Extras Flashcards
Partial agonists exhibit a low efficacy
what is the defining property of a partial agonist?
A) it has a high binding affinity
B) it has a low binding affinity
C) Has a maximum response the same as a full agonist
D) must occupy all receptors to elicit maximum response
E)it will always be less potent than a full agonist
D) must occupy all receptors to elicit maximum response
For mild to moderate pain , the drug paracetamol can be administered orally
What is the reason for the oral administration of paracetamol as opposed to other
routes of administration?
A) its absorbed from the mouth
B) it is a prodrug requiring hepatic metabolism to be activated
C) easy to administer orally
D) less toxic if administered orally
E) poorly absorbed from the intestine
C) easy to administer orally
The GP practice pharmacist is conducting a review of an 80 year old woman’s
medications.
What is the most common type of prescribing error they are likely to encounter?
A) contraindication to medicine use
B) potential severe drug-drug reaction
C) duplication of therapy
D) Incomplete medication or personal details
E) wrong frequency of medication use
D) incomplete medication or personal details
Which disorder of haemostasis is best detected with the prothrombin time laboratory test? A) acquired fibrinogen deficiency B) coagulation factor VII deficiency C) DIC D) hyperfibronlysis E) Immune thrombocytopenia
b) coagulation factor VII deficiency
They are used to determine the clotting tendency of blood, in such things as the measure of warfarin dosage, liver damage, and vitamin K status. PT measures the following coagulation factors: I (fibrinogen), II (prothrombin), V (proaccelerin), VII (proconvertin), and X (Stuart–Prower factor).
what does APTT test for
intrinsic blood clotting factors
factors 8, 9, 11
An unknown patient is brought into A&E with massive bleeding after a road
traffic accident. They need immediate transfusion but there is insufficient time
to determine their blood group.
What ABO group red cells and platelets and plasma should be administered while
the laboratory is processing their blood group sample?
A) Group A Red cells, Group A platelets, Group AB plasma
B) Group A Red cells, Group O platelets, Group O plasma
C)Group O Red cells, Group A platelets, Group AB plasma
D) Group O Red cells, Group O platelets, Group AB plasma
E) Group O Red Cells, Group O platelets, Group O plasma
C) Group O red cells, group A platelets, group AB plasma
You are discussing the risks and benefits of transfusion with a 25 year old
patient with newly diagnosed leukaemia, who is likely to need multiple
transfusions for their care.
Which complication of transfusion currently causes the largest number of
transfusion-related deaths in the UK?
A) ABO incompatible transfusion
B) Anaphylaxis
C) TACO
D)transfusion transmitted infection
E) wrong blood given to wrong patient
C) taco - transfusion associated circulatory overload
A 45 year old woman presents with fatigue. Her past medical history includes
hypothyroidism and vitiligo. A full blood count shows a macrocytic anaemia,
and severe vitamin B12 deficiency is confirmed with an appropriate laboratory
test.
Based on the information available, what is the most likely underlying cause of her
anaemia?
A) coeliac disease
B) Chron’s disease
C) dietary inadequance
D) fish tape worm
E) pernicious anaemia
E) pernicious anaemia
Pernicious anaemia is an autoimmune condition that affects your stomach. An autoimmune condition means your immune system, the body’s natural defence system that protects against illness and infection, attacks your body’s healthy cells. Vitamin B12 is combined with a protein called intrinsic factor in your stomach.
An 80 year old asymptomatic woman is found to have a persistent stable
lymphocytosis with an otherwise normal full blood count. She has no
lymphadenopathy or splenomegaly. On the blood film there are small mature
lymphocytes and smear cells. Flow cytometry detects a clone of B cells.
What is the likely diagnosis?
A) acute lymphoblastic leukaemia
B) chronic lymphocytic leukaemia
C) Lymphoma
D) myeloproliferative neoplasm
E) reactive lymphocytosis (due to viral infection)
B) chronic lymphocytic anaemia
blood test results for acute lymphoblastic leukemia
Tests and procedures used to diagnose acute lymphocytic leukemia include: Blood tests. Blood tests may reveal too many or too few white blood cells, not enough red blood cells, and not enough platelets. A blood test may also show the presence of blast cells — immature cells normally found in the bone marrow.
how would you diagnose lymphoma
Testing for lymphatic cancer generally begins with a physical examination, during which your physician will review your medical history and discuss your symptoms. Lymphoma can be confirmed with a biopsy, in which a tissue sample is taken from an affected area of the body for analysis.
how to confirm myeloproliferative neoplasm
The diagnosis of myeloproliferative neoplasms (MPNs) requires a combination of CBC and peripheral smear examination, bone marrow histology, chromosome analysis, and molecular testing. The combination of these studies allows clinicians to determine whether results meet corresponding diagnostic criteria.
A patient is admitted to hospital suffering from chest pain. Following a series
of tests, it is revealed that they are suffering from a heart attack. Prior to a
percutaneous intervention by a cardiologist, the patient is administered
ticagrelor.
How does the antiplatelet drug ticagrelor reduce platelet function?
A) By acting as a reversible antagonist at the P2Y12 receptor
B) By acting as an agonist at the TP thromboxane receptor
C) By acting as an antagonist at the Glycoprotein IIb/IIIa receptor
D) By acting as an antagonist at the TP thromboxane receptor
E) By acting as an irreversible antagonist at the P2Y12 receptor
A) By acting as a reversible antagonist at the P2Y12 receptor
what are P2Y12 receptor blocks
give some examples
P2Y12 receptor blockers are another group of antiplatelet drugs. This group of drugs includes: clopidogrel, ticlopidine, ticagrelor, prasugrel, and cangrelor.
function of thromboxane
Thromboxane is a potent vasoconstrictor and stimulus for platelet aggregation and the reduced vasoconstriction and platelet aggregation that occur may be significant in patients with bleeding tendencies or may complicate surgical procedures.
A 65 year old man with suspected ST elevation myocardial infarction was
taken to the cardiac catheter laboratory for primary percutaneous coronary
intervention. Angiography revealed occlusion of the right coronary artery.
Which of the following leads of his 12 electrocardiogram would most likely have
revealed ST elevation prior to the procedure?
A) I,II and aVL
B) II,III, and aVR
C) II,III and aVL
D) II,III and aVF
E)V1 and V2
D) II, III and aVF
How to remember leads for ECG
acronym LISA L = lateral -> I, aVL, V5 and V6 = LAD I = inferior -> II,III, aVF = RCA S = septal -> V1, V2 = LAD circumflex A = anterior -> V3, V4 = LAD Bundle branch
A GP requests a U&E profile on a patient, and the sample is taken at 9am.
Unfortunately, it is not delivered to the lab until the next morning.
Which of the analytes in the sample is likely to be inaccurate?
A) all of them
B) creatinine
C)potassium
D) sodium
E) urea
c) potassium
A 35 year old man is diagnosed with Familial hypercholesterolaemia (FH). Which clinical sign, along with a raised cholesterol and a family history, indicates a diagnosis of FH? A) corneal arcus B) eruptive xanthomata C) palmar xanthomata D) tendon xanthomata E) xanthelesmata
D) tendon xanthomata
You have a 50 year old male patient with a blood pressure of 125/85, BMI 29
and a history of smoking. He complains of being tired, frequently out of breath
with no major chest pains and his shoes get very tight when standing (but the
swelling goes down when he puts his legs up). You carry out a medical
examination.
What is the most likely prescription after this examination?
A) atenonolol
B) chorthalidone
C) enalapril
D) isosorbide dinitrite patch
E) lose weight and exercise more
C) enalapril
A 65 year old woman is on warfarin for an aortic mechanical valve, she is
involved in a road traffic accident and has multiple injuries with shock due to
major haemorrhage. Her recent INR is 3.
What is the correct course of action?
A) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, protamine, and vitamin K
B) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, idarucizumab
C) Resuscitation (including blood products according to major haemorrhage
protocol), local measures and aprotinin
D) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, prothrombin complex concentrate
and vitamin K
E) Resuscitation (including blood products according to major haemorrhage
protocol), local measures and tranexamic acid
D) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, prothrombin complex concentrate
and vitamin K
when to give tranexamic acid
Tranexamic acid (sometimes shortened to txa) is a medicine that controls bleeding. It helps your blood to clot and is used for nosebleeds and heavy periods. If you're having a tooth taken out, using tranexamic acid mouthwash can help stop bleeding. also major haemorrhage
when to give vitamin K in bleeding
xVitamin K is needed for blood to clot. Not having enough vitamin K is the main cause of vitamin deficiency bleeding. If your baby’s blood doesn’t clot, they may have severe bleeding or a hemorrhage. This can be life-threatening.
Or if they are on warfarin
when is prothrombin complex concentrate given in bleeding
Prothrombin complex concentrate (PCC), also known as factor IX complex, is a medication made up of blood clotting factors II, IX, and X. Some versions also contain factor VII. It is used to treat and prevent bleeding in hemophilia B if pure factor IX is not available.
when is aprotinin used in bleeding
is indicated for prophylactic use to reduce perioperative blood loss and the need for blood transfusion in patients undergoing cardiopulmonary bypass in the course of coronary artery bypass graft surgery who are at an increased risk for blood loss and blood transfusion.
when to give idaruxicumab
Idarucizumab is used during a medical emergency to treat severe or uncontrolled bleeding that has been caused by taking dabigatran. Idarucizumab is also used when an emergency surgery or other invasive medical procedure is needed in a person who takes dabigatran.
when to give protamine
Protamine is a medication used to reverse and neutralize the anticoagulant effects of heparin. Protamine is the specific antagonist that neutralizes heparin-induced anticoagulation
A 72 year old woman presents with sudden severe tearing chest pain
radiating to her back. She has a history of poorly controlled hypertension. Her
chest X-ray shows a widened mediastinum. ECG is normal.
What would be the next diagnostic test that should be immediately arranged?
A) coronary angiogram
B) CT aorta
C) trans thoracic echocardiogram
D). D dimer
E) troponin
B) CT aorta
A 60 year old woman with a chronic respiratory condition is found to have a
blue/purplish discolouration of her nailbeds, lips and tongue.
Which pathophysiological process best describes the disturbance in her oxygen
cascade?
A) anaemic hypoxia
B) decreased barometric pressure
C) histotoxic hypoxia
D) hypoxaemia (hypoxic hypoxia)
E) stagnant hypoxia
D) hypoxaemia (low oxygen)
not A not anemia
Not B
Not C because not poisoning ( like cyanide)
Not stagnant (not reduced cardiac pressure)
causes of stagnant hypoxia
Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock.
(occurs in raynauds, shock states, cardiac arrest, severe congestive heart failure)
what causes histotoxic hypoxia
Histotoxic hypoxia results from tissue poisoning, such as that caused by cyanide (which acts by inhibiting cytochrome oxidase) and certain other poisons like hydrogen sulfide (byproduct of sewage and used in leather tanning).
what causes hypoxaemia (hypoxic hypoxia)
Hypoxia can also result from lung damage due to trauma. Other things can cause hypoxia include: Lung diseases such as chronic obstructive pulmonary disease (COPD), emphysema, bronchitis, pneumonia, and pulmonary edema (fluid in the lungs) Strong pain medicines and other drugs that hold back breathing.
A 24 year old woman is training to run a marathon.
During moderate aerobic exercise how will her PaCO2, alveolar ventilation and rate
of carbon dioxide production compare with resting levels?
A. PaCO2 ↑ CO2 production ↑ Alveolar ventilation ↑
B. PaCO2 ↔ CO2 production ↑ Alveolar ventilation ↑
C. PaCO2 ↓ CO2 production ↑ Alveolar ventilation ↑
D. PaCO2 ↓ CO2 production ↓ Alveolar ventilation ↓
E. PaCO2 ↔ CO2 production ↑ Alveolar ventilation ↔
B PaCO2 ↔ CO2 production ↑ Alveolar ventilation ↑
A 63 year old man presents with acute shortness of breath and tightness in
his chest. He has a mild non-productive cough. He has no fever but appears
to be working hard to breathe, with low oxygen saturations. Respiratory
examination is normal, but he has significant oral thrush. He rapidly
deteriorates and is admitted to the intensive care unit. Following transfer onto
ICU, he is found to have reduced air entry on the right, and a chest X-ray
shows a right sided pneumothorax. The gentleman is diagnosed
withPneumocystis jiroveci.
What is the most appropriate next investigation?
A) blood film
B) HIV test
C) Mycobacterium culture
D) Pneumococcal urinary antigen
E) Sputum culture
B) HIV test
Pneumocystis jirovecii is a yeast-like fungus of the genus Pneumocystis. The causative organism of Pneumocystis pneumonia, it is an important human pathogen, particularly among immunocompromised hosts. Prior to its discovery as a human-specific pathogen, P. jirovecii was known as P. carinii.
A patient has persistent breathlessness. His GP arranges spirometry which shows: FEV160%, FVC 95%, FEV1/FVC 58% What is the pattern seen? A) Mixed obstructive and restrictive B) Normal C) obstructive D) reduced gas transfer E) restrictive
C) obstructive
Spirometry criteria for obstructive lung disease
A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction. Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
Spirometry criteria for restrictive lung disease
the classic definition of a restrictive pattern on spirometry is low FVC in the presence of a normal FEV1/FVC ratio. However, restrictive lung disease is characterized by a decrease in total lung capacity (TLC).
what is interstitial lung disease
Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream. Lung damage from ILDs is often irreversible and gets worse over time.
A 76 year old man reports 6 months of breathlessness. He has minimal past
medical history and is not taking any medications. His chest X-ray shows
signs of interstitial lung disease.
What type of interstitial lung disease is most likely?
A) connective tissue interstitial lung disease
B) hypersensitivity pneumonitis
C) Non - specific interstitial lung disease
D) idiopathic pulmonary fibrosis
E) sarcoidosis
D) idiopathic pulmonary fibrosis
what is sarcoidosis of lung
Sarcoidosis is a rare disease caused by inflammation. It usually occurs in the lungs and lymph nodes, but it can occur in almost any organ. Sarcoidosis in the lungs is called pulmonary sarcoidosis. It causes small lumps of inflammatory cells in the lungs.
What is the most appropriate method of qualitative data collection to explore an individual's views in detail? A) diaries B) focus groups C) in depth interview D) meta - analysis E) non - participant observations
C) in depth interview
A 67 year old man presents to his GP with chronic obstructive pulmonary disease. What is the most likely clinical examination finding? A) asterixis (flapping tremor) B) cyanosis C) finger clubbing D) hyper-inflated chest E) peripheral oedema
D) hyper inflated chest
what does the right coronary artery supply
right atrium
right ventricle
inferior aspect of left ventricle
posterior septal area
what does the circumflex artery supply
left atrium
posterior aspect of the left ventricle
what does the left anterior descending artery supply
anterior aspect of left ventricle
anterior aspect of septum
. A 78 year old man develops increasing confusion on the ward at night. He is
wandering around naked asking for his wife, shouting, and threatening staff
and patients. He was admitted this morning with 1 week of productive cough
and temperature. He has a history of idiopathic Parkinson’s disease.
His temperature is 37.6°C, pulse rate 100 bpm, BP 132/71 mmHg and oxygen
saturation 95% breathing air. His capillary blood glucose is 5 mmol/L.
Attempts to calm him with nursing measures do not improve the situation, and
he begins hitting staff.
Which is the most appropriate treatment?
A. Amitriptyline
B. Haloperidol
C. Immediate release carbidopa-levodopa
D. Lorazepam
E. Risperidone
Correct Answer: D Lorazepam
Justification for correct answer
Whilst anti-psychotics are first-line to manage delirium where medication required, they
are contra-indicated in Parkinson’s disease. (NICE CG103 Delirium: prevention,
diagnosis and management).
A 28 year old man is investigated for polyuria and polydipsia. He has bipolar
disorder for which he has taken lithium for 2 years.
Initial investigations:
Sodium 145 mmol/L (135–146)
Potassium 3.9 mmol/L (3.5–5.3)
Serum osmolality 296 mOsmol/kg (285–295)
Urinary osmolality 356 mOsmol/kg (350–1000)
Fasting glucose 5.8 mmol/L (3.0–6.0)
Serum lithium 0.75 mmol/L (0.5–1.2)
Which is the most useful diagnostic investigation?
A. 24-h urinary cortisol test
B. Glucose tolerance test
C. Serum corrected calcium
D. Short Synacthen test
E. Water deprivation test
Correct Answer: C serum corrected calcium
Justification for correct answer
It is essential to exclude hypercalcaemia due to hyperparathyroidism before progressing
to a water deprivation test.
A 65 year old woman had a stroke 2 weeks ago causing right arm weakness
and dysphasia. CT scan of head showed a left parietal lobe infarct. Her
medication since the stroke includes aspirin and simvastatin.
Her pulse rate is 82 bpm and irregular.
Investigations:
ECG: atrial fibrillation, rate 68 bpm.
Which is the most appropriate long-term plan for secondary stroke prevention?
A. Apixaban
B. Aspirin
C. Aspirin and dipyridamole
D. Clopidogrel
E. Ticagrelor
Correct Answer: A
Justification for correct answer
For patients with a stroke and AF should start anticoagulation as secondary prevention.
This can be with either warfarin or with a factor Xa inhibitor such as apixaban. This is
covered in both NICE AF guidelines (https://pathways.nice.org.uk/pathways/atrialfibrillation#path=view%3A/pathways/atrial-fibrillation/preventing-stroke-in-people-withatrial-fibrillation.xml&content=view-node%3Anodes-anticoagulation-treatment ) and the
most recently updated stroke guidance (2016) (https://www.rcplondon.ac.uk/guidelinespolicy/stroke-guidelines ). This version reflects increasing use of the novel oral
anticoagulants, which FY doctors need to be aware of.
What is Kayser-Fleischer rings
Kayser–Fleischer rings are dark rings that appear to encircle the iris of the eye. They are due to copper deposition in part of the Descemet’s membrane as a result of liver diseases.
(including Wilsons disease)
Difference between type 1 and type 2 respiratory failure
Respiratory failure is divided into type I and type II. Type I respiratory failure involves low oxygen, and normal or low carbon dioxide levels. Type II respiratory failure involves low oxygen, with high carbon dioxide.
examples of type 1 respiratory failure
Causes of type 1 respiratory failure include: pulmonary oedema, pneumonia, COPD, asthma, acute respiratory distress syndrome, chronic pulmonary fibrosis, pneumothorax, pulmonary embolism, pulmonary hypertension.
causes of type 2 respiratory failure
Type 2 respiratory failure is commonly caused by COPD but may also be caused by chest-wall deformities, respiratory muscle weakness and Central nervous system depression (CNS depression.) CNS depression is associated with reduced respiratory drive and is often a side effect of sedatives and strong opioids.
example of factor xa inhibitor
mechanism
and use
examples: apixaban, rivaroxaban, edoxaban
mechanism: inhibit fibrin formation in the final common pathway of the coagulation cascade
use: Treat and prevent venous thromboembolism
A 67 year old man is due to have a CT scan of chest, abdomen and pelvis
with intravenous contrast as assessment for possible lymphoma. He had a
renal transplant 5 years ago. His medication includes prednisolone, tacrolimus
and lisninopril.
His BP is 131/86 mmHg.
Investigations:
Urea 12.9 mmol/L (2.5–7.8)
Creatinine 165 µmol/L (60–120)
eGFR 39 mL/min/1.73 m2
(>60)
Which is the most appropriate treatment to give before the scan?
A. Intravenous 0.9% sodium chloride infusion
B. Intravenous acetylcysteine
C. Intravenous furosemide infusion
D. Intravenous hydrocortisone
E. Intravenous mannitol
Correct Answer: A
Justification for correct answer
The patient is due to receive IV contrast and has existing CKD. He is an increased risk of
contrast nephropathy. Volume expansion with 0.9% sodium chloride infusion (1 mL/kg) is
recommended and shown to reduce the incidence of contrast nephropathy. Some units
still recommend oral acetylcysteine (although trial data is lacking), but IV acetylcysteine is
no longer used due to risk of anaphylactoid reaction. There is no indication for additional
steroids. IV furosemide may increase risk of contrast nephropathy. IV mannitol is no
longer used as no evidence of benefit.
A 78 year old woman is admitted after been found collapsed at home. She
has been lying on the floor overnight. She has a history of hypertension and
takes amlodipine.
Her temperature is 35.8°C, pulse rate 88 bpm and irregular, and BP 102/60
mmHg.
Investigations:
Sodium 136 mmol/L (135–146)
Potassium 5.8 mmol/L (3.5–5.3)
Urea 20.9 mmol/L (2.5–7.8)
Creatinine 180 μmol/L (60–120)
Creatine kinase 870 U/L (25–175)
Urinalysis: glucose negative, ketones negative, blood 2+, protein 1+,
leucocytes positive (catheter sample).
She has passed 60 mL of urine over the past 2 hours.
Which is the most likely cause for her acute kidney injury?
A. Glomerulonephritis
B. Hypovolaemia
C. Renal arterial emboli
D. Rhabdomyolysis
E. Ureteric obstruction
Correct Answer: B
Justification for correct answer
This patient is hypovolaemic due to long lie without hydration and the probably sepsis.
The level of CK is compatible with minor soft tissue injury. Rhabdomyolysis would give a
CK of >10,000. There is no indicators of glomerulonephritis and the urinalysis
abnormalities are compatible with a catheter sample +/- urosepsis. Renal emboli are
rare and would give loin pain. Ureteric obstruction is unlikely as the patient is still
passing some urine.
- A 76 year old woman has become increasingly confused over the past 2
weeks. She has a history of hypertension and cardiac failure. She is taking
bendroflumethiazide, doxazosin, amlodipine, ramipril and atenolol.
Her BP is 108/71 mmHg.
Investigations:
Sodium 121 mmol/L (135–146)
Potassium 3.5 mmol/L (3.5–5.3)
Urea 10.0 mmol/L (2.5–7.8)
Creatinine 105 µmol/L (60–120)
Which medication is most likely to be responsible for her presentation?
A. Amlodipine
B. Atenolol
C. Bendroflumethiazide
D. Doxazosin
E. Ramipril
Correct Answer: C
Justification for correct answer
Of the medications listed, bendroflumethiazide is most likely to cause hyponatraemia.
A 92 year old woman has severe neck, chest and back pain and tingling in her
left hand following a mechanical fall. She has bruising around her right eye.
Investigations:
CT scan of head no intracranial injury or bleed, mild small vessel disease;
right orbital fracture
Chest X-ray lung fields clear; left sided 4th rib fracture
Full blood count and clotting screen are normal.
Which is the most appropriate next investigation?
A. Cervical spine X-ray
B. CT angiography
C. CT scan of chest
D. CT scan of neck
E. MR scan of brain
Correct Answer: D
Justification for correct answer
The history and examination suggest a cervical spine fracture. This is best detected by a
CT scan of the neck.
A 24 year old woman attends her GP with 2 months of intermittent
palpitations. She describes the episodes as feeling as if the heart stops for a
second followed by a pounding sensation. She reports episodes two to three
times per week lasting 5–10 minutes, most commonly when she is going to
sleep. She is otherwise well. She has been taking the combined oral
contraceptive pill for 2 years.
Her pulse rate is 68 bpm and BP 108/71 mmHg. Her heart sounds are normal.
Investigations:
ECG: sinus rhythm, rate 70 bpm.
Which is the most likely diagnosis?
A. Paroxysmal atrial fibrillation
B. Sinus arrhythmia
C. Sinus tachycardia
D. Supraventricular premature beats
E. Supraventricular tachycardia
Correct Answer: D
Justification for correct answer
The description of the arrhythmias best fits with ectopics (either supraventricular or
ventricular). Supraventricular are probably more common in this age group. There are no
worrying features and the cause is most likely benign.
what type of drug is mesalazine/what does it treat
Mesalazine is used to treat ulcerative colitis and Crohn’s disease and other types of inflammatory bowel disease. It belongs to a group of medicines called aminosalicylates. These help to reduce redness and swelling (inflammation) and can help with healing.
A 52 year old man has 3 months of fatigue. He has a history of ulcerative
colitis and takes mesalazine. He drinks 20 units of alcohol per week.
His temperature is 36.8°C and pulse rate 80 bpm. He has 3 cm
hepatomegaly.
Investigations:
Albumin 36 g/L (35–50)
ALT 65 IU/L (10–50)
ALP 580 IU/L (25–115)
Bilirubin 18 µmol/L (<17)
γGT 230 IU/L (9–40)
Ultrasound scan of abdomen: bile duct wall thickening and dilatation
Which is the most appropriate next diagnostic investigation?
A. CT scan of abdomen
B. Endoscopic retrograde cholangiopancreatography
C. Liver biopsy
D. MR cholangiopancreatography
E. Percutaneous transhepatic cholangiography
Correct Answer: D
Justification for correct answer
The patient has a classic cholestatic pattern of blood test abnormalities. PSC often has
limited symptoms at presentation and bilirubin and albumin are often normal. There is a
strong association with UC. Ultrasound shows evidence of abnormal bile ducts. MRCP
is the typical initial diagnostic investigation as it is non-invasive. This usually shows
typical beaded appearance of the bile duct.
A 60 year old woman has 6 weeks of a cough productive of blood streaked
sputum.
Investigations:
CT scan of chest: mass in left lower lobe
Needle biopsy: nuclei that are enlarged, hyperchromatic and pleomorphic
Which is the most likely diagnosis?
A. Adenoma
B. Carcinoma
C. Hamartoma
D. Sarcoidosis
E. Tuberculosis
Correct Answer: B
Justification for correct answer
This is because nuclear enlargement, hyperchromasia and pleomorphism are features
that suggest carcinoma in all sites of the body.
features that suggest sarcoidosis
think histology
Sarcoidosis is a multisystem disorder that can affect practically any organ of the body. The hallmark of sarcoidosis is the presence of noncaseating granuloma, a cluster of macrophages, epithelioid cells, mononuclear cells, and CD4+ T cells with a few CD8+ T cells in the peripheral zone
A 65 year old woman has an infective exacerbation of COPD.
Her temperature is 37.8°C, pulse rate 108 bpm, BP 100/75mmHg, respiratory
rate 26 breaths per minute and oxygen saturation 88% breathing 15 L/minute
oxygen via a non-rebreather mask. She is alert.
Investigations:
Arterial blood gas on 15 L/min oxygen
pH 7.28 (7.35–7.45)
PO2 7.2 kPa (11–15)
PCO2 8.9 kPa (4.6–6.4)
Bicarbonate 31.3 mmol/L (22–30)
Lactate 1.2 mmol/L (1–2)
Which is the most appropriate next management option?
A. Continuous positive airway pressure
B. Invasive ventilation
C. Nasal high flow oxygen
D. Nasopharyngeal airway
E. Non-invasive ventilation
Correct Answer: E
Justification for correct answer
Respiratory acidosis needs to be corrected with ventilation in an alert patient.
CPAP for type 1 (just low O2)
because she is high CO2 and Low O2 she is type 2 and so she needs BiPAP (non invasive ventilation)
A 50 year old woman has acute onset of shortness of breath. She underwent
a laparoscopic cholecystectomy 10 days ago.
Her temperature is 37.4°C, pulse rate 104 bpm, BP 122/80 mmHg, respiratory
rate 24 breaths per minute and oxygen saturation 94% breathing air. Her
chest is clear. She has minimal tenderness over the right hypochondrium.
Which is the most likely diagnosis?
A. Myocardial infarction
B. Pancreatitis
C. Pneumonia
D. Pulmonary embolus
E. Subphrenic abscess
Correct Answer: D
Justification for correct answer
This is because she is most likely to have suffered pulmonary embolus after period of
surgery.
A 39 year old man has had fever, chills and generalised weakness for
1 month. He has a history of systolic heart murmur. He is an intravenous drug
user.
Investigations:
White cell count 15 × 109
/L (3.0–10.0)
Erythrocyte sedimentation rate 55 mm/hr (<20)
Blood cultures are awaited.
Which further investigation will help to establish the diagnosis?
A. Chest X-ray
B. ECG
C. Nasal swabs
D. Transoesophageal echocardiogram
E. Urine dipstick analysis
Correct Answer: D
Justification for correct answer
The patient has a likely diagnosis of endocarditis and requires a TOE and blood cultures
A 16 year old girl presents to the Emergency Department after an episode of
loss of consciousness following a fall. She had consumed an excessive
amount of alcohol at a party before the fall.
She has a dirty scalp wound and cannot remember recent events. Her pulse
rate is 68 bpm, BP 110/80 mmHg and oxygen saturation 98% breathing
air. She opens her eyes to command and is confused. Her capillary blood
glucose is 6.0 mmol/L.
Her wound is cleaned and sutured.
Which is the most appropriate immediate management plan?
A. Admit and observe for 24 h
B. CT scan of head
C. Discharge with head injury instructions
D. Refer to neurosurgeon
E. X-ray of skull
Correct Answer: B
Justification for correct answer
Current guidelines. Safety issue. A child of 16 doesn’t need a tetanus booster.
A 72 year old woman has 6 months of mild constipation. Investigations: Haemoglobin 110 g/L (115–165) Creatinine 70 µmol/L (60–120) Calcium 2.90 mmol/L (2.2–2.6) Phosphate 0.65 mmol/L (0.8–1.5) 24 h urinary calcium 7 mmol (2–6) Parathyroid hormone 11.2 pmol/L (1.6–8.5) Vitamin D 65 nmol/L (>60) Which is the most likely diagnosis? A. Familial hypocalciuric hypercalcaemia B. Multiple myeloma C. Primary hyperparathyroidism D. Tertiary hyperparathyroidism E. Vitamin D intoxication
Correct Answer: C
Justification for correct answer
This is because primary Hyperparathyroidism is commoner in older female patients. In
most cases symptoms are either mild, as in this case or absent. Biochemistry
hypercalcaemia, elevated PTH and hypercalciuria point towards primary
hyperparathyroidism. Tertiary hyperparathyroidism is possible but less likely as renal
function is normal. There is no evidence for anaemia (malabsorption) and the patient is
well.
A 52 year old man visits his GP for health screening. He is well. His pulse rate is 80 bpm and irregular, and BP 128/84 mmHg. Investigations: Sodium 136 mmol/L (135–146) Potassium 3.9 mmol/L (3.5–5.3) Urea 4.9 mmol/L (2.5–7.8) Creatinine 80 μmol/L (60–120) HbA1c 40 mmol/mol (20–42) Thyroid function tests are normal. ECG shows atrial fibrillation, 76 bpm. Which is the most appropriate treatment? A. Apixaban B. Aspirin C. Diltiazem hydrochloride D. No treatment E. Warfarin sodium
Correct Answer: D
Justification for correct answer
The patient has incidental non-symptomatic AF. This is a common way to pick up AF. The
rate is controlled. He has no other risk factors and his CHA2DS2-VASc score is 0 and
anticoagulation is not recommended (Atrial fibrillation: management (2014) NICE
guideline CG180)
what is epistaxis
nose bleed
An 80 year old man presents to the Emergency Department with 2 hours of
epistaxis that has not stopped despite compression. He has a history of
hypertension.
A bleeding site is visible in the anterior nasal cavity. His BP is 160/95 mmHg.
Which is the most appropriate initial management option?
A. Anterior pack
B. Antihypertensive medication
C. Cautery
D. Cryotherapy
E. Ice pack
Correct Answer: C
Justification for correct answer
Minor bleeding from an accessible site can be treated with cautery using a silver nitrate
stick or electrocautery. Anterior pack is for profuse bleeding with site difficult to localise.
Anti hypertensives will only prevent further attacks of epistaxis. Cryotherapy and ice pack
of little advantage and secondary.
what is a paralytic ileus
A condition in which the muscles of the intestines do not allow food to pass through, resulting in a blocked intestine. Paralytic ileus may be caused by surgery, inflammation, and certain drugs.
A 65 year old man has abdominal distension and vomiting 48 hours after a
sigmoid colectomy with primary anastomosis for bowel cancer. He has not
passed any flatus for 24 hours. He is taking regular paracetamol and as
required intravenous morphine.
His abdomen is distended with tenderness over the wound but no rebound or
guarding. There are no bowel sounds.
His temperature is 37.6°C, pulse rate 96 bpm and BP 122/85 mmHg.
Which is the most appropriate initial management?
A. Give intravenous piperacillin with tazobactam
B. Give Microlax ® enema
C. Insert a nasogastric tube
D. Start regular intravenous morphine
E. Take to theatre for laparotomy
Correct Answer: C
Justification for correct answer
The patient has evidence of a paralytic ileus. The initial treatment would involve making
patient nil by mouth and inserting a nasogastric tube. Morphine would make the condition
worse. There is no indication for antibiotics. An enema would not be appropriate and
unlikely to be of benefit. There is no indication for immediate surgery as further
investigations will be required to identify treatable causes
A 23 year old man attends the sexual health clinic with a painful swelling in his
groin and pain when opening his bowels. He had unprotected anal sex with a
new male partner 4 weeks ago.
He has a perianal ulcer and tender inguinal lymphadenopathy.
Which is the most likely diagnosis?
A. Genital herpes
B. Gonorrhoea
C. HIV seroconversion
D. Lymphogranuloma venereum
E. Secondary syphilis
Correct Answer: D
Justification for correct answer
Proctitis and lymp
A 30 year old woman attends 3 months after a diagnosis of iron deficiency
anaemia. She was advised to take oral iron supplements and has been taking
these regularly. She has some looseness of her stools, and her periods are
scanty on a combined oral contraceptive.
Investigations:
Haemoglobin 92 g/L (115–165)
MCV 70 fL (80–96)
Ferritin 8 µg/L (12–200)
Which antibody test is most likely to diagnose the underlying cause?
A. Anti-gastric parietal cell
B. Antimitochondrial
C. Antinuclear
D. Anti-smooth muscle
E. Anti-tissue transglutaminase
Correct Answer: E
Justification for correct answer
Coeliac disease is the most likely diagnosis.
A 20 year old man has 2 days of visible haematuria. Three days before the
haematuria started, he developed tonsillitis and was treated with
phenoxymethylpenicillin. He has no significant medical history.
His BP is 112/54 mmHg.
Investigations:
Urea 3.2 mmol/L (2.5–7.8)
Creatinine 61 µmol/L (60–120)
Urinalysis: glucose negative, ketones negative, blood 3+, protein 3+, nitrites
negative, leucocytes negative.
Which is the most likely cause of his haematuria?
A. Alport’s nephropathy
B. Drug reaction
C. Granulomatosis with polyangiitis
D. IgA nephropathy
E. Postinfectious glomerulonephritis
Correct Answer: D
Justification for correct answer
IgA characteristically causes visible haematuria a few days after URTI (post-infectious
GN has lag time of around 2 weeks before haematuria occurs and would be a less benign
presentation if associated with visible haematuria).
A 38 year old man has 2 months of epigastric pain that radiates into his back.
It is worse at night and sometimes wakes him up. It is better after eating. He
has been very busy at work. He occasionally misses lunch, which worsens the
pain. He has not lost weight. He smokes 10 cigarettes per day and drinks two
bottles of wine per week.
Examination is normal.
Which is the most likely diagnosis?
A. Cholecystitis
B. Chronic pancreatitis
C. Duodenal ulcer
D. Gastric ulcer
E. Gastric carcinoma
Correct Answer: C
Justification for correct answer
Duodenal ulcers tend to be made worse with stress and the pain is often worse at night
radiating into the back - it is relieved by eating and patients tend to put weight on - in
contrast to a gastric ulcer which is made worse with eating and people often lose weight.
A 26 year old woman has 12 months of back pain, located in the low
lumbosacral region. She has intermittent bilateral thigh pain. The back pain
disturbs her sleep. The pain is improved by activity but not relieved by resting.
She finds it difficult to bend down during the day to pick things up from the
floor.
Which clinical feature is most specific for inflammatory back pain?
A. Improvement with activity
B. Nocturnal pain
C. Radiation to leg
D. Stiffness during the day
E. Young age
Correct Answer: A
Justification for correct answer
Inflammatory back pain (IBP) is typically improved with activity and not relieved by rest,
as opposed to mechanical pain which is worse with activity and is relieved by rest. IBP
can wake the patient in the early hours of the morning and sacroilieitis can radiate to the
thigh, but these features are much less specific. Morning stiffness is specific for
inflammatory back pain but not persistent daytime stiffness. IBP can occur at any age
although mechanical pain is less common in young people.
A 68 year old man has a swollen tender knee for 3 days and cannot weight
bear. He has had previous episodes of big toe swelling. He has a history of
chronic kidney disease stage 4.
Investigations:
Fluid analysis of knee aspirate:
White cell count 55 000/mL, 95% neutrophils
Gram stain negative
Copious 10 μm intracellular needle shaped crystals
Which is the best initial treatment for his acute knee pain and swelling?
A. Arthroscopic joint washout
B. Intravenous flucloxacillin
C. Oral allopurinol
D. Oral naproxen
E. Oral prednisolone
Correct Answer: E
Justification for correct answer
The presentation is likely due to an acute attack of gout. Although infection is not
completely excluded at this stage it is less likely as G stain is negative and there are
several positive features of gout in the history. IA or oral steroids, colchicine or NSAIDs
are all effective treatments for acute gout. NSAIDs are contraindicated in CKD of this
stage. Allopurinol will not help the acute attack
An 18 year old man is in the intensive care unit with septic shock as a result of
a compound fracture of his leg. His urine output has been <30 mL for the past
2 hours.
His pulse rate is 125 bpm, BP 85/40 mmHg and JVP 4 cm above the sternal
angle. There are basal crackles on auscultation of the chest.
Investigations:
ECG shows sinus rhythm, 125 bpm.
He is being treated with intravenous 0.9% sodium chloride at 125 mL/h and
antibiotics.
Which is the most appropriate additional intravenous treatment?
A. 500 mL 0.9% sodium chloride over 15 min
B. 500 mL Hartmann’s solution over 15 min
C. Dopamine hydrochloride
D. Furosemide
E. Noradrenaline/norepinephrine
Correct Answer: E
Justification for correct answer
Description of adequate (if not over) hydration. Needs vasoconstriction.
A 34 year old man has pain in his right shoulder and upper arm for 6 weeks
that worsens when elevating his arm above his head. He does not recall any
injury.
There is no deformity, tenderness or reduced range of movement. There is
pain on abduction of the right shoulder that is worse with the arm in internal
rotation and when abduction is resisted. He is treated with ibuprofen.
Which is the most appropriate next step in management?
A. MR scan of shoulder
B. Refer for orthopaedic opinion
C. Refer for physiotherapy
D. Ultrasound scan of shoulder
E. X-ray of shoulder
Correct Answer: C
Justification for correct answer
Clinically the diagnosis is right supraspinatus tendinopathy and no further investigation is
required to confirm the diagnosis. Most cases can be managed in primary care and a
referral to orthopaedics is not required. The most appropriate management is either
general advise and home exercises or referral to a physiotherapist.
A 65 year old woman with advanced carcinoma of the breast with cerebral
and liver metastases is rapidly deteriorating and is recognised to be dying.
She becomes confused and agitated.
Which is the most suitable initial treatment?
A. Diamorphine hydrochloride
B. Glycopyrronium
C. Hyoscine hydrobromide
D. Midazolam
E. Mirtazapine
Correct Answer: D
Justification for correct answer
Terminal restlessness is a common and distressing condition that requires active
management: important knowledge for FY doctors. The diagnosis of dying has already
been made and reversible causes of her deterioration will thus have been considered and
excluded: NICE guidelines indicate that terminal restlessness should be managed with
Midazolam by prn subcutaneous injections / continuous subcutaneous infusion via a
syringe driver.
what is amitriptyline
hydrochloride
This medication is used to treat mental/mood problems such as depression. It may help improve mood and feelings of well-being, relieve anxiety and tension, help you sleep better, and increase your energy level. This medication belongs to a class of medications called tricyclic antidepressants.
A 43 year old woman is admitted to hospital with an overdose of amitriptyline
hydrochloride taken 4 hours previously. She has a history of chronic
headache.
Her pulse rate is 105 bpm and BP 95/40 mmHg. She is drowsy and her pupils
are dilated. ECG shows significant QRS prolongation.
Which is the most appropriate immediate management option?
A. Activated charcoal
B. Intravenous amiodarone hydrochloride
C. Intravenous atropine sulfate
D. Intravenous magnesium
E. Intravenous sodium bicarbonate
Correct Answer: E
Justification for correct answer
Bicarbonate is the treatment of the choice in patients with prolonged QRS complexes
following a tricyclic antidepressant overdose
A 56 year old woman has home blood pressure readings averaging 160/90
mmHg.
Hypertension is confirmed on 24 hour ambulatory monitoring. She has type 1
diabetes mellitus.
Investigations:
Urinary albumin: creatinine ratio 42 mg/mmol (<3.5)
eGFR 43 mL/min/1.73 m2
(>60)
Which type of antihypertensive is most appropriate?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Calcium channel blocker
E. Thiazide-like diuretic
Correct Answer: A
Justification for correct answer
There is good evidence for renal function protection in diabetic nephropathy with ACE-1
in addition to its hypertensive properties.
A 70 year old man has dry cough and breathlessness on exertion for the past
3 months. He has lost 4 kg is weight. He has a history of ischaemic heart
disease and atrial fibrillation. He takes warfarin sodium, ramipril and
amiodarone hydrochloride. He is a never smoker.
His temperature is 37.5°C, pulse rate 70 bpm, respiratory rate 18 breaths per
minute and oxygen saturation 91% breathing air. He has fine bibasal
inspiratory crackles. There is no finger clubbing.
Investigations:
Haemoglobin 141 g/L (130–175)
White cell count 14.0 × 109
/L (3.0–10.0)
Erythrocyte sedimentation rate 65 mm/hr (<20)
Chest X-ray shows bilateral reticular opacities in both bases.
Which investigation is most likely to confirm the diagnosis?
A. Blood cultures
B. Bronchoscopy
C. Echocardiography
D. High resolution CT scan of chest
E. Induced sputum for microscopy and culture
Correct Answer: D
Justification for correct answer
This is because the patient has pulmonary fibrosis as a complication from amiodarone
therapy. This classically does not cause clubbing. Patients present with cough and
dyspnoea. Fever and reactive blood changes (raised WCC, ESR) are not uncommon. An
HRCT would confirm changes of interstitial lung disease. Blood cultures are indicated but
this is unlikely to be an infective cause. Bronchoscopy is not indicated. The features are
not those of heart failure so an echo will not confirm the diagnosis. An induced sputum is
not indicated at this stage.
what does a high erythrocyte sedimentation rate mean
an erythrocyte sedimentation rate (ESR) is a type of blood test that measures how quickly erythrocytes (red blood cells) settle at the bottom of a test tube that contains a blood sample. Normally, red blood cells settle relatively slowly. A faster-than-normal rate may indicate inflammation in the body
A 43 year old woman has a sudden severe headache that started 24 hours
ago. She has a history of autosomal dominant polycystic kidney disease.
Her temperature is 36.8°C, pulse rate 92 bpm and BP 140/100 mmHg.
Neurological examination is normal. CT scan of head is normal.
Which is the most appropriate next step in management?
A. Erythrocyte sedimentation rate
B. Lumbar puncture
C. MR scan of brain
D. Refer to outpatient headache clinic
E. Start amlodipine
Correct Answer: B
Justification for correct answer
This is because APKD is associated with subarachnoid haemorrage. A lumbar puncture
should be performed. MRA would be reasonable, but not MRI.
what does prednisolone do
Prednisolone is a medicine used to treat a wide range of health problems including allergies, blood disorders, skin diseases, inflammation, infections and certain cancers and to prevent organ rejection after a transplant. It helps by reducing swelling (inflammation) and can also calm down your immune system.
A 74 year old man has progressively worsening muscle aches that are now
causing him to struggle to get up from a chair or raise his arms above his
head. He has a history of oesophageal cancer treated surgically and
ischaemic heart disease. He is taking bisoprolol, clopidogrel, ramipril and
simvastatin.
Investigations:
Haemoglobin 125 g/L (130–175)
White cell count 7.8 × 109
/L (3.0–10.0)
Platelets 391 × 109
/L (150–400)
Erythrocyte sedimentation rate 105 mm/hr (<20)
Which is the most appropriate therapeutic change?
A. Start co-codamol
B. Start ibuprofen
C. Start prednisolone
D. Stop bisoprolol
E. Stop simvastatin
Correct Answer: C
Justification for correct answer
Classical PMR history, presentation and raised inflammatory markers.
PMR - polymyalgia rhuematica
A 59 year old woman has 6 months of pain affecting her hips and lower back.
She is Libyan and has lived in the UK for 10 years. She has chronic kidney
disease stage 3 and hypertension. She is taking lisinopril and
simvastatin. She has weakness of hip flexion bilaterally. There is no muscle or
bony tenderness.
Investigations:
Urea 7.8 mmol/L (2.5–7.8)
Creatinine 122 μmol/L (60–120)
Calcium 2.1 mmol/L (2.2–2.6)
eGFR 41 mL/min/1.73 m2
(>60)
Alkaline phosphatase 230 IU/L (25–115)
Parathyroid hormone 14.5 pmol/L (1.6–8.5)
Which additional investigation is most likely to confirm the diagnosis?
A. Creatine kinase
B. Erythrocyte sedimentation rate
C. Serum 25-OH cholecalciferol
D. Ultrasound scan of neck
E. X-ray of thoracic and lumbar spine
Correct Answer: C
Justification for correct answer
The clinical features suggest osteomalacia. She has hypocalcaemia and proximal
muscle weakness. The low serum calcium is not adequately explained by CKD. Serum
vitamin D would establish the diagnosis. 24 hour urinary calcium is sometimes
performed in primary hyperparathyroidism but not in a secondary case such as this. The
presentation is not one of myositis and this is unlikely to be significantly elevated.
Ultrasound of neck is another primary hyperparathyroidism test. The lumbar spine X-ray
is most likely to show osteopenia but does not give diagnostic features (unlike in
children)
How high does creatine kinase have to be to suggest rhabdomyolysis
> 10,000
what is polymyalgia rheumatica
Polymyalgia rheumatica is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.
which responds well to prednisolone and poorly to analgesics such as Naproxen or cocodamol
A 60 year old man has 2 days of a swollen, painful right leg. He has a history of hypertension and takes ramipril. He is otherwise well. He has a swollen right leg. The remainder of the examination is normal. Investigations: Haemoglobin 140 g/L (130–175) White cell count 8.0 × 109/L (3.8–10.0) Platelets 340 × 109/L (150–400) Creatinine 94 µmol/L (60–120) Calcium 2.5 mmol/L (2.2–2.6) ALT 30 IU/L (10–50) ALP 99 IU/L (25–115) APTT 30 seconds (22–41) PT 12 seconds (10–12) Urinalysis: normal Chest X-ray: normal Venous duplex ultrasound scan: thrombus in superficial femoral vein Which is the most appropriate additional investigation? A. CT of abdomen and pelvis B. Serum carcinoembryonic antigen C. Serum prostate specific antigen D. Serum protein electrophoresis E. Ultrasonography of abdomen
Correct Answer(s): A
Justification for correct answer
The patient has an unprovoked DVT. Patients should be offered CT scan abdomen and
pelvis to help identify possible malignancy
A 65 year old woman had a mechanical aortic valve replacement and
coronary revascularisation 3 days ago. She is being treated with dalteparin
sodium. She is also taking aspirin long term.
Which is the most appropriate long-term patient management?
A. Apixaban
B. Clopidogrel
C. Continue dalteparin sodium
D. Rivaroxaban
E. Warfarin sodium
Correct Answer(s): E
Justification for correct answer
All patients with mechanical valves require treatment with aspirin and warfarin. Low
molecular weight heparin is used as bridging anti-coagulation but not long-term. There is
no place for novel oral anticoagulants (yet).
low molecular weight heparin (dalteparin sodium)
Clopidogrel (P2Y12 receptor ) - anti platelet drug and irreversible
An 18 year old woman has had a chronic skin condition for several years. She
has noticed that she gets well-defined areas of scale formation at the sites of
minor skin injuries, such as scratches or insect bites, typically when the
injuries are healing. The scaling can persist for several weeks or months.
What is the most likely underlying skin condition?
A. Acne vulgaris
B. Eczema
C. Psoriasis
D. Seborrhoeic dermatitis
E. Vitiligo
Correct Answer(s): C psoriasis
Justification for correct answer
This is typical of Koebnerisation. Psoriasis is by far the commonest underlying cause,
though it can also occur in vitiligo
What is Koebner phenomenon?
is the appearance of new skin lesions on previously unaffected skin secondary to trauma.
It happens most often in people with psoriasis, but it happens in other skin conditions, too, including warts and vitiligo. If you have active flares, you are more likely to have a Koebner response.
A 64 year old man has vomiting and severe chest pain after eating a large
meal.
His temperature is 37.6°C, pulse rate 130 bpm, BP 95/50 mmHg and
respiratory rate 30 breaths per minute. There is palpable subcutaneous
emphysema on the left side of his neck.
Which is the most likely diagnosis?
A. Diaphragmatic rupture
B. Mallory–Weiss tear
C. Necrotising fasciitis
D. Oesophageal rupture
E. Spontaneous pneumohaemothorax
Correct Answer(s): D
Justification for correct answer
The scenario describes Boerhaave’s syndrome (oesophageal rupture).
A 54 year old woman has polyuria and the feeling that she needs to drink
continuously. She drinks at least 1 litre of water before bedtime and gets up
three to four times during the night to pass urine. She has another glass of
water each time that she gets up.
Investigations:
Sodium 140 mmol/L (135–146)
Potassium 4.1 mmol/L (3.5–5.3)
Urea 4.5 mmol/L (2.5–7.8)
Creatinine 86 µmol/L (60–120)
Calcium 2.56 mmol/L (2.2–2.6)
Fasting glucose 4.8 mmol/L (3.0–6.0)
Serum osmolality 295 mOsmol/kg (285–295)
Urinary osmolality 86 mOsmol/kg (100–1000)
After 8 hours of a water deprivation test, the serum osmolality is 308
mOsmol/kg and the urinary osmolality is 152 mOsmol/kg.
Following the administration of desmopressin, the serum osmolality is 286
mOsmol/kg and the urinary osmolality is 660 mOsmol/kg.
Which is the most appropriate next investigation?
A. CT scan of thorax, abdomen and pelvis
B. MR scan of pituitary
C. Oral glucose tolerance test
D. Technetium-99 Sestamibi parathyroid scan
E. Supervised fluid restriction and daily weights
Correct Answer(s): B
Justification for correct answer
The test results are consistent with cranial diabetes insipidus
A 32 year old man is referred to a gastroenterology clinic with hepatomegaly.
He has a history of type 2 diabetes that is diet controlled. He is taking no
regular medication. He is a non-smoker and drinks approximately 16 units of
alcohol per week. He is married with no children.
Cardiovascular and respiratory examinations are normal. His abdomen is soft,
with a 3 cm palpable liver edge. His BMI is 23 kg/m2(18–25).
Investigations:
Albumin 38 g/L (35–50)
ALT 90 IU/L (10–50)
ALP 112 IU/L (25–115)
Bilirubin 15 µmol/L (<17)
Ferritin 710 µg/L (12–200)
CRP 6 mg/L (<5)
Which is the most appropriate next investigation?
A. Hepatitis C serology
B. Liver biopsy
C. Reticulocyte count
D. Serum γGT
E. Transferrin saturation
Correct Answer(s): E
Justification for correct answer
Transferrin saturation is the screening test for haemochromatosis.
A 27 year old man is brought to the Emergency Department with left-sided
chest pain of sudden onset that is worse on taking a deep breath.
His temperature is 36.8°C, pulse rate 126 bpm, BP 108/60 mmHg, respiratory
rate 28 breaths per minute and oxygen saturation 94% breathing air.
Investigations:
ECG: sinus tachycardia
Which is the most appropriate next investigation?
A. Chest X-ray
B. CT pulmonary angiography
C. D dimers
D. Echocardiography
E. Ventilation/perfusion isotope lung scan
Correct Answer(s): A
Justification for correct answer
CXR to rule out other pathology before Well’s score and then CTPA (or V/Q) if PE likely
or D-dimer if PE unlikely. (NICE CG144) Diagnostic investigations for pulmonary
embolism 1.1.7 If a patient presents with signs or symptoms of pulmonary embolism
(PE), carry out an assessment of their general medical history, a physical examination
and a chest X ray to exclude other causes. [2012]
A 33 year old woman has 4 months of joint pain and stiffness, predominantly
affecting her feet. This is worst in the morning and gradually improves through
the day. She feels tired all the time but reports no other health problems.
Which investigation would confirm the most likely diagnosis?
A. Anti-cyclic citrillinated peptide antibody
B. Anti-double-stranded DNA antibodies
C. Antinuclear antibody
D. CRP
E. Rheumatoid factor
Correct Answer(s): A
Justification for correct answer
The correct answer is A (Anti CCP) antibody. This is the test that has the highest
specificity for rheumatoid arthritis, which is what the question is asking. CCP antibodies
are found in 80% of people with rheumatoid arthritis, but fewer than 0.5% of healthy
individuals. Rheumatoid factor is present in up to 10% of the healthy population, and
whilst of similar sensitivity to CCP, is much less specific. CRP is a non-specific marker of
inflammation, and can often be normal in early rheumatoid. ANA testing is high
sensitivity (but low specificity) test for connective tissue disorders such as SLE and
Sjorgren’s.
Which test is used to diagnose bronchiectasis? A. CT scan B. exercise test C. spirometry D. sputum samples E. tests for allergies
A. CT scan
A patient presents to his GP with shortness of breath. The GP suspects that the patient may have heart failure, and wants to investigate this. What investigation should he request? a) CRP b) D-dimer c) ESR d) NT-pro-BNP e) Troponin I
d) NT-pro-BNP
Treatment of anticholinergic toxidrome
is physostigmine salicylate. Most patients can be safely treated without it, but it is recommended for those who have tachydysrhythmia with subsequent hemodynamic compromise, intractable seizure, severe agitation or psychosis, or some combination thereof.
4 types of infective endocarditis
- native valve
- prosthetic valve
- PWID (people who take drugs/IV )
- Nosocomial (related to a hospital procedure)
What does CHA2DS2-VASc score stand for
congestive heart failure hypertension age >75 (+2 points) diabetes stroke (+2 points) vascular disease sex (Female)
Test that’s raised in coeliac disease
Anti-tissue transglutaminase
A 54-year-old woman presents with a long history of fatigue and joint pain. She complains particularly of joint stiffness in her knees that is worst in the morning and lasts for an hour before settling. Her knees are swollen on examination, with generalised tenderness. Her blood tests reveal a mildly elevated CRP, with a positive rheumatoid factor. Her doctor requests a knee x-ray, to attempt to narrow the differential diagnosis, which induces rheumatoid arthritis and osteoarthritis.Which radiographic feature would best support a diagnosis of rheumatoid arthritis in this patient?
a) Loss of joint space
b) Marginal erosions
c) Osteophyte formation
d) Subchondral cyst formation
e) Subchondral sclerosis
B) marginal erosions
Classic feature of RA
LOSS is an acronym for OA
Auto-inflammatory conditions are increasingly recognised as a cause of recurrent fever. Which of the following applies to this disease spectrum?
a) Auto-antibodies are typically present
b) Cytokines are important in disease pathogenesis
c) Family history is not relevant
d) Infection is confirmed in 50% of cases
e) Inflammatory markers are generally not raised
b) Cytokines are important in disease pathogenesis
Normal skin structure allows for cells to be regularly shed from the surface of the epidermis without damage to the underlying tissue.
What is this impermeable shedding layer of the epidermis of the skin known as?
a) Stratum basale
b) Stratum corneum
c) Stratum granulosum
d) Stratum lucidum
e) Stratum spinosum
b)stratum corneum
A 37-year-old female, day 3 post transsphenoidal surgery for pituitary macroadenoma, is passing 7-8 litres of urine a day. Her thirst sensation is intact, and she is able to match urinary loss with adequate fluid intake.
What is the cause of her polyuria, and what do you expect her urine osmolality to be?
a) Central diabetes insipidus, urine osmolality will be high
b) Central diabetes insipidus, urine osmolality will be low
c) Nephrogenic diabetes insipidus, urine osmolality will be high
d) Nephrogenic diabetes insipidus, urine osmolality will be low
e) This is the normal condition in all postoperative patients, urine osmolality will be
normal
b) Central diabetes insipidus, urine osmolality will be low
A 71-year-old male had surgery 4 days ago to resect a bowel cancer. He becomes breathless and lightheaded. On examination, he is apyrexial, pulse is 115 bpm, respiratory rate is 26/min.
What clinical scoring system is there to assess the pre-test probability of a pulmonary embolism?
a) AVPU scale
b) MRC (Medical Research Council) dyspnoea score
c) NEWS (National Early Warning Score)
d) PHQ-9 (Patient Health Questionnaire-9)
e) Wells’ criteria
E) wells criteria
A 56-year-old man is admitted to the emergency department with an adverse drug reaction.
Which of the following is an example of a Type B adverse drug reaction?
a) Anaphylactic reaction to penicillin
b) Dry mouth with tricyclic antidepressant
c) Gastrointestinal haemorrhage following warfarin use
d) Hypokalaemia with furosemide
e) Syncope with beta-blocker
a) anaphylactic reaction to penicillin
Type B Reactions Type B (bizarre) reactions are novel responses that are not expected from the known pharmacological actions of the drug. These are less common, and so may only be discovered for the first time after a drug has already been made available for general use.
