MaM mocks Flashcards

Answers are uptodate and defo correct

1
Q
A

Bumetanide 1mg PO -> Furosemide has poor bioavailability. Therefore IV to Oral there is a need to have a high dose. This means that another loop diuretic such as bumetanide is needed.

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2
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NaCl Fluids -> the fluids are needed as this is likely to be Fast AF due to hypovolaemia and therefore reversible AF. Reversing the cause can treat this. The hypovolaemia is suggested by the tachycardia and also by the fact there is history of vomiting.

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3
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Isosorbide mononitrite -> This is a vasodilator, this can lead to reduced CO and so can lead to a drop in BP…

Beta blockers are actually used in HF and are not contraindicated in patients with AS

Metformin is stopped 48 hours before surgery to reduce the risk of lactic acidosis however does not need to be stopped upon discharge

Apixaban should again be stopped before surgery.

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4
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Tricuspid Regurg PSM on the RSE 4th intercostal space is characteristic of this.

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5
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Repeat OGD in 6 months -> For low grade dysplasia, there is a need to do a repeat OGD at 6 months if there is evidence of low grade dysplasia at 2 separate points before the use of endoscopic intervention of Barrets oesophagus with dysplasia

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6
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Albuminocytologic dissociation -> Seen in GBS…
Increase in protiens and a normal white cell count.

Oligoclonal IgG antibodies are associated with MS…

Xanthochromia -> SAH

Indian ink stain suggests -> Cryptoformus neoformis

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7
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A

Campylobacter Jejuni -> Common cause of bloody diarrhoea caused by undercooked paultry.

Histolytica does not cause bloody diarrhoea

E.coli can present like this but takes a week

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8
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Tertiary HyperPTH -> long term CKD leads to PTH being hypertrophic -> this makes it more likley.

Kidney transplant or no kidney transplant changes the phosphate level

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9
Q

Papillary
Follicular
Medullary
Thyroid cancers

Buzzworddsss

A

Papillary -> thyroglobulin + most common Psamomma bodies
Follicular -> Thyroglobulin
MEdullary -> Calcitonin + MEN 2

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10
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A

L-DOPA and DOPA-Decarboxylase inhibitor -> The decoarboxulase inhibitor will stop the Dopamine beibnng activated in the peripheries and make this so that is only works centrally.

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11
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A

Amitriptyline
There are 3 main preventative treatment for mrecurrant migraines they are -> Propanolol + topiramate and Amitriptyline

Bisoprolol is a cardioselective inhibitor used for rate control in AF

Aspirin can be used in the acute manageme t of migraines but is contraindicated in children less than 16

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12
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High HCO3- the reversible equation tilts to one direction and so it causes there to be raised levels of HCO3-

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13
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The hernia is direct if it appears upon coughing while your finger is pressed down on the deep inguinal hernia

Additionally inguinal hernias present medial and above the pubic tubercle.
The most common between indirect or direct inguinal hernia is indirect inguinal hernia.

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14
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Left hemicolectomy with end colostony and mucus fistula ->

Hartman is often used in emergency scenarois of a perforation or infection. IT is useually used in the context of diverticulitis or colon cancer.

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15
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A

Subacromial impingement syndrome

The above presents with progressive pains worsend by abduction notably between 60-120 degrees

Ahill-sach lesion-> Compression fracture in the head of the humerus following impaction of the humeral head against the glenoid labrum arising from anterior shoulder disloaction or instability

Adhesive capsulitis -> Limited range of movement of the shoulder joint particularly affecting ecternal rotation and flexion of the shoulder. This patient has full range of motion making this less likely

Fracture of the head of the humerus is unlikkely as there is no trauma history.

Subscapularis tear -> This presents with weakness in abduction, which this patient is not experiencing.

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16
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Intrarticular steroid injections -> Adhesive capsulitis is initially treated wtih physiotherapy, the next line in management isintraarticular steroid therapy

Wduaion and assurace should have been offered at the time of diagnosis

Repeat physiotherapy could have been used if there was an improvement in symtptoms

Surgical release is only indicated after ther extensie therapy has been unsuccessful often after 3 monts

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17
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A

Bread cancer -> the features descibed sounds likel inflammtory breast cancer. This cancer mimics mastitis. The skin tetheringm pitting og the areola should be raising alrm bells of cancer.

Fat necrosis -> After breast trauma

Fibrocystic disease -> Bilateral breast changes that occur cyclically in pre menopausal women

Fibroadeonma -> Smooth well demarcated benign stromal tumour

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18
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A

Throat culture -> throat swab is the gold standard.

Antistreptolysin is less useful as it cannot determine previous vs current infection.

Rapid strptococcal antigent test is faster than throat swab but is less sensitive

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19
Q
A

Analgesia -> The patient has symptroms and it is causeing them diffficulties. The management of viral tonsillitis is supportive and this can be done with analgesia.

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20
Q

A 64-year-old woman is receiving CPR following a cardiac arrest. She has received three shocks from the defibrillator as her initial rhythm was ventricular fibrillation, but at her next rhythm check, organised, regular QRS patterns, each with an associated P wave are seen. Unfortunately, there is still no palpable pulse and chest compressions are restarted.

What is the next most appropriate step in her management?

A) Defibrillation
B) IV Adrenaline 1mg (1:1000)
C) IV Adrenaline 1 mg (1:1000) and IV Amiodarone 300 mg
D) IV Amiodarone 300mg
E) IV Alteplase

A

IV adrenaline 1mg (1:1000)

This is a description of pulseless electrical activity. This is not shockable and a dose of adrenaline needs to be administered as soon as this is recognised.

Amiodarone is only needed if she was still in a shockable rhythm and finished having her 3 shocks. As she has changed to a non-shockable rhythm this is no longer indicated.

The alteplase would be indicated if the arrest was due to a PE.

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21
Q

A 61-year-old man presents to his GP with ongoing itching, aching, and occasional bleeding of the varicose veins in his legs. His symptoms have been bothering him for the last 6 months despite getting regular exercise and keeping his legs elevated at night. He is referred to a vascular surgeon for specialist input.

What intervention are they most likely to offer?

A) Surgical Avulsion
B) Start Atorvastatin
C) Continue Conservative Management
D) Endothermal Radiofrequency Ablation
E) Surgical Vein Stripping

A

Endothermal Radiofrequency ablation

Conservativ emanaged cant be used again as this has been ineffective. additionally the symptoms are impacting patients life
Endotheram ablation is preferred as it is less invasive than traditiona; surgical approaches

Surgical avulsion is not used really
Statin is used to modify risk factos
Surgical stripping should be considered if other management options are not successful.

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22
Q

A 70-year-old man is attending the vascular outpatient clinic. He has a known abdominal aortic aneurysm (AAA) and the ultrasound performed today measures its diameter at 5.1 cm. Last year, the diameter was 3.9 cm. He has no symptoms at present.

What is the most appropriate management option?

A) Surgical Consideration
B) 3-Monthly Ultrasound
C) Discharge from Clinic
D) Annual Ultrasound
E) Ambulance Transfer to A&E

A

surgical consideration

this is because the patient had a AAA that increased in size > 1cm over a year and so needs to be cosidered for removal

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23
Q

A 49-year-old woman is receiving bystander CPR in the community after collapsing on the street. The paramedics arrive and confirm cardiac arrest. Upon attaching the defibrillation pads, the monitor reveals no evidence of cardiac electrical activity. Chest compressions are immediately restarted.
Which of the following is most appropriate at this point?

A) Administer Shock
B) IV Adrenaline 1 mg (1:1000) and IV Amiodarone 300mg
C) IV Adrenaline 1 mg (1:1000)
D) IV Amiodarone 300 mg
E) No Drugs Until 3 Shocks Administered

A

IV adrenaline 1mg (1:1000)

asystole, which is a non-shockable rhythm. The non-shockable arm of the ALS algorithm recommends administering IV Adrenaline 1 mg (1:1000) as soon as IV access is obtained and it should then be given every 2-3 minutes thereafter.

A: Defibrillation is recommended for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia).

B: Amiodarone is not administered for non-shockable rhythms.

D: IV Amiodarone 300 mg is used in shockable rhythms once three shocks have been administered.

E: Adrenaline should be administered as soon as possible once a non-shockable rhythm has been identified

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24
Q

A 22-year-old woman has been admitted to the gastroenterology ward after presenting with new-onset confusion and abdominal distension. An ultrasound of her abdomen reveals a craggy liver edge and small volume ascites. She has been feeling unwell for the past year but did not seek medical attention. She has no other medical history, however, she is currently receiving dialectical behavioural therapy for emotionally unstable personality disorder. Her LFTs are reported below.

Bili 62 3-17
ALT 254 < 40
AST 198 3-30
Alb 24 35-50

Given the most likely diagnosis, which other initial investigation should be requested?

A)Serum Caeruloplasmin
B)Serum Ferritin
C)Serum Alpha-1 Antitrypsin
D)MRI Brain
E)Genetic Testing

A

Seum Ceruloplasmin

Wilson’s disease is an autosomal recessive condition in which copper accumulates in various tissues across the body, in particular, the brain and liver. It results in** liver failure** at a young age along with various** neuropsychiatric manifestations** such as atremor and emotional lability (which may be masked by a psychiatric diagnosis). The most common causes of liver failure are alcoholic liver disease, non-alcoholic steatohepatitis and viral hepatitis, however, in young patients, other causes to consider include Wilson’s disease, hereditary haemochromatosis and alpha-1 antitrypsin deficiency. Wilson’s disease results from a deficiency in caeruloplasmin, the main copper transporting molecule in the body. This results in an increase in free copper which, subsequently, deposits in the tissues. Serum caeruloplasmin is a useful initial investigation as low levels would be suggestive of Wilson’s disease.

B:* Serum ferritin* would be useful in* hereditary haemochromatosis, which can presents with liver failure but is also likely to cause diabetes mellitus* (due to pancreatic deposits) and bronzed skin (due to skin deposits). It is less likely to cause neuropsychiatric symptoms.

C: Alpha-1 antitrypsin deficiency typically causes liver failure and* early-onset emphysema*.

D: MRI brain may be useful to visualise the copper deposits, however, it would not be the most appropriate initial investigation

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25
Q

Hesselbach’s triangle is an anatomical landmark that demarcates the areas of weakness in the abdominal wall through which abdominal contents could herniate.

Which one of the following statements is true with regards to hernias?

A) Indirect inguinal hernias occur medial to the inferior epigastric vessels
B) Inguinal hernias are typically found superior and lateral to the pubic tubercle
C) Direct inguinal hernias typically herniate along the medial border of the rectus abdominis muscle
D) The deep inguinal ring is located within Hesselbach’s triangle
E) Direct inguinal hernias occur medial to the inferior epigastric vessels

A

Direct inguinal hernias ccur medial to the inferior epigastric vessels

Hesselbach’striangle is an anatomical landmark that demarcates the potential areas of weakness in the anterior abdominal wall through which herniation can occur.

It has three borders:
● Medial: lateral border of the rectus abdominis
● Lateral: inferior epigastric vessels
● Inferior: inguinal ligament

In a direct inguinal hernia, the viscera herniates through Hesselbach’s triangle (medial to the inferior epigastric vessels). In an indirect inguinal hernia, the viscera passes through the deep inguinal ring and along the inguinal canal. It, therefore, arises lateral to the inferior epigastric vessels.

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26
Q

A 74-year-old female presented to hospital with increasing confusion. It is difficult to take a history or get a collateral. Bloods show the sodium is 98. There are no previous blood results available and there is no other potential source of the confusion identified. The patient has not had any seizures. On examination the patient is clinically dry. The patient had been started on a slow bag of 0.9% saline overnight.

How frequently should the sodiumvalue have been measured with VBGs?

A) 12 hourly VBGs
B) 2 hourly VBGs
C) 6 hourly VBGS
D) 24hrly VBGs
E) 30mins VBGs

A

2 hourly VBGs

There is a worry about raising the sodium too quickle and causing demylination, to prevent this there is a need to take 2 hourly VBFS intially. with a formal U+Es every 4-6 hours. This is so that if the rate is increasing to greatly then a dextrose infusion can be given.

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27
Q

A 72-year-old woman presents to a follow-up clinic after being notified that her faecal immunohistochemical test produced a positive result. Upon questioning, she has not noted any change in bowel habit but has been experiencing increasing fatigue over thelast 3 months. After undergoing further investigations, including a colonoscopy and a staging CT scan, she is diagnosed with a T3N1M0 colorectal adenocarcinoma of the ascending colon.

What is likely to be the most appropriate surgical approach to manage this case?

A) Extended Right Hemicolectomy
B) Hartmann’s Procedure
C) Anterior Resection
D) Abdomino-Perineal Resection
E) Right Hemicolectomy

A

Right Hemicolectomy

In Caecal or ascending cancers there is a need to do a right hemicolectomy

In transverse cancers there is a need to an exttended right hemicolectomy

An anterior resection is done i there is a cancer greater than 5 cm from the anal verge. The operation leaves the acus intact. This however requrires a temporary loop ileostomy as a way for the anastamosis to heal.

Hartman’s is doe in emergencied and is used to manage acute mamanegement of the sigmoid colon aka diverticular obstruction or bowel obstruction. Often results in a endcolostomy and a rectal stump.

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28
Q

A 74-year-old man is recovering on the elderly medicine ward after developing a severe community-acquired pneumonia. He had responded well to antibiotics, however, he is noted to have become very hyperglycaemic.

His investigation results are shown below.

Glucose 32 4-7
Ketone 0.1 < 0.6
pH 7.4 7.35-7.45
Na 155 135-145
Ur 7.2 2-7

Which of the following correctly describes the diagnosis and management plan?

A)HHS, Fixed-Rate Insulin Infusion
B) DKA, Variable-Rate Insulin Infusion
C) DKA, Fixed-Rate Insulin Infusion
D) HHS, IV Fluids
E) Isolated Hyperglycaemia, STAT Actrapid

A

HHS, IV fluids

Serum osmolality = 2(Na) + Ur + Glu

Diagnosis of HHS:

  • BM levels > 30
  • Serum osmolality >320 mOsmol/kg
  • Hypovolaemia
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29
Q

A 32-year-old woman is referred to the neurology clinic due to complaints of recurrent headaches. The headaches are particularly bad when going to bed and are associated with nausea. She has noticed some blurring of her vision but has not noted any manifestations typical of an aura.

Cranial nerve examination is normal, however, fundoscopy reveals swelling of the optic discs bilaterally with blurring of the margins.

An urgent CT head scan is requested which is reported as being normal. She undergoes a lumbar puncture which reveals no abnormalities other than an opening pressure of 31 cm H2O (5-25). She has a background of well-controlled systemic lupus erythematosus.

What is the most appropriate management option?

A) Topiramate
B) Acetazolamide
C) Propranolol
D) Verapamil
E) Lumbar-Peritoneal Shunt

A

Acetazolamide -> They are suffering from a raised ICP. This is the first line pharmacological management

The topiramate is the managment of an acute migraine
The propanalol is the long term management of this

The Lumbar peritoneal shunt would be used if the raised ICP is persisitant after medical managmeent

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30
Q

A 48-year-old woman presents to her GP surgery complaining of pain in her right eye that has been bothering her for 3 days. It has been associated with neck pain.

On examination, she has reduced visual acuity in her right eye but both pupils are equal and reactive to light. The patient complains of right eye pain when eye movements are tested. The rest of the neurological examination is unremarkable.

Upon examination of her neck, she complains of a tingling sensation in her fingers and a shooting sensation down her spine.

What is the name of this clinical sign?

A) Uhthoff’s Phenomenon
B) Kernig’s Sign
C) Brudzinski Sign
D) Lhermitte’s Sign
E) Babinski Sign

A

Lhermitte sign

So the pain in the eye with reduced visual acuity was suggestive of Multiple sclerosis.

This sign is seen that when the patient flexes the neck they get parathersiia in the upper limbs and trunk. Often associated with MS, cervical spondylosis, cervical spinal cord tumour.

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31
Q

A 45-year-old man has been under investigation by the respiratory medicine department for chronic shortness of breath. It began 6 months ago and has progressed steadily in that time. He does not complain of a cough,and he has never smoked. He has, however, become increasingly lethargic over this period and has developed vague joint pains. His CXR is shown below.

Given the most likely diagnosis, which of the following investigations may also be useful?

A) Serum Vitamin D
B) Serum Ca 19-9
C) Serum aFP
D) Serum LDH
E) Serum ACE

A

Serum ACE

This patient has sarcoidosis….
The non-pulmonary features of sarcoidodid include -> lethargy, joint pain, neuropathy and erythema nodosum and uveitis. ACE is a surrogate marker for granuloma burden in the body and is elvated in sarcoidosis patients. It is released bu macrophages in the granulomas

Vitamin D taht is measured are the precursor levels and as sarcoidosis is activates Vitamin D the precursor levels will not highlight a surplus of activated Vitamin D.

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32
Q

A 42-year-old woman is brought into A&E with severe shortness of breath and a fever. The fever began 2 days ago, however, the shortness of breath has become particularly bad only today. She has taken several puffs of her salbutamol inhaler, however, it hasnot given her any relief. She has a background of poorly controlled type II diabetes mellitus and asthma, and she has recently been in contact with someone who tested positive for COVID-19. Her admission observations and bloods are shown below:

A CXR and PCR confirm COVID-19 pneumonitis.

What is the most appropriate treatment option?

A) Supplementary oxygen therapy only
B) Dexamethasone only
C) Remdesivir only
D) Remdesivir and Dexamethasone
E) Non-invasive ventilation

A

Dexamethasone only

Remdesvir, Oxygen therapy and dexamethasone are all treatments of COVID 19 pneumonitis

HOWEVER Remdesevirs is contraindicated in Renal impairement <30 mL/min or if ALT > x5 upper limit normal

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33
Q

An 81-year-old woman has desaturated and become acutely short of breath on the elderly medicine ward. She is currently being treated with IV ciprofloxacin for urosepsis and was improving clinically until today. A CXR reveals no abnormalities so a CTPA is requested due to high clinical suspicion of a PE.

CTPA Report: pulmonary embolus in the left lower lobar branch of the pulmonary artery.

The patient has a background of CKD with a baseline eGFR of 18 mL/min. He is started on an IV heparin infusion.

Which of the following is required as part of the monitoring requirements for a heparin infusion?

A) INR
B) PT
C) APTT
D) APTT Ratio
E) Fibrinogen

A

APTT ratio

Unfractioned heparin has a very short half life compared to low molecular weight heparn so will be given as an infusion.

Heparins are anti thrombin III enhancers -> It leads to the ability for anti thrombin III binding and inhibitin factor 2 4 10 and 11. As these factors are involved in the intrinsic pathway the APTT is needed,

Anti Xa can be used but to help results to be followed earier often the APTT will be expressed as a ration as a way to better monitor the infusion of unfractioned heparin

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34
Q

A 42-year-old woman presents to the GP with a 6-month history of tiredness and 3 kg of unintentional weight loss.

On further questioning, she reveals an extensive family history for colorectal cancer with her father being diagnosed aged 50 years and her paternal grandmother being diagnosed aged 60 years.

She is sent for further investigation including colonoscopy and genetic testing. A mutation in a DNA mismatch repair gene (MLH1) was identified.

After colorectal cancer, which cancer is next most closely associated with the underlying diagnosis?

A) Endometrial Cancer
B) Thyroid Cancer
C) Gastric Cancer
D) Pancreatic Cancer
E) Breast Cancer

A

Endometrial cancer

the inheritable cancers include HNPCC and FAP.
If you have the gene for HNPCC there is a near garuntee that you will have a cancer… This is also the more common reason for inheritable cancers…

HNPCC is also heavily linked with enndometrial cancers.

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35
Q

A 16-year-old man presented to A&E with severe abdominal pain. He has vomited 3 times this morning butdenies dysuria or a change in bowel habit. On examination, he is hot and clammy, with diffuse abdominal tenderness, worse in the right lower abdomen. His observations and blood test results are shown below.

Which of the following is the most appropriate initial management option?

A) Ultrasound Scan
B) CT Scan
C) MRI Scan
D) IV Morphine
E) Bleep the registrar about taking the patient to theatre

A

Bleep the regitrar about taking patient to the theatre

the diagnosis is Acute appendicitis… this patient is acutely unwell considering his low BP and the relevant team needs to be notified first before starting the invetigations or management,,,,

In regards to this case a clinical diagnosis can be made

Ultrasound and CT scans can be used to aids diagnosis

Ultrasound can’t rule out diagnosis
CT scan is generally avoided in younger patients due to radiation worries.

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36
Q

A 58-year-old man presents to his GP with complaints of persistent lower abdominal discomfort. He has a background of hypertension, type 2 diabetes mellitus and constipation, and has a BMI of 28 kg/m2. On abdominal examination, he has mild tenderness on deep palpation of the left lower quadrant. His current observations are shown below.

He is referred for an outpatient CT abdomen and pelvis with contrast which reveals multiple outpouchings of the colonic wall in the distal sigmoid colon.

Which of the following is the most appropriate management option?

A) Diagnostic Laparoscopy
B) Reassure and Discharge
C) Analgesia and Antibiotic Therapy
D) Analgesia and Dietary Advice
E) Inpatient Colonoscopy

A

Analgesia and diettary advice

The CT rules out Cancer and there is no need for colonoscopy for this reason as there are also no features of a cancer

Therfore as the diverticular disease is not infected or bleeding this can be managed conservatively with analgesia and a high fibre diet

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37
Q

A 40-year-old former semi-professional footballer presents to the knee clinic. He had previously presented to his GP with bilateral knee pain. On examination, he was found to have bilateral crepitus and varus deformity. X-rays confirmed bilateral medial compartment osteoarthritis, worse on the left. He has undergone a course of intensive physiotherapy with good compliance but is still finding his symptoms unbearable.

After discussion, he elects to undergo a left medial compartment knee replacement.When should rehabilitation be offered?

A) No more than 12 hours after surgery
B) No more than 24 hours after surgery
C) Patient must wait 36 hours after surgery before mobilising
D) Patient must wait 72 hours after surgery before mobilising
E) Patient must wait one week after surgery before mobilising

A

no more than 24 hours post surg

Guidelines state Physio should be done on the day of the surgery and this rehabilitation includes mobilisation of people who have had knee or hip replacement as errl as advice on managing activities of daily living ot home exercises.

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38
Q

A 65-year-old man who has recently received his third cycle of chemotherapy for multiple myeloma has been brought in by ambulance after becoming very unwell at home. Upon arrival in resus, his blood pressure is 88/62 mm Hg with a heart rate of 112 bpm and a temperature of 39.8C. He is commenced on empirical antibiotics for presumed neutropenic sepsis and given 3 x 500 mL fluid boluses without a satisfactory improvement in his blood pressure. Aside from the multiple myeloma, he has no other past medical history.

Which of the following additional agents would be most appropriate in this patient?

A) Dobutamine
B) Metaraminol
C) Adrenaline
D) Milrinone
E) Epoprostenol

A

Metaraminol

Metaraminol is a alpjha 1 agonist and a vasoconstrictor like this is needed. Apparently the metaraminol is better and is great if the patient doesnt not have a central line.

Adrenaline would increase both the HR and the BP

Dobutamine -> improves the contractility of the heart.

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39
Q

This 45-year-old male presents for review 1-week after receiving his first round of chemotherapy for acute lymphoblastic leukaemia. His blood test results are shown below.

Which of the following additional investigations is most helpful in confirming the underlying diagnosis?
A) CT CAP
B) Serum Urate
C) ECG
D) Biopsy of Lymph Node
E) Venous Blood Gas

A

Serum Urate

This patient has Tumour lysis syndrome. This is associated with chemotherapy of leukaemia and lymphoma.

Electrolyte changes seen inc:
* Urate > 476 or 25% increase from baseline
* K+ > 6 or 25% increase from baseline
* PO4 >1.45 or 25% increase from baseline
* Ca < 1.75 or 25% increase from baseline

It can lead to AKI or suddent death as well as arrythmias

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40
Q

A 23-year-old man has presented to A&E with a 1-day history of intense right loin pain associated with vomiting. On examination, his abdomen is soft and nontender and the patient’s pain has improved with a PR diclofenac. He denies dysuria and is able to provide a urine sample. A subsequent non-contrast CT KUB reveals a 21 mm stone in the right renal pelvis. There is no hydronephrosis and his renal function is normal.

What is the most appropriate management option?

A) Extracorporeal Shock Wave Lithotripsy
B) Percutaneous Nephrostomy
C) Percutaneous Nephrolithotomy
D) JJ Stent Insertion
E) Ureteroscopic Lithotripsy

A

Percutaneous Nephrolithotripsy

This is a large renal calculus that will require direct removal,

Extracorporeal shockwave lithotripsy may be considered for stones smaller than 20mm

Percutaneous nephrostomy is an emergency decompress

JJ stents are inserted for obstructed ureters, stones tumours or retroperitoneal fobrosis

Ureteroscopic lithotripsy is primarily used for lower ureteric stones

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41
Q

A primigravida 31-year-old woman on the labour ward, who is at term, is complaining of severe pain during contractions. Her pregnancy has been uneventful so far. She requests an epidural as she cannot tolerate the pain any longer. The anaesthetist draws up a syringe of low-dose mix containing bupivacaine and fentanyl. She begins performing the procedure, inserting the needle into the L3/L4 space, but notices cerebrospinal fluid leaking through the catheter.

What is the main concern if the anaesthetist proceeds in injecting the full syringe?

A) Cardiac arrest
B) Direct trauma to spinal cord
C) Inadequate analgesia for the patient
D) Intravascular injection of medication
E) Severe headache on injection

A

Cardiac arrest

The leakage of fluid suggests that the needle is within the dura and therefore in the subarachnoid space.

If the dose was given in the subasrachnoid space then there is achance that the anaesthetic block will extend above the desired level above T4 and result in a a dangerous bradycardia and life thretening hypotension….

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42
Q

A 72-year-old man has presented to A&E after his wife noticed that he was drooling and had become weak on his right side. He has a CT head scan which reveals no intracranial haemorrhage,so he is given 300 mg Aspirin STAT. He has been reviewed by the speech and language therapist and his swallow has been deemed unsafe. He is noted to be very tachycardic and has an ECG which reveals atrial fibrillation with a rapid ventricular response (180 bpm).

Which of the following beta-blockers would be most appropriate to rate control this patient?

A) Propranolol
B) Metoprolol
C) Bisoprolol
D) Labetalol
E) Sotalol

A

Metoprolol

Bisoprolol is the first line in treating AF with rate control medications such as B eta blockers. BUTTT this persion is nbm and so there is a need to have a medications that can be delivered by a different route and that Beta blockers is metoprolol

Another possible option is IV atenolol

Other than that labetolol can come in an IV preparation but this is non-cardioselective and is more indicatedd for high blood pressure,

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43
Q

A 75-year-old man has been admitted to hospital after having a fall at home. He has sustained a Colles’ fracture of his right wrist and is being reviewed by the orthopaedic team. He has an ECG upon admission (shown below).

What is the most likely diagnosis?

A) Complete Heart Block
B) Paced Rhythm
C) Premature Ventricular Complex
D) Ventricular Escape Rhythm
E) Junctional Bradycardia

A

Premature Ventricular complex

Ventricular because it is wide. Premature becuase it is before the anticipated next heart beat.

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44
Q

A 47-year-old man visits his GP complaining of epigastric pain that is particularly bad after spicy meals and is exacerbated by lying down. He is diagnosed with gastro-oesophageal reflux disease and is prescribed omeprazole 20 mg OD.

Which of the following is associated with omeprazole use?

A) Pancreatic Cancer
B) Hypernatraemia
C) Fractures
D) Norovirus Infection
E) Somnolence

A

Fractures
Omeprazole is a PPI. There is an increased risk of osteoperosis with omeprazol and increased riisk of fractyres.

There is also an increased risk of C.Diff infection and hyponatraeima.

It can increase the risk of gastric cancer with long term use.

Nizatidine is an alternative to treat gord.

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45
Q

A 34-year-old woman is referred to the outpatient gastroenterology clinic after her epigastric pain, thought to be gastro-oesophageal reflux, failed to improve with a trial of proton-pump inhibitors. A full blood count reveals microcytic anaemia, so an
OGD is arranged (report below).

OGD: normal appearance of proximal oesophagus, extensive ulceration seen across loweroesophagus, stomach and proximal duodenum.

Given the most likely diagnosis, which of the following investigations would be most appropriate?

A) Urease Breath Test
B) Serum Gastrin
C) Oesophageal Manometry
D) Haematinics
E) CT Abdomen and Pelvis

A

Serum Gastrin -> The extensive ulceration with multiple locations is suggestive of zollinger ellison syndrome. This conditions results in an excess production of gastrin and produces gastric acid.

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46
Q

A 44-year-old man underwent an endoscopy for persistent epigastric pain and dyspepsia that was refractory to treatment with omeprazole. A biopsy from the lower oesophagus was reported by the histopathologist as being consistent with Barrett’s oesophagus.

Which of the following types of epitheliawould you expect to see in the affected area?

A) Keratinising Squamous
B) Non-Keratinising Squamous
C) Ciliated Columnar
D) Non-Ciliated Columnar
E) Transitional

A

Non-ciliated Columnar

Barrets oesophagus is the metaplasia of the oesophageal cells to the stomach cells. These cells are columnar and non-cilated.

Ciliated columnar cells are found in airways

Keratinisisng Squamous is found in the skin

Non-keratinising squamous is found in the oesophagus

Transitional is found in the urinary tract.

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47
Q

A 46-year-old female presents to her GP with intermittent palpitations and sweating. She has noticed she has lost weight recently and that she has developed a tremor in her hands. Otherwise, she is usually fit and well. She smokes 3 packs of cigarettes a week and drinks minimal alcohol.

Her main concern is that her neck feels larger, and given hermother and sister have hyperthyroidism, she is keen to have some thyroid function tests. She explains her sister has been visiting an endocrinologist as she has been having issues with her eyes.

Which of the following is the strongest prognostic factor for the development of Graves’ eye disease?

A) Family History
B) Smoking
C) TSH Receptor Antibody Titre
D) Radioactive Iodine Treatment
E) Single Nucleotide Polymorphisms

A

Smoking -> This is the risk factor most liked with the progression and the severity of Graves disase.

TSH receptor antibody levels -> is somewhat useful in checking to response to treatment and predictiong disease course but not eye disease

Family history, radioiodine and some single nucleotide polymorphisms are all associated with higher risk of thyroid eye disease by far the biggest risk factor is smoking.

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48
Q

A 66-year-old female is admitted to hospital with fever, a productive cough and chest discomfort. On examination, she has well perfused peripheries with a normal, regular pulse. The JVP is not visible. On chest auscultation, there are crepitations over theright lung base. There is also a dull percussion note over this area andincreased vocal resonance. There is no pitting oedema of the sacrum or lower limbs. Her past medical history includes type 2 diabetes mellitus, hypertension, ischaemic heart disease, heart failure, and hypothyroidism. Her regular medications are levothyroxine, metformin, gliclazide, ramipril, indapamide, bisoprolol and isosorbide mononitrate. Her initial blood tests show raised inflammatory markers, as well as a serum sodium concentration of 120 mmol/L. Therefore, a hyponatraemia screen is completed (results below).

What is the most likely diagnosis?

A) Diabetes Insipidus
B) Adrenal Insufficiency
C) SIADH
D) Decompensated Heart Failure
E) Hypothyroidism

A

SIADH

Urine osmlality > 100
Urinary sodium > 20

there is excess SIADH produced….
with the low sodium in the serum there shoud be an even lower concentration of urine as it would be very diluted.

Diabetes insipidus is urine osmolality would be innapproapriately low cpmpared to the raised plasma osmolality

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49
Q

A 49-year-old man is brought in by ambulance to the Emergency Department after collapsing at work. He has a past medical history of hypertension and smokes 5-10 cigarettes per day. About 3 hours ago, he developed sudden-onset right-sided neck pain after which he lost vision in his right eye and lost consciousness. His vision has since returned to normal,but the neck pain has persisted. His eyelid is drooping on the right side.

Which other signs would you expect to find on examination?

A) Right facial anhidrosis and right sided miosis
B) Left facial anhidrosis and left sided miosis
C) Right facial anhidrosis and left sided miosis
D) Left facial anhidrosis and right sided miosis
E) Bilateral anhidrosis with right sided miosis

A

Right sided facial anhidrosis and righ sided miosis

The description is of sudden onset neck pain is suggestive of carotid dissection.

With cases of dissection the symptoms of horner syndrtome present on the ipsilateral side.

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50
Q

A 68-year-old woman presents to her GP with ongoing left-sided shoulder and arm pain. It has been getting progressively worse over the last 6 months, and has recently noticed that parts of her left arm feel numb to touch. She has a past medical history of hypothyroidism, right total knee replacement, and is an ex-smoker.On examination, power is normal in both arms, but she has lost fine touch sensation in the medial aspect of her left arm. The range of motion in her left shoulder is limited by pain in all directions. She is also noted to have left-sided ptosis.

What is the most appropriate initial investigation?

A) MRI Spine
B) Chest X-Ray
C) Ultrasound left shoulder
D) MRI Brain
E) Nerve conduction studies

A

Chest X-ray

Lateralising shoulder girl pain associated with upper limb neurological symptoms should raise suspicion of potential brachial plexus injury.

the patient also complains of horners syndrome togethere this is could be explained with a pancoast tumour. this would meand that CXR would be the best investigation

The ultrasound of the shoulder could be used to investigate a rotator cuff injury.

A: An MRI spine would be useful for investigating potential radiculopathy secondary to cervical vertebra or disc disease

D: MRI brain would be useful in delineating parenchymal brain abnormalities like multiple sclerosis. It would not be the most appropriate initial investigation.

E: Nerve conduction studies may be carried out to diagnose diseases that affect peripheral nerves (e.g. motor neurone disease).

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51
Q

A 24-year-old man presents to the Emergency Department with severe chest pain and breathlessness that started 3 hours ago whilst he was watching TV. He is otherwise fit and well with no past medical history. On examination the patient is visibly in pain. On auscultation there are clear lung fields and his trachea is central.His observations are as follows:

Which of the following investigations is most likely to reveal the most likely diagnosis?

A)Chest X-Ray
B)Electrocardiogram
C)CT Pulmonary Angiogram
D)CT Aortic Angiogram
E)Ultrasound Chest

A

Chest X-ray

For a patient of this age with no other PE risk factors a spontaneous Pneumothorax is the most likely cause of this patients symptoms and the best way to investigate that is with the use of Chest X-ray.

PE is unlikely in this age group.

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52
Q

A 59-year-old man presents to A&E with a 6-week history of breathlessness. He has completed a course of antibiotics prescribed by his GP, yet he is still coughing up some green phlegm. He has come to hospital today as he has coughed up some blood.His past medical history includes COPD and hypertension, and he stopped smoking 10 years ago. On examination, the patient has visibly increased work of breathing and with right basal crackles and a monophonic wheeze. Routine bloods are sent,and a chest X-ray has been ordered.

What is the most likely diagnosis?

A) Infective Exacerbation of COPD
B) Adenocarcinoma
C) Pulmonary Tuberculosis
D) Lung Abscess
E) Squamous Cell Carcinoma

A

Squamous cell carcinoma

Patient has haemoptysis, dyspnoea and poorly resolcving pneumonia secondary to bronchial obstruction which is suggested by monophasic wheeze.

85% lunc cancers are non-small cell lung cancers of which 40% are squamouce cell carcinoma. which is more common in smokers. Another 40 % of the 85% are adenocarcinoma and these are more associated woth non-smokers. The remaining 20 % are Large cell carcinoma, carcinoid tumours and bronchoalveolar carcinomas

NSCLC
* 40 % Smokers -> SCC
* 40 % Non-smokers -> Adenocarcinoma
* 20 % -> large cell carcinoma/ carcinoid / Bronchoalveolar cell carcinoma

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53
Q

A 56-year-old man presents to A&E with acute lower abdominal pain. He was found to have large bowel obstruction secondary to a tumour in his sigmoid colon and was treated with an emergency Hartmann’s procedure. This left him with an end colostomy. He has been recovering well since the operation and discharge planning is underway. During a routine review, it is noted that his stoma output over the last four daysis as follows: 800 mL, 1100 mL, 1600 mL, 1300 mL (today). His bloods are all within normal range and the patient feels well.

Which of the following is the most appropriate management option?

A) Routine Stoma Nurse Follow-Up
B) Restrict Fluid Intake to < 500 mL/day
C) Abdominal X-Ray
D) Loperamide and Omeprazole
E) Oral Rehydration Solution

A

Loperamide and omeprazole

Complications of stoma:
* Ileus
* Necrosis
* High stoma output defined as >1L in 24 hours for 3 or more days

This can lead to the development of Electrolyte imbalances. Therefore the first step to manage this is to give loperamide and a PPI which decreases stomach ascid.

Fluid restriction is used along side the above

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54
Q

A 66-year-old man presents to his GP with concerns about blood in his stools. Over the last 2 months, he has intermittently noted fresh red blood in the toilet pan, associated with some perianal itching. He has not noticed any change in stool consistency or his body weight. On examination, he has a 1 cm blue-ish swelling that protrudes from the anal canal. It is easily reducible. The patient adds that he has noticed the swelling before but that it seems to go away once he is off the toilet.

Which of the following is the most appropriate management option?

A) Topical Diltiazem
B) Surgical Haemorrhoidectomy
C) Rubber Band Ligation
D) Haemorrhoidal Artery Ligation
E) Sclerotherapy

Describe the management of Haemorrhoids

A

Rubber band ligation therapy

This is describing a grade 2 haemorrhoid.

Diltiazam is used in anal fissure

Steroids could be used to ease itching.

Surgical removal would be considered in stage 4 disease and if other methods fail.
Artery ligation is the third line measure after 1) rubber band ligation and 2) sclerotherapy

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55
Q

A 40-year-old woman has undergone a total hysterectomy for dysfunctional uterine bleeding secondary to uterine fibroids. The operation was uneventful,and she is recovering well. On postoperative day 2, she develops a temperature of 38.1 C. A full septic screen is performed and a chest X-ray reveals loss of lung volume in the right lower zone.

How could this post operative complication have been prevented?

A) Prophylactic Co-Amoxiclav
B) High Flow Oxygen Therapy
C) Incentive Spirometry
D) Prophylactic Tinzaparin
E) Delayed Extubation

A

Incentive spirometry

This is atelectasis. This can be avoided with breathing excercises which would be possible with spirometry

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56
Q

A 20-year-old woman has presented to A&E after developing an exquisitely tender spot on her lower back. She works as a data analyst and has found it difficult to work because the pain is unbearable when she sits down at work. She has a background of type 1diabetes mellitus that is managed with a basal bolus insulin regimen.

On examination, there is a single 2 x 3 cm tender, fluctuant mass to the right of the natal cleft. The mass has an opening that expresses a purulent substance upon compression. What is the most likely diagnosis?

A) Perianal Abscess
B) Anorectal Fistula
C) Pilonidal Sinus
D) Sacral Osteomyelitis
E) Hidradenitis Suppurativa

A

Piloniddal sinus

A pilonidal sinus is a chronic inflammatory condition caused by an ‘ingrown hair’ usually in the natal cleft of the buttocks. The insertion of hair into the skin initiates an inflammatory response which leads to the formation of a sinus tract deep into the tissue. This will usually present as a painful swelling with purulent, foul-smelling discharge. It affects younger men and women and risk factors include hirsutism, metabolic conditions (e.g. diabetes mellitus) and a sedentary lifestyle. It isusually treated surgically with excision of the tract.

A: A perianal abscess will present as a red, painful, fluctuant mass in the perianal region. Its overlying skin will be intact, unlike the pilonidal sinus described that is discharging a purulent substance.

B: An anorectal fistula will similarly present with a mass draining purulent discharge, however, it is usually found around the anus.Furthermore, there is likely to be a background of an underlying inflammatory condition (e.g. Crohn’s disease).

D: Sacral osteomyelitis would not cause a mass on the surface.

E: Hidradenitis suppurativa is a chronic inflammatory condition characterised by the development of recurrent abscesses in the skin. The abscesses tend to arise in areas with lots of hair (e.g. groin, axillae)

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57
Q

A 20-year-old netball player presents to A&E after sustaining an injury during a netball match. She reports pivoting on her right leg and feeling a “pop” in her knee followed by a deep, intense pain that has been making it difficult for her to bear weight.The knee is difficult to examine due to the extent of the swelling. Her admission X-ray shows a Segond fracture.

Which of the following is the most appropriate definitive management option?

A) Meniscal Repair
B) Anterior Cruciate Ligament Reconstruction
C) Posterior Cruciate Ligament Reconstruction
D) Intra-articular Steroid Injection
E) Open Reduction and Internal Fixation of the Tibial Plateau

A

Anteroir Cruciate ligament injury

Segmond fracture is a avulsion fracture of the proximal lateral tibia and is associated with ACL injuries.

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58
Q

An 86-year-old Afro-Caribbean woman with severe peripheral vascular disease is admitted to the vascular surgery ward with extensive gangrene of the right lower limb. She is a bedbound nursing home resident and has a past surgical history of a below knee amputation of the left leg 9 years ago. On examination, the entire right foot is black, dry and shrunken, with a clear demarcation line between black and pink tissue just above the level of the ankle.

What is the most appropriate management option in this scenario?

A) Surgical Debridement
B) Revascularisation Surgery
C) Below Knee (trans-tibial) Amputation
D) Through-the-Knee Amputation (Knee Disarticulation)
E) Above Knee (trans-femoral) Amputation

A

Above knee amputation

Honestly the most BS qs… Essentially they are not mobalising so there is no point for below the knee amputation as this person does not need the below knee to help with prosthesis.

Revascuralisation would be useful if the tissue was viable with gangrene the tissue is dead and so it cannot be reversed.

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59
Q

Describe the different definitions and stages of AKI using the RIFLE stage… Urine output and GFR (Creatinine and GFR)

A
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60
Q

A 74-year-old man presents to his GP with a 2-day history of dysuria. He also tells the GP that for the last 2 years he has been getting up to pass urine up to 4 times every night. He also goesmuch more frequently during the day. When he passes urine, the stream is very slow and there is dribbling at the end. He says that these symptoms do not bother him except for dysuria. The results of his urine dipstick test are shown below.

This patient has had 3 similar episodes in the last 6 months.

Alongside antibiotics, what is the most appropriate management option?

A) Prescribe Tamsulosin
B) Prescribe Phenoxybenzamine
C) Prescribe Finasteride
D) Refer to Urology
E) Watchful Waiting

A

Refer to urology

Benign prostatic hyperplasia (BPH) is extremely common. This patient has presented with typical symptoms of BPH
-frequency, nocturia, terminal dribbling and poor stream.

The dysuria and urine dipstick testing positive for nitrites and leucocytes suggest that this patient currently also has a urinary tract infection for which he requires antibiotics. He has had three other urinary tract infections in the last 6 months. These are most likely a complication of his BPH.

    • BPH that has led to complications is an indication for referral to urology for surgery*.

Surgery can be both minimally invasive or open which will depend on the size of the prostate alongside clinical factors.

A: Tamsulosin is an alpha-blocker that is used first-line in the management of uncomplicated BPH. It induces smooth muscle relaxation in the prostate and bladder neck.

B: Phenoxybenzamine is an alpha-blocker that is used in the treatment of phaeochromocytomas, not BPH.

C: Finasteride is a 5-alpha-reductase inhibitor that is also used first-line in the management of uncomplicated BPH. It inhibits the synthesis of dihydrotestosterone which, in turn, reduces prostate volume

E: Watchful waiting is only appropriate for patients who present with mild symptoms and whose symptoms are not bothersome.

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61
Q

A mother brings her 10-day-old son to the GP. She is worried about something she saw around the baby’s testicles when giving him a bath. The GP examines the baby and reassures the mother by saying it should resolve on its own within the next few months, but that she will refer the baby to a specialist at one year of age if it has not resolved by then.

What is the most likely diagnosis?

A) Epididymal Cyst
B) Haematocele
C) Varicocele
D) Hydrocele
E) Inguinal Hernia

A

Hydrocele

They are common in newborn boys, especially if preterm. The majority resolve on their own within the first year of life.

If the hydrocele has not resolved on its ownby the time the baby is one year old, referral to a paediatric surgeon should be considered.

Persistent hydroceles may require surgery (usually laparoscopic) at 12-24 months of age.

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62
Q

A 64-year-old woman has been brought into the anaesthetic room before her elective knee replacement. The anaesthetist induces the patient with propofol and also administers rocuronium. The patient is then maintained on sevoflurane. Shortly after the administration of these medications, the anaesthetic monitor shows the following values.

They also notice significant contracture of the patient’s masseter muscle.

What should the anaesthetist do next?

A) Give Dantrolene
B) Give Sugammadex
C) Active Cooling of Patient
D) Permissive Hypoventilation
E) Give IV Fluids

A

Dantrolene

This is malignant hyperthermia….
This is a a congential problem where when given anesthetic agents they react with a really high temperature. This is treated with dantrolene

This would also be managed with hyperventialation

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63
Q

An 82-year-old man has been recovering on the elderly medicine ward after being admitted with sepsis secondary to a chest infection. His stool chart reveals that he has not opened his bowels in 4 days. The medications on his inpatient drug chart are listed below.

Omeprazole 40 mg OD
Metformin 1 g BD
Ondansetron 4 mg PRN
Magnesium Aspartate 1 Sachet OD
Co-Amoxiclav 500/125 mg TDS

Which of these options is most likely to contribute to constipation?

A) Omeprazole
B) Metformin
C) Ondansetron
D) Magnesium Aspartate
E) Co-Amoxiclav

A

Ondansetron

Constiapation is a common cause of delerium in patients.

It is important to be able to identify the drug causes of constiaption.

Common drugs to cause constipation
* codiene
* CCB
* Iron supplelemts
* Ondansetron

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64
Q

A 52-year-old female is being treated for left leg cellulitis with IV antibiotics in hospital. On her blood test results, a low sodium is identified. She undergoes a hyponatraemia screen, upon which she is diagnosed with SIADH. Her past medical history includes HTN, T2DM, hypercholesterolaemia, GORD, and epilepsy. Her regular medications are metformin, ramipril, atorvastatin, carbamazepine and omeprazole.

What is the best initial management plan?

A)Prescribe Furosemide
B)Prescribe Urea
C)Prescribe Demeclocycline
D)Prescribe Desmopressin
E)Consider Alternatives to Carbamazepine and Omeprazole

A

Consider alternatives to carbamazepine and omeprazole

SIADH can be precipitated by drugs such as
* SSRI
* TCAs
* Anti epileptics (carbamazepine)
* PPIs

Therefore the first step in management should be to stop these medications as a way to stop the precipatiatng factors.

Then fluid restrict
Then Demeclocycline

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65
Q

A 31-year-old woman presents to ED with a left-sided headache accompanied by loss of vision in her right eye and strange sensations spreading up her right arm. She has no past medical history. She was brought in by ambulance as her family thought that she was having a stroke.Her visual and sensory symptoms have spontaneously resolved, but her headache persists.

She undergoes a CT head scan which is reported as normal. What is the most appropriate treatment of her ongoing headache?

A) Codeine 30 mg PO
B) Diclofenac 150 mg PR
C) Propranolol 80 mg PO
D) Aspirin 900mg PO
E) Morphine Oral Solution 5 mg

A

Aspirin 900mg PO

The patient has presented with a unilateral severe headache accompanied by a preceding visual and sensory aura, in keeping with migraine. Patients with migraines should be advised to keep a headache diary to identify possible triggers. Acutely, migraines can be treated with high-dose aspirin (900 mg), paracetamol or ibuprofen in the first instance. Triptans (e.g. sumatriptan) may also be used. Other classes of medications, such as antiemetics, may be used to provide symptomatic relief. Patients who experience two or more headaches per month should be considered for migraine prophylaxis (amitriptyline, topiramate or propranolol).

A: Codeine does not tend to be effective in migraines.

B: PR Diclofenac is highly effective at relieving pain caused by ureteric calculi.

C: Propranolol is used for migraine prophylaxis.

E: Morphine is a strong opioid that is effective in managing various types of pain, however, opioids are generally not thought to be particularly effective in migraines.

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66
Q

An 89-year-old woman has presented to A&E with abdominal pain. She is a nursing home resident with a background of type 2 diabetes mellitus, chronic kidney disease, previous NSTEMI and severe Alzheimer’s disease. She has a community DNACPR in place. Her carers have said that she has vomited twice over the last 24 hours and has been off her foot for 1 week. She also developed a high fever this morning. On examination, the patient is visibly tender in the right upper quadrant and is Murphy’s sign positive. A CT scan reveals a thick-walled gallbladder with some pericholecystic fluid. An obstructing stone is identified within the common bile duct. Her observations are shown below.

She is started on IV fluids, IV ceftriaxone and metronidazole, and paracetamol.
Which of the following is the most appropriate management option?

A)Percutaneous Cholecystostomy
B)Emergency Laparoscopic Cholecystectomy
C)ERCP
D)Elective Laparoscopic Cholecystectomy Once Stable
E)Refer to Intensive Care Unit

A

Percutaneous cholecystomy

This patient has ascending cholangitis. the main aim is to decompress the biliary system.

This can be done with all of the above management except the referral, but the least invasive method would be with percutaneous cholecystomy therefore making it the right answer.

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67
Q

A 50-year-old woman presents to the emergency department with severe epigastric pain radiating to the back. She is known to the community alcohol and drug services and has previously presented to ED intoxicated.

Which of the following investigations is most useful in predicting the severity of this patient’s pancreatitis?

A) Serum Lipase
B) Serum Albumin
C) Serum Amylase
D) Abdominal Ultrasound
E) Alanine Aminotransferase

A

Serum Albumin

Low albumin is associated with multiorgan failure…

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68
Q

A 56-year-old man presents to his GP with rectal bleeding that has persisted over the last 3 months. He is examined using a proctoscope and right posterior internal haemorrhoids are visualised. They are painless and can be manually reduced.

How would these haemorrhoids be classified?

A) Grade I
B) Grade II
C) Grade III
D) Grade IV
E) Grade V

A

Grade III

Grade I: does not prolapse

Grade II: spontaneously reduces

Grade III: can be reduced manually

Grade IV: irreducible

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69
Q

A 55-year-old man is seen in clinic with difficulty walking. His past surgical history includes a left total hip replacement.On examination, there is a well healed surgical scar on the anterolateral left hip. Whilst standing upright, the patient is asked to stand on his left leg alone and his hip tilts toward his right side.

Which of the following abnormalities would explain the examination findings?

A) Wasting of left gluteus medius
B) Inferior gluteal nerve injury
C) Superior gluteal nerve injury
D) Wasting of left gluteus maximus
E) Wasting of left gluteus minimus

A

Superior gluteal nerve injury

The above nerve innervates the hup abductors, gluteus medius and minimus, this means that injury to this nerve will cause weak hip abduction that presents in the trendelenburg test.

This is a common complication of the Total hip replacement surgery.

The inferior gluteal nerve which is also at risk in a total hip replacement if the scar was seen posteriorly would present with weakness on hip extension.

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70
Q

Which of the following is most likely to be injured with the use of a plaster cast that has been applied for a tibial fracture?

A) Tibial Nerve
B) Common Peroneal Nerve
C) Femoral Nerve
D) Lateral Cutaneous Nerve
E) Sciatic Nerve

A

Common peroneal nerve

Common peroneal nerve damage is usually caused by compression of the fibular head as the nerve passes along its fibular neck. Injury leads to foot drop. The common peroneal nerve is a terminal division of the sciatic nerve which divides above the knee joint at the popliteal fossa into the tibial and common peroneal nerves.

A: The tibial nerve travels down the posterior compartment of the leg into the foot. It is deep and well protected and thus not commonly injured.

C: The femoral nerve supplies the anterior compartment of the thigh and is commonly injured in hip and pelvic fractures. It is responsible for knee extension and provides sensory function to the anterior and medial aspect of the thigh.

D: Lateral cutaneous nerve injuries occur due to compression near the ASIS, leading to paraesthesia and pain at the lateral aspect of the thigh (meralgia paraesthetica).

E: The sciatic nerve divides into the tibial nerve and the common peroneal nerve. ALSO PRESENTS WITH FOOT DROP

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71
Q

A 48-year-old man presents to hospital with a red, hot swollen knee. He explains that this happened quite suddenly overnight and denies receiving any trauma to the area. The knee is extremely painful upon active and passive movement but he otherwise feels well. He has no significant past medical history.

He has an X-ray of the affected knee which reveals subchondral cysts, joint degeneration and calcification of the medial meniscus.

What is the most likely diagnosis?

A) Osteoarthritis
B) Pseudogout
C) Psoriatic Arthritis
D) Reactive Arthritis
E) Gout

A

Pseudogout

the calcification of the cartilage with the acute history is suggestive of pseudogout.

Acute flares of pseudogout are usually managed similarly to gout -with NSAIDs and colchicine.

A: Osteoarthritis presents with chronic joint pain and radiographic features including loss of joint space, osteophytes, subchondral cysts and subchondral sclerosis.

C: Psoriatic arthritis refers to the development of arthritis in patients with psoriasis. It can take five main forms: symmetrical polyarthritis, asymmetrical oligoarthritis, distal interphalangeal joint disease, arthritis mutilans and psoriatic spondylopathy.

D: Reactive arthritis is a sterile arthritis that arises several weeks after an infection (e.g. usually gastrointestinal or genitourinary). It classically manifests with a triad of arthritis, urethritis and uveitis.

E: Gout presents similarly to pseudogout, with acute-onset joint pain. It has a predilection for affecting the first metatarsophalangeal joint and is caused by the deposition of monosodium urate crystals. It does not cause chondrocalcinosis

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72
Q

A 46-year-old woman has a background of end-stage renal failure secondary to poorly controlledtype 1 diabetes mellitus. She undergoes a simultaneous pancreas and kidney transplant which was uneventful. She returns to hospital 2 weeks later complaining of reduced urine output and feeling generally unwell. Graft rejection is suspected.

What type of rejection is this most likely to be?

A) Hyperacute
B) Accelerated Acute
C) Acute
D) Chronic
E) Acute-on-Chronic

A

Acute

Hyperacute
● Within seconds of clamp release
● Mediated by preformed antibodies
● Results in immediate loss of graft

Accelerate Acute
● First few days
● Cellular and antibody mediators

Acute
● Days to weeks
● Cell mediated –usually lymphocytes

Chronic
● Most common
● Graft atrophy and atherosclerosis
● Fibrosis is a very late event

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73
Q

A 77-year-old man has been brought to A&E after becoming drowsy at his residential home. On examination, he has a GCS of 10 and engages poorly. He has a background of hypertension and hypercholesterolaemia. His vital signs and ECG findings are shown below.

ECG: widespread T wave inversion with ST elevation in leads I, II, V3, V4, V5 and V6.

What is the most appropriate initial management option?

A) CT Head Scan
B) Administer Aspirin 300 mg and Clopidogrel 300 mg immediately
C) Administer Aspirin 300 mg and Clopidogrel 300 mg once troponin result has returned
D) Commence IV unfractionated heparin infusion and arrange PCI
E) Administer IV Alteplase

A

CT scan of head

Raised ICP can present with ECG changes that mimic STEMI.

Patients who are driwsy and have ECG changes should have a CT head

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74
Q

A 55-year-old man is undergoing inpatient investigations after presenting with a severe bout of haematemesis. He had an OGD which revealed bleeding varices, which have since been banded, and extensive gastric ulceration. He also has evidence of chronic liver disease with a background of alcohol excess. During his inpatient admission, he is noted to have developed a swollen, tender right calf. A doppler ultrasound scan confirms a large thrombuswithin the right femoral vein. His blood test results are shown below.

What is the most appropriate management option?

A) 4500 U Tinzaparin
B) 10500 U Tinzaparin
C) IV Unfractionated Heparin Infusion
D) 15 mg Rivaroxaban BD
E) IVC Filte

A

** IVC filter**

This patient has a DVT and just had a major oesophageal variceal bleed meaning the risk of putting then in anticoags is too great therefore in an attempt to reduce the risk of the clot spreading into the lungs and IVC filter can be used.

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75
Q

A 52-year-old woman presented to A&E with a 1-month history of diarrhoea and rectal bleeding. The blood is bright red and mixed in with the stools. She also experiences intermittent abdominal pain. A PR examination reveals tenderness upon insertion and traces of blood on withdrawal. Her admission blood test results are shown below.

She has been prescribed tinzaparin 4500 units SC OD by the admitting doctor and her first dose has been given.

Which of the following is the most appropriate action to take?

A) Remove tinzaparin from drug chart only
B) Remove tinzaparin from the drug chart andprescribe vitamin K
C) Remove tinzaparin from the drug chart and prescribe protamine
D) Remove tinzaparin from the drug chart and prescribe prothrombinase complex concentrate
E) No action needed

A

No Action Needed

This patient probably has a diagnosis of IBD. there is a second peak incidence at around 60 years old.

However as IBD is a pro inflammatory condition and is associated with a dehydrated state because of blood loss and diarrhoea there is a larger thrombotic risk, when confounded with the being ADMITTED into hospital, meaning they do need prophylaxis.

Therefore patients who have symptomatic IBD in hospital and are being admitted do need VTE prophylaxis.

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76
Q

A 55-year-old man has presented to the GP with ongoing symptoms of heartburn despite trialling omeprazole 40 mg OD for the past 3 months. He has undergone H. pyloritesting which was negative.

What is the most appropriate next step in his management?

A) Lansoprazole 30 mg OD
B) Nizatidine 150 mg BD
C) Ranitidine 150 mg BD
D) POEM
E) Nissen Fundoplication

A

Nizatidine

GORD that is not treated with PPI should be trialled on a histamine antagonist -> Nizatidine

Peroal endocscopic myotomy -> Treatment for Achalasia

Nissen Fundoplications -> Surgical treatment of GORD where medical treatment is not effective

RANITDIINE is generally avoided because of carcinogen worries.

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77
Q

A 77-year-old man has been admitted to the stroke unit after developing sudden-onset right sided arm and facial weakness. His CT scan revealed no abnormalities and as he presented promptly after symptom onset, he was thrombolysed successfully. He has also been started on aspirin 300 mg OD. What is the mechanism of action of aspirin?

A) Leukotriene Receptor Antagonist
B) P2Y12 Receptor Antagonist
C) Phosphodiesterase Inhibitor
D) Endothelin Receptor Antagonist
E) Irreversible COX Inhibitor

A

Irreversible COX inhibitor

B -> Clopigogrel

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78
Q

A 56-year-old man is admitted to the general surgical ward after presenting with sudden onset abdominal pain. Acute pancreatitis is suspected and an ABG is performed to calculate his Glasgow (results below). He has a past medical history of recurrent venous ulcers on his lower limbs, type II diabetes mellitus and morbid obesity.

Which of the following is likely to have given rise to his ABG abnormality?

A) Poorly Controlled Diabetes Mellitus
B) Metformin Use
C) Obesity
D) Angiodysplasia
E) Parkes Weber Syndrome

A

Obesity

Obesity Hypoventilation syndrome -> They develop high CO2 concentration because they are less able to breathe fast or deeply enough to clear the CO2… This is associated with Obstructive sleep apnoea

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79
Q

An 81-year-old man is being reviewed in the respiratory clinic after undergoing a high-resolution CT scan to investigate his chronic shortness of breath. The CT scan reveals widespread ground glass opacities in keeping with a diagnosis of interstitial lung disease.

He explains that he spent the majority of his younger years as a shipbuilder and many of his colleagues had developed similar health problems.

What is the most likely diagnosis?

A) Pneumoconiosis
B) Mesothelioma
C) Extrinsic Allergic Alveolitis
D) Hypersensitivity Pneumonitis
E) Bronchiectasis

A

Pneumoconiosis

This is a term used to describe a group of interstitial lung diseases that occurs secondary to the inhalation of iatrogenic allegens such as : Aesbestosis, coal dust or silica.

This particular presentation is suggestive of asbestosis.

Extrinsic allergic alveolitis -> would have exposure to organic allergens such as moulds

Hypersensitivity pneumonitis is another term used for extrinsic allergic alveolitis

Bronchiectasis is irreversible dilatation of the airways usually secondary to infections or inflammations.

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80
Q

A 63-year-old man has been referred to the respiratory clinic with a 2-year history of worsening shortness of breath. More recently, he has developed a persistent dry cough. He explains that he has never smoked and has tried his best to remain active by regularly playing golf, however, he is now unable to do so because of his breathlessness.

A high-resolution CT scan reveals extensive reticulonodular changes suggestive of idiopathic pulmonary fibrosis.

Which of the following medications is likely to confer some prognostic benefit to this patient?

A) Carbocisteine
B) Pirfenidone
C) Azithromycin
D) Beclomethasone
E) Prednisolone

A

Pirfenidone

This is a antifibrotic medication that reduces the proliferation of fibroblasts. In turn this reduces the progression of Pulmonary fibrosis.

Carbocisteine -> Mucolytic and reduces the viscous secerestions and provides symptmatic relief in COPD, Cystic fibrosis or bronchiectasis

Azithromycin -> this is used as prophylaxis in COPD patients

Beclomethasone is given as a inhaled steroids wio help in asthma and COPD

Prednisolone -> USed in the exacerbation of COPD and Asthma. it is used in interstitial lung disease where the pathophysiology is inflammatory like sarcoidosis.

81
Q

Which of the following drugs is associated with pulmonary fibrosis?

A) Nitrofurantoin
B) Bisoprolol
C) Tobramycin
D) Empagliflozin
E) Rosuvastatin

A

Nitrofurantoin

This is associated with both acute and chronic pulmonary reactions with the pulmonary reactions may lead to fibrosis.

82
Q

A 44-year-old man has been complaining of chest tightness and breathlessness for the past 3 months. He describes becoming acutely short of breath and hearing a rattling sound when he breathes. He has a background of eczema and hay fever, however, he has never been told that he has asthma. Spirometry with a direct bronchial challenge test is requested.

Which of the following may be used as a trigger in a direct bronchial challenge?

A) Histamine
B) Nebulised Adrenaline
C) Pilocarpine
D) Bradykinin
E) Ibuprofen

A

Histamine

This challenge test is done if the reports following spirometry or FeNO is uncertain.

83
Q

A 37-year-old man, with a known background of haemophilia A, has presented with a profuse nosebleed after falling at home. Adrenaline-soaked gauze has been applied and silver nitrate cautery was attempted, however, the patient continues to bleed. Which of the following is the most appropriate management option?

A) Emergency Septoplasty
B) Anterior Nasal Packing
C) Embolisation
D) IV Prothrombinase Complex Concentrate
E) Tranexamic Acid

A

Anterior Nasal Packing

So initially pinch -> conservative such as adrenalinse soaked gauze, lidocaine solution and silver nitrate cautery

If unsuccessful anterioir nasal packing is needed .

84
Q

A 68-year-old retired civil engineer presents to his GP with a 1-month history of intermittent blood in his urine. He occasionally experiences some mild discomfort whilst urinating but has not noticed any change in urinary frequency nor does he have any difficulty initiating urination. He drinks 4 cans of beer per week and has been smoking 15 cigarettes a day since he left university aged 24 years. Examination of his abdomen is unremarkable, and appearances of the external genitalia are normal.

Urinalysis demonstrates the following

Which of the following likely diagnoses requires further investigation?

A)Transitional Cell Carcinoma
B)Urinary Tract Infection
C)Benign Prostatic Hyperplasia
D)Nephrolithiasis
E)Renal Cell Carcinoma

A

Transitional cell carinoma

Patient is over 55 has haematuria has a smoking history and this is a sterile urine analysis makes it suggestive of bladder cancer,

85
Q

A 72-year-old Afro-Caribbean man presents to A&E with intense suprapubic pain. The pain first began as a mild discomfort around 3 weeks ago but has gradually been getting worse since. Over the last 10 days, he has had difficulty urinating and has not been to the toilet at all in the last 2 days. His regular medications include amlodipine, simvastatin, finasteride and allopurinol; however, he says he stopped taking these around a month ago due to their side-effects. Which of the following is the most appropriate initial management option?

A) Tamsulosin
B) Nitrofurantoin
C) Catheterisation
D) Percutaneous Nephrostomy
E) Abdominal Ultrasound Scan

A

Cathertisation

This is acute retention secondary to BPH.

This should be managed urgently with cathertisation…

If there was signs of hypdronephrosis then there is a need for percutaneous nephrostomy

An Abdo Us would only be indicated if an alternative underlying pathology was suspected.

86
Q

The mother of a 6-year-old boy calls the GP explaining that her son has been having trouble retracting back the foreskin over the head of his penis. The child is not distressed, nor does he complain of any pain, only that it feels “tight” and is slightly uncomfortable. His mother does not think that the glans of the penis appears red or swollen, and the child reports no issues with urination.

What is the most appropriate managementoption in this scenario?

A) Give mother advice on penis hygiene and follow up in 3 days’ time
B) Application of 0.05% betamethasone ointment
C) Application of 2% lidocaine gel and manual displacement of the foreskin
D) Oral flucloxacillin
E) Referral to surgeons for circumcision

A

Application of 0.05% betamethasone ointment

This patient has phimosis. this is whent there is difficulty in retracting the foreskin.

Phimosis is common between 2-6. Surgical input is only needed if there is redness soreness or sweeling of the glans as well as difficulty in urinating.

Uncomplicated phimosis like in this case requires topical steroids to help soften and make retracting the foreskin easier.

PARAPHIMOSIS is when after the foreskin is retracted and does not return to position. This is a urological emergency and needs to be reffered yo urology. 2% lidocaine and phycical manipulation is the first way you would attempt to treat this.

INDICATIONS for circumcision
* medical management not successful
* Complicated by balantis or urethral obstruction

87
Q

Which of the following terms refers to a stress fracture of the pars interarticularis?

A) Spondylitis
B) Spondylosis
C) Spondylolysis
D) Spondylolisthesis
E) Spondylectomy

A

Spondylysis

Lysis means break.
itis inflammation
spondylosis -> OA of the vertebrae
spondylolisthesis -> Stress facture with vetebra sliding out of position EXAMPLE BELOW FROM PPQ that is
Spondylectomy -> Removal of part of the spine

88
Q

A 64-year-old patient is recovering in ITU after developing severe sepsis secondary to a urinary tract infection. His renal function has deteriorated markedly as a result of the sepsis. His U&E are shown below.

Which of the following would be an indication for dialysis?

A) Serum Urea > 15 mmol/L
B) eGFR < 15 mL/min
C) Hypernatraemia
D) Pruritus
E) Pleural Effusion

A

Pruritis

What are the indications for Dialysis: (AEIOU)
Acidosis
Electrolyte-> Hyperkalaemia that is not treatable
ToxIns
Overload -> Again treatment resistant
Uraemia -> but symptomatic

89
Q

A 62-year-old man has presented to A&E with an extremely painful right ankle. The pain began gradually earlier in the day and he denies any recent injury. On examination, his right ankle is swollen and very tender. An X-ray reveals no bony injury and a joint aspirate is taken.

Which of the following would be suggestive of a diagnosis of gout?

A) Abundance of neutrophils
B) Positively birefringent rhomboid-shaped crystals
C) Negatively birefringent rhomboid-shaped crystals
D) Positively birefringent needle-shaped crystals
E) Negatively birefringent needle-shaped crystals

A

Megatively bifringent needle shaped crystals

This is characteristic of gout

Positively bifringent rhomboid shaped is charateristic of pseudogout.

90
Q

A 79-year-old woman, who is currently on day 2 of oral co-amoxiclav and clarithromycin for a community-acquired pneumonia, is found by the nursing staff to have an ulcer on her right leg. Her past medical history includes hypertension and ischaemic heart disease. She is reviewed by the vascular surgeons, who find a 3 cm ulcer with sloped edges located just above the medial malleolus. Additionally, they find that the right lower leg is swollen, and that the skin around the ulcer is hard but flaky. Numerous varicose veins are noted. Following treatment of the current episode, which of the following interventions would be most appropriate to prevent future ulceration?

A) Advice and Reassurance
B) Compression Stockings
C) Injection Sclerotherapy
D) Saphenofemoral Ligation and Stripping
E) Femoral-Popliteal Bypass

A

Injection sclerotherapy

This patient had a venous ulcer as a result of the venous insufficiency meaning she hhas quirte severe disease.

This meets the threshold of interventional therapy.

Compression stockings are deemed suitable if other invasive techniques are deemed not suitable.

The saphenofemoral ligation is BETTER as it is the most effective… However this is more of a strenous procedure and takes longer to recover making it less useful… the sclerotherapy therefore is more approapriate as it does not require GA and has quicker recovery.

91
Q

What procedures damage the following nerves + Features?

A) Sciatic Nerve
B) Superior Gluteal Nerve
C) Common Peroneal Nerve (3)
D) Tibial Nerve
E) Femoral Nerve

A

A) Sciatic Nerve L5-S3 supplies posteroir thigh muscles
* posterior approach hip arthroplasties
* -> Loss of sensation below the knee, foot drop and inabiliy to evert the ankle as well as a loss of the ankle reflex

B) Superior Gluteal Nerve
* Anterolateral approach to the hip arthroplasties
* -> Trendelenburg positive gait and sigm
* -> loss of hip abductors -> Gluteus minimus and medius

C) Common Peroneal Nerve L4-S2
* Knee replacement surgery
* Fibular fractures
* Trauma to the knee
* -> leads to foot drop and a high steppping gait

D) Tibial Nerve . L4 to S3. terminal branches of the sciatic
* damaged through direct trauma and compression
* -> inability to plantarfex the ankle (patients cannot stand on their tiptoes)
* -> loss of sensation on the sole of the foot. It can be damaged

E) Femoral Nerve L2 -L4
* trauma
* Surgery
* Tumours
* -> Quadricep wasting
* -> Loss of knee jerk
* -> numbness along the medial thigh and calf

92
Q

A 46-year-old man presents to A&E with abdominal pain, nausea, and a temperature of 38.6. He explains the pain was previously episodic and relieved by itself a few hours after eating, but he is now very distressed by the continuous pain. On examination, a yellowish tinge to his skin is noted. He tenses in pain upon light palpation of the right side of his abdomen.

His blood test results are shown below.

Given the most likely diagnosis, which investigation is most appropriate?

A) Ultrasound Abdomen
B) MRCP
C) Endoscopic Ultrasound
D) ERCP
E) CT Abdomen and Pelvis with Contrast

A

ERCP

Patient has RUQ pain, jaundice fever -> Ascending cholangitis

GOLD standard treatment / investigation is ERCP…

Abdo US -> GOLD standard for Gallstones but not obstructive disease.

93
Q

A 56-year-old woman presents to A&E with nausea, abdominal pain and constipation. She has not opened her bowels or passed any flatus in 2 days. On examination, her abdomen is grossly distended and there is a tympanic percussion note centrally.

She undergoes an urgent abdominal radiograph which shows the following.

What is the most likely diagnosis?

A)Ileus
B)Toxic Megacolon
C)Bowel Perforation
D)Small Bowel Obstruction
E)SigmoidVolvulus

A

Sigmoid volvulus -> this is the coffee bean sign

Sn ileus will be seen as generalised distension on a radiograph

Toxic megacolon is a when there is severe dilataion and the diameter of the colon is >6cm

perforation will have pneumoperitoneum signs including riglers as well as hepatic edge sign (gas in the subphrenic area)

The loops of bowel that would be dilated would be more central and there will be transverse lines that vwill completely cross the lumen,

94
Q

A 52-year-old woman has been brought into A&E with sudden, severe pain and swelling of her right leg. On examination, her right leg is considerably more swollen than the left, all the way up to her mid-thigh. Furthermore, it is notably cyanotic and oedematous. She is given 10 mg IV morphine to ease her pain and a doppler ultrasound scan is performed. It reveals an extensive thrombus that is occluding the major and collateral veins.

What is the most likely diagnosis?

A) Acute Limb Ischaemia
B) Critical Limb Ischaemia
C) Phlegmasia Cerulea Dolens
D) Phlegmasia Alba Dolens
E) Leriche Syndrome

A

Phlegmasia Cerulea Dolens -> this is a major block of both the collateral and the deep veins.

Critical limb ischaemia -> This is when there is severe vascular disease with rest pain and tissue loss

Phlegmasia Alba dolens -> this is just the occlusion of the deep veins but not the collaterals, essentially one step before the Cerulea

Leriche syndrome -> this is a peripheral vascular disease it is a arterial disease of the ilac arteries… It presents with butt claudication and ED and weak femoral pulses.

95
Q

A 66-year-old man with a background of poorly controlled type II diabetes mellitus has presented to A&E feeling very unwell with a high fever. He has an arterial ulcer on his right foot between his first and second toes, which is regularly dressed by the district nurse. On examination, the ulcer has a foul smell and is oozing pus.

What is the most likely diagnosis?

A) Dry Gangrene
B) Wet Gangrene
C) Gas Gangrene
D) Marjolin Ulcer
E) Necrotising Fasciitis

A

Wet Gangrene

Gangrene is dead tissue due to ischaemia, then there is wet gangrene when the dead tissue gets infected. This is often needs urgent debridement and IV abx

96
Q

A 63-year-old-man, who was previously fit and well, attends respiratory outpatient clinic to discuss his investigation results. He had been urgently referred due to weight loss and haemoptysis.

The results are summarised below.

Given the above results, what is the most appropriate management option?

A) Chemotherapy
B) Nintedanib
C) Radiotherapy
D) Surgical Lobectomy
E) Palliative Care Referra

A

Surgical Lobectomy

Squamous cell carcinoma is a type of non small cell carcinoma.

This is at Stage 2 disease and if there are no other comorbidities the treatment of choice is Lobectomy.

Stage I or II is treated with surgical resection

Stage III or IV is treated with Chemotherapy

If this was a small cell carcinoma it is treated with Chemo, with surgery + radiotherapy being a consideration

B -> Used in adenocarcinoma that is metastatic or recurring

C -> This is offered in NSCLC in Stage I-III but without being able to have a surgery

97
Q

A 36-year-old man is being reviewed in the endocrine clinic with the results of a recent MRI scan. He had initially been referred due to weight gain anda new diagnosis of type 2 diabetes mellitus. His low-dose dexamethasone suppression test confirmed a diagnosis of Cushing syndrome and his MRI scan confirms that he has Cushing disease.

What is the most definitive management option for this patient?

A) Bilateral Adrenalectomy
B) Transphenoidal Hypophysectomy
C) Cabergoline
D) Fludrocortisone
E) Metyrapone

A

Transphenoidal Hypophysectomy

Dumbass Cushing disease is the disease of the pituitary gland and so there is a need to remove the pituitary tumour not the adrenals….

Cabergoline -> Dopamine agonist that is used to treat prolactinoma

98
Q

A 56-year-old man with a past medical history of hypertension and COPD presents to A&E with sudden-onset breathlessness that started 2 hours ago whilst walking his dog.

He has a chest X-ray which reveals a left-sided pneumothorax with the intrapleural distance at the level of the hilum measuring 1.5 cm.

He does not require any oxygen and his other observations are within normal range.

What is the most appropriate management plan?

A) Urgent needle decompression
B) Discharge with outpatient follow-up
C) Aspirate with 16-18G cannula and repeat CXR
D) Admit and insert 8-14 F Chest drain
E) Discharge with reassurance

A

Admit and insert 8-14 F chest drain

The British Thoracic Society (BTS) recommends chest drain insertion and admission for all secondary spontaneous pneumothoraces that are > 2 cm or presenting with breathlessness.

A: Urgent needle decompression in the 2ndintercostal space, mid-clavicular line is recommended for tension pneumothorax. (I think this has changed to the 4th or 5th intercostal space)

B: Patients with asymptomatic primary spontaneous pneumothoraces that are < 2 cm in size may be considered for discharge with outpatient follow-up.

C: Aspiration is used in primary spontaneous pneumothoraces that are > 2 cm in size and/or presenting with breathlessness. It may also be considered in cases of asymptomatic secondary spontaneous pneumothoraces which are 1-2 cm in size.

D: If a patient is discharged with a small pneumothorax with no shortness of breath, they should have a follow-up chest X-ray to ensure that the pneumothorax has resolved.

99
Q

A 46-year-old woman has been referred to the neurology clinic with progressive hearing loss affecting her right ear that she first noticed 1 year ago. Over the last 2 months, she has experienced intermittent bouts of dizziness, ringing in the right ear and right-sided headaches. On examination, Weber’s test lateralises to the left ear and Rinne’s test is positive in both ears. He also has nystagmus and diplopia on right lateral gaze and, when he walks, he has a notable ataxic gait.

An urgent MRI scan is arranged.

What is the most likely diagnosis?

A

Vestibular Schwannoma

This is the same as an acoustic neuroma

This is a slow growing tumour in the brain

Presntation:
* Unilateral sensorinueral hearing loss (IF THIS IS BILATERAL THEN IT IS NEUROFIBRAMOTOSIS 2)
* Dizziness
* facial numbness

The features mentioned here about Ataxia are features if the Vestibular schwannoma is particularly big. If there is papilloeoedema and obstructiv hydrocephalus.

Investigation of choice is MRI…

REFER URGENTLY TO ENT
.
.
.
Other options to the question and why they werent right…

meningioma is a benign tumour of the meninges. It is less likely to cause a hearing impairment but may lead to features due to the mass effect (e.g. persistent headache). MRI head will show a large angle between the tumour and dura not centred over the internal acoustic meatus, often with a dural tail and without any internal acoustic meatus enlargement.

Non-functional pituitary adenomas are categorised based on size. Macro-adenomas (over 1 cm) present with symptoms secondary to mass effect such as headaches, visual field defects and hypopituitarism. Pituitary MRI is the preferred investigation and will show a sellar mass – which is not present on the MRI in this case.

Brain metastases are the most common type of brain tumour. There are usually multiple small deposits and there are likely to be features suggestive of an underlying malignancy.

CNS lymphoma typically occurs in patients who are immunosuppressed (e.g. poorly-controlled HIV).

100
Q

A 51-year-old man has been brought in by ambulance to A&E after developing sudden-onset, central chest pain. An ECG reveals 4 mm ST elevation in leads V1 to V5. His serum troponin concentration is initially 108 ng/mL and rises to 156 ng/mL after 3 hours.

He has been given a STAT dose of 300 mg Aspirin and 300 mg Clopidogrel, 10 mg IV Morphine and 10 mg IV Metoclopramide.

The cardiac catheterisation suite has been informed and they are able to do a PCI within 1 hour.

Which of the following additional measures should be taken?

A) Fondaparinux 2.5 mg SC
B) IV Unfractionated Heparin Infusion
C) Tinzaparin 4500 U SC
D) 2.5 mg Bisoprolol
E) 15 L/min Oxygen via Non-Rebreather Mask

A

IV unfractioned heparin

So in a PCI there is an introduction of a guide wire into the arterial system and this can cause clot formation. Unfractioned heparin is needed to help counteract this…

STEMI managememnt

101
Q

A 44-year-old man presents to A&E with severe chest pain that began 3 hours ago. He describes the pain as sharp and is relieved by sitting forwards. He has never had this type ofpain before. His ECG is shown below

Which of the following is the most appropriate treatment option?

A) Nizatidine
B) Aspirin and Clopidogrel
C) Aspirin and Ticagrelor
D) Colchicine
E) Prednisolone

A

Colchicine

This is a diagnosis of pericarditis -> Treatment is with NSAIDS and Colchine.

102
Q

A 71-year-old man has been referred to secondary care after presenting to his GP with a 3-month history of intermittent buttock pain. He has noticed that when he climbs the stairs, he feels a cramping pain within his buttocks which goes away after he sits down. He also, rather timidly, mentions that he has been suffering from erectile dysfunction and is planning on starting to take sildenafil.

Which anatomical structure is most likely to be affected?

A) Aortic Bifurcation
B) Internal Iliac Artery
C) External Iliac Artery
D) Sacral Plexus
E) Pudendal Nerve

A

Aortic bifurcation

Thiis is Leriche syndrome… The vascular disease is at the bifurcation and causes problems with tje proximal oortic arteries.

Presentation with triad:
* butt claudication
* erectile dysfunction
* Absent or weak femoral pulse.

103
Q

Which of the following would be considered a normal pulmonary artery pressure?

A) 10 mm Hg
B) 20 mm Hg
C) 40 mm Hg
D) 60 mm Hg
E) 100 mm Hg

A

20 mmHg

The normal range in the pulmonary system is 18-25.

104
Q

Which of the following is part of the recommended monitoring for patients with chronic pancreatitis?

A) Amylase
B) Ultrasound Abdomen
C) Glycosuria
D) HbA1c
E) Snellen Char

A

** HbA1c**

Chronic pancreatitis can lead to DM and so HbA1c monitorting is indicated

They should also have a 2 yearly bone scan

CHRONIC PANCREATITIS MONITORING

105
Q

What is the most likely explanation for his worsened confusion?

A) Ongoing Upper GI
B) Ventilator-Associated Pneumonia
C) Hepatorenal Syndrome
D) Complication of TIPS Procedure
E) Intracranial Bleed

A

Complication of TIPS procedure

There is no detoxification of the blood from the GI tract to the sytemic circulation and this leads to the hepatic ecephelopathy

if the bleed was continuing the blood test wont show an increasin Hb level

The inflammatory markers are only slightly raised and his observations are otherwise normal

this patient does have hepatorenal syndrome,…. but this is mild and the uraemic encephelopathy is less liklely than hepatic encephelopathy.

106
Q

A 71-year-old man has been placed on a monitor bed in the cardiology ward after presenting with chest pain at rest. His troponins were 322 ng/mL and 1322 ng/mL with minimal ECG changes so he was diagnosed with an NSTEMI and is due to undergo a coronary angiogram within the next two days. He has been started on aspirin and ticagrelor.

Which of the following medications should this patient be prescribed?

A) Dabigatran
B) Fondaparinux
C) Tinzaparin
D) Unfractionated Heparin
E) Rivaroxaban

A

Fondaparinux

Fonda should be started in an NSTEMI

The unfractioned heparin only needs to be started around the time of the procedure with regards to the PCI. THIS IS because there is a high chance of clots in PCI the procedure

107
Q

A 31-year-old woman has presented to her GP complaining of irregular periods. She recently underwent an ultrasound scan for lower abdominal pain at the gynaecology emergency room which revealed no acute issues but did note that she has polycystic ovaries. She adds that she has no plans on having children in the future but is planning on going travelling for 1 year and would like to have better control of her periods.

Which of the following would allow her to have morepredictable periods?

A) Weight Loss
B) Metformin
C) Clomiphene
D) Cyclical Progestogen
E) Levonorgestrel Intrauterine System

A

Cyclical Progesterone
This would mean the patient would know her period would be during the pill free week.

Wt loss should be reccomended if the stem mentioned the patient being overweight

Metformin is if patients show they are insulin resistant

Clomifene is selective oestrogen receptor modulator and is used to stimulate ovilation

Levongesteerol IUS makes periods lighter but not more predictable

108
Q

A 38-year-old man has presented to his GP with ongoing pain after being diagnosed with an anal fissure a month ago. He has been taking paracetamol, ibuprofen and laxatives regularly but said that the pain is still incredibly intense.What is the most appropriate next step in his management?

A) Topical GTN
B) Topical Ibuprofen
C) Topical Diltiazem
D) Topical Lidocaine
E) Topical Lubricant

A

Topical GTN
After analgesia and having warm shallow baths and laxatives have been attempted the next step in management is Topical GTN this will help as it relaxes the anal sphiter and allows for healing

If Topical GTN was uneffective then you would attempt topical Diltiazem

109
Q

A 61-year-old man presents to A&E with shortness of breath which began earlier in the day. Upon admission, he had desaturated to 90% on room air and had been started on 15 L/min via a non-rebreather mask. He has a chest X-ray which reveals widespread airspace opacification in keeping with pulmonary oedema.

He is noted to have a blood pressure of 226/156 mm Hg.

He has a background of hypertension and is usually on 5 mg Ramipril OD and 5 mg Amlodipine OD.

What is the most appropriate managementoption?
A) IV Labetalol
B) PO Atenolol
C) IV Sodium Nitroprusside
D) IV Methyldopa
E) IV Phentolamine

A

Sodium Nitroprusside

HF due to severe HTN give sodium Nitroprusside

AVOID beta blockers in the above population

MethylDopa can be used in pregnant women

Phentolamine is a potential treatment option in pheeochromocytoma.

110
Q

A 44-year-old man has been diagnosed with neurofibromatosis type 2 after a recent MRI brain scan revealed bilateral vestibular schwannomas.

What is the pattern of inheritance of neurofibromatosis type 2?

A) Autosomal Recessive
B) Autosomal Dominant
C) X-Linked Recessive
D) X-Linked Dominant
E) Mitochondrial

Decribe the presentation of both…

A

Autosomal Dominant
This is an Autosomnal dominant conditions.

There is NF1 + NF2

NF1 peripheral disease
* Cafe au lait spots
* Axillary freckling
* Phaecochromocytomas

NF2
* Bilateral vestibular schwannomas
* Meningiomas
* Glioma

111
Q

Which of the following is the most common cause of infective exacerbations of COPD?

A) Staphylococcus aureus
B) Streptococcus pyogenes
C) Haemophilus influenzae
D) Pneumocystis jirovecii
E) Pseudomonas aeruginosa

A

Haemophilus influenza

S. aureus is a common skin commensal that can cause severe infections if introduced to the bloodstream.

B: S. pyogenes can cause pharyngitis, skin infections and necrotising fasciitis.

D: Pneumocystic jiroveciiis a fungus that causes pneumonia in immunocompromised hosts (e.g. people with HIV). It used to be called Pneumocystis carinii.

E: Pseudomonas aeruginosais a Gram-negative rod that can cause troublesome infections in people with COPD. It is resistant to a wide variety of antibiotics so requires targeted antibiotic therapy

112
Q

.A 66-year-old man is recovering on the respiratory ward after his 5th admission in the last 12 months with an infective exacerbation of COPD. He has been diligently attending his chest physiotherapy sessions and has given up smoking but is becoming frustrated with his frequent setbacks.

Which of the following antibiotics should be considered for long-term prevention of infective exacerbations of COPD?

A) Co-Amoxiclav
B) Doxycycline
C) Gentamicin
D) Azithromycin
E) Ciprofloxacin

A

Azithromycin

Prophylaxis for COPD.

113
Q

A 66-year-old farmer has been referred to the respiratory clinic on the 2-week wait pathway after presenting to his GP with progressive breathlessness, cough and weight loss. He has never smoked and has remained physically active on the farm throughout hislife. His HRCT is shown below.

What is the most likely diagnosis?

A)Sarcoidosis
B)Asbestosis
C)Extrinsic Allergic Alveolitis
D)COPD
E)Bronchiectasis

A

Extrinsic allergic alveolitis

Caused by exposure to mould, which is seen in the history as this patient was a farmer

The mainstay treatment is avoid the allergen and steroids

A: Sarcoidosis can cause interstitial lung disease, however, a more classical imaging finding is bilateral hilar lymphadenopathy.

B: Asbestosis is pulmonary fibrosis secondary to asbestos exposure. The main jobs that are historically at risk of asbestos exposure are ship building and construction.

D: COPD would present similarly but is very unlikely in a patient who does not smoke.

E: Bronchiectasis classically presents with chronic shortness of breath, copious sputum production and recurrent chest infections.

114
Q

An 81-year-old woman has been admitted with acute shortness of breath. Her troponins are significantly raised and she is diagnosed with acute heart failure secondary to an NSTEMI. She fails to respond adequately to two doses of IV furosemide so she is started on CPAP, however, she does not tolerate the mask and keeps removing it.

What is the next best option?

A) Intubate and Ventilate
B) High Flow Nasal Oxygen Therapy
C) Non-Rebreathe Mask
D) 60% Venturi Mask
E) Heavy Sedation for NIV

A

** High flow nasal oxygen therapy**

High-flow nasal oxygen therapy is a good option for patients who have high oxygen requirements and are unable to tolerate NIV. The device delivers humidified oxygen which means that patients are able to tolerate very high flow rates.

A: Intubation and ventilation may be considered at a later stage, however, this will be dependent on the patients frailty and comorbidities.

C: A non-rebreathe mask is unlikely tobe sufficient to meet the oxygen requirements of the patient.

D: A 60% Venturi mask is unlikely to be sufficient to meet the oxygen requirements of the patient.

E: Heavy sedation would not be recommended for patients having NIV as reduced consciousness is a contraindication for NIV

115
Q

An 85-year-old man is being reviewed in the respiratory clinic after presenting to his GP with worsening shortness of breath, weight loss and malaise. He underwent a high resolution CT scan, prior to his appointment, which revealed a large left-sided mesothelioma. He used to work as a carpenter and explains that he did have significant exposure to asbestos. In which other site is a mesothelioma most likely to be found?

A) Brain
B) Abdomen
C) Urinary Tract
D) Heart
E) Liver capsule

A

Abdomen

Often grows in the lungs then the next most common site is the abdomen and then finally the pericardium

116
Q

A 15-year-old boy presents to hospital with severe abdominal pain. The pain initially started in the centre of the abdomen but has now localised in the right iliac fossa.
When asked to cough, the patient complains of worsening pain in his right lower quadrant.

What is the name of the sign elicited?

A) Dunphy’s Sign
B) Rovsing’s Sign
C) Psoas Sign
D) Murphy’s Sign
E) Obturator Sign

A

Dunphy’s sign

this is a sign associated with appendicitis, pain while coughing

Rovsing’s sign
palpation of the left ilac fossa causes pain in the right iliac fossa

Psoas sign
For a retrocaecal appendix, when extension of the hip produces abdominal pain

Murphy’s sign
Acute cholecystitis
palpation over the right subcostal margin elicits pain on deep inspiration

Obturator sign
acute appendicitis
Pain is produced on flexion and interal rotation of the hip as the inflamed appendic comes into contact with the obturator muscle

117
Q

A 54-year-old woman is being assessed in the breast clinic. Examination revealed an irregular mass in the left breast which had radiographic features that were suspicious of malignancy on a mammogram.

A core biopsy has been taken which reveals an intraductal carcinoma that is HER2 positive, ER negative and PR negative. She subsequently undergoes a wide local excision with clear margins.

Sentinel lymph node biopsy reveals no cancerous cells so no axillary dissection is performed.

Which of the followingoptions should be offered to this patient to reduce the risk of recurrence?

A) Chemotherapy
B) Radiotherapy
C) Trastuzumab
D) Mastectomy
E) Tamoxifen

A

Trastuzumab

This is given to breast cancers that are HER 2 positive

Hormone therapy would be given to breast cancer that are hormone receptive to reduce the risk of recurrance.

chemotherapy
This is given as a neo adjuvant when the tumours is > 4cm before the surgery.
And after the surgery for younf woman with cancer lymph nodes positive status, high grade histological features and ER negative cancers.

Radiotherapy
This used to reduce the rate of local recurrence, offered to patients with aggressive disease such as lymph node involvement, large tumours, and surgical margins that were not clear of tumour.

Surgery is the first-line treatment for patients with breast cancer and is offered to everyone who is fit enough to undergo surgery.
Mastectomy and wide local excision are the two surgical approaches. The choice of surgery depends on factors such as the size of the tumour compared to the tumour to the breast, location of the tumour.

Tamoxifen
Oestrogen receptor positive cancers are treated with tamoxifen or aromatase inhibitors.
Tamoxifen is a selective oestrogen receptor modulator given to women who are pre and perimenopausal.
Anastrozole is an aromatase inhibitor and is given to postmenopausal women as most oestrogen is produced through aromatisation in this age group.

118
Q

A 49-year-old woman presents to her GP with a breast lump. She first noticed the lump 3 weeks ago. She was prescribed hormone replacement therapy (HRT) by another GP at the practice 3 months ago due to persistent hot flushes and sleep disturbance.

The GP examines the breast lump and finds a non-tender, smooth and highly mobile lump in the right breast behind the nipple.

What is the most likely diagnosis?

A) Breast Abscess
B) Intraductal Papilloma
C) Fibroadenosis
D) Fibroadenoma
E) Fat Necrosis

A

Fibroadenoma

This fibroadenoma was probably present for many years but became noticable after starting the HRT. HRT can increase the size of fibroadenomas. Contrceptives can also have this effect.

breast abscess presents with systemic upset (i.e. fever, malaise). On examination, there is a painful breast lump which may be fluctuant and associated erythematous swollen skin.

Intraductal papillomas are benign growths found within milk ducts. They are often located near the nipple. They may present with a lump but it would not be smooth and highly mobile like the lump described in this patient. Other symptoms may be a clear or bloody nipple discharge and breast pain or discomfort.

Fibroadenosis, also called fibrocystic disease, is the most common cause of breast lumps in women of reproductive age. Patients present with breast pain, changes in breast size and breast nodularity. It is unlikely to present with a solitary lump.

Fat necrosis occurs after trauma to the breast. It may present as one or multiple lumps and there may be some associated skin changes. There is often tenderness on examination.

119
Q

A 27-year-old woman presents to her GP with a breast lump which she first noticed last night whilst showering. She is very distressed as her mother died from breast cancer. The GP examines the lump and finds a mass in the upper outer quadrant of the patient’s left breast. The GP estimates the lump to be 2 cm in size. The lump is firm and smooth but not tethered to any underlying structures and is very mobile.

What is the most appropriate management option?

A) Non-urgent referral to breast clinic
B) Urgent referral to breast clinic
C) Reassure the patient that this is a fibroadenoma and that no further investigations are needed
D) Emergency referral to breast clinic
E) Reassure the patient and follow-up in 1 month to ensure the lump has disappeared

A

Non-urgent referral to breast clinic

According to NICE guidelines, an urgent referral (on the 2-week-wait pathway) is required for
* anyone over the age of 30 years presenting with an unexplained breast lump (with or without pain) or
* over 50 years with unilateral changes to a nipple including discharge or retraction.
* A 2-week-wait referral should also be considered for anyone presenting with skin changes suggestive of breast cancer (i.e. peau d’orange, Paget’s disease of the nipple) or
* patients under the age of 30 years presenting with an axillary lump

The GP should reassure the patient about these findings. Although it is highly unlikely that this lump is cancerous, NICE guidelines state that any woman under the age of 30 years presenting with an unexplained breast lump should receive a non-urgent referral (within 6 weeks) to a breast clinic.

120
Q

A 57-year-old woman is seenby her GP because of a lump around her back passage. She has had this lump for over a year now but is embarrassed by it. Previously the lump was only present when she strained on the toilet and would retract as she stood up. Recently she has felt the lumpwhen she is out walking and she has to manually replace it after passing stool. She does not complain of any pain or bleeding but has noticed mucus in the toilet bowl.

She has two children, both born via vaginal delivery over 20 years ago. She has neversmoked and has no underlying health conditions.

What is the most likely diagnosis?

A) Haemorrhoids
B) Skin Tag
C) Anal Fissure
D) Rectal Ulcer
E) Rectal Prolapse

A

Rectal prolapse

Risk Factors:
* Pelvic floor dysfunction
* Previous abdominal surgery
* Chronic constipation

Presentation:
* lump protruding through the anus (initially only while straining)
* this progresses to the lump protruding with activities, leading to a prolapse that will only retracts with manual force.
* ASSOCIATED with faecal incontinence, rectal bleeding and mucus and pain
* Examinaition -> cocentric rings of bowel

Haemorrhoids:
Often presents with bright painless bleeding and pruritus ani.

A rectal ulcer would not present with a lump protruding through the anus. Symptoms of a rectal ulcer include rectal bleeding, mucus, pain or discomfort and tenesmus. These ulcers should be biopsied to exclude malignancy.

121
Q

A 37-year-old woman comes to see her GP. She feels hopeless as she has not managed to lose weight despite adopting the lifestyle changes the GP suggested and trialling orlistat for the last 6 months.

She has been overweight since she was 17 years old.

Which of the following is an indication for bariatric surgery?

A) Failed weight loss after lifestyle interventions only
B) BMI of 32 kg/m2and hypertension
C) BMI of 42 kg/m2 without comorbidities
D) 10-year-old with BMI of 31 kg/m2
E) BMI of 38 kg/m2without comorbidities

A

BMI of 42 kg/m2 without comorbidities

Indications of bariatric surgery inc:
* BMI > 40
* BMI 35-40 and serious combobidities (HTN + T2DM)
* All other methods of Wt loss have been attempted
* BMI > 50 it is the FIRST LINE treatment
* BMI < 35 and diagnosed with T2DM

Qualifying for surgery:
* Fit for general anaesthesia
* agree to long term follow up
* Be prepared to make long term changes

122
Q

An 81-year-old woman with osteoporosis is brought into A&E by ambulance following a fall at home. An X-ray of her pelvis and lower limbs suggests a displaced, right-sided intracapsular neck of femur fracture with shortening and external rotation of the distal segment. She was previously able to walk up to 200 m from her house to get to the shops each day with the assistance of a Zimmerframe.

What is the most appropriate surgical management option in this scenario?

A) Open reduction and internal fixation with an intramedullary nail
B) Open reduction and internal fixation with a plate and cannulated screws
C) Open reduction and internal fixation with a plate and dynamic hip screw
D) Hemi-arthroplasty
E) Total hip replacemen

A

Hemi-arthroplasty

Involves replacement of the femoral head and neck only.

A hemi-arthroplasty is indicated in displaced intracapsular fractures where the patient is older than 65 years of age but is not deemed to be* fit enough* to qualify for a total hip replacement.

Open reduction and internal fixation with an intramedullary nail is only indicated in patients with an extracapsular fracture. It involves the placement of a titanium rod through the medullary cavity of the bone.

Open reduction and internal fixation with a plate and cannulated screws is indicated in *intracapsular fractures *which are not displaced. Given that this patient’s X-ray demonstrates shortening and external rotation of the distal bone fragment, internal fixation with a plate and cannulated screws is inappropriate here

Open reduction and internal fixation with a plate and dynamic hip screw (DHS) is typically reserved for patients with a stable intertrochanteric fractured neck of femur (a type of extrcapsular).

A total hip replacement is indicated in patients over the age of 65 years who are independent for their activities of daily living, can walkover a mile per day and have few comorbidities. It involves replacing the femoral neck, head as well as the pelvic acetabulum.

Extra-capsular - outside the capsule, subdivided into: Inter-trochanteric, which are between the greater trochanter and the lesser trochanter. Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point.

123
Q

A 70-year-old man, with a background of type 2 diabetes mellitus, obesity and hyperlipidaemia, is admitted to the vascular surgery ward from the community with a new grade II arterial ulcer on the plantar aspect of his right foot and ongoing calf pain in his right leg which has been present for the last 4 months. He is reviewed by the consultant the following morning.

Examination of the right leg reveals weak popliteal, anterior tibial and dorsalis pedis pulses. The left leg is normal. Before coming into hospital, he had been participating in a supervised exercise programme at home, where he lives alone. His current medications include atorvastatin, aspirin, metformin, gliclazide and sitagliptin.

What is the next most appropriate investigation in this patient?

A) Ankle-Brachial Pressure Index
B) Duplex Ultrasound Scan
C) CT Angiogram with Contrast
D) Echocardiogram
E) Serum Lactate

A

Duplex US scan

this is the next best scan

CT angio will be done after as it is a gold standard and will help assist surgeons to plan for surgery…

124
Q

A 47-year-old woman has presented to the GP practice with a 9-month history of intermittent numbness affecting both of her hands. This has also led to a loss of dexterity in her hands which has made it difficult for her to keep up with the demands of her job as the CEO of a multinational company. At the time of assessment, she said that she does not feel any of the symptoms, however, tapping over the flexor retinaculum reproduces the symptoms described. She is otherwise well with no significant past medical history.

Which of the following investigations would offer the most useful information in this case?

A) Ultrasound Scan of Wrist and Elbows
B) Electromyogram
C) MRI Wrist and Hand
D) Thyroid Function Test
E) MRI Cervical Spine

A

Electromyogram

this patient has carpal tunnel syndrome.

Tinel’s sign is what is being described with the tapping of the flexor retinaculum

THIS is mainly a clinical diagnosis but
Electromyogram may be used to confirm diagnosis.

an US of the wrist can be used to diagnose a ganglionic cyst.

MRI wrist is semi useless

Hypothyroidism can cause Carpal tunnel syndrome but this patient does not have any of the hypothyroid signs

MRI cervical spine would be reccomended if there was any concerns about degenerative cervical myelopathy ot radiculopathy.

125
Q

A 44-year-old woman has presented to her GP complaining of ongoing epigastric discomfort despite an 8-week trial of omeprazole. It is arranged for her to undergo a screening test for Helicobacter pylori.

What is the most appropriate investigation?

A) Stool Antigen
B) Urea Breath Test
C) Hydrogen Breath Test
D) CLO Test
E) FIT Test

A

Urea breath test

this is the FIRST test

second test is the stool antiged test and the hydrogen breath test is for Small bowel growth,

126
Q

A 48-year-old woman has presented to her GP complaining of widespread pruritus that has not improved with the use of antihistamines. On examination, she has notable scleral icterus and widespread excoriation marks with no visible rash. She has not noticed any other recent changes in her health. She has a past medical history of hypothyroidism and type 1 diabetes mellitus.

Which of the following investigations is most likely to reveal the underlying diagnosis?

A) Ultrasound Abdomen
B) MRCP
C) ERCP
D) Endoscopic Ultrasound
E) CT Pancreas

A

MRCP

Ok so the diagnosis of this patient is not pancreatic cancer… Essentially this is painless jaundice but you need to look for the risk factors… In this case there are none for pancreatic cancer but there are signs of atopy with T1DM and Hypothyroidism making PBC more likely.

Additionally the patient is a woman, and she is middle aged.

This patient has primary biliary cirrhosis and this can be seen in MRCP as there is features on the intrahepatic ducts.

Ultrasound abdomen is likely to be the first investigation to be performed because it can demonstrate the presence of gallstones (more common cause of biliary tract obstruction), however, it would not be able to diagnose PBC.

ERCP is more commonly used to investigate and treat biliary tract obstructions caused by gallstones. As this patient has painless jaundice, it is less likely to be due to gallstones.

Endoscopic ultrasound is rapidly becoming a useful diagnostic and interventional tool. It can be used in a variety of situations including the investigation of mural invasion in oesophageal cancer, and for biliary drainage in ascending cholangitis.

CT Pancreas is the gold-standard investigation for chronic pancreatitis.

127
Q

A 13-year-old boy has recently been diagnosed with nephrotic syndrome secondary to minimal change disease. He has been started on prednisolone and has been fluid restricted.

Which of the following is this patient at risk of?

A) Macrocytic Anaemia
B) Venous Thromboembolism
C) Hypoglycaemia
D) Hyperthyroidism
E) Primary Hyperaldosteronism

A

Nephrotic syndrome is defined as a condition in which urinary protein loss exceeds 3.5 g per day.
More recently, urine albumin creatinine ratio (ACR) has been used as a spot test to assess proteinuria as it is far more convenient than 24 hr urine collections.

An ACR > 220 mg/mmol is suggestive of nephrotic range proteinuria.

Minimal change disease is the most common cause of nephrotic syndrome in children.

It is described as ‘minimal change’ because a renal biopsy in these patients will reveal little or no abnormalities when viewed under a light microscope.

Electron microscopy, however, may reveal effacement of the podocyte foot processes which compromises the barrier that would normally prevent albumin from leaking into the urine.

This damage results in many other proteins, in addition to albumin, leaking into the urine.

*Patients with nephrotic syndrome lose a considerable amount of antithrombin-III in their urine, which is a major component of the body’s endogenous anticoagulant mechanism. Therefore, patients with nephrotic syndrome are at increased risk of venous thromboembolism. *

128
Q

A 54-year-old man is being treated on the general medicine ward for severe sepsis. He had attended hospital with a tender, distended abdomen and was treated for spontaneous bacterial peritonitis with antibiotics and an ascitic drain. He has a background of asthma, diabetes mellitus, nephrotic syndrome secondary to focal segmental glomerulosclerosis, CKD Stage 2 and schizophrenia which is treated with clozapine. His most recent blood test result is shown below.

Which feature of his medical history is likely to have contributed most to the development of his current clinical state?

A) Long-Term Budesonide for Asthma
B) Diabetes Mellitus
C) Nephrotic Syndrome
D) Clozapine for Schizophrenia
E) Chronic Kidney Disease

A

Nephrotic syndrome

The ascites is probably due to the nephrotic syndrome. The static water is likely to be a source of infection.Additionally there is an impaired immune response due to the loss of immunological antibodies in the urine.

Budesonide is a steroid that is commonly used in the treatment of asthma. It is given in relatively low doses and is unlikely to cause a systemicimmune suppressed state that predisposes patients to serious infections. Given that it is an inhaler, it can cause local immunosuppression within the oral cavity, thereby predisposing patients to the development of oral candidiasis.

Diabetes mellitus does increase the risk of developing infections (mainly skin and respiratory tract infections). It may increase the risk of peritonitis in patients who have peritoneal dialysis.

One of the major side-effects of clozapine therapy is the development of neutropaenia. This is why clozapine requires close monitoring and patients should be advised to seek medical attention if they start showing any features of infection (e.g. sore throat). This patient is not neutropaenic.

Patients on peritoneal dialysis for end-stage renal failure are at risk of developing peritonitis. This patient only has CKD Stage 2, so is unlikely to be on dialysis.

129
Q

A 4-month-old boy is brought to the GP by his mother with a swelling of his right testis. The mother says that she first noticed the swelling 2 days ago, however it does not appear to be causing any distress at all.

The boy was delivered via uncomplicated vaginal delivery at 39+5 weeks and has had all of his scheduled vaccinations since. He is meeting his developmental milestones and is progressing well on his height and weight charts. There have been no other issues raised since he was born.

On examination, the right testis is swollen compared to the left. The swelling is smooth, fluctuant, cannot be palpated separately from the testis and cannot be reduced. The swelling transilluminates under light. There is no erythema, tenderness on palpation or lymphadenopathy, and the infant’s observations are normal.

What is the most appropriate management option in this patient?

A)Watchful Waiting
B)Oral Antibiotics
C)Aspiration
D)Excision
E)Radical Orchidectomy

A

Watchful waiting

HYDROCELE

for under the age of 1 the first step is watchful waiting.

Aspiration is the management of choice in patients with hydroceles which do not respond to watchful waiting. Whilst they are benign, it is important that hydroceles resolve eventually, as they are associated with complications including rupture, infection and testicular atrophy if they persist. Surgical management with aspiration is therefore used in patients with hydroceles which are refractory to conservative management.

Excisionis a potential treatment option for a haematocele, but not a hydrocele. Excision might also be used to obtain a biopsy in patients with suspected testicular cancer.

130
Q

A 72-year-old man has been diagnosed with bladder cancer after a recent transurethral resection of bladder tumour (TURBT). The biopsy revealed poorly differentiated
transitional cell carcinoma invading the subepithelial connective tissue but sparing the muscle layer underneath.

What is the next most appropriate step in their management?

A) Repeat TURBT with intravesical BCG treatment
B) Single dose of intravesical mitomycin-C
C) Adjuvant radiotherapy
D) 6 doses of intravesical mitomycin-C therapy
E) Surveillance cystoscopy every 4 months for 2 years

A

Repeat TURBT with intavesical BCG treatment

The described Bladder cancer is a high risk tumour that is quite superficial….

Another TURBT is done to make sure no inasice disease has been missed

The use of the BCG is used to stimulate the immune system at the site of the cancer in a way to make the immune system attack the cancer cells that may still be there/

131
Q

A 47-year-old obese man with Haemophilia A has been brought into the anaesthetic room prior to surgery. The anaesthetist has finished “sign in” and has administered propofol. The patient becomes apnoeic and bag-valve-mask ventilation is initiated by the medical student. The student is struggling to adequately ventilate the patient and the patient’s oxygen saturations are dropping.

Which one of the following is most likely to improve the patient’s oxygen saturations?

A) Pushing the mask firmly down onto the patient’s face
B) Oropharyngeal airway
C) Nasopharyngeal airway
D) Hyperventilation
E) One-handed EC clamp technique

A

Bag-valve-mask (BVM) ventilation is fundamental in ensuring oxygenation of the apnoeic patient. Sometimes, patients can be difficult to ventilate, regardless of good technique, due to a number of factors such as high BMI, large neck circumference and the presence of facial hair.

An oropharyngeal airway (OPA/Guedel) can be used to help maintain the airway. When a patient becomes unconscious, the muscles of the jaw relax which allows the tongue to obstruct the airway. The OPA moves the tongue out of the way. It can only be used in unconscious patients, due to the absence of the gag reflex

Pushing the mask down into the face actually causes the tongue to be forced to the back of the throat, obstructing the airway. Good technique is to thrust the jaw upwards into the mask.

Nasopharyngeal airways (NPAs) are always used in conscious patients as OPAs would trigger the gag reflex. NPAs are also indicated in unconscious patients however coagulopathy is a relative contraindication, which is present in this patient.

Hyperventilation is dangerous as it can result in gastric insufflation, which can lead to regurgitation and aspiration of the stomach contents, as well as gastric rupture.

132
Q

A 52-year-old man arrives in hospital for an elective cholecystectomy. The anaesthetist decides to give the patient total intravenous anaesthesia (TIVA). He will be using a propofol and remifentanil infusion to induce and maintain sedation. He gives rocuronium as well.

Which one of the following is the best method of monitoring the depth of anaesthesia in this patient?

A) Train-of-Four Monitor
B) MAC
C) EEG
D) Blood Pressure
E) ECG

A

EEG

EEG monitoring is the best way of assessing the depth of anaesthesia in patients under TIVA. Anaesthetists use a number called the bispectral index (BIS) on the EEG monitor to titrate the dose of anaesthesia given. The lower the BIS, the less likely the patient is to become aware under anaesthesia

133
Q

A 36-year-old woman has presented to her GP asking for advice about polycystic ovarian syndrome. She recently received the diagnosis from a private gynaecologist whom she had initially visited due to heavy periods. She has read online that polycystic ovarian syndrome increases the risk of her developing a number of other medical conditions, and she is particularly concerned about her cancer risk.

Which of the following types of cancer do women with polycystic ovarian syndrome have the greatest risk of developing compared to the general population?

A) Breast
B) Adrenal
C) Endometrial
D) Ovarian
E) Skin

A

Endometrial cancer

Womb is exposed to a high amount of uncontested oestrogen and that leads to endometrial hyperplasia and later carcinoma.

134
Q

A 41-year-old woman has had an OGD for epigastric discomfort. It revealed some gastric erosions with no ulcers. A CLO test was positive. It is decided that she should receive triple therapy to eradicate H. pylori.

In addition to metronidazole and omeprazole, what else should be given as part of this treatment?

A) Amoxicillin
B) Gentamicin
C) Ciprofloxacin
D) Chloramphenicol
E) Nizatidine

A

Amoxicillin

Triple therapy is the recommended approach to treating H. pylori infection. It involves a combination of a proton pump inhibitor and two antibiotics (most commonly amoxicillin and either metronidazole or clarithromycin). H. pylori increases the risk of peptic ulcer disease and gastric malignancies, so should be treated if detected

135
Q

A 75-year-old man has been referred to the surgical team after being admitted with abdominal pain. He appears quite confused with an AMTS of 6 out of 10, and is unable to give a clear history. An abdominal X-ray is requested.

What is the most likely underlying diagnosis?

A) Constipation
B) Sigmoid Volvulus
C) Rectal Tumour
D) Paralytic Ileus
E) Incarcerated Hernia

A

Constipation

So this is Faecal impaction. The line that is seen on the radiograph is a common feature of faecal impaction on top of constipation.

Sigmoid volvulus will have dilated loops originating from the left iliac fossa and the classic coffee bean sign may be seen

Rectal tumour may not be seen on AXR, but it can cause bowel obstruction

Paralytic ileus affects the small bowel and is hard to diagnose for AXR

Hernias normall lead to small bowel obstruction larger than large bowel obstruction.

136
Q

A 35-year-old man has presented to his GP complaining of ongoing rectal bleeding. He describes having very dark and very smelly stools that he first noticed two weeks ago. He has a background of chronic back pain and has been using diclofenac regularly over the years. He undergoes an OGD which reveals no abnormalities.

What is the most likely diagnosis?

A) Colorectal Cancer
B) Haemorrhoids
C) Meckel’s Diverticulum
D) Diverticulitis
E) Colonic Angiodysplasia

A

Meclel’s diverticulum

Meckel’s diverticulum is a congenital gastrointestinal abnormality characterised by the presence of a remnant of the omphalomesenteric duct. It is usually found around the ileum. It is often asymptomatic and may be an incidental finding on imaging, however, it can become infected (Meckel’s diverticulitis) or bleed. It usually contains ectopic gastric mucosa which can ulcerate. Scintigraphy using technetium-99m pertechnetate may be used to identify the presence of a Meckel’s diverticulum.

The age makes colorectal cancer and diverticulitis unlikely. Additionally the lack of pain also points away from diverticulitis.

Colonic angiodysplasia presents with painless fresh rectal bleeding.

137
Q

A 33-year-old man is being reviewed in the endocrinology clinic with the results of some recent blood tests. He had initially been referred along the secondary hypertension pathway by his GP. The blood tests revealed evidence of primary hyperaldosteronism, and a subsequent CT scan revealed the presence of bilateral adrenal hyperplasia.

What is the most appropriate treatment option for this patient?

A) Bilateral Adrenalectomy
B) Spironolactone
C) Fludrocortisone
D) Cabergoline
E) Bisoprolol

A

Spironolactone.

Primary hyperaldosteronsismm is caused bilateral adrenal hyperplasia and it tends to be medically managed with an aldosterone antagonist.

Bilateral adrenalectomy is rarely performed and is normally only done in refractory cushing’s syndrome with disabling symptoms

Fludrocortisone will make the symptoms worse as it is the treatment of addison’s disease

Cabergoline is used in the treatment of acromegaly and prolactinomas

138
Q

An 81-year-old man has been admitted under the medical take with new-onset confusion of unknown cause. It is difficult to take a history and clinical examination does not reveal any obvious causes of his delirium. A full delirium screen is sent including thyroid function tests (results below).

TSH: Low
Free T3: Low
Free T4: Low

Which of the following is the most likely diagnosis?

A) Hashimoto’s Thyroiditis
B) Levothyroxine Overdose
C) Panhypopituitarism
D) Subclinical Hypothyroidism
E) Central Hypothyroidism

A

Central Hypothyroidism

139
Q

An 8-year-old girl has been referred to the paediatric neurology clinic after concerns were raised by her teachers about her losing focus in school. On several occasions, she has been found staring into space and not responding to those around her. She does not remember these episodes and appears to be back to normal immediately afterwards.

What is the first-line antiepileptic drug used in the treatment of this condition?

A) Sodium Valproate
B) Ethosuximide
C) Phenytoin
D) Lamotrigine
E) Levetiracetam

A

Ethosuxmide

This is a treatment of abscence seizures.

140
Q

A 66-year-old man is being reviewed in the Parkinson’s disease clinic. He developed Parkinson’s disease at a relatively young age and has been struggling to manage his symptoms over the past 6 months. He is currently on co-careldopa, ropinirole and rasagiline, all of which are struggling to control his symptoms. It is decided that he may benefit from starting amantadine.

In addition to being a treatment for Parkinson’s disease, which of the following classes of drugs does amantadine also fall into?

A) Anti-Hypertensive
B) Anti-Viral
C) Anti-Fungal
D) Weak Opioid
E) Tricyclic Antidepressant

A

Anti Viral -> Used to treat influenza

Amantadine is used in the treatment of Parkinson’s disease as it has some agonist activity on central dopamine receptors. It also blocks the M2 proton channel of influenza A which prevents endosomal escape of the virus. It is, therefore, used to treat influenza A.

141
Q

A 54-year-old man has been urgently referred to the respiratory clinic by his GP after presenting with a persistent cough that failed to resolve with antibiotics. His CXR revealed a 3 x 2 cm cavitating lesion in the right midzone. He has a blood test prior to his appointment

What is the most likely diagnosis?
What is the most common lung cancer associated with smokers??
What lung cancer is associated with ACTH production what is associated with ADH production?

A) Mesothelioma with Bone Metastases
B) Large Cell Lung Cancer with Bone Metastases
C) Small Cell Lung Cancer
D) Squamous Cell Lung Cancer
E) Lung Adenocarcinoma

A

Squamous cell lung carcinoma

The normal ALP should have pushed you away from bone metastassis addistionally the large cell lung cancer is very rare cancer within non small cell lung cancer….

Squamous cell lung cancer is a non small cell lung cancer and it is a 2nd most common cause of it. It can sometimes produve PTH related peptide hence the electrolyte abnormality shown.

Small cell lung cancer is the most common lung cancer associated with smoker, and is associated with the ACTH and ADH production.

142
Q

A 96-year-old woman has been admitted to hospital from her nursing home after becoming suddenly hypoxic. She has a background of COPD and previous PE. Her CXR shows hyperexpanded lungs with chronic fibrotic changes and no collapse or consolidation. On examination, she is tachypnoeic and has a notable parasternal heave.

Which of the following ECG changes would be suggestive of right heart strain secondary to a pulmonary embolism?

A) Atrial Fibrillation
B) ST Elevation in I, II and aVF
C) Left Bundle Branch Block
D) T Wave Inversion in V1-3
E) Dominant R Wave in V5-6

A

T wave inversion in V1-3

So right heart strain may show ischaemic changes to the right side of the heart. this would be T wave inversion or ST depression in the leads that represent the right side of the heart aka V1-3 and II and III. With dominant S waves in V5-6.

143
Q

A 25-year-old man had a chest drain inserted 2 days ago for the treatment of a 3 cm right-sided spontaneous pneumothorax. He is 6 ft 8 inches tall and has a family history of pneumothoraces. The chest drain has stopped swinging and the most recent chest X-ray shows that the pneumothorax has resolved.

Which of the following is most important to administer before removal of the chest drain?

What are other indications for the drugs below?

A) Glycopyrronium Bromide
B) Morphine
C) Paracetamol
D) Carbocisteine
E) Tranexamic Acid

A

Morphine

Removal of the chest drain is painful and so important to provide pain relief for the patient.

Glycopyrronium -> palliative care for secretions

Paracetamol -> Analgesic and antipyretic but not gonna be helpful when removing the chest drain

Carbocisteine is a mucolytic and helps with mucou related redpiratory conditions such as bronchiectasiis

Transxeamic acid is an antifibrinolytic and can reduce blood loss in menorrhagia and epixstasis..

144
Q

A 34-year-old man is being reviewed by his GP about his weight loss options. He currently has a BMI of 34 kg/m2. He has listened to his GP’s advice and tried making changes to his diet and activity levels over the last 3 months but has not managed to lose much weight.

He was diagnosed with type 2 diabetes mellitus 2 months ago for which he takes metformin. He takes no other regular medications. There is a strong family history of diabetes mellitus and ischaemic heart disease.

What is the most appropriate management option for this patient?

A) Refer to bariatric surgery
B) Start orlistat
C) Further lifestyle advice about diet and exercise
D) Behavioural interventions
E) Start liraglutide

A

Bariatric surgery

BMI < 35 and NEW diagnosis of DM -> needs to be referred for bariatric surgery.

orlistat is indicated BMI >28 + Risk factors or BMI >30, therfore this would have been the answer if the patient did not also have T2DM

Has not lost weight despite triallyin lifestyle changes….

Liraglutide is another medical treatment of obesity and would have been approapriate once unsuccessful with lifestyle treatments were not effective.

145
Q

A patient attends surgery outpatients to discuss his upcoming p[eratopm. He would like to understand what the surgery will involve.

This is the surgeon’s reply:

“I will remove a large part of your stomach and then close the remaining part of your stomach using staples. You will feel full much quicker and will therefore eat less, which will help you lose weight.”

Which type of surgery has the surgeon just described to the patient?

A) Gastric Band
B) Gastric By[ass
C) Sleeve Gastrectomy
D) Intragastric Balloon
E) Biliopancreatic Diversion

A

Sleeve gastrectomy

Sleeve gastrectomy involves the surgical excision of the majority (about 80%) of the stomach. The remainder of the stomach is closed to create a tube-shaped stomach. The stomach is therefore much smaller so patients feel full much quicker and eat less. This type of bariatric surgery cannot be reversed.

A: Gastric band involves the surgeon placing a ring (‘band) around the stomach to create a small stomach pouch. Patients feel full much quicker and they eat less due to the smaller size of the stomach. The band can beadjusted by injecting saline solution to increase or decrease the size of the stomach.

B: Gastric bypass is also called Roux-en-Y gastric bypass. The stomach is initially stapled to create a much smaller pouch at the upper end. Patients feel full quicker and they eat less due to the smaller stomach. The small intestine is then divided into two parts and the distal part is attached to the newly created smaller stomach pouch. This results in a significant part of the small intestine being bypassed, and since most nutrients are absorbed in the small intestine, fewer calories are absorbed. The upper part of the divided small intestine is then attached to a later part of the small intestine so that digestive juices from the bypassed stomach and small intestine can enter and help digest food in the remainder of the gastrointestinal tract. This surgery results in significant weight loss as patients eat less (due to feeling satiated much quicker) and less food is absorbed (due to bypassing of a significant portion of the small intestine).

D: An intragastric balloon is not a permanent form of bariatric surgery. It involves a gastroscopy (where an endoscopy tube is passed through the oesophagus into the stomach) to place a small balloon into the stomach. This balloon is filled with air or water and reduces the relative size of the stomach. Patients therefore feel full quicker and eat less.

E: Biliopancreatic diversion is a form of bariatric surgery that is similar to a gastric bypass. The stomach pouch is connected further along the small intestine (than in gastric bypass surgery) which means more of the small intestine is bypassed so even fewer nutrients are absorbed.

146
Q

She first noticed the lump last night in the shower and is very worried this could be breast cancer. The GP examines her and finds a fluctuant lump that is tender on palpation with surrounding erythema and swelling.

What is the most important initial investigation to organise?

A) Ultrasound-Guided Fine Needle Aspiration
B) Mammogram
C) Core Biopsy
D) Blood Culture
E) Breast Ultrasound

A

US-guided Fine needle aspiration

Eventhough generally speaking the next investigation would be an scan normally and in under 35 the scan is an US scan.

In the case of a patient that has suspected breast abscess the most important intial test is a fine needle aspiration to send off for an MCS while also treating the problem.

147
Q

A 43-year-old woman is brought to A&E by her partner. She complains of generalised abdominal pain and vomiting but thinks that it is most likely due to constipation. She has requested laxatives from the nurses in the department.

She adds that she has had several episodes of upper abdominal pain in the past year which have resolved spontaneously after a few hours or days. She has not sought medical attention for these episodes as they always seem to go away by themselves.

She has not opened her bowels in 3 days and, on examination, her abdomen is significantly distended with a tympanic percussion note. An abdominal X-ray reveals distended loops of bowel with visible valvulae conniventes. She has never had any abdominal operations in the past.

What is the most likely diagnosis in this patient?

A) Gallstone Ileus
B) Sigmoid Volvulus
C) Cholecystitis
D) Inguinal Hernia
E) Pancreatitis

A

Gallstone ileus

There are no lumps seen on the examination and so a inguinal hernia or intrabdominal adhesions are unlikely.

Cholecystitis would not explain the obstruction that is described here.

Pancreatitis usually presents with severe epigastric pain associated with nausea and vomiting. The abdomen will be very tender upon palpation

148
Q

A 27-year-old cyclist is brought to the Emergency Department after he hit a pothole and fell from his bike.He is complaining of severe right wrist pain and the joint is obviously deformed. AP and lateral X-rays are performed.

Which of the below correctly describes the injury demonstrated on X-ray? Inc MANAGMENT?

A) Smith’s fracture
B) Colles Fracture
C) Galeazzi Fracture
D) Monteggia Fracture
E) Lisfranc Fracture

A

Smiths fracture

There is a volar angulation and this is a Smiths fracture

if the fracture was displaced dorsally then that would be a colles fracture…

Volar is taking about the distal portion of the fracture and where that ends up aka doe the distal end of the radius face palmar side that would be VOLAR

If the distal end of the fracture is pointing to the dorsum of the hand that would be a DORSAL and a Colles fracture.

**Initial management **involves ensuring the neurovascular function of the limb is intact and providing adequate analgesia. Reduction with analgesia/anaesthetic support is the mainstay of initial management, followed by immobilisation of the joint with a back slab and plaster of Paris. A repeat X-ray is required post reduction to ensure realignment of the joint and displaced fragments. The patient should be reviewed in fracture clinic.

149
Q

A 47-year-old woman presents to A&E with severe abdominal pain and bloating. Paracetamol has providedno relief. She has been unable to go to the toilet for the last day and has not been passing any wind either. She has a history of recurrent right upper quadrant pain. She is reviewed by the surgical registrar on call and a CT abdomen and pelvis with contrast is requested (report below).

‘There is gas present within the biliary tree. The gallbladder is inflamed and there is a cholecystoduodenal fistula. There is a 4 centimetre stone within the lumen of the distal ileum with dilated, fluid-filled bowel loops proximally to the transition point and collapsed bowel loops distally.’

What is the most appropriate definitive management option for this patient?

A) Intravenous fluids and admit to the ward for observation
B) Intravenous antibiotics
C) Endoscopic retrograde cholangiopancreatography
D) Interval cholecystectomy
E) Enterotomy on emergency surgery list

A

Enterotomy on emergency surgery list

This patient has a gallstone ileus secondary to a cholecystoduodenal fistula. This often presents with a triad of :
* pneumobilia
* Bowel obstruction
* Calcified gallstones within the bowel

The treatment for this is to remove the mechanical obstruction and an enterotomy does this by making an incision in the small bowel to remove the stone.

150
Q

A 72-year-old woman with unexplained weight loss and heartburn is referred to the outpatient endoscopy department following a discussion with her GP. During the procedure, the gastroenterologist finds a suspicious lesion in the middle third of the oesophagus and takes biopsies. After a subsequent review of the specimen by the consultant histopathologist and a PET-CT scan, a T2N1M0 squamous cell carcinoma of the oesophagus is diagnosed, with a single positive lymph node identified near the tumour.

After she is informed of the diagnosis, the patient states that she is willing to have “whatever treatment is necessary” to improve her chances of long-term survival. The patient currently lives at home with her husband, is independent for all activities of daily living and has planned to go on holiday to Italy within the next year.

Which of the following is the most appropriate management option?

When will the other treatment options be used?

A) Endoscopic Resection
B) Oesophagectomy
C) Oesophagectomy and Chemotherapy
D) Chemotherapy and Radiotherapy
E) Endoscopic Ablation and Stenting

A

Oseophagectomy and chemotherapy

the N1M0 of the TNM stage informs us that the extent of disease in this patient is limited to the oesophagus. Hence, a surgical resection through an oesophagectomy is appropriate. However, at least one nearby lymph node contains malignant cells. Therefore, adjuvant and neoadjuvant chemotherapy are also indicated

endoscopic resection is only appropriate in patients a low-grade tumour that is limited to the muscularis mucosa with no lymph node involvement.

Oesophagectomy alone is the management of choice in patients who have disease limited to the oesophagus, but with no nearby lymph node involvement. Involvement of any lymph nodes at all would indicate eligibility to adjuvant and/or neoadjuvant chemotherapy

Chemotherapy plus radiotherapy is offered to patients with stage IV tumours. This includes tumours which have spread to distant lymph nodes and/or other organs. It may also be used in patients with lower stage tumour who are not fit for surgery.

Endoscopic ablation and stenting is a palliative procedure indicated for non-surgical candidates to enable them to continue eating by mouth

151
Q

A 66-year-old woman has presented to her GP with a 3-day history of dysuria and urinary frequency. Her urine dipstick is positive for leucocytes and nitrites so she is diagnosed with a urinary tract infection.

She has a background of ischaemic heart disease, hypertension and CKD Stage 3 with a baseline eGFR of 38 mL/min. AT WHAT eGFR COULD THE MANAGEMENT CHANGE??

Which of the following is the most appropriate treatment option?
A) Co-Amoxiclav
B) Trimethoprim
C) Nitrofurantoin
D) Gentamicin
E) Fosfomycin

A

Trimethoprim

Nitrofurantoin is excreted by the kidneys so should be avoided in imparired renal disease with eGFR < 45

152
Q

A 79-year-old man is admitted to hospital after becoming unwell and developing marked peripheral oedema. He said that he has been feeling generally weak for the last 3 months with generalised body aches and a loss of appetite. He has recently developed a tingling sensation in both his hands. A panel of test is requested on admission (results below)

What is the most likely diagnosis?

A) Membranous Glomerulonephritis
B) Minimal Change Disease
C) Rapidly Progressive Glomerulonephritis
D) Amyloidosis
E) Systemic Lupus Erythematosus

A

Amyloidosis

Amyloidosis is a condition in which abnormal amyloid proteins accumulate in various tissues across the body. It can accumulate in the kidneys resulting in nephrotic syndrome, in the heart and cause heart failure and within nerves causing peripheral neuropathy and autonomic dysfunction. It is also known to cause carpal tunnel syndrome due to the deposition of amyloid around the tissues of the carpal tunnel.

There are two main forms of amyloidosis that are defined based on the type of protein produced. AA amyloidosis arises in patients with chronic inflammatory conditions (e.g. rheumatoid arthritis) as the chronic inflammatory state results in persistently elevated levels of serum amyloid A protein (acute phase protein) which can aggregate to form amyloid.

AL amyloidosis arises in patients with multiple myeloma (Hence the CRAB symptoms). The excess production of immunoglobulins results in the aggregation of light chains to form amyloid. The two types can be remembered as A for Amyloid A, and Lfor Light chains.

153
Q

A 28-year-old man has presented to his GP with concerns about blood in his urine. He has not had any abdominal pain, dysuria or fevers, but does mention that he has been feeling more tired than usual. He provides a urine sample which appears rosé coloured.He explains that he rarely has to seek healthcare attention. He had a mild sore throat about 3 weeks ago but this resolved spontaneously.

What is the most likely diagnosis?

A) Recently Passed Renal Calculus
B) IgA Nephropathy
C) Post-Streptococcal Glomerulonephritis
D) Benign Haematuria
E) Renal Cell Carcinoma

A

Post Strepococcal

Haematuria weeks after infection -> Post streptococcal nephropathy.
Patients may present with painless haematuria, peripheral oedema, oliguria or incidentally raised blood pressure. Most cases will resolve spontaneously so treatment is mainly supportive.

For a passed stone there would be a pain history

IgA nephropathy is caused because of IgA causing glomeruli inflammation. it often presents 24-72 hours post infection

A cause of haematuria should always be sought as it is pathological

RCC would present with constituitional symptoms….

154
Q

A 53-year-old woman presents to ED with a 1-week historyof worsening headache and fatigue. She also describes neck pain and stiffness in her upper arms. Examination reveals tenderness over both temples and good peripheral pulses. Her blood results are shown below

What is the most likely diagnosis?

A)Takayasu’s Arteritis
B)Polymyositis
C)Hypothyroidism
D)Giant Cell Arteritis
E)Systemic Lupus Erythematosus

A

Giant cell arteritis

(also known as temporal arteritis) is a vasculitis that typically occurs in adults over the age of 50 years and usually involves the branches of the external carotid artery. It is commonly associated with polymyalgia rheumatica, so patients may describe a background of shoulder and pelvic girdle pain. GCA usually presents with a unilateral headache and tenderness over the temporal artery. It may also be associated with scalp tenderness, jaw claudication and, in some cases, visual changes. In patients with suspected GCA, a blood sample should be sent to check the ESR. If elevated or if there is a strong index of suspicion of GCA, patients should be started on high dose steroids. A temporal artery biopsy is the gold-standard diagnostic test for GCA.

Takayasu’s arteritis is a large-vessel vasculitis that typically occurs in younger females. A key diagnostic factor is absent or asymmetrical peripheral pulses and multiple bruits on auscultation.

Polymyositis is an inflammatory myopathy characterised by proximal muscle weakness and raised muscle-derived enzymes such as creatine kinase.

Hypothyroidism can cause myalgias but the TFTs are normal in this case

Systemic lupus erythematosus is a chronic multisystem disorder –typically involving the skin and joints –features manifest over a prolonged period and include malar rash, photosensitivity, arthralgia/arthritis –although ESR and CRP may also be elevated, you often find cytopenias and deranged renal function on the blood test results.

155
Q

A 5-year-old Sudanese boy has been referred to the neurology clinic after he was noted to have had multiple seizure-type episodes by his mother. She adds that his teachers have expressed concerns about his ability to keep up with the rest of the children in his class. He was born in Sudan and did not undergo any neonatal screening. On examination, he has multiple small papules on his face and hypopigmented patches across his torso

What is the most likely diagnosis?

A) Neurofibromatosis
B) Tuberous Sclerosis
C) Lennox-Gestaut Syndrome
D) Juvenile Myoclonic Epilepsy
E) Sturge-Weber Syndrome

A

Tuberous Scleroris

Tuberous sclerosis is an inherited disorder characterised by the presence of cutaneous manifestations (e.g. ash leaf hypopigmentation, Shagreen patches, adenoma sebaceum) and neurological manifestations (e.g. epilepsy, developmental delay). Other features include renal angiomyolipomas and retinal hamartomas

Neurofibromatosis is another inherited disorder in which patients develop neurological and cutaneous manifestations. NF1 is characterised by cafe-au-lait patches, axillary freckling, cutaneous neurofibromas and phaeochromocytoma. NF2 is characterised by bilateral vestibular schwannoma, meningiomas and ependyomas.

Lennox-Gestaut syndrome is a seizure disorder in which young children develop seizures in association with* severe learning disability*. It is not associated with cutaneous changes.

Juvenile myoclonic epilepsy is a common form of epilepsy in which children develop myoclonic jerks, usually in their limbs. It is often precipitated by a lack of sleep, and patients are often seizure-free by adulthood

Sturge-Weber syndrome is a neurocutaneous disorder characterised by the presence of a port-wine stain on the face, seizures and developmentaldelay. BABIES

156
Q

A 62-year-old man has been referred to the urology team after presenting to A&E with severe left-sided abdominal pain and a fever. He is difficult to examine as he is writhing in pain. He is noted to be especially tender in the left flank. He appears clammy and is warm to touch. His observations and urinalysis results are shown below.

His CT KUB scan demonstrates an 8mm ureteric calculus on the left side. A coronal section from his scan is shown below

Given his presentation and investigation results, what is the most appropriate management option?

A) Medical Expulsive Therapy
B) Manage Expectantly with Diclofenac Suppository
C) Percutaneous Nephrolithotomy
D) Extracorporeal Shockwave Lithotripsy
E) Percutaneous Nephrostomy

A

Percutaneous Nephrostomy

the CT shows hydronephrosis and this needs to be urgently managed with a nephrostomy, to relieve pressure on the kidney.

Medical expulsive therapy is considered in patients with non-obstructive stones that are less than 10 mm in size. It involves using alpha-blockers (e.g. tamsulosin) and calcium channel blockers (e.g. nifedipine) to relax the ureteric smooth muscle and facilitate the passage of the stone

157
Q

A 25-year-old man presents to A&E with pain in his scrotum. He tells you that the pain had started off as a mild, intermittent discomfortbut became extremely severe 3 hours ago. Upon further questioning, he explains that he had noted some abnormal discharge from his penis over the last 1 week and was planning on attending the sexual health clinic next week. He has not had any sexually transmitted infections in the past, but has been having unprotected sex with multiple partners over the last 6 months. On examination, he is screaming in pain upon palpation of the testicles. It is difficult to assess the presence of any masses as the patient does not tolerate the examination.

What is the most important next step in the management of this patient?

A) Take urethral swabs and give ceftriaxone 500 mg IM STAT with doxycycline 100 mg BD for 7 days
B) Take urethral swab and urine sample, and give STAT benzylpenicillin and doxycycline 100 mg BD for 7 days
C) Urgent doppler ultrasound
D) Urgent referral to urology for consideration of bilateral fixation
E) Urgent referral to urology for consideration of unilateral fixation

A

Urgent referral to urology for consideration of bilatera fixation

This patient has signs and features of testicular torsion that cant be differentiated from epididymitis. Therefore this should be treated as such until proven otherwise.

158
Q

A 65-year-old man is in hospital for coronary artery bypass surgery. Prior to surgery, the anaesthetist administers the anaesthetic medication. Thepatient’s vital signs 10 minutes after the surgery begins is shown below.

Significant muscle contraction is also noted.

Which one of the following medications is most likely to have caused this patient’s deterioration?

A) Propofol
B) Sevoflurane
C) Vecuronium
D) Fentanyl
E) Lidocaine

A

Sevoflurane

Common agents that trigger malignant hyperthermia are -> Sevoflurane and suxamethonium

patients who have this reaction have a mutation on the ryanodine receptor and it leads to increased intracellular Ca concentration and this lead sto excessive muscle contraction.. re storing the Ca causes the use of a lot of ATP and this is what causes the hyperthermia.

159
Q

A 21-year-old man is brought into the emergency theatre for an appendicetomy. The anaesthetist carries out rapid sequence induction using thiopentone and suxamethonium.

What is the easiest way to assess that the patient is sufficiently paralysed?

A) Train-of-four monitor
B) Visual assessment of transient fasciculations
C) No response to verbal stimulus
D) No response to painful stimulus
E) EEG monitoring

A

Visual assessment of transient fasciculations

The fascicualtions are because of the depolarising affect of the suxamethonium. This can be seen progressively starting supraorbitally and then travelling down the body.

160
Q

A 55-year-old man has been admitted to the coronary care unit after being diagnosed with an NSTEMI. He had presented with a 4-hour history of central, crushing chest pain. He is known to the cardiology department as he recently underwent an echocardiogram which revealed a normal left ventricular ejection fraction and severe aortic stenosis with a mean gradient of 45 mm Hg. He is awaiting an aortic valve replacement.

Which medication is contraindicated in this patient?

A) Glyceryl Trinitrate
B) Aspirin
C) Bisoprolol
D) Ramipril
E) Ticagrelor

A

Glyceryl trinitrate

In severe AS nitrates are contraindicated. This is because nitrates cause a sudden decrease in preload and the in patients with AS the hear will not be able to compensate by sufficiently increasing the stroke volume and this can lead to myocardial ischaemia.

161
Q

What is the MOA of fondaparinux?

Give examples of drugs with the following MOA?

A) Irreversible COX Inhibitor
B) P2Y12 Receptor Antagonist
C) Potentiates Action of Antithrombin-III
D) Vitamin K Epoxide Reductase Inhibitor
E) Converts Plasminogen to Plasmin

A

A) Irreversible COX Inhibitor -> ASPIRIN

B) P2Y12 Receptor Antagonist -> CLOPIDOGREL OR TICAGRELOR

C) Potentiates Action of Antithrombin-III -> FONDAPARINUX

D) Vitamin K Epoxide Reductase Inhibitor -> WARFARIN

E) Converts Plasminogen to Plasmin -> ALTEPLASE

162
Q

A 51-year-old woman has attended the gastroenterology clinic for review after undergoing an outpatient MRCP. She had initially presented 2 weeks ago with painless jaundice, fatigue and widespread pruritus. The MRCP report and significant blood test findings are shown below.MRCP: intrahepatic duct fibrosis and sclerosis with evidence of biliary outflow obstruction. Extrahepatic ducts appear normal.

Which of the following is true regarding her condition?

A) It is associated with ulcerative colitis
B) Steroids have no role in management
C) Ursodeoxycholic acid can improve the prognosis
D) Most commonly presents in young men
E) Is associated with raised unconjugated bilirubin

A

Ursodeoxycholic acid can improve the prognosis.

This is PBC.

Primary biliary cholangitis (previously known as primary biliary cirrhosis) is a chronic inflammation disease that is characterised by progressive intrahepatic bile duct damage.

Features of PBC:
● Associated with other autoimmune diseases
● Associated with anti-mitochondrial antibody (AMA)
● Ursodeoxycholic acid confers a prognostic benefit

163
Q

What is the most common cause of hypothyroidism worldwide?

A) Iodine Deficiency
B) Zinc Deficiency
C) Tuberculosis
D) Autoimmune Thyroiditis
E) Iatrogenic Hypothyroidism

A

Iodine deficiency

Common in areas where iodine fortified grains are not readily available. This often causes a large goitre.

164
Q

The mother of a 12-year-old boy has presented to his GP with concerns about his body weight. She explains that she has been trying to improve his diet and enrol him in after school activities but that he continues to gain weight. In this child, what is the most appropriate measure to use to determine whether he is obese?

A) BMI Centiles
B) Raw BMI
C) Weight Centiles
D) Raw Weight
E) Waist Circumference

A

BMI Centiles

98 centile -> obese

91-98 -> overweight

165
Q

An 81-year-old woman has been referred to the older persons clinic with concerns about her memory. According to her nephew, she had been a civil engineer and was always very quick witted, however, she has gradually become more and more forgetful over the past 2 years. Her MMSE is 24/30.

Which of the following medications would be most appropriate for her at present?

A) Aspirin
B) Donepezil
C) Haloperidol
D) Risperidone
E) Memantine

A

Donepezil
the above is an acetylcholinesterase inhibitor that is used in the treatment of Alzheimer’s dementia. Alzheimers is thought to be associated with a deficiency of acetylcholine in the brain. Therefore, acetylcholinesterase inhibitors can bring about an improvement in the symptoms that the patient experiences. Other examples of acetylcholinesterase inhibitors include rivastigmine and galantamine.

A: Aspirin is an antiplatelet agent.

C: Haloperidol is a typical antipsychotic.

D: Risperidone is an atypical antipsychotic that is sometimes used in the treatment of difficult behaviour in the context of dementia.

E: Memantine is an NMDA receptor antagonist that is used to treat severe Alzheimer’s disease.

166
Q

An 88-year-old man has been referredto the memory clinic with worsening memory problems. His daughter explains that his memory and cognitive abilities have declined considerably over the past 5 years, and that he appears to always be muddled about where he is. His MMSE is 14/30 and a decision is made to start memantine.

What is the mechanism of action of memantine?

A) Muscarinic Agonist
B) Acetylcholinesterase Inhibitor
C) Serotonin Reuptake Inhibitor
D) NMDA Receptor Antagonist
E) Dopamine Agonist

A

NMDA receptor antagonist

In Severe Alzheimer’s NMDA receptor antagonists cn be used.

Muscarini agonists are not used in Alzheimers disease. Pilocarpine is an example and is used in acute close angle glaucoma

Acetycholinesterase inhibitors such as dinzepil is used in the treatment of Alzheimers dementia but in the earlier stages

Serotonin reuptake inhibitors are used in the treatment fo depression, OCD and anixiety

Dopamine agonits (ropinerole) -> Can be used in parkinson’s disease or prolactinomas

167
Q

A 71-year-old woman with a background of asthma has been admitted with a severe bronchopneumonia. She has been started on IV antibiotics and is currently saturating at 88% on a 60% Venturi mask. On examination, she has markedly increased work of breathing and, on auscultation, there are coarse crepitations bilaterally with no wheeze.

Which of the following interventions would be most appropriate at this point in time?

A) Urgent Surgical Review
B) Salbutamol and Ipratropium Nebuliser
C) CPAP
D) BiPAP
E) Intubation and Ventilation

A

BiPAP

this should be attempted before intubation in patients with type 2 RF

168
Q

A 63-year-old man presents to the emergency department with sudden-onset abdominal pain, which he scores as 10/10 in severity. He feels nauseous and has vomited twice since the pain started an hour ago. He suffers from heartburn but this pain is different.He did take Gaviscon® earlier which provided no relief. The notes from his initial assessment are shown below.

On Examination
- HS I+II+0, pulse irregular, tachycardic
- Chest clear
- Abdo soft throughout, no peritonism, no guarding, pulsatile but not expansile abdominal aorta
- Impression: abdo pain out of proportion with clinical findings

Which of the following simple tests is likely to provide the most useful information regarding the cause of this patient’s presentation?

A) Urine Dipstick
B) Venous Blood Gas
C) Serum Amylase
D) ECG
E) Faecal Calprotectin

A

ECG

There is an irregular pulse and there signs of ischaemic bowel. If there is a irregularly irregular pulse then AF can be assumed, however there are multiple reasons for an irregular pulse. This can be confirmed to be AF with an ECG.

The AF would most likely be the cause of the ischaemic of bowel… The VBG may show raised lactate and that is a sign of ischaemic bowel but does not tell us the cause of this.

169
Q

A 58-year-old woman attends A&E with severe abdominal pain and 3 episodes of vomiting since the pain started 2 hours ago. Her abdomen is mildly distended, tender throughout, without guarding or evidence of peritonism. She is still in pain despite paracetamol, codeine and oramorph®.

Her erect chest X-ray reveals no pneumoperitoneum, her ECG shows atrial fibrillation with a rate of 98 bpm and a CT abdomen and pelvis with contrast has been requested.

What is likely to be the mainstay of managing this patient after initial resuscitation in A&E?

A) Admit for observation overnight
B) Book onto the emergency theatre list
C) Broad-spectrum antibiotics
D) Admit to the intensive care unit
E) Anticoagulation

A

Book onto the emergency theatre list.

Acute mesenteric ischaemia, this is a surgical emergency. and so requires urgent booking to the emergency theater list.

A is inapproapriate as the patient needs intervention

The rest of the options are all possible but the main next initial managment should be the most urgent which is booking into emergency surgery.

170
Q

A 72-year-old woman is transferred to A&E from her care home with colicky abdominal pain. The nurse present with her explains that she has not opened her bowels in two days and that her abdomen appears considerably more bloated than usual. She has not been vomiting. The patient has advanced Parkinson’s disease and, in addition to her Parkinson’s disease medications, she regularly takes macrogol, lactulose and ramipril.

Her surgical history includes 3 C-sections and a left-sided mastectomy. On examination, the abdomen is grossly distended with high-pitched bowel sounds. There is no rebound tenderness or guarding.

Which of the following investigations will be most useful in this scenario?

A) Serum Amylase
B) Abdominal Ultrasound
C) Abdominal X-Ray
D) CT Abdomen and Pelvis
E) U&E, Bone Profile and Magnesium

A

CT abdo and pelvis.

The patient has bowel obstruction and this is seen by the mentioned risk factor -> parkinsons, constipation and multiple previous abdo surgeries. The lack of vomiting suggests the obstruction is in the large bowel.

AXR may be preferred there is a history of recurrant sigmoid volvulus otherwise generally speaking a CT abdo is better for obstruction.

U+Es and bone profile is causes of paralytic ileus, to check for those but these are less urgent.

171
Q

A 57-year-old man presents with abdominal pain to the Emergency Department. He describes the pain as sharp and constant. The pain started suddenly 30 minutes ago and worsened very rapidly. It was initially located underneath his ribs at the centre but has now spread throughout his whole abdomen. He has not vomited.

On examination, his breathing is shallow and rapid. The patient says he often experiences pain in his chest that comes on after meals which is normally relieved by Gaviscon®, but it failed to settle his symptoms today. His current observations are shown below.

What is the most likely diagnosis of this patient’s pain?

A) Acute Cholecystitis
B) Perforated Peptic Ulcer
C) Acute Pancreatitis
D) Biliary Colic
E) Gastro-oesophageal Reflux Disease

A

Perforated Peptic ulcer

CLUES :
* History of chest pain relieved by gaviscon. AKA GORD, known RF for Peptic Ulcer disease
* Peritonitic picture with shallow breaths and generalised abdo pain.
* TRIAD : Sudden Abdo pain/Tachycardia/abdominal rigidity.

Acute pancreatitis -> Sever pain that radiates to the back and is relieved whil leaning forward and is associated with vomiting

Acute cholecystitis -> severe RUQ continous pain that may radiate to the scapula, Murphy’s sign maybe positive

172
Q

A 76-year-old woman presents to the emergency department with a 1-hour history of excruciating abdominal pain, which was initially concentrated in the epigastrium but now involves her entire abdomen. On examination, she is tachycardic, tachypnoeic and is lying very still on the examination couch.

Her current medications are listed below.

●Ranitidine
●Omeprazole
●Ramipril
●Metformin
●OTC Gaviscon

Which of the following should be performed first?

A) Ultrasound
B) Abdominal X-Ray
C) ECG
D) Serum Amylase
E) Erect Chest X-Ray

A

Erect CXR

Lying very still on the examination couch. This is suggestive off perforated peptic ulcer. CT abdo is needed if there is suspected surgery needed, to plan for surgery.

173
Q

A 68-year-old man presents to the A&E department with severe abdominal pain. The pain started an hour ago and was very severe almost as soon as it started. Movement and breathing deeply make the pain worse. He has a history of epigastric pain after meals, which is relieved by over-the-counter medications and he explains that he has lost several kilograms over the last 3 months.

He is assessed in A&E and an erect chest X-ray is ordered. His observations are shown below.

What is the most appropriate management option for this patient?

A) H. pylori eradication (What is the medication in the triple therapy for this?)
B) Nil-by-mouth and wide-bore nasogastric tube insertion
C) Rigid sigmoidoscopy with gas insufflation
D) Endoscopic retrograde cholangiopancreatography
E) Laparotomy

A

Laparotomy

This is the most approapriate management option for perforation of a peptic ulcer.

NBM and NGT would be initial management of obstruction.

h.Pylori treatment -> Omeprazole, Amoxicillin and Clarithromycin/Metrondiazole.

Rigid sigmoidoscopy with gas insufflation is the initial management of patients with UNCOMPLICATED sigmoid Volvulus. It may also be used in children presenting with intussusception.

174
Q

A 42-year-old man attends the Emergency Department following a fall on an outstretched hand whilst running. He has no past medical history of note. There is pain and obvious deformity of the right wrist. AP and lateral X-rays are performed.

What is the most appropriate management option?

A) Manuel reduction and immobilisation with plaster of paris
B) Polysling
C) Open reduction and internal fixation (ORIF)
D) K-wire insertion
E) External fixation

A

Open reduction and internal fixation
This is the treatment of choice of a Barton Fracture which is when there is a dorsal displacement of the fracture component. Different to Colles or Smiths fracture where there is a complete fracture and it is extrarticular aka does not break the surface of the articulating point of the joint.

Wrist injury -> presents to AE -> Examine and check if neurovasculalary intact -> AP and Lateral CXR of the wrist

Polysling is the treatment of choice to support the elbow and the shoulder joint so does not help with the wrist injuries.

K wires are indicates in small fractues usually involving the phalanges or metacarpals.

External fixation is indicated when there is no definitive stabilisation of a fracture or no immediate wound cover at the time of the first operation. It may be indicated in OPEN fractures or fractues that have significant COMINUTION OR TISSUE LOSS

175
Q

A 7-year-old boy is brought in by ambulance as a priority call to a major trauma centre. He has been involved in a road-traffic accident and sustained severe injuries to his left leg.

A primary survey is performed, and the patient is found to be haemodynamically stable with no other life-threatening injuries.

What action(s) should be taken next in the Emergency Department?

A) Provisionally clean and irrigate wound, transfer to theatre within 24 hours.
B) Provisionally clean and irrigate wound, administer antibiotics and tetanusprophylaxis, transfer to theatre immediately.
C) Transfer immediately to theatre.
D) Administer antibiotics and tetanus prophylaxis, transfer to theatre within 24 hours.
E) Photograph wound, transfer to theatre immediately

A

Administer antibiotics and tetanus prophylaxis, transfer to theatre within 24 hours

Cleaning and irrigation is no longer indicated, unless htere is gross contamination or there is a need to seal the wound or photograph the wound.

Debridement needs to occur within 24 hours.

176
Q

A 20-year-old student, who is also a professional gymnast, has presented with pain in her left shoulder. The pain first came on 3 days ago whilst she was practising a gymnastics routine on the uneven bars, during which she heard a “snapping” sound followedby excruciating pain in her shoulder. She presented soon afterwards to A&E where an X-ray of her shoulder showed no evidence of a fracture. She was discharged from A&E with a shoulder brace.

On examination, there is tenderness on palpation of the shoulder and weakness of shoulder abduction, which is limited to 90° due to the pain. An MRI scan of the shoulder shows a 4.2 cm full-thickness tear of the left subscapularis muscle. The patient is right-handed.

What is the most appropriate management option in this patient?

A) Activity Modification
B) Physiotherapy
C) Steroid Injection
D) Arthroscopic Tendon Repair
E) Shoulder Arthroplasty

A

Arthroscopic tendon repair

Tears can also be divided by size: up to 1cm, 3 cm, 5 cm or over 5 cm are classified as being small, medium, large or massive, respectively. This patient has a large, acute, full-thickness tear, which is unlikely to heal with conservative management. Surgical intervention is therefore required, which in this scenario would involve an arthroscopic tendon repair. Surgery is also indicated in patients where conservative management has failed, and in those where at least 2 weeks have elapsed since the initial injury. One might also consider an open repair given the size of the tear, but a shorter recovery period and fewer associated complications make an arthroscopic approach a much more appealing option in this younger patient.

A: Conservative management including activity modification and analgesia for at least two weeks would usually be considered before surgery. However, this patient has a large, symptomatic tear, which, as previously discussed, is unlikely to heal by itself. Therefore, conservative management is inappropriate.

B: Physiotherapy should form part of the management plan regardless of whether or not the patient undergoes surgery. However, it is only an adjunct to treatment, and in this case will not help the patient’s large tear to heal without surgery.

C: A steroid injection may also be considered as an adjunct in patients undergoing conservative management where the pain is not improving.

E: A shoulder arthroplasty, also known as a shoulder replacement is not indicated in this patient. It would only be considered in patients with massive tears where the quality of the remaining tissue is too poor for a repair to be effective

177
Q

A 45-year-old man is being reviewed in the pre-dialysis clinic. He has presented for routine review, however, his blood tests in clinic reveal a dangerous electrolyte derangement so he is immediately admitted onto the renal ward and placed on cardiac monitoring.

He has a background of CKD stage 4 secondary to poorly-controlled type 1 diabetes mellitus. His electrolyte derangement is managed acutely and a request is placed for a dietician to review the patient and recommend some changes that may reduce the risk of developing dangerous electrolyte derangements in the future.

Which three components of the patient’s diet will the dietician most likely focus on?

A) Magnesium, Calcium and Urea
B) Potassium, Calcium and Protein
C) Potassium, Phosphate and Protein
D) Phosphate, Bicarbonate and Protein
E) Iron, Vitamin B12 and Folate

A

Potassium, Phosphate and Protein

The kidney maintains fluids and electrolyte homeostasis. kidney dysfunction often presents with Potassium retention, phosphate retention and impaired abilirt to excrete urea.

178
Q

A 35-year-old woman with known rheumatoid arthritis presents to the GP with a 2-month history of a dry mouth, sore eyes and pain during sexual intercourse. On examination, her eyes appear red and her oral mucosa is very dry.

Given the most likely diagnosis, which of the following clinical tests is most appropriate?

A) Dix-Hallpike Test
B) Pathergy Test
C) Phalen’s Test
D) Schirmer’s Test
E) Schober’s Test

A

Schirmer’s test

This is Sjrogen’s disease

Schirmer’s test involves placing a strip of filter paper under the patient’s eyelid and monitoring the progress that the tears make through the paper. Progression of less than 10 mm after 5 mins is considered a positive result.

A -> BPPV

Pathergy test -> Non-specific Skin reaction (BEHCHET’s DISEASE)

Phalens test -> Carpal tunnel syndrome

Schrober test -> Ankylosing Spondylitis, where there is a less than 5 cm increase in range of movment.

179
Q

A 61-year-old man with no past medical history attends the Emergency Department with pain and blurriness in his left eye, which began around 2 hours ago whilst he was reading a book. On examination, both the sclera and conjunctiva of the patient’s left eyeare red, and the left pupil is more dilated than the right. Visual acuity testing demonstrates 6/15 vision in the left eye and 6/6 in the right eye.

At the end of the examination the patient explains that he is starting to feel nauseous. What is the mostlikely diagnosis?

WHAT IS THE DIFFERENCE BETWEEN C AND D? and inc Mx?

A) Giant Cell Arteritis
B) Orbital Cellulitis
C) Episcleritis
D) Scleritis
E) Acute Glaucoma

A

Acute Glaucoma
The history provided by this patient is typical: rapid-onset pain and disturbed vision unilaterally, with no obvious precipitant. The injection of the sclera and conjunctiva seen in this patient are common, as is the sensation of nausea. Further examination findings may include dilation of the pupil in the affected eye, “corneal haze”and a rock-hard eyeball on gentle palpation.

Giant cell arteritis is also a medical emergency which can lead to blindness, but it presents quite differently to acute glaucoma. Often, the patient has no visual symptoms at all. Instead, the pain experienced by the patient is not located in the eye socket, but instead manifests as a headache, typically worst in the temple area and featuring scalp tenderness. Other associated symptoms include jaw claudication, constitutional upset and features of polymyalgia rheumatica (shoulder and pelvic girdle pain and stiffness).

Orbital cellulitis is another ophthalmological emergency, this time resulting from an infection of the skin and tissues around the orbit. Unlike periorbital cellulitis, which is a superficial infection of the skin around the eye, orbital cellulitis extends through the orbital septum, and, as a result, requires in-patient treatment. Both feature pain, swelling and erythema in the tissues around the orbit (which this patient does not have). Red flags signs which point to orbital cellulitis as the diagnosis over periorbital cellulitis include pain with extraocular movements, proptosis, visual impairment, ophthalmoplegia and fever.

Episcleritis is self-limiting inflammation of the episclera, the layer which lies between the conjunctiva and the sclera. It is a common cause of a red eye, however it does not affect vision and pain is minimal, if present at all. Most cases are idiopathic, but around a third are associated with an underlying vasculitis, connective tissue disorder or seronegative spondyloarthropathy.

scleritis is an emergency which requires immediate intervention with steroids. It presents with pain, redness and sometimes impaired vision in the affected eye. In this patient, however, the presence of nausea and dilatation of the pupil in the affected eye make acute glaucoma a more likely diagnosis.

180
Q

A 63-year-old woman with chronic open angle glaucoma and type 2 diabetes mellitus presents to A&E due to an “achy” pain in her left eye and left eyebrow. Thepain began first thing this morning when she woke up. At the time, she decided against attending A&E as she thought the pain would go away.

Since then, the left eye has become red, and her vision in that eye is now blurry. She has had open angle glaucoma for the past 3 years, but the symptoms have been well-controlled using topical latanoprost. She is reviewed by the on-call ophthalmologist, who despite normal appearances on fundoscopy, suspects a diagnosis of acute angle closure glaucoma.

What is the nextmost appropriate investigation in this patient?

A) Goldmann Tonometry
B) Ultrasound Biomicroscopy
C) Automatic Static Perimetry
D) Fluorescein Angiography
E) Slit Lamp Gonioscopy

A

Slit lamp Gonioscopy
Slit lamp gonioscopy is the first-line investigation of choice in acute angle closure. It involves using a goniolens in conjunction with a slit-lamp to directly visualise the iridocorneal angle in the patient’s affected eye. This is the angle which is “closed” in acute angle closure. It isa rapid, non-invasive test which can be used by ophthalmologists to quickly reach a diagnosis in the acute setting. A slit lamp examination is often the go-to investigation of choice for diagnosing pathology in the anterior segment of the eye and can evenbe used to facilitate the removal of foreign bodies.

Goldmann tonometry involves using a tonometer in conjunction with a slit lamp to introduce a probe which contacts the eye. The position of the probe is adjusted using a dial, the reading from which is used to determine the intraocular pressure of the eye. It is the gold standard for assessing and monitoring open angle glaucoma but is not used in the diagnosis of acute angle closure.

181
Q

A 26-year-old woman presents to A&E with severe right flank pain which comes in waves and radiates towards her lower abdomen. She has a past medical history of chronic urinary tract infections and ulcerative colitis.

Clinically, she shows no signs of infection. Her white blood cells are within the normal range and her urea and electrolytes demonstrate that she does not have an acute kidney injury.

She undergoes a CT KUB which reveals a 22 mm non-obstructed stone in the renal pelvis with no hydronephrosis.

What is the most appropriate definitive management for this patient?

A) NSAIDsand Reassurance
B) Nephrostomy Insertion
C) Shock Wave Lithotripsy
D) Ureteroscopy
E) Percutaneous Nephrolithotomy

A

Percutaneous lethotripsy

Non contrast CTKUB is the gold standard imaging modality to diagnose ureteric colics.

Non obstructive renal stone management ->
* < 10mm -> analgesia and watch and weight -> if persistent then shockwave
* 10-20 mm -> /shockwave or ureterscopic -> percutaneous nephrolithotomy
* > 22 mm percutaneous nephrolithotomy

Non-obstructive Ureteric Stones:
* < 10 mm Analgesia and alpha blockers
* >10 mm Uretoscopy or shockwave lithotripsy -> If fails then percutaneous nephrolithotripsy

All patients willl recieve NSAIDs for oain relief most oftenlly with PR diclofenac.

182
Q

A 64-year-old man presents to the urology clinic to discuss the progress of his benign prostatic hyperplasia (BPH). He is still experiencing urinary frequency, nocturia, weak stream and incomplete voiding despite trials of tamsulosin and finasteride. Anultrasound scan of the renal tract demonstrates a prostate mass of 35 g.

Which is the most appropriate next step in his management?

A) Trans-urethral incision of prostate
B) Trans-urethral resection of prostate
C) Radical prostatectomy
D) Brachytherapy
E) Watch andwait

A

TURP

TUIP is the prostate was smaller than 30 g

if it doesnt mention the mass go for TURP….

183
Q

A 42-year-old woman is brought into A&E after being found unconscious.

Which one of the following will establish a definitive airway?

A) Oropharyngeal Airway
B) Nasopharyngeal Airway
C) Laryngeal Mask Airway
D) I-gel®Supraglottic Airway
E) Endotracheal Tube

A

Endotracheal tube

DEFINITIE AIRWAYS:
* Crico
* Tracheo
* endotracheal tubes

184
Q

A 51-year-old woman has been brought to A&E with sudden-onset lower back pain and bilateral leg weakness. Upon examination, she is unable to weight bear and complains of some shooting pains along both legs. She recently had her third round of chemotherapy for breast cancer.

Which of the following is the most important additional measure to take?

A) Arterial Blood Gas
B) Forced Vital Capacity
C) IVIG
D) Oral Prednisolone
E) Digital Rectal Examination

A

Digital rectal examination

Cauda equina syndromeis a condition in which the cauda equina becomes compressed. This usually occurs due to a disc prolapse, but can also occur due to bone metastases, abscesses and trauma. It usually presents with severe lower back pain, bilateral lower limb weakness and shooting pains, saddle anaesthesia and bladder and bowel dysfunction. It is, therefore, very important to perform a digital rectal examination in patients with suspected cauda equina to check for saddle anaesthesia and reduced anal tone. It should be investigated urgently with a whole spine MRI scan.

185
Q

A 24-year-old man has been admitted to the endocrinology ward after having a hypertensive crisis. A CT abdomen revealed the presence of bilateral adrenal masses, suggestive of a phaeochromocytoma. He has been started on phenoxybenzamine prior to surgery. Upon examination, it is also noted that he has multiple hyperpigmented patches across his trunk and freckles in his axillae.

What is the most likely diagnosis? (Explain the presentation of each of the following/)

A) Tuberous Sclerosis
B) Neurofibromatosis I
C) Neurofibromatosis II
D) MEN I
E) MEN II

A

Neurofibromatosis 1

NF1 -> Cafe au lait sots and axillary and groin freckles and phaeco

NF2 -> Bilateral schwanommas, meningiaoma + ependymomas

MEN 1 -> 3 ps, pitu, para, pancreatic

MEN 2 -> parathyroid hyperplasia, phaeochromocytomas and medullary thyroid cancer. MEN IIb is a subtype of MEN II which is also associated with mucosal neuromas and a Marfanoid body habitus

TS -> cutaneous manifestations (e.g. ash leaf hypopigmentation, Shagreen patches, adenoma sebaceum) and neurological manifestations (e.g. epilepsy, developmental delay). Other features include renal angiomyolipomas and retinal hamartomas

186
Q

A 41-year-old man has been admitted to hospital after being found collapsed on the street. He had a GCS of 3 when he was found by ambulance staff, but this has since improved by the time he arrives at hospital. He appears confused and keeps trying to get out of his bed. He is obviously ataxic with a notable strabismus.

What is the most likely diagnosis?

A) Cerebellar Stroke
B) Lateral Medullary Syndrome
C) Wernicke’s Encephalopathy
D) Cerebellopontine Angle Tumour
E) Viral Encephalitis

A

Wernicke’s ecncephalopathy

Age makes stroke less likely.

Wernicke’s -> confusion, ophtalmoplegia (strabismus-> abnormal alignment of the eyes) and ataxia/

187
Q

Which of the following is a common risk factor for the development of atelectasis?

A) Deep Breathing
B) Oxygen Use During Anaesthesia
C) Dry Cough
D) Alcohol Excess
E) Adenoidectomy

A

Oxygen use during anaesthesia

188
Q

A 56-year-old woman is referred to the breast clinic under the 2-week-wait pathway. On examination, there are 2 small lumps behind the right nipple. There is no dimpling or puckering of the skin. The lumps are tender on palpation and the patient reports some discomfort in her breast when lying on her right-hand side. She also reports a small amount of blood-stained discharge.

Considering the most likely diagnosis, what management option is the breast surgeon likely to recommend?

A) Reassure patient and no follow-up required
B) Follow-up in six months with safety-netting advice for the patient to return to GP if symptoms develop
C) Excision
D) Unilateral mastectomy
E) Bilateral mastectomy

A

Excision biopsy

This patient will need the full triple assessment hence the answer.

I do think the qs is a bit stupid because considering the most likely diagnosis, would be you do nothing if it is that condition… Anyway…

189
Q

A 49-year-old man presents to his GP with tingling in his right hand. He first noticed the symptoms 3 months ago when playing golf and it has progressively worsened since. He has recently found it difficult to grip a pen at work. He has a past medical history of type 1 diabetes mellitus. On examination, there is altered sensation over the right thumb, index and ring fingers. He maintains 5/5 power in his right hand in all movements except opposition of the thumb which has 4/5 power.

What is the most likely diagnosis?

A) Lateral epicondylitis
B) Medial epicondylitis
C) Amyotrophiclateral sclerosis
D) Multiple Sclerosis
E) Carpal Tunnel Syndrome

A

carpal Tunnel syndrome
It manifests with numbness in the distribution of the median nerve (first three digits and lateral half of the palm). The median nerve provides motor innervation to the muscles of the thenar eminence and the lateral two lumbricals. Loss of motor function of the median nerve will lead to difficulties with the pinch grip.

Lateral epicondylitis or ‘Tennis elbow’ causes forearm and lateral elbow pain due to overuse

Medial epicondylitis or ‘Golfer’s elbow’ causes forearm and medial elbow pain due to overuse of the flexor muscles of the forearm.

Amyotrophic lateral sclerosis is the most common type of motor neurone disease. It presents with the development of progressive upper and lower motor neuron signs. It does not cause any sensory impairment.

Multiple sclerosis can present with a variety of neurological symptoms (e.g. sensory impairment, motor impairment, visual impairment). Diagnosis requires evidence of more than one neurological manifestation separated in time and space.

190
Q

RTA with increased discomfort especially on passive movement and there is mention of new tingling and numbness on the leg involved.

What is the most approapriate next investigation?

A) CT Lower Limb Angiogram
B) Compartmental Needle Manometry
C) Lower Limb Ultrasound Scan
D) Lymphoscintigraphy
E) MRI Lower Limb

A

Compartment needle manometry

The neuro and passive movement history is suggestive of compartment syndrome. This needs to be ruled out and that can be done quickly with the above investigation.

Urgent fasciotomy is needed and this should not be delayed.

191
Q

A 74-year-old retired accountant presents to her GP with loss of vision. Over the last 4-5 years, she has noticed that her vision has become increasingly blurry and now finds it difficult to see, especially in low light. She explains that she finally decided to seek help after nearly crashing into another car whilst driving yesterday. She has not seen any objects in her peripheral vision nor any flashing lights, however, she has noticed that she finds it much more difficult to tolerate bright lights than she used to. She has never had any previous issues with her eyes or her vision and does not wear glasses. She has no past medical or surgical history. She has smoked 10 cigarettes a day for the last 40 years and drinks alcohol socially.

Using a Snellen chart, the GP determines that she has 20/50 vision in both eyes.

Examination of the patient’s cranial nerves and fundoscopy are unremarkable.

What is the most likely diagnosis?

A) Age-related Macular Degeneration
B) Retinal Detachment
C) Cataracts
D) Chronic Open Angle Glaucoma
E) Myopia

A

cataracts

In patients where ageing is the main cause, cataracts tend to be bilateral, meaning that both eyes will be abnormal when tested individually (although there is often a discrepancy in visual acuity between the two). Additional symptoms of blurred vision, glare and washed-out colour vision are all typical of cataracts. On examination one might see a straw-coloured lens or an absent red reflex on fundoscopy, but these are not always present or obvious.

Age-related macular degeneration (AMD) is caused by damage and atrophy to the cells of the retinal pigment epithelium, which lies between the photoreceptors and choroid of the retina. Unlike age-related cataracts, the symptoms of which come on over a period of months or years as they have in this patient, age-related macular degeneration usually has a relatively quick onset. There is blurring and/or visual loss at the centre of the patient’s visual fields, whilst the patient’s peripheral vision is spared. AMD becomes even more unlikely when one considers that normally, signs would be observed on fundoscopy. These include small yellow spots on theretina (called drusen deposits), atrophy, pigment clumping and occasionally neovascularisation

192
Q

A 73-year-old woman who was admitted to hospital with an infective exacerbation of COPD is found to have loss of her peripheral visual fields on a cranial nerve examination. The finding is considered to be incidental and, following her discharge from hospital, she attends an appointment at the ophthalmology outpatient clinic. The ophthalmologist confirms the defect and decides to perform further tests. On fundoscopy, he finds a raised optic cup-to-disc ratio in both eyes, with appearances otherwise normal.Tonometry reveals raised intraocular pressure in both eyes and slit lamp examination and gonioscopy are normal.

A diagnosis of chronic open-angle glaucoma is made. What is the most appropriate management option?

A) Topical Latanoprost
B) Topical Brinzolamide
C) Laser Trabeculoplasty
D) Trabeculectomy
E) Peripheral Iridotomy

A

Topical Latanoprost

Topical prostaglandin analogues, such as latanoprost, are the first-line treatment for open angle glaucoma and will help to prevent further deterioration in vision. Prostaglandin analogues improve the outflow of aqueous humour through the trabecular meshwork by relaxing the ciliary muscle and stimulating matrix metalloproteinases, which break down the trabecular meshwork.

Carbonic anhydrase like B can be used if the above doesnt work

C -> is used if medical does not work. and is prefered over D as D is more invasive.

E -> This is only for acute angle glaucoma

193
Q

A 43-year-old woman is being reviewed by the weekend ward cover team. She had been admitted with cholecystitis and is currently being treated medically with IV ceftriaxone and metronidazole. Her observations are stable and, on examination, her abdomen is soft and nontender. She had been noted to be hyponatraemic earlier in the week and a panel of tests had been requested.

Urine output: 36 ml/hr (patient weight:65kg)

Her drug chart states that she has been on her current antibiotics for 4 days and that she received two STAT doses of gentamicin when she was admitted.

Given the information provided, that is the most likely cause of her renal impairment?

A) Cardiorenal Syndrome
B) Sepsis
C) Obstructive Uropathy
D) Acute Tubular Necrosis
E) Post-Streptococcal Glomerulonephritis

A

Acute tubular necrosis

Intrarenal tubular -> leads to hyponatraemia and increased urinary sodium concentration and low urinary osmolality

Pre-renal kidney -> Urine osmolality is raised/ urinary sodium is low

Gentamicin is known to be toxic to the tubiular epithelial cells.

194
Q

What is the managment of bladder cancer?

T1
T2
T3-4 OR N1-3 OR M1

A) Transurethral Resection of Bladder Tumour
B) Intravesical Bacillus Calmette-Guerin Therapy
C) Radical Cystectomy
D) Chemotherapy
E) Palliative Care Referra

A

T1 -> Transurethral resection of bladder tumour (MEANS NO MUCULAR INVASION) OR B) if the tumour is high riskmight add Intravesical BAcillus calmette Guerin therapy

T2 -> In our case, the tumour is T2b meaning that it invades the deep muscle of the bladder. Most cases of muscle-invasive bladder cancer warrant radical cystectomy (removal of whole bladder and parts of surrounding structures depending on the sex of the patient). Patients with muscle-invasive disease will also be considered for neo-adjunctive chemotherapywith the aim of reducing the tumour size prior to resection.

T3… -> Chemotherapy alone is offered if curative surgical resection cannot be offered. These patients should also have a palliative discussion.

195
Q

What is the next step for an patient with a hydrocele in 30 yr old male?

A) Arrange an Urgent Ultrasound
B) Refer to Urology
C) Manage Conservatively
D) Urine MC&S
E) Refer for Aspiration

A

Arrange Urgent US

In pts 20-40 + hydrocele means should have urgent US. This is done first then referred to Uro.

196
Q

What is the gold standard investigation for ureteric Colic?

A

NON contrast CT KUB.

197
Q

A 63-year-old woman is admitted to A&E with a blood glucose level of 1.6. This is her second admission in 2 months with low blood glucose levels. She has been listed as a Distributing this file can amount to a criminal offence©Make a Medic. Reg: 1192343vulnerable adult and some concerns had been raised by social services about her main carer (her son). She is a known type II diabetic who is on Humulin M3, Novorapid, Linagliptin and Gliclazide. Her serum glucose was 1.9 and her C-peptide level was 12.3 ng/mL (0.5-2.7). What is the most likely diagnosis?

A) Humulin M3 Overdose
B) Novorapid Overdose
C) Linagliptin Overdose
D) Gliclazide Overdose
E) Insulinoma

A

Gliclazide Overdose

C-peptide is raised
Can be caused by insulinoma or gliclazide as it causes increased insulin production.

198
Q
A

Furosemide -> This patient has hyponatraemia but this is a transfusion complication of TACO and this is treated with Furosemide.