2021 paper Flashcards
We think are answers??
A 19 year old man has pain in the ulnar aspect of his right hand since he threw a punch with his right fist. Which structure is most likely to have been injured?
* Distal humerus
* Distal radius
* Fifth metacarpal
* Lunate
* Scaphoid
fifth Metacarpel -> This is a boxer’s fracture The pain is in the ulnar aspect of the hand. There is another fracture involving boxers that is called the Bennett’s fracture and is on the first metacarpal joint.
Scaphoid fracture is the most common but is associated with pain in and around the snuff box and there is pain on wrist movement.
Distal Radius fracture is the colles fracture or Smith’s -> Colles is when you fall forward on to extended hands and wrist whereas Smith’s is when you fall backwards on you your hand and wrist
A 44 year old man is admitted for a day-case knee arthroscopy. He is first on the list and is scheduled for 09.00. He drank a cup of black coffee at 06.00. He has a history of oesophagitis and has suffered severe nausea and vomiting after general anaesthesia for a hernia repair. He is recovering from a cold but still has a hoarse voice. His temperature is 37.2°C and BP 160/95 mmHg. His throat is inflamed. Which clinical feature is most likely to indicate postponing the operation?
* History of oesophagitis
* Hypertension
* Laryngitis
* Previous postoperative nausea and vomiting
* Recent consumption of black coffee
Laryngitis
The consumption of black coffee is fine if there was milk then this would be more concerning, but clear liquids uptill 2 hours before surgery is fine.
A 28 year old man has had a painful red eye for five days.
He has a redness around the border of the sclera and cornea and the eye is watery. Fluorescein staining is normal. The pupil is irregular.
Which is the most likely diagnosis?
* Acute closed angle glaucoma
* Acute conjunctivitis
* Anterior uveitis
* Corneal abrasion
* Dendritic ulcer
Anterior Uveitis -> The irregular pupils and the painful red eye is suggestive of Anterior uveitis. The pupils can also present as small. there is eye pain and there is reduced acuity. This also presents with Anterior uveitis
Acute closed angle Glaucoma -> Will have a painful red eye but will likely present with a fixed and dilated pupil rather than an irregular one. Acuity can be reduced in both Anterior Uveitis and Acute Glaucoma. May present with HALOS.
Corneal Abrasian -> will have a Fluorescein staining defect green on slit lamp
Acute Conjunctivitis -> This can present as painful, there should be no drop in acuity and there pupil and the cornea should be normal and unaffected. There may be photophobia.
A 67 year old woman has an ulcer with a raised white margin on her left ear; it has been present for 3 years, growing slowly and never completely healing. She spent 20 years living in Australia before returning to the UK recently.
On examination, she has a small ulcerated area, 4mm x 6mm, on her left pinna.
Which is the most likely diagnosis?
* Actinic keratosis
* Basal cell carcinoma
* Malignant melanoma
* Seborrhoeic keratosis
* Squamous cell carcinoma
Basal Cell Carcinoma -> This is slow growing and is found in sun exposed areas commonly. This is more likely than SCC as it is very small but has a long history whereas SCC is normally larger… Additionally SCC is not likely to be pale as described but more pink or red.
BCC this would start of as a raised nodule that slowly starts growing and becomes a ulcerated in the middle with dilated vessels in the middle. telegiectasia
Actinic keratosis -> This is small crusty scaly lesions and can progress to become a SCC but I dont think it causes ulcerations.
Seborrhoeic keratosis -> This is a wart. this does not normally ulcerate.
A 35 year old woman has an ill-defined lumpy area in the upper outer quadrant of her right breast which becomes larger and tender during the second half of her menstrual cycle.
Which is the most likely diagnosis?
* Breast cancer
* Duct ectasia
* Fat necrosis
* Fibroadenoma
* Fibrocystic disease
Fibrocystic Disease -> The changes with relation to the Menstrual cycle I think is more suggestive of fibrocystic disease.
Fibroadeonams are in the same sort of age group, infact it is the case that if less than 30 and presenting with a lump like a fibroadenoma they may not need to be referred urgently. {NEED TO ASK MRS HOGBEN ABOUT URGENT AND NOT URGENT REFERRALS,}
A 43 year old man is rescued from a house fire. There are no signs of burns to the face or neck, but he has soot deposits in his nose and mouth.
His temperature is 37.5°C, pulse rate 120 bpm, BP 135/86 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 97% breathing air. He has widespread wheeze.
Which is the most appropriate management?
* Hyperbaric oxygen
* Intravenous dexamethasone
* Intubation and ventilation
* Nebulised salbutamol
* Non-rebreather mask and 100% oxygen
Intubation and ventilation - early I&V indicated in smoke inhalation when suspected oropharynx oedema
In patients with suspected Carbon monoxide poisoning there is a need to give 100% 15 L oxygen to the patient, The gold standard treatment however is a
hyperbaric O2 Chamber (This is a relative contraindication in COPD patients.)
A 71 year old man is brought to the Emergency Department with increasing drowsiness and confusion for the past 12 hours. He is taking clozapine for schizophrenia and has a history of intravenous drug abuse.
He has a temperature of 39.8°C, pulse rate 110 bpm and BP of 110/70 mmHg, and his oxygen saturation is 91% on air. Heart sounds are normal. His GCS is 12/15 (eyes 3/4, motor 6/6, verbal 3/5). He has neck stiffness. He moves all four limbs equally. There is no rash.
Which is the most likely diagnosis?
* Bacterial meningitis
* Cerebral abscess
* Neuroleptic malignant syndrome
* Serotonin syndrome
* Viral encephalitis
Viral Encephalitis -> This stem clearly indicates a meningitic picture. Viral is more likely to present with confusion, seizures and drowsiness and this patient presents with 2 of these symtoms -> the prescence of a rash makes the Bacterial more likely.
Neuroleptic Malignant syndrome or Serotonin syndrome -> Needs evidence that he is actually taking those medications.
NMS -> high fever, confusion, tachy - would have stiff muscles, stem says can move arms equally
A 56 year old woman with breast cancer has a mastectomy followed by adjuvant chemotherapy. Molecular profiling of the tumour is performed and further treatment with trastuzumab is considered.
When might this further treatment be indicated?
* BRCA1 is mutated
* Tumour is oestrogen receptor positive
* Tumour is progesterone receptor positive
* Tumour is triple negative
* Tumour overexpresses HER2 protein
Tumour overexpresses HER2 protein -> Trastuzumab is another word for Herceptin. This means that it the patient is HER 2 positive and so an antagonist is used to stop the activation of this receptor to stop cancer cells replicating.
A 24 year old man with long-standing atopic eczema develops a rash that is different from his usual eczema.
There are multiple eroded papules on the head and neck, in addition to excoriated eczema on the trunk and limbs.
Which is the most appropriate treatment for the acute eruption?
* High-potency topical corticosteroid ointment
* Oral acyclovir
* Oral flucloxacillin
* Oral prednisolone
* Topical fusidic acid
Oral Acyclovir -> this is under the assumption that they are describing Eczema herpeticum On an eczema rash. I which the treatment is with Oral Acyclovir.
A 64 year old man with a two year history of intermittent claudication presents with worsening lumbar back pain, not related to movement. He has type 2 diabetes mellitus.
Examination of his abdomen and spine is normal, but he has an absent right popliteal pulse and absent pulses in his left foot.
Which is the most appropriate initial investigation?
* Dual energy x-ray absorptiometry (DEXA) scan
* MR scan of spine
* Ultrasound scan of abdomen
* X-ray of abdomen
* X-ray of lumbosacral spine
US of the Abdomen -> this is to rule out a possible diagnosis of Abdominal Aortic Aneurysm
An 80 year old woman has recurrent abdominal pain approximately 20 minutes after she has a meal. She has noticed weight loss of 14 kg over the past six months.
She is thin and has tarstained fingers. Her temperature is 36.5°C and pulse rate 85 bpm. She has an abdominal bruit.
Which is the most likely diagnosis?
* Duodenal ulcer
* Gallstones
* Gastric carcinoma
* Mesenteric angina
* Pancreatic carcinoma
Mesenteric Angina -> The risk factors of smoking and the abdominal bruit suggests a vascular cause. Additionally the loss in weight is likely due to the bowels not working properly and so nutrients not being absorbed as well.
A 59 year old man has a prolonged postoperative ileus after a sigmoid colectomy for diverticulitis.
Which is the most appropriate method of nutrition for this patient?
* Fortified oral supplements
* Intravenous 10% glucose
* Intravenous total parenteral nutrition
* Nasogastric feeding tube
* Percutaneous endoscopic gastrostomy feeding tube
Intravenous Total parentral nutrition
In the case of a post operative ileus -> Initially pt should be NBM + with IV fluids–> be placed with an NGT if they are vomiting . This is then progressed into total paraentral nutrition if the Post operative Ileus is PROLONGED.
Add BMJ SCREENSHOT
Prolonged > 4days
Total parade trail nutrition should be started after 7 days
If not prolonged if fluids is 1st and you consider an NGT
A 69 year old woman has constant dribbling of urine and has had to wear pads continuously for the last 12 month. She had radiotherapy for carcinoma of the cervix when she was 48 years old.
Her temperature is normal. Her bladder is not palpable or tender and neurological examination is normal.
Which is the most likely cause of her symptoms?
* Detrusor overactivity
* Neurogenic bladder
* Stress incontinence
* Urinary infection
* Vesicovaginal fistula
Vesicovaginal fistula -> Would explain the constant dribbling. Neurogenic bladder and detrusor activity will have more of an urge incontinance history. Additionally the Radiotherapy is a risk factor for vesicovaginal fistula.
A 65 year old woman has a hoarse voice for 4 weeks. She has lost 2 kg in weight over the past 2 months. She had a right hemithyroidectomy 10 years ago for a solitary nodule. She has an 80 pack-year smoking history.
There are no lymph nodes palpable in the neck. Chest X-ray is normal.
Which is the most important next investigation?
* CT scan of chest
* Flexible nasendoscopy
* Isotope scan of thyroid
* Thyroid function tests
* Ultrasound scan of neck
Nasoendoscopy -> The hoarse voice is persistent and is a red flag sign. This needs to be further investigated with after a 2week referral to ent with a nasoendoscopy followed by a contrast CT
Paste email from reg
A 23 year old woman has 8 weeks of intensely itchy transient circular weals on her trunk and limbs. Individual lesions last for less than 24 hours and resolve without any discolouration of the skin. She is otherwise fit and well.
Which is the best management advice?
* Frequent application of emollient
* Oral loratadine
* Oral prednisolone
* Topical hydrocortisone
* Trial of dairy-free diet
Oral Loratadine -> Describing Uritcaria -> this needs to be treated intially with Oral Antihistamines of which Loratadine is one. In Severe cases thoug I dont know what that would be it would be treated with corticosteroids.
A 67 year old man has back pain that is not controlled by paracetamol (1 g four times daily). He is receiving palliative care for pancreatic cancer.
Which is the most appropriate next analgesic?
* Fentanyl patch
* Lidocaine patch
* Regular codeine phosphate
* Regular controlled release morphine
* Short acting morphine as required
Regular Codeine phosphate -> The pain ladder starts with paracetamol-> this then progresses to NSAIDS or another non opiod management of pain. This can then be progressed onto a opioids but first weak opiods such as codeine phsophate. Morphine is a stronger and so would not be used. Short acting would be used initially if there is evidence that this is used a lot then a regular controlled release morphine may be used.
Apparent patches can only be started if analgesia has been established
A 20 year old man has a painless lump arising from the lower pole of his right testis. His left testis is normal. An ultrasound scan shows a solid mass in his right testis and a radical orchidectomy is planned.
In addition to β-human chorionic gonadotropin (HCG), which tumour marker should be measured before the procedure?
Cancer antigen 19-9 (CA 19-9)
Cancer antigen 27.29 (CA 27.29)
Cancer antigen 125 (CA 125)
Carcinoembryonic antigen (CEA)
A-Fetoprotein (AFP)
Alpha Fetoprotein -> is one of the tumour markers for testicular cancer. This makes it an approapriate marker to test for. Teratoma linked.
Beta HCG -> Also linked with testicular cancer
Ca 19-9 -> Pancreatic cancer
CA125 -> Ovarian cancer
CEA -> Colorectal cancer
Ca 27.29 -> Another tumour marker for breast cancer Ca15-3 is the other breast cancer one
A 62 year old woman has blurred vision and extreme pain in her right eye of sudden onset. She is nauseated, has a headache and is seeing haloes around bright lights. The ocular pressure is reduced with drugs. The ophthalmologist explains to the patient that medical management alone is likely to be insufficient to reverse the problem.
Which I the most appropriate surgical treatment? (Mentiont the medical management for Acute close angle glaucoma)
* Laser capsulotomy
* Laser peripheral iridectomy
* Macular grid laser
* Optic nerve sheath fenestration
* Panretinal photocoagulation
Laser Peripheral iridectomy ->
This patient has Acute closed angle glaucoma. -> The definitive management for this patient would be to have the above surgery.
The initial medical managment for this would however be -> a combination of eye drops -> Pilocarpine, beta blocker and an* alpha 2 agonist*
Acetazalomide + Topical steroids are also sometimes used
Pan retinal Photocoagulation -> is the treatment for Diabetic retinopathy, It is also sometimes used in the treatment of Age related macular degeneration
A 55 year old man undergoes endoscopy for haematemesis. A duodenal ulcer is seen with a clot visible in its base.
Which substance is the primary factor facilitating platelet adhesion?
* Factor IX
* Factor VIII
* Fibronectin
* Tissue factor
* Von Willebrand factor
Von Willebrand factor
A 78 year old man has a serum creatinine of 148µmol/L (60-120). Three months ago, his serum creatinine was normal. He has prostate cancer with multiple bone metastases and recently had a pathological facture of the L4 vertebral body. He also has heart failure and diabetes mellitus. He takes amlodipine, bisoprolol, gliclazide, ibuprofen and morphine.
Which drug is the most likely cause of his deteriorating renal function?
* Amlodipine
* Bisoprolol
* Gliclazide
* Ibuprofen
* Morphine
Ibuprofen Nephrotoxic drug because it causes reduced renal plasma flow.
Drugs like morphine and Metformin need to be carefully used in renal failure as they are likely to accumulate as they are renally excreted. However these drugs are not nephrotoxic.
A 40 year old man has an extensive rash that started 2 days ago and is worsening. He is shivering and feeling generally unwell. He has no past medical history, but has recently been treated for a chest infection.
His skin is now red over most of the body, with some large blisters and some areas of erosion. There is extensive ulceration in the mouth, and the conjunctivae are injected.
Which is the most likely diagnosis?
* Bullous pemphigoid
* Eczema herpeticum
* Pemphigous vulgaris
* Staphylococcal scalded skin syndrome
* Toxic epidermal necrolysis
Toxic Epidermal Necrolysis -> The fact that mucousal lesions are present means that staphylococcal scalded skin syndrome is unlikely. This leaves Toxic epidermal necrolysis or Steven Johnson syndrome. If there is mention of rupture of the bullae with mild lateral pressure makes the above SSS and TEN more likely
The systemic features points more towards the diagnosis of Toxic Epidermal Necrolysis and SSS
Bullous pemphigoid also does not useually have mucousal involvment and often the blisters heal. -> PEMPHIGUS Vulgaris Will have mucousal involvement, And will have less systemic features.. Apparently it is also less itchy…
Additionally Pemphigus Vulgaris will have blisters that rupture easily like SSS and TEN but this is different to bullous pemphigoid.
A 50 year old woman has suddenly become short of breath. She has found it painful to swallow for two months, and she has coughed up a small amount of blood. She is distressed and cannot lie flat.
Her temperature is 37.5°C. Her respiratory rate is 40 breaths per minute and her oxygen saturation is 78% using 15L pe minute via a re-breather mask. She has inspiratory stridor.
What is the most appropriate action to take?
* Continuous positive airways pressure ventilation
* Endotracheal intubation
* Nebulised bronchodilators
* Oral airway
* Tracheostomy
Endotracheal Intubation
This seems to be the start of airway obstruction and a secure airway needs to be placed.
The crico would be the other possible emergency airway that is patent and garunteed. Tracheostomy is a planned emergency procedure…
If there was stridor on its own with no painfuls swallow I would be inclined to try the bronchodilators or nebulaised adrenaline.
CPAP if there is tType 1 respiratory failure eg with HF.
A 29 year old man presents after a fall on to his outstretched left arm.
The left shoulder is deformed and there is sensory loss over the deltoid muscle. The radial pulse is palpable and the patient is able to extend his wrist.
What nerve is most likely to have been damaged?
* Axillary
* Median
* Musculocutaneous
* Radial
* Ulnar
*
Axillary -> This is the innervation of the Deltoid. hence the sensort loss there. This is often damaged in a* shoulder dislocation*
Radial Nerve is responsible for the extenstion movments of the arm. This is damaged in humoral shaft injuries
Ulnar and median nerve is often caused by fractures and disloncations of the elbows. They can both present with a claw deformity however the resting position would be claw shaped for an ulnar deformity and when trying to make a fist there will be the claw deformity in median nerve palsy.
Add info on musculocutaneous nerve injury
An 88 year old woman has had a major stroke and has developed bilateral bronchopneumonia and acute kidney injury. Her breathing becomes noisy, with a water rattling noise with each inspiration. Her family become distressed by this noise and ask what is causing it.
Which is the most likely mechanism for this noisy breathing?
* Bacterial infection of the larynx
* Compensatory hyperventilation in acidosis
* Increased parasympathetic tone leading to increased salivary secretion
* Pooling of saliva because of poor swallowing
* Unidentified pharyngeal foreign body
Pooling of saliva because of poor swallowing -> the stroke increases the likeliness of this being the cause.
