenous hydrocortisone or where hydrocortisone treatment is not appropriate - ulcerative colitis

Answer 20

ciclosporin

Question 21

maintenance therapy for UC

Answer 21

mesalazine

Question 22

A 60-year-old man presented with right-sided chest pain, dyspnoea and a recurrent right sided pleural effusion without any apparent cause at the time of presentation. After 2 years he died.

He had a hx of ACS with two stents inserted in the last 5 years.
Look at the postmortem image below. Which of the following correctly describes this appearance?

Answer 22

mesothelioma

There is a pleural tumour encasing the lung.

Question 23

mesothelioma

Answer 23

This tumour arises from the mesothelial cells of the pleura and spreads initially via the pleural space to encase the lung.

Question 24

What aspect of the clinical history is important to enquire about if this condition is suspected?

Question 24

What aspect of the clinical history is important to enquire about if this condition is suspected?

Question 24

What aspect of the clinical history is important to enquire about if this condition is suspected?

Question 24

What aspect of the clinical history is important to enquire about if this mesothelioma is suspected?

Answer 24

occupational
all cases of mesothelioma are due to exposure to asbestos. It is important to enquire about asbestos exposure which is usually occupational exposure. In particular: boilermakers, plumbers, heating engineers, electrical engineers and anyone working with building materials may have been exposed.

The “lead time” between asbestos exposure and development of mesothelioma is almost always more than 20 years.

Question 25

can mesotheliomas spread

Answer 25

yes
Mesotheliomas usually spread through one
then invade into the contiguous lung and chest wall. They can also spread to the other pleural cavity and pericardial cavity as well as the peritoneal cavity. Hilar nodes are involved by lymphatic spread. Death is usually due to lung/pleural involvement.

Question 26

What are two signs of mitral stenosis on ECG?

Answer 26

bifid P waves or abesent p waves

Question 27

lung cancer: paraneoplastic features

Answer 27

small cell

• ADH
• ACTH- not typical

squamous cell

• PTH-rp
• TSH

Question 28

if a patient is not tolerating (diarrhea) metformin i.e. 500mg x3 daily what is the next step

Answer 28

Start metformin modified release

Question 29

You are seeing a 62-year-old lorry driver with poorly controlled type 2 diabetes. He is on the maximum tolerated dose of metformin and you are thinking about adding in a second drug.

His past medication includes heart failure, eczema and hayfever.

His latest renal function was normal.

Answer 29

Start a sodium-glucose transport protein 2 (SGLT2) inhibitor

Question 30

NICE guidelines in regards to managing type 2 diabetes

Answer 30

NICE recommends the following step wise approach to managing type 2 diabetes:
Start with lifestyle modifications, then add metformin
Add second oral drug to metformin

If this fails, NICE recommends triple therapy with either
Metformin + gliclazide + gliptin/glifozin/pioglitazone or
Metformin + pioglitazone + glifozin or
Insulin +/- other drug

Question 31

how does posterior MI present on ECG

Answer 31

tall R waves V1-2

Question 32

A 54-year-old man is admitted to the Emergency Department with a left hemiplegia. His symptoms started around 5 hours ago and he has had no headache, visual disturbance or loss of consciousness. On examination a dense left hemiplegia is noted. Blood pressure is 120/78 mmHg, GCS is 15/15 and pupils are equal and reactive to light. An urgent CT scan is performed shortly after his arrival. This demonstrates no abnormality. What is the most appropriate initial management?

Answer 32

This patient has had an ischaemic stroke. He is however outside the thrombolytic window and should therefore be treated with aspirin

Question 33

which chemotherapy causes hypomagnesia

Answer 33

cisplatin

Question 34

A 40-year-old patient with HIV was assessed in the neurology clinic after reporting worsening clumsiness over the past month; he regularly falls into door frames and this is not something that he has experienced before.

On physical examination, the patient had an unsteady gait and dysdiadochokinesia. Cranial nerve testing and speech were normal, and the rest of the examination was unremarkable.

The patient underwent extensive investigation and his MRI scan was found to show multifocal non-enhancing lesions.

Which virus is likely to have caused this condition?

Answer 34

A patient who is known to have HIV presents gradually worsening speech and behavioural problems associated with coordination difficulties. A MRI shows multifocal non-enhancing lesions - John Cunningham virus

Question 35

who should LTOT be offered to

Answer 35

LTOT should be offered to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension

Question 36

Which one of the following is most likely to cause a collapsing pulse

Answer 36

aortic regurgitation

Question 37

Respiratory acidosis causdes

Answer 37

COPD
life-threatening asthma (decompensated)
opiate overdose
neuromuscular disease
benzodiazepines overdose
obesity hypoventilation syndrome

Question 38

Respiratory alkalosis

Answer 38

pulmonary embolism
anxiety leading to hyperventilation
CNS disorders e.g. stroke, subarachnoid haemorrhage, encephalitis
altitude
pregnancy
salicylate poisoning (initial stages)

ANY LUNG WHICH CAUSES HYPERVENTILATION

Question 39

Which bacteria causes most community acquired pneumonia

Answer 39

Streptococcus pneumonia

Question 40

A 65-year-old man presents to the emergency department. He has a history of crushing chest pain, scored 9 out of 10, which started one hour ago. He is a smoker and he is taking amlodipine for his high blood pressure.

After an ECG and troponin testing, he is diagnosed with non-ST segment elevation myocardial infarction (NSTEMI). You assess him using the GRACE score and his predicted 6‑month mortality is 2%. He does not have a high risk of bleeding. The nearest primary percutaneous intervention unit is more than one hour away.

How should this patient be managed?

Answer 40

Aspirin, ticagrelor and fondaparinux

NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk

Question 41

A 61-year-old man attends the emergency department with a one-hour history of palpitations and chest pain. His observations are as follows: heart rate 168 beats per minute, respiratory rate 22 per minute, oxygen saturations 98% on air, blood pressure 88/59 mmHg and temperature 37.1ºC. His ECG confirms the above heart rate and shows a regular broad complex tachycardia.

Which of the following would be the most appropriate treatment?

Answer 41

In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion

if no haemodynamic instability-> IV amiodarone is the correct treatment for regular broad complex tachycardias such as VT if adverse features are not present.

Question 42

The treatment for Helicobacter pylori is typically

Answer 42

a proton pump inhibitor (e.g. omeprazole) + 2 antibiotics; amoxicillin and either clarithromycin or metronidazole.

Question 43

A 60-year-old man has just been treated for a peptic ulcer which had evidence of Helicobacter pylori. He is otherwise fit and well, with no other medical problems. He currently takes Helicobacter pylori eradication therapy medication and says he feels much better when he sees his GP. However, the next day the patient experiences palpitations, shortness of breath and dizziness. The patient has no allergies other than metronidazole. The ambulance is called and they perform an ECG on the patient whilst he is awake.

What will the ECG most likely show?

Answer 43

Macrolides can cause torsades de pointes

Question 44

Aortic stenosis murmur characteristics

Answer 44

• ejection systolic murmur
• loudest in the right parasternal 2nd intercostal space
• louder on expiration due to increased left ventricular preload
• aortic stenosis commonly radiates to the carotids which was not the case in this patient

Question 45

Mitral regurgitation murmur characteristics

Answer 45

• pan-systolic murmur loudest
• left mid-clavicular 4th intercostal space
• louder on expiration due to higher left ventricular preload, and softer on inspiration due to pooling of the blood in the lungs.
• mitral regurgitation often occurs in patients with hypertension

Question 46

Mitral stenosis murmur characteristics

Answer 46

• end-diastolic murmur
• loudest in the left mid-clavicular fourth intercostal space.
• It often leads to left heart failure with pulmonary oedema and breathlessness.

Question 47

Tricuspid stenosis murmur characteristics

Answer 47

• rare and usually presents in neonates
• end-diastolic murmur
• loudest in the left parasternal 4th intercostal space.

Both tricuspid stenosis and regurgitation increase on inspiration as the intrathoracic pressure decreases leading to right heart filling and increased preload. Despite being in the same anatomical location as in this patient, it is a diastolic rather than a systolic murmur.