MSAKT paper qs bank 2023 Flashcards

Answers are uptodate and defo correct

1
Q

A 67 year old man is found to have an ejection systolic murmur. He is otherwise well. His pulse rate is 72 bpm and BP 128/84 mmHg. His chest is clear. Investigations: ECG shows sinus rhythm. Echocardiography shows aortic stenosis, valve gradient 50 mmHg. Left ventricular (LV) diastolic dysfunction, LV ejection fraction 45% (>55).
Which is the most appropriate management?

A. Clinical review and echocardiography in 6 months
B. Reassure and discharge
C. Refer for aortic valve replacement
D. Start bisoprolol fumarate and advise review if symptomatic
E. Start lisinopril and advise review if symptomatic

A

Refer for aortic valve replacement
>= 50mmhg valve gradient is where Aortic valve replacement should be considered.
Mild LV dysfunction is also reason to consider valve replacement. A and B will not be safe to do and medical management will not help with valve disease progression.

Asymptomatic aortic valve replacement referral should be made if:
* valve area < 0.6 cm2
* LVEF < 55%
* BNP or proBNP more than 2 uln
* symptoms during exercise.

Considered if during stress echo:
* LVEF < 50 + valve pressure gradient >40 + aortic valve < 1cm 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A 60 year old man has 6 months of dry cough and increasing shortness of breath on effort. He was previously fit and well, and is a non-smoker. His temperature is 36.8°C, pulse rate 60 bpm and oxygen saturation 89% breathing air. He has finger clubbing. Cardiac examination is normal, and chest examination reveals bibasal crepitations.

Which is the most likely diagnosis?

A. Bronchiectasis
B. Extrinsic allergic alveolitis
C. Idiopathic pulmonary fibrosis
D. Lung carcinoma
E. Pulmonary tuberculosis

A

Idiopathic Pulmonary Fibrosis -> All the answers are causes of cough finger clubbing and increasing breathlessnes but IPF is most likely

Lack of smoking hx means that Lung cancer is less likely, additionally symptoms are more likely to be unilateral

EAA is possible but again is less common that IPF also EAA is often associated with a specific trigger antigen

Pulmonary TB is less likely as there is no fever and the cough dry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

A 65 year old man attends the anticoagulant clinic. He has had a metal mitral valve replacement and atrial fibrillation. He takes warfarin 7 mg daily. There are no signs of bleeding. His pulse rate is 70 bpm, irregularly irregular, with a mechanical second heart sound. His INR is 5.1.

Which is the most appropriate next step in management?

A. Continue warfarin at lower dose
B. Continue warfarin at same dose
C. Give vitamin K intravenously
D. Give vitamin K orally
E. Withhold warfarin for 2 days then restart at lower dose

A

Withold Warfarin for 2 days and restart at a lower dose ->

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

A 52 year old man has three days of severe epigastric pain, radiating to his back, but no chest pain. He has vomited several times. He was previously well. He drinks approximately 60 units of alcohol a week and smokes 20 cigarettes per day. There is epigastric tenderness but his abdomen is not distended, and bowel sounds are present.

Which test would confirm the most likely diagnosis?

A. Abdominal X-ray
B. Gastroduodenoscopy
C. Serum alkaline phosphatase concentration
D. Serum amylase concentration
E. Ultrasound scan of abdomen

A

Serum Amylase -> Acute pancreatitis a lot of risk factors present suggesting pancreatitis.

This is an important diagnostic test early in pancreatitis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

A 55 year old man is rescued from a collapsed building where he has been trapped for 12 hours without water.His temperature is 35.6°C, pulse rate 100 bpm and BP 90/42 mmHg. His JVP is not visible. His abdomen is non tender.

Investigations:

Haemoglobin 168 g/L (130–175)
Sodium 148 mmol/L (135–146)
Potassium 6.0 mmol/L (3.5–5.3)
Urea 25.1 mmol/L (2.5–7.8)
Creatinine 184 μmol/L (60–120)
Creatine kinase 840 U/L (25–200)

Which is the most likely cause of this biochemical picture?

A. Bladder outflow obstruction
B. Direct renal trauma
C. Hypovolaemia
D. Rhabdomyolysis
E. Sepsis

A

Hypovolaemia -> Low BP and high HR additionally there is evidence of an AKI and the most common cause of this is hypovolaemia.

There is no reason for Sepsis to have developed in this scenario and no temperatire.

Ther Creatinine Kinase will be near 10,000 or in the 10,000s for rhabdomyolysis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

A 24 year old woman has diarrhoea. She is HIV positive and has been working in Namibia. Investigation:
Faeces microscopy (following modified Ziehl–Neelsen stain): protozoa

Which is the most likely causative organism?

A. Acanthamoeba
B. Cryptosporidium parvum
C. Entamoeba coli
D. Plasmodium falciparum
E. Schistosoma mansoni

A

Cryptosporidium Parvum -> This is a protozoa, It is a common causative organism that is associated with HIV and Nambia and causes Diarrhoea

IT is found in contaminated water sources and is a signigicant cause of diarrhoea in developing countries

The others can also cause diarrhoea the HIV and the Nambia makes Parvum more likely.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

A 67 year old man has difficulty chewing and speaking. He underwent carotid surgery 2 days ago. His tongue deviates to the right when he is asked to protrude it.

Which nerve has been damaged?

A. Left glossopharyngeal nerve
B. Left hypoglossal nerve
C. Left vagus nerve
D. Right glossopharyngeal nerve
E. Right hypoglossal nerve

A

Right Hypoglossal nerve -> The motor function of the Hypoglossal is the movement of the tongue.

The Tongue deviates Towards the lesion

The UvulA deviates Away from the lesion -> it is also associated with a lesion in the vagus nerve
(it might be glossopharyngeal but i think it is vagus.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

A 72 year old woman has had 4 months of progressive difficulty walking. She describes numbness and tingling in her feet and has fallen on several occasions. On examination of her lower limbs, she has normal tone, moderate weakness of ankle dorsiflexion and plantar flexion, normal knee jerks, but absent ankle jerks and extensor plantars. Romberg’s test is positive. She has reduced vibration sense, and joint position sense is impaired up to the ankle joints.
Temperature and pinprick sensations are normal.

Which investigation is most likely to confirm the diagnosis?

A. HbA 1c
B. Serum folate
C. Serum protein electrophoresis
D. Serum vitamin B 12
E. Serum vitamin D

A

Vitamin B12
A deficiency in B12 causes subacute combined degeneration of the cord

Presents with UMN and LMN signs as well as glove and stock loss of sensation I think anyway

BELOW IS WHAT WAS EXPLAINED ON THE WEBSITE…
The clinical picture is consistent with subacute combined degeneration of the cord, giving a mixture of upper motor neurone (extensor plantars) and lower motor neurone (absent ankle jerks) features. The sensory ataxia (positive Romberg test and absent position sense in the ankles) is most likely due to dorsal column dysfunction from vitamin B12 deficiency, and this can be confirmed by serum vitamin B12 measurement. Vitamin B12 deficiency of this severity is usually caused by pernicious anaemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

A 34 year old woman has a recurrent itchy rash which lasts for several hours before resolving (see image). She has not identified any triggers. She is systemically well. She is a firefighter and says that she does not want any treatments that may affect her level of alertness.

Which is the most appropriate treatment to control her symptoms?
A. Oral chlorphenamine maleate
B. Oral loratadine
C. Oral prednisolone
D. Topical aqueous cream
E. Topical hydrocortisone

A

Oral Loratadine -> first line management of uritcaria is non-sedative anti histamines as there are less adverse effects. An example of this is oral Loratadine…

Oral Chlorophenamine maleate is also an anti histamine but this is sedative

oral pred - Steroids may be approapriate in a severe outbreak

Topical steroids are ineffective and so should not be used.

Topical Aqueous cream is an alternative to soap and has no place in the manafement of uritcaria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

A 29 year old woman has 2 days of marked loss of vision and acute pain in her left eye. The pain is worse when she changes her gaze direction. Her eyes appear normal on general inspection. Her vision is ‘count fingers only’ in the affected eye. The swinging flashlight test shows that the left pupil dilates when a bright light is moved from the right eye to the left eye. The optic discs are normal on fundoscopy.

Which is the most likely diagnosis?

A. Acute closed angle glaucoma
B. Giant cell arteritis
C. Idiopathic intracranial hypertension
D. Migraine with aura
E. Retrobulbar optic neuritis

A

Retrobulbar Optic neuritis -> Acute onset eye pain, marked loss off vision as well as a relative afferent pupillary defect = Optic neuritis

The optic disc swelling along with the above suggests retrobulbar lesion

Acute angle glaucoma -> can present similarly but there is sometimes mention of vominting, headaches, red eye with dilated pupils.

Giant cell arthritis would present with more systemic features which are not present here as well as malaise and jaw claudication

Idiopathic intracranial HTN -> Does not tend to cause pain with eye movement

Migraine with aura can have visual disturbance but not associated with RAPD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

A 45 year old woman develops an intensely painful eruption around her right eye. The illness started with pain 5 days previously, followed by the appearance of a few vesicles, which has now developed into the rash (see image). She has no significant medical history. Treatment is started.

Which is the most likely long-term outcome?

A. Complete resolution with no sequelae
B. Corneal ulceration
C. Extensive scarring of the right temple
D. Partial ptosis
E. Reduced visual acuity

A

Complete Resolution with no sequelae -> This herpes zoster ophthalmicus. this is chicken pox that represents on the V1 distribution. Most of the time this has a complete resolution with no sequelae.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

A 48 year old woman has rheumatoid arthritis. She takes regular paracetamol and has no drug allergies. She is due to commence methotrexate weekly.

Which additional treatment should be prescribed?

A. Calcium carbonate
B. Folic acid
C. Pyridoxine hydrochloride
D. Thiamine
E. Vitamin D

A

Folic acid -> Methotrexate is an Anti folate and so to reduce the adverce effects folic acid is needed.

Methotrexate is taken ONCE a week

Thiamine is Vitamin B1 and is needed in alcohol patinets.

Calcium carbonate is often used if there is hypocalcaemia

Pyrodoxine -> I believe is used to treat B6 deficiency in patients that are being treated with RIPE for tuberculosis as the Isonazid causes a depletion of B12

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

A 61 year old man has had 2 months of ankle swelling. He has hypertension and a 30 year history of seronegative polyarthritis. His medication includes ramipril, sulfasalzine, hydroxychloroquine sulfate and diclofenac. His BP is 156/90 mmHg. He has pitting oedema to mid thigh and signs of chronic deforming polyarthropathy in his hands, but no joint tenderness. His optic fundi show silver wiring and arteriovenous nipping. Urinalysis: protein 4+, no other abnormalities.

Investigations:
Sodium 133 mmol/L (135–146)
Potassium 5.4 mmol/L (3.5–5.3)
Urea 9.0 mmol/L (2.5–7.8)
Creatinine 119 µmol/L (60–120)
Albumin 21 g/L (35–50)
CRP 43 mg/L (<5)
Urinary protein:creatinine ratio 1100 mg/mmol (<30)

Which is the most appropriate initial treatment?

A. Candesartan cilexetil
B. Furosemide
C. Indapamide
D. Prednisolone
E. Prednisolone and cyclophosphamide

A

Furosemide -> This is nephrotic syndrome there is HTN and there is peripheral oedema as well as protein in urine. This is a loop diuretic and can cause hyponatreaemia and hypokalaemia

The patient needs to be referred but would be started on furosemide for the time being,

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

A 75 year old woman has had 5 months of a 2 cm red plaque on her leg. Investigation: Skin biopsy: Bowen’s disease

Which is the most appropriate topical treatment?

A. 5-fluorouracil (Efudix® ) cream
B. Betamethasone valerate (Betnovate® ) cream
C. Diclofenac (Solaraze® ) gel
D. Isotretinoin gel
E. Salicylic acid gel

A

5-Fluorouracil -> This is the topical treatment that is used in the management of Bowen’s disease.

5 fluorouracil is also used to treat acitnic keratosis

Bowen’s disease is a type od squamous cell carcinoma

Diclofenac can be used in the management Acitinic keratoisis but not Bowen’s disease

Isoretononin is used in the management in ACNE.

Salicycic acid is used in the treatment of hyperkeratototic lesions such as warts and acitinic keratosis. -> Even though there is hyperkeratosis in Bowen’s disease it does not treat the underlying dysplasia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

A 32 year old woman has had palpitations and hot flushes for 4 weeks. She has noticed a painless swelling in her neck over the same time and her weight has decreased by 2 kg. She gave birth 4 months ago after a normal pregnancy. She is not breastfeeding. Her pulse rate is 120 bpm and BP 140/90 mmHg. She is tremulous and restless. She has a large smooth non-tender goitre. Investigations:

Free T4 35.6 pmol/L (9–25)
Free T3 10.8 pmol/L (4.0–7.2)
TSH <0.01 mU/L (0.3–4.2)
Thyroid peroxidase antibodies >1600 IU/L (<50)
Thyroid stimulating antibodies <1.0 IU/L (<1.75)

Which is the most appropriate initial treatment?

A. Carbimazole
B. Propranolol
C. Propylthiouracil
D. Thyroidectomy
E. Thyrotropin alfa

A

Propanolol -> this is the most approapriate initial management. This can be done to manage the HTN and the High HR while further ix and management is initiated.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

An 80 year old man has an ulcer over the left heel and reduced mobility. He has a loss of appetite. He has type 2 diabetes mellitus and has previously had a myocardial infarction. The ulcer is 3 cm in diameter and deeply penetrating. Sensory testing shows reduced vibration sense but normal sensation to light touch. His Doppler ratio (ankle brachial pressure index) on the left is 0.68 and on the right is 0.98 (normal value 1.00).

Which is the most likely mechanism of his ulcer?

A. Arterial
B. Neuropathic
C. Nutritional
D. Vasculitic
E. Venous

A

Arterial -> There is sig hx for vascular disease. There is normal sensation and so neuropathic is not possible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A 78 year old woman is admitted to the surgical unit with a suspected vesicocolic fistula. She has a history of hypertension, type 2 diabetes mellitus and angina. She is taking amlodipine, metformin, gliclazide, simvastatin and bisoprolol.Her serum creatinine is 120 µmol/L (60–120). The consultant surgeon requests a CT scan of abdomen with contrast.

Which medication should be stopped before her CT scan?

A. Amlodipine
B. Bisoprolol
C. Gliclazide
D. Metformin
E. Simvastatin

A

Metformin -> needs to be stopped along with a CT contrast as there is risk of contrast induced retinopathy - ALSO imp for PSA

18
Q

A 50 year old man has a 3 month history of right loin pain and weight loss. For the past 20 years, he has smoked ten cigarettes per day. His temperature is 37.4°C, pulse rate is 72 bpm and BP is 142/74 mmHg. Investigations: Haemoglobin 11.2 g/L (130–175) Platelets 340 × 109/L (150–400) White cell count 10.1 × 109/L (4.0–11.0) Urinalysis blood 3+

Which is the most likely diagnosis?

A. Benign prostatic hypertrophy
B. Pyelonephritis
C. Renal calculus
D. Renal cancer
E. Urinary tract infection

A

REnal Cell cancer -> There is the triad or mass, loin pain and blood in urine -> Renal cell carcinome. This needs to be confirmed with CT or US.
Additionally there is RF for the cancer.

19
Q

A 74 year old man with type 2 diabetes has been increasingly unwell and experiencing progressive thirst and nausea for 2 weeks. Initially he described needing to pass urine more frequently than usual, but now he has not passed urine for 24 hours. He is dehydrated. Investigations: Sodium 149 mmol/L (135–146) Potassium 5.2 mmol/L (3.5–5.3) Chloride 101 mmol/L (95–106) Urea 15.4 mmol/L (2.5–7.8) Creatinine 208 µmol/L (60–120) Fasting glucose 41.7 mmol/L (3.0–6.0)

Which is the calculated serum osmolality? What is the formula?

A. 206.1 mmol/L
B. 255.2 mmol/L
C. 312.3 mmol/L
D. 355.1 mmol/L
E. Impossible to calculate, more information needed

A

2Na + Ur + Glu -> therefire D

20
Q

A 65 year old man receives a renal transplant. He is transferred back to the ward after four hours in recovery. His pulse is 106 bpm regular, BP 110/70 mmHg and respiratory rate 18 breaths per minute. His chest is clear on auscultation. His urine output has been 15–20 mL per hour while in recovery. Drain output has been 120 mL since surgery. Investigations:
Haemoglobin 90 g/L (130–175) (preoperative level 103 g/L)
Sodium 142 mmol/L (135–146)
Potassium 5.8 mmol/L (3.5–5.3)
Urea 31.9 mmol/L (2.5–7.8)
Creatinine 590 µmol/L (60–120)

Which is the next most appropriate management step?

A. Blood transfusion
B. Fluid challenge
C. Furosemide
D. Haemofiltration
E. Insulin and dextrose infusion

A

Fluid Challenge -> haemofiltration needs to be done if the high urea causes symptoms.
The low urine output with tachycardia and hypotension shortly after renal transplant or even a presentation of AKI needs to be treated with fluid challenge.

21
Q

A 70 year old man has a sharp stabbing pain in his jaw and cheek that lasts for seconds. He reports that the pain is triggered when brushing his teeth, cold wind and touching his face.

Which is the most appropriate treatment?

A. Carbamazepine
B. Indometacin
C. Morphine
D. Prednisolone
E. Pregabalin

A

Carbamazepine -> This is the first line management for trigeminal neuralgia

22
Q

An 85 year old man is admitted from a nursing home with a spreading cellulitis originating from an ulcer over his right ankle. Cultures taken from the ulcer and blood have grown MRSA. He is mildly confused. His temperature is 39.5°C, pulse rate 96 bpm and BP 114/60 mmHg.

Which is the most appropriate initial antibiotic treatment?

A. Co-amoxiclav
B. Flucloxacillin
C. Meropenem
D. Piperacillin with tazobactam
E. Vancomycin

A

Vancomycin -> Initial management of MRSA cellulitis.

Meropenem or Piperacillin and tazobactam -> Are broad spectrum abx that are used to treat cellulitis that is caused by gram negative bacteria or if there is a severe penecillin allergy

23
Q

A 76 year old woman with hypertension is taking amlodipine 10 mg daily. A 24 hour BP measurement shows a mean BP of 168/90 mmHg. Investigations: Sodium 135 mmol/L (135–146) Potassium 4.0 mmol/L (3.5–5.3) Urea 7 mmol/L (2.5–7.8) Creatinine 100 μmol/L (60–120) eGFR 68 mL/min/1.73 m2(>60) Urinary albumin : creatinine ratio 50 mg/mmol (<3.5)

Which class of antihypertensive should be added?

A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Loop diuretic
E. Thiazide-like diuretic

A

ACE i -> In terms of Standard HTN management ACEi would be next anyway.

However, in this caes the fact that the Albumin to creatinine ratio was >30 mg/mmol meant that it would benefit to be on ACEi as it delays the progression of end stage renal failure.

There is no other medication that is shoud to reduce protienuria and thus CVS risk

24
Q

An 80 year old man has sudden onset of loss of vision in his right eye. He has hypertension and a previous stroke. His visual acuity is hand movements only in the right eye and 6/9 in left eye. The right eye has an afferent pupillary defect; left eye pupil responses are normal. On fundoscopy there is a red spot at the right macula.

Which is the most likely diagnosis?

A. Anterior ischaemic optic neuropathy
B. Branch retinal vein occlusion
C. Central retinal artery occlusion
D. Macular degeneration
E. Retinal detachment

A

Central Retinal artery occlusion -> The red spot refers to the cherry red spot and apparently that is consistent with a retinal artery occulision

A central vein occlusion will have multiple retnal haemorrhages in the distribution of the vein

Macular degeneration will not present with sudden onset loss of vision

A and E however do have acute vision loss but on fundoscopy will present differently
Retinal detachement could clinically present very similarly but fundoscopy
the red reflex is lost and retinal folds may appear as pale, opaque or wrinkled forms
if the break is small, however, it may appear normal.

25
Q

A 35 year old man visits his GP with 3 days of a red, painful left eye with no discharge. There is a diffuse area of redness in the medial aspect of his left sclera. His pupils and visual acuity are normal.

Which is the most appropriate management?

A. Arrange assessment in emergency eye clinic
B. Prescribe chloramphenicol eye drops
C. Prescribe corticosteroid eye drops
D. Prescribe topical aciclovir
E. Reassure patient that it will resolve spontaneously

A

Arrange assessment in emergency eye clinic -> painful red eye without discharge is suggestive os scleritis and this has many serious complications.

This means that they need to be referred to the emergency eye clinic.
Topical corticosteroids can be used to treat this but this needs to be started by an ophthalmologist.

26
Q

A 35 year old man with type 1 diabetes mellitus has burning pain in his feet and difficulty sleeping. He has retinopathy and nephropathy.
Investigation:
eGFR 28 mL/min/1.73m2(> 60)

Which is the most appropriate management?

A. Acupuncture
B. Amitriptyline
C. Duloxetine
D. Physiotherapy
E. Sodium valproate

A

Amitriptyline -> is what is reccomended to treat this patient. Duloxetine can be used but the eGFR being less than 30 makes it not the right answer.

First line for neuropathic Pain according to NICE is -> Amitriptyline, duloxetine, gabapentin or pregabalin.

27
Q

A 76 year old woman has progressive breathlessness with right-sided pleuritic chest pain and weight loss over 6 months. She is a retired mechanic and has a 25 pack-year smoking history. Investigations: Chest X-ray: marked volume loss in right hemithorax CT scan of chest: see image

What is the most likely diagnosis?

A. Asbestosis
B. Chronic hypersensitivity pneumonitis
C. Lung cancer
D. Malignant pleural mesothelioma
E. Tuberculosis

A

Malignant pleural mesothelioma -> The wt loss is more suggestive of a cancer disease
The thickening of the pleura in the CT is more suggestive a proble with the mesothelium, hence a diagnosis of mesothelioma.

No fever points away from the diagnosis of TB

The chronic hypersensitivity pneumonitis and Asbestosis will both present with both likely present with bilateral symptoms and crackles hear at the area of abnormality. Additionally the CT will show changes within the lung fields not in the pleura. That being said pleural plaques may be present in Aesbestosis.

Lung cancer tends not to be painful and will not look like this on CT.

28
Q

A 65 year old woman has severe left-sided abdominal pain. Yesterday, she noticed blood mixed in with her stools. There is no history of weight loss. Her temperature is 37.7°C. She is very tender on palpation in the left lower quadrant. No masses are felt on rectal examination, but there is blood on the glove.

Which is the most likely cause of her symptoms?

A. Angiodysplasia
B. Colorectal cancer
C. Diverticulitis
D. Haemorrhoids
E. Ulcerative colitis

A

Diverticulitis -> Left sidede abdo pain with blood mixed with stools and tenderness on palpation is suggestice of diverticulitis

Angiodysplasia -> This is a cause of painless bleeding

Colorectal cancer can cause pain and bloeeding but i unlikely to present accutely. They are more likely with Wt loss and hx of new blood in stool with anaemia.

Haemorrhoids -> Bleeding during bowel movemebts but doesnt normally cause severe pain

UC -> is something that canc cause bloody diarhoea and pain but this will not likely present with an acute hx.

29
Q

A 35 year old woman was admitted two days ago after taking 32 paracetamol tablets. She has alcohol use disorder and weighs 40 kg. She has been treated with a full dose of acetylcysteine.

Which investigation best demonstrates restoration of liver synthetic function?

A. Albumin
B. ALT
C. Bilirubin
D. γGT
E. PT

A

PT -> The synthetic functuion of the liveris best measured by assessing the PT.

Albumin is also produced by the liver however there is a lag before this is seen in blood test therefore PT is better at assessing liver’s synthetic function

ALT -> This is a useful LFT that is tells us about liver damage. However it is not a meausure of synthetic function and it is not helpful in determining the severity of cirrhosis linked with mortaliy.

Bilirubin is conjuggated in the liver and is a measure of the liver metabolic function

GGT is not specific to liver damage and also can be raised even if liver function is restored.

30
Q

A 64 year old woman has thumping palpitations and says that she sometimes feels her heart ‘gives a sudden jump’. Her husband recently died due to myocardial infarction. Her pulse rate is 70 bpm, BP 136/80 mmHg. Her heart sounds are normal. Her 12-lead ECG is shown in the tracing.

Which is the most likely cause of her palpitations?

A. Atrial fibrillation
B. Premature supraventricular beats
C. Premature ventricular beats
D. Sinus arrhythmia
E. Ventricular tachycardia

A

Premature Ventricular beats -> this can be differentiated from premature supraventricular beats because this is wide qrs complex and so the beat origniates from the ventricles so not from above. The common jumps and thumping palpitation is a common description of ectopic beats.

31
Q

A 67 year old woman has an ulcer with a raised white margin on her left ear; it has been present for 3 years, growing slowly and never completely healing. She spent 20 years living in Australia before returning to the UK recently. On examination, she has a small ulcerated area, 4 mm × 6 mm, on her left pinna.

Which is the most likely diagnosis?

A. Actinic keratosis
B. Basal cell carcinoma
C. Malignant melanoma
D. Seborrhoeic keratosis
E. Squamous cell carcinoma

A

Basal Cell carcinoma -> High UV light exposure. The long history but also the small size as well as the raised ab d pale border is more suggestive of BCC. Other features not mentioned is shiny pearly surface or rolled edges or overlying telangiectasia.

Acitinic ketaosis -> Would be pink or scaly and do not ulcerate

Melanoma would be multicoloured

Seborrhoeic keratosis is a harmless wart lesion which is pigmented and does not ulcerate.

SCC normally grows at a much faster rate and is red and not pale.

32
Q

An 82 year old woman with atrial fibrillation takes warfarin to reduce her risk of stroke. Her INR is fluctuating between 1.1 and 3.8 (1.0), and she admits that she does not always remember to take her tablets. Her CHA2DS2-VASc score is 4. She lives alone and independently.

Which is the safest way to manage her stroke risk?

A. Change to aspirin using a monitored dosage system
B. Change to dalteparin administered by district nurse
C. Change to rivaroxaban using a monitored dosage system
D. Continue warfarin using a monitored dosage system
E. Stop anticoagulation

A

Monitored Dosage system Rivaroxaban -> The monitored dosage system is a good choice as it is indicated in this specific scenario. It also saves the use of a district nurse for other roles.

Warfarin is some reason not approapriate to be used as metered dosing… Though the asnwers dont explain why….

33
Q

A 48 year old man has visible haematuria and right loin pain. His temperature is 37.3°C, pulse rate 72 bpm and BP 170/97 mmHg. Masses are palpable in both flanks.

Investigations: Creatinine 220 µmol/L (60-120) Urinalysis: blood 4+

Which is the most appropriate next investigation? + Management?

A. CT scan of kidneys, ureters and bladder
B. Cystoscopy
C. MR scan of renal tract
D. Ultrasound scan of renal tract
E. Urine cytology

A

US of the renal tract -> The diagnosis is likely to be PCKD with bilateral massess. Renal US will confirm the precence of cysts.

CT scan would be used in suspected Renal stones or malignancy

An MR scan maybe done later to assess renal sizes ahead of possible therapy with** vasopressin antagonists** (tolvaptan)

34
Q

A 21 year old woman presents to her GP with moderately severe acne. She has tried topical retinoids and topical antibiotics without satisfactory response. She has a history of a deep vein thrombosis following a long-haul flight.

Which is the most appropriate treatment?

A. Co-cyprindiol
B. Desogestrel
C. Flucloxacillin
D. Isotretinoin
E. Lymecycline

A

Lemecyline -> Isotretinoin is added afterwards as this medication has a lot of side effects.

  • first line:
    • Topical combination ⇒ topical benzoyl peroxide + adapalene OR topical tretinoin + Topical clindamycin OR benzoyl peroxide + topical clindamycin.
    • Topical benzoyl peroxide only if other medications are contrainficated
  • Moderate to severe
    • topical benzoyl peroxide + adapalene OR topical tretinoin + Topical clindamycin OR topical benzoyl peroxide + adapalene + either lymecycline or doxycycline OR topical azelaic acid + oral lymecycline or oral doxycycline
35
Q

A 65 year old man is invited to the abdominal aortic aneurysm screening programme. An ultrasound scan shows his abdominal aorta to be 33 mm in diameter.

Which is the most appropriate management plan? + What are the different management options of AAA after screening?

A. Reassure and discharge
B. Refer for angiography
C. Refer for vascular surgery
D. Repeat ultrasound scan in 12 months
E. Request CT scan of abdomen

A

Repeat Ultrasound scan in 12 months -> an aneurysm is defines as >3cm in diameter. Therefore this patient has an aneurysm.

UK screening program for men starts at the age of 65

If the Aorta is between 3-4.4 cm then there is a need to have annual checks on the AAA.

if the Aneurysm is between 4.5-5.4 cm then there is a need to have a check every 3 months.

Greater than 5.5 cm requires patient to be referred to surgery.

36
Q

A 28 year old woman has pain on swallowing. She has a history of asthma that is well controlled using metered dose salbutamol and beclometasone dipropionate (800 micrograms/day) inhalers. She has white plaques in her mouth. An anti-fungal oral suspension is prescribed.

What is the most appropriate management with regard to her beclometasone?

A. Change beclometasone dipropionate to a dry powder formulation
B. Change beclometasone dipropionate to fluticasone
C. Change beclometasone dipriopionate to salmeterol
D. Take beclometasone dipropionate using a large volume spacer
E. Take salbutamol and beclometasone dipropionate at least 1h apart

A

Take Beclomethasone dipropionate using a large volume spacer -> Large spacers are used as a way to make sure that the steroids is delivered to the targe tissue the lungs.

The patient is suffereing from a complication of Oral candidiasis due to steroid use.

37
Q

A 56 year old man has had a single episode of painless visible haematuria. He has no other urinary symptoms and is otherwise fit and well. He has smoked ten cigarettes per day for the past 35 years. He has a BP of 140/85 mmHg. Urinalysis performed after this episode shows blood 2+, no protein and no nitrites. Investigations:

Urea 6.5 mmol/L (2.5–7.8)
Creatinine 95 µmol/L (60–120)
Urine culture: no growth

Which investigation is most likely to confirm the diagnosis?

A. Flexible cystoscopy
B. Serum prostate specific antigen
C. Transrectal ultrasound scan of prostate
D. Ultrasound scan of kidneys E. Urine cytology

A

A flexible cystoscopy -> Worried about bladder cancer because of the prescene of haematuria as well a history of smoking. This is the gold standard investigation for suspected cancer.

38
Q

The daughter of a 78 year old man is concerned about an area of redness on her father’s back. He lives alone and spends most of his day sitting in a chair. There is a reddened area over the sacrum, but his skin is intact. He is considered to be at risk of pressure ulcers.

Which member of the community multidisciplinary team would be most suited to conduct an initial assessment?

A. Dietician
B. District nurse
C. Occupational therapist
D. Physiotherapist
E. Tissue viability nurse

A

District nurse -> This is just something to know

Tissue viability nurses -> They work with District nurses providing support to complex wounds management.

Dietitian are important in the hollistic management of patients at risk od pressure damage but do not carry out the initial management.

Occupational therapists provide suppport to indviduals who are struggling to carry out everyday tasks.

Physiotherapist optimise the movement of and function in patients.

39
Q

A doctor in training sustains a needle-stick injury while inserting a venous cannula into a patient. The patient has a history of intravenous drug use.

Which is the most important first action for the doctor in training?

A. Encourage bleeding from the needle-stick injury wound
B. Make an appointment with occupational health
C. Seek post-exposure prophylaxis
D. Test the patient for HIV
E. Get an immediate blood sample taken from themselves

A

Encourage bleeding from the needle stick injury wound ->

Puncture wounds should be encouraged to bleed freely but should not be sucked. Small wounds and punctures may also be cleansed with an antiseptic, for example an alcohol-based hand hygiene solution.

40
Q

A 32 year old woman has 3 weeks of fever, rigors and lethargy. In the past week, she has also become breathless on exertion. She is an intravenous drug user. Her temperature is 38°C, pulse rate 100 bpm regular, and BP 100/60 mmHg. Her JVP is raised with predominant V waves. There is a pansystolic murmur at the left sternal edge on inspiration. She has reduced air entry with dullness to percussion at the right lung base. She has swelling of both ankles.

Which is the most likely pathogen? Name when the other organisms may be more likely to occur.

A. Enterococcus faecalis
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Streptococcus bovis / streptococcus equinus complex
E. Streptococcus viridans

A

Staphylococcus aureus-> Associated with IVDU in Infective endocarditis patients

  • Streptococci viridans (>20%) second most common. Also strep mitis and strep sanguini. Classically linked to poor dental hygiene.
  • Strptococci. bovis - linked to colorectal cancer
    • Staphylococci aureus (coagulase +ve) = IVDU - most common cause
    • Staphylococci. epidermidis (coagulate negative) - Patients with previous prosthetic valve.
  • Enterococcus Facaelis

Culture -ve (HACEK) or Right sided
- Haemophillis
- Actinobacillus
- Cardiobacterium
- Eikenella
- Kingella
- Coxiella
- Chlamydia

Non-infective otherwise called “marantic”
- SLE