2023-4 IMP mocks 1-4

Question 1

A 49 year old man has 3 days of cough and fever. He undergoes haemodialysis three times per week. His temperature is 38.6°C, pulse rate 90 bpm, BP 122/80 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 95% breathing 15 L/min oxygen via a non-rebreather mask. His JVP is 4 cm above the sternal angle. He has inspiratory crackles in the right mid and lower zone and left upper zone. His blood capillary glucose is 12 mmol/L. Investigations: Sodium 131 mmol/L (135–146) Potassium 5.7 mmol/L (3.5–5.3) Urea 16.7 mmol/L (2.5–7.8) Creatinine 327 μmol/L (60–120) Chext X-ray: see image
Which is the most appropriate initial treatment?
A. Haemodialysis
B. Intravenous 10 mL 10% calcium gluconate
C. Intravenous 1000 mL 0.9% sodium chloride over 1 h
D. Intravenous co-amoxiclav and clarithromycin
E. Intravenous furosemide

Answer 1

IV Co-amo and clarithro -> This patient is suffereing from a severe pneumonia and so needs to be treated accordingly. The hyponatraemia may be suggesting a legionella infection. Therefore the addition of the clarith

Question 2

A 28 year old man is investigated for polyuria and polydipsia. He has bipolar disorder for which he has taken lithium for 2 years. Initial investigations: Sodium 145 mmol/L (135–146) Potassium 3.9 mmol/L (3.5–5.3) Serum osmolality 296 mOsmol/kg (285–295) Urinary osmolality 356 mosmol/kg (100–1000) Fasting glucose 5.8 mmol/L (3.0–6.0) Serum lithium 0.75 mmol/L (0.5–1.2)
Which is the most useful diagnostic investigation?
A. 24-h urinary cortisol test
B. Glucose tolerance test
C. Serum corrected calcium
D. Short Synacthen test
E. Water deprivation test

Answer 2

Serum corrected Calcium -> Lithium can cause Diabetes insipidus but it can also cause Hyperparathyroidism that can cause Hypercalcaeima that can lead to the symptoms described.

Question 3

A 92 year old woman has severe neck, chest and back pain and tingling in her left hand following a mechanical fall. She has bruising around her right eye. Investigations: CT scan of head: no intracranial injury or bleed, mild small vessel disease; right orbital fracture Chest X-ray: lung fields clear; left sided 4th rib fracture Full blood count and clotting screen are normal.
Which is the most appropriate next investigation?
A. Cervical spine X-ray
B. CT angiography
C. CT scan of chest
D. CT scan of neck
E. MR scan of brain

Answer 3

CT scan of neck -> The hx and exam is suggetive of a Cervical spine fracture. This is best tested with a CT scan of the neck.

Severe neck pain + tingling

Question 4

A 24 year old woman attends her GP with 2 months of intermittent palpitations. She describes the episodes as feeling as if the heart stops for a second followed by a pounding sensation. She reports episodes two to three times per week lasting 5–10 minutes, most commonly when she is going to sleep. She is otherwise well. She has been taking the combined oral contraceptive pill for 2 years. Her pulse rate is 68 bpm and BP 108/71 mmHg. Her heart sounds are normal. Investigations: ECG: sinus rhythm, rate 70 bpm.
Which is the most likely diagnosis?
A. Paroxysmal atrial fibrillation
B. Sinus arrhythmia
C. Sinus tachycardia
D. Supraventricular premature beats
E. Supraventricular tachycardia

Answer 4

**Supraventricular premature beats ** -> The singular pounding sensation is suggestive of the diagnosis.

Question 5

A 52 year old man has 3 months of fatigue. He has a history of ulcerative colitis and takes mesalazine. He drinks 20 units of alcohol per week. His temperature is 36.8°C and pulse rate 80 bpm. He has 3 cm hepatomegaly. Investigations: Albumin 36 g/L (35–50) ALT 65 IU/L (10–50) ALP 580 IU/L (25–115) Bilirubin 18 μmol/L (<17) γGT 230 IU/L (9–40) Ultrasound scan of abdomen: bile duct wall thickening and dilatation
Which is the most appropriate next diagnostic investigation?
A. CT scan of abdomen
B. Endoscopic retrograde cholangiopancreatography
C. Liver biopsy
D. MR cholangiopancreatography
E. Percutaneous transhepatic cholangiography

Answer 5

MR Cholangiopancreatography -> PSC gold standard investigation
It has a beaded appearance

Question 6

A 60 year old woman has 6 weeks of a cough productive of blood streaked sputum. Investigations: CT scan of chest: mass in left lower lobe Needle biopsy: nuclei that are enlarged, hyperchromatic and pleomorphic.
Which is the most likely diagnosis?
A. Adenoma
B. Carcinoma
C. Hamartoma
D. Sarcoidosis
E. Tuberculosis

Answer 6

Carcinoma -> Nuclear enlargement, hyperchromasia and pleomorphism are all suggestive of a carcinoma

Question 7

A 16 year old girl presents to the Emergency Department after an episode of loss of consciousness following a fall. She had consumed an excessive amount of alcohol at a party before the fall. She has a dirty scalp wound and cannot remember recent events. Her pulse rate is 68 bpm, BP 110/80 mmHg and oxygen saturation 98% breathing air. She opens her eyes to command and is confused. Her capillary blood glucose is 6.0 mmol/L. Her wound is cleaned and sutured.

Which is the most appropriate immediate management plan?

A. Admit and observe for 24 h (when?)
B. CT scan of head (immediate or within 8hrs?)
C. Discharge with head injury instructions
D. Refer to neurosurgeon
E. X-ray of skull

Answer 7

CT Head -> The indications for a CT head are the following…. If retrograde amnesia,otherwise admit and observe
Immediate:
* a GCS score of 12 or less on initial assessment in the emergency department
* a GCS score of less than 15 at 2 hours after the injury on assessment in the emergency pdepartment
* suspected open or depressed skull fracture
* any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
* post-traumatic seizure
* focal neurological deficit
* more than 1 episode of vomiting.

within 8hrs:
* age 65 or over
* any current bleeding or clotting disorders
* dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of more than 1 m or 5 stairs)
* more than 30 minutes’ retrograde amnesia of events immediately before the head injury.

Question 8

A 52 year old man visits his GP for health screening. He is well. His pulse rate is 80 bpm and irregular, and BP 128/84 mmHg. Investigations: Sodium 136 mmol/L (135–146) Potassium 3.9 mmol/L (3.5–5.3) Urea 4.9 mmol/L (2.5–7.8) Creatinine 80 μmol/L (60–120) HbA1c 40 mmol/mol (20–42) Thyroid function tests are normal. ECG shows atrial fibrillation, 76 bpm.
Which is the most appropriate treatment?
A. Apixaban
B. Aspirin
C. Diltiazem hydrochloride
D. No treatment
E. Warfarin sodium

Answer 8

No treatment -> CHADSVASc = 0 therefore there is no need to anticoagulate.

In terms of rate or rhythm control. This meets the criteria of rate control however as at rest the HR is less than 90bpm the rate control medication is not needed.

Question 9

An 80 year old man presents to the Emergency Department with 2 hours of epistaxis that has not stopped despite compression. He has a history of hypertension. A bleeding site is visible in the anterior nasal cavity. His BP is 160/95 mmHg.
Which is the most appropriate initial management option? Why not other options.

A. Anterior pack
B. Antihypertensive medication
C. Cautery
D. Cryotherapy
E. Ice pack

Answer 9

Cautery -> Cautery is the way to treate a accessible site .

Anterior pack is used for profuse bleeding with sites that are difficult to localise.

Antihypertensive may help prophylactically but not with the current bleed

Cryotherapy and Ice packs are of little advantage and secondary…

Question 10

A 23 year old man attends the sexual health clinic with a painful swelling in his groin and pain when opening his bowels. He had unprotected anal sex with a new male partner 4 weeks ago. He has a perianal ulcer and tender inguinal lymphadenopathy.
Which is the most likely diagnosis?
A. Genital herpes
B. Gonorrhoea
C. HIV seroconversion
D. Lymphogranuloma venereum
E. Secondary syphilis

Answer 10

Lymphogranuloma venereum -> Proctitis (pain with bowel can be suggestive of prostitis) and lymphadenopathy make LGV the most likely

This is caused by Chlamydia trachomatis.
This is not the same as chlamydia just caused by the same organism. RF inc MSM

Question 11

A 25 year old man presents to the Emergency Department after vomiting a large quantity of blood. At endoscopy, a deep ulcer is identified in the posterior wall at the junction of the first and second parts of the duodenum. There is a bleeding vessel in the base.
From which artery is the bleeding most likely to be arising?
A. Gastroduodenal artery
B. Left gastric artery
C. Short gastric artery
D. Splenic artery
E. Superior mesenteric artery

Answer 11

Gastroduodenal Artery

Question 12

A 27 year old woman has a long history of irregular menstruation. She does not take any medication. Her BMI is 29.4 kg/m2. Investigations:

LH (pre-menopausal female) 15 U/L (follicular) (1–11)
FSH 6 U/L (follicular) (2–8)
Testosterone 3.5 nmol/L (0.2–2.9)
Cortisol post 1 mg dexamethasone 40 nmol/L (<50)
Prolactin 425 U/L (100–500)

Which is the most likely diagnosis?
A. Androgen secreting tumour
B. Cushing’s syndrome
C. Polycystic ovary syndrome
D. Premature ovarian failure
E. Prolactinoma

Answer 12

PCOS -> There are olgomenohrrea and there is signs of high testosterone… Increased LH to FSH ratio…

Question 13

A 75 year old man is admitted with weakness in his legs. He has a squamous cell lung cancer treated by radiotherapy 18 months previously. He is cachetic. He has 4 out of 5 power in hip flexion and knee flexion bilaterally. Sensation and reflexes are normal, and sphincter function is preserved. His BMI is 17 kg/m2. MR scan of spine shows destructive bony lesions of T12 and L2–L4 vertebral body.
Which treatment is most appropriate to preserve neurological function?
A. Chemotherapy
B. External beam radiotherapy
C. Intravenous bisphosphonates
D. Radiation brachytherapy
E. Surgical decompression of the spinal cord

Answer 13

External beam Radiotherapy -> This is the next step in management post Dexamethasone. Surgical decompression cannot be done as the patient is to unwell and mets mean that there are multiple sites as well, however can be an option a Spinal cord compression patient,.

Question 14

A 26 year old woman has 12 months of back pain, located in the low lumbosacral region. She has intermittent bilateral thigh pain. The back pain disturbs her sleep. The pain is improved by activity but not relieved by resting. She finds it difficult to bend down during the day to pick things up from the floor.
Which clinical feature is most specific for inflammatory back pain?
A. Improvement with activity
B. Nocturnal pain
C. Radiation to leg
D. Stiffness during the day
E. Young age

Answer 14

Inflammatory pain -> Improvement with activity is the most specific

Inflammatory pain can wake the patiens up in early hours of the morning

Morning stiffness is specific to inflammatory pain

Question 15

A 68 year old man has a swollen tender knee for 3 days and cannot weight bear. He has had previous episodes of big toe swelling. He has a history of chronic kidney disease stage 4.

Investigations:
Fluid analysis of knee aspirate:
White cell count 55 000/mL, 95% neutrophils
Gram stain negative
Copious 10 μm intracellular needle shaped crystals
Which is the best initial treatment for his acute knee pain and swelling?

A. Arthroscopic joint washout
B. Intravenous flucloxacillin
C. Oral allopurinol
D. Oral naproxen
E. Oral prednisolone

Answer 15

prednisolone -> Dumbass the pt is CKD stage 4 so NSAIDs should be avoided as such the next best option is Steroids…

Negatively bifringent needle shaped crystals are gout
Pseudo gout is positively bifringent rhomboid crystals

Question 16

An 18 year old man is in the intensive care unit with septic shock as a result of a compound fracture of his leg. His urine output has been <30 mL for the past 2 hours. His pulse rate is 125 bpm, BP 85/40 mmHg and JVP 4 cm above the sternal angle. There are basal crackles on auscultation of the chest. Investigations: ECG shows sinus rhythm, 125 bpm. He is being treated with intravenous 0.9% sodium chloride at 125 mL/h and antibiotics.
Which is the most appropriate additional intravenous treatment?
A. 500 mL 0.9% sodium chloride over 15 min
B. 500 mL Hartmann’s solution over 15 min
C. Dopamine hydrochloride
D. Furosemide
E. Noradrenaline/norepinephrine

Answer 16

Noradrenaline -> th vasopressors are used rn because of the fact that this was a patient who has been pumped with liquids as they are a septic and had been treatedl. Additionally their JVP is normal and already on an infusion. As such more fluids may be overloading them and so vasoconstriction is needed with the use of vasopressors.

Question 17

A 34 year old man has pain in his right shoulder and upper arm for 6 weeks that worsens when elevating his arm above his head. He does not recall any injury. There is no deformity, tenderness or reduced range of movement. There is pain on abduction of the right shoulder that is worse with the arm in internal rotation and when abduction is resisted. He is treated with ibuprofen.
Which is the most appropriate next step in management?
A. MR scan of shoulder
B. Refer for orthopaedic opinion
C. Refer for physiotherapy
D. Ultrasound scan of shoulder
E. X-ray of shoulder

Answer 17

Physiotherapy -> This is a diagnosis of tendinopathy of the right supraspinatus…
No further investigations are needed. Just need s home excercises and physiotherpay.

Question 18

A 65 year old woman with advanced carcinoma of the breast with cerebral and liver metastases is rapidly deteriorating and is recognised to be dying. She becomes confused and agitated.
Which is the most suitable initial treatment?
A. Diamorphine hydrochloride
B. Glycopyrronium
C. Hyoscine hydrobromide
D. Midazolam
E. Mirtazapine

Answer 18

Midazolam -> Terminal restness is just treated with Midaxolam…
The stem choooses to highlight the fact that this patient is deterioting and it is due to a terminal illness suggesting that they have ruled out other causes.

Question 19

A 80 year old man has progressive memory loss over 2 years. He scores 20/30 on the Montreal Cognitive Assessment, and he requires an MR scan of brain.
In which part of the brain are changes most likely to be found in early Alzheimer’s disease?
A. Basal ganglia
B. Frontal lobe
C. Medulla oblongata
D. Parietal lobe
E. Temporal lobe

Answer 19

Temporal Lobe-> It affects the hippocampus and that is found in the temporal lobe.

Question 20

A 43 year old woman is admitted to hospital with an overdose of amitriptyline hydrochloride taken 4 hours previously. She has a history of chronic headache. Her pulse rate is 105 bpm and BP 95/40 mmHg. She is drowsy and her pupils are dilated. ECG shows significant QRS prolongation.
Which is the most appropriate immediate management option?
A. Activated charcoal
B. Intravenous amiodarone hydrochloride
C. Intravenous atropine sulfate
D. Intravenous magnesium
E. Intravenous sodium bicarbonate

Answer 20

IV sodium Bicarb -> This is the management of arrythmias in patients with TCA overdose/

Question 21

A 74 year old man has progressively worsening muscle aches that are now causing him to struggle to get up from a chair or raise his arms above his head. He has a history of oesophageal cancer treated surgically and ischaemic heart disease. He is taking bisoprolol, clopidogrel, ramipril and simvastatin. Investigations: Haemoglobin 125 g/L (130–175) White cell count 7.8 × 109/L (3.0–10.0) Platelets 391 × 109/L (150–400) Erythrocyte sedimentation rate 105 mm/hr (<20)
Which is the most appropriate therapeutic change?
A. Start co-codamol
B. Start ibuprofen
C. Start prednisolone
D. Stop bisoprolol
E. Stop simvastatin

Answer 21

Start prednisolone -> This patient has Polymyalgia rheumatica.
They often present with pain that means they struggle from getting up from chair or bed in the moring.There is also a raised ESR.

Their Creatinine kinase and EMG will be normal!!

Question 22

A 61 year old woman is admitted with 2 days of confusion. She has a history of hypertension and takes nifedipine. She smokes 20 cigarettes per day. She is confused but has no focal neurological deficit. Her pulse rate is 75 bpm, BP 139/87 mmHg and JVP 2 cm above the sternal angle. Investigations: Sodium 117 mmol/L (135–146) Potassium 4.2 mmol/L (3.5–5.3) Urea 1.9 mmol/L (2.5–7.8) Creatinine 57 μmol/L (60–120) Serum osmolality 252 mOsmol/kg (285–295) Urine osmolality 585 mOsmol/kg (100–1000)
Which mechanism best explains the development of hyponatraemia?
A. Increased sodium secretion in the distal tubule
B. Increased water absorption in the collecting duct
C. Increased water ingestion
D. Reduced cortisol secretion
E. Reduced sodium reabsorption in the proximal tubule

Answer 22

Increased water absorption in the collecting duct -> This is SIADH. They have hyponatreamia and this should result in dilute urine as well but instead the urine is inapproapriately diluted…. ASH is secreted and causes increased water reabsorption.

Question 23

A 56 year old woman has home blood pressure readings averaging 160/90 mmHg. Hypertension is confirmed on 24 hour ambulatory monitoring. She has type 1 diabetes mellitus. Investigations: Urinary albumin: creatinine ratio 42 mg/mmol (<3.5) eGFR 43 mL/min/1.73 m2 (>60)
Which type of antihypertensive is most appropriate?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Calcium channel blocker
E. Thiazide-like diuretic

Answer 23

ACE inhibitor -> There is good evidence ACEi in addition to its hypertensive properties

Question 24

A researcher is seeking to examine whether long-term mobile phone use is linked to acoustic neuroma risk. The information on mobile phone usage is collected from participants with acoustic neuroma and a comparable group of participants without acoustic neuroma, selected from the general practice register.
Which type of study design is being used?
A. Case–control study
B. Case series
C. Cohort study
D. Cross-sectional study
E. Ecological study

Answer 24

Case control study ->
This a study with the disease and without the disease and then you go back and count the exposure of something…

Cohort study is prospective where you take to groups and measure the percent of people who get that outcome.

Both are observational studies.
Case control -> They have the outcome and are checking the occurence of the exposure… Here the outcome is rarer
Cohort study -> they have the exposure and then check the incidence of the outcome. Here the exposures is rarer.

Question 25

A 76 year old man undergoes an abdominoperineal resection for a low rectal carcinoma. He has a history of severe COPD and hypertension.
Which is the most appropriate method for providing analgesia during the early postoperative period?
A. Epidural anaesthesia
B. Intramuscular opioid
C. Oral non-steroidal analgesia
D. Patient controlled intravenous analgesia
E. Spinal anaesthesia

Answer 25

Epidural Anaestheisa -> ‘A patient with abdominal surgery and respiratory comorbidities should not be given opiods.

Epidural is the best as it can be topped up or titrated. Spinal anaesthesia cannot. IM is difficult to titrate.

Question 26

An 18 year old woman has had a chronic skin condition for several years. She has noticed that she gets well-defined areas of scale formation at the sites of minor skin injuries, such as scratches or insect bites, typically when the injuries are healing. The scaling can persist for several weeks or months.
What is the most likely underlying skin condition?
A. Acne vulgaris
B. Eczema
C. Psoriasis
D. Seborrhoeic dermatitis
E. Vitiligo

Answer 26

Psoriasis -> Describing Koebnerisation. Psoriasis is the most common cause.

Question 27

A 65 year old woman underwent mechanical aortic valve replacement and coronary revascularisation 3 days ago. She is being treated with dalteparin sodium. She is also taking aspirin long term.
Which is the most appropriate long-term patient management?
A. Apixaban
B. Clopidogrel
C. Continue dalteparin sodium
D. Rivaroxaban
E. Warfarin sodium

Answer 27

Warfarin Sodium -> All mechanical valves require treatment with aspirin and warfarin.

Question 28

A 78 year old woman has pain in both shoulders, hips and thighs. She is very stiff on waking in the morning and takes 2–3 hours to loosen up. She finds getting dressed difficult. Investigations:Erythrocyte sedimentation rate 67 mm/hr (<20) CRP 87 mg/L (<5)
What is the most appropriate initial treatment?
A. Co-codamol
B. Leflunomide
C. Methotrexate
D. Naproxen
E. Prednisolone

Answer 28

Prednisolone -> NSAIDS dont really work. Prednisolone works.

Question 29

A 27 year old man has left-sided chest pain of sudden onset that is worse on taking a deep breath. His temperature is 36.8°C, pulse rate 126 bpm, BP 108/60 mmHg, respiratory rate 28 breaths per minute and oxygen saturation 94% breathing air. Investigations: ECG: sinus tachycardia
Which is the most appropriate next investigation?
A. Chest X-ray
B. CT pulmonary angiography
C. D dimers
D. Echocardiography
E. Ventilation/perfusion isotope lung scan

Answer 29

Chest X-ray

There is a need to rule out other pathology before considering a PE. The NICE guidelines suggests that patients that are presenting with symptoms of PE should have MEdical Hx and Examinaiton . This should be then followed by a CXR to rule out other pathology. After this the WELLS score needs to be used.

Question 30

A 28 year old woman has a neck lump that she noticed incidentally when rubbing her neck. There is a smooth, non-tender 1.5 cm mobile lump within the thyroid gland. Investigations: TSH 2.3 mU/L (0.3–4.2) Free T4 17 pmol/L (9–25)
Which is the most appropriate next investigation?
A. CT scan of neck
B. No further investigation needed
C. Thyroid antibodies
D. Thyroid scintigraphy
E. Ultrasound scan of neck

Answer 30

US scan of the neck -> There is evidence of a non-functioning thyroid nodule. this needs to be US so that it can be classified. An FNA may be indicated

Question 31

A 78 year old man has type 2 diabetes. His clinician does not invite him to join an internet-based self-monitoring programme because she considers him to be too old to engage with it effectively.
What is the most appropriate description of the clinician’s approach?
A. Bias
B. Discrimination
C. Inequity
D. Prejudice
E. Stereotyping

Answer 31

Discrimination

Question 32

A 78 year old patient is admitted with chronic oropharyngeal dysphagia. He has left ventricular systolic dysfunction from ischaemic heart disease. He is breathless on exertion, particularly when climbing stairs. He is being prepared for a percutaneous endoscopic gastrostomy feeding tube. The passage of a nasogastric tube has been unsuccessful, and he is having nil by mouth. He weighs 70 kg. His pulse rate is 72 bpm and BP 132/80 mmHg.

Which is the most appropriate volume of maintenance fluids (in mL) to prescribe for the next 24 hours? What is the formula?

A. 1750
B. 2450
C. 2800
D. 3000
E. 3250

Answer 32

20-25ml/kg = maintenance fluid requirement

1750

Question 33

A 72 year old woman has 6 months of increasing pain at the base of her right thumb. She is having difficulty opening jars and sewing. She is otherwise well. No other joints are painful. She is taking regular analgesia. The first carpometacarpal joint is swollen and tender, with reduced opposition of the thumb.
Which is the most likely diagnosis?
A. De Quervain’s tenosynovitis
B. Gout
C. Osteoarthritis
D. Rheumatoid arthritis
E. Septic arthritis

Answer 33

Osteoarthritis

Rheumatoid Arthritis is a polyarthritis… Only one joint is affected.

Gout and septic arthrtitis will have a lot of a shorter history for presentation

Movement associated pain is likely to mechanical pain and that is associated with osteoarthritis.

De quervain’s tenosynovitis would be pain on the radial aspect of the wrist and all over that region.

Question 34

A 62 year old man has acute breathlessness with a weak cough, following a recent viral upper respiratory infection. Over the past 4 months, he has had double vision, limb weakness and slurred speech when tired. His respiratory rate is 18 breaths per minute and oxygen saturation 96% breathing air. He is sweating and using his accessory muscles of inspiration.
Which is the most appropriate test to monitor his respiratory function?
A. Arterial blood gas
B. FEV 1
C. FVC
D. Peak expiratory flow rate
E. Ratio of FEV 1 to FVC

Answer 34

FVC -> Diagnosis is likely to be myasthenia Gravis. This needs to be monitored as it can lead to myasthenic crisis which is diagnosed when the FVC is less than 1L.

Question 35

An 80 year old woman is admitted to the Emergency Department after being found collapsed at home. She has central chest pain. Her pulse rate is 30 bpm, BP 70/40 mmHg and respiratory rate 26 breaths per minute. Her 12-lead ECG shows sinus bradycardia with no evidence of myocardial ischaemia.
Which is the most appropriate initial treatment?
A. Adrenaline/epinephrine
B. Atropine sulfate
C. Dobutamine
D. Normal saline
E. Permanent cardiac pacemaker

Answer 35

atropine

Question 36

A 52 year old woman has had three episodes of severe epigastric pain associated with vomiting over the past 3 months. The episodes occurred following eating and lasted for about 1 hour. She has type 2 diabetes mellitus and takes metformin. Abdominal examination is normal. Her BMI is 35 kg/m2(18–25). Investigations:ALT 15 IU/L (10–50) ALP 71 IU/L (25–115) Bilirubin 9 μmol/L (<17) Ultrasound scan of abdomen: single 2 cm gallstone in gallbladder, common bile duct normal, evidence of fatty liver.
Which is the most appropriate management?
A. Endoscopic retrograde cholangiopancreatography
B. Laparoscopic cholecystectomy
C. MR cholangiopancreatography
D. Open cholecystectomy
E. Ursodeoxycholic acid

Answer 36

Laparoscopic Cholecystectomy -> Symptomatic Gall stones is treated with a laparoscopic cholecystectomy. ERCP will be done bas only in ascending cholangitis.

Question 37

1.

A 63 year old woman has 4 months of abdominal bloating, fatigue and nausea. She is found to have with ovarian cancer. Staging CT is performed to look for lymphatic spread and metastatic disease.
To what regional lymph nodes is her tumour most likely to spread initially?
A. Deep inguinal nodes
B. External iliac nodes
C. Internal iliac nodes
D. Para-aortic nodes
E. Superficial inguinal nodes

Answer 37

Para-aortic nodes

Question 38

A 55 year old man has 2 days of painful red swelling of his left lower leg. He has a history of type 2 diabetes mellitus and takes metformin. His temperature is 37.6°C. He has a tender erythematous area extending from the ankle to the proximal calf.
What is the most likely causative organism?
A. Bacteroides species
B. Proteus mirabilis
C. Pseudomonas aeruginosa
D. Staphylococcus epidermidis
E. Streptococcus pyogenes

Answer 38

Streptococcus pyogenes -> This is the most common cause of leg cellulitis

Question 39

A 10 year old boy has deafness of new onset. He has a history of a recent respiratory tract infection. Tuning fork tests show: a) when the tuning fork is placed in the middle of his forehead he hears the tone loudest in his right ear;b) when the tuning fork is placed on the bone behind the right ear the sound is louder than when it is held in front of his right external auditory meatus;c) when the tuning fork is held in front of the left external auditory meatus the sound is louder than when it is placed on the bone behind the same ear.
Which ear(s) is/are affected and which type of hearing loss is this?
A. Bilateral mixed deafness
B. Left conductive deafness
C. Left sensorineural deafness
D. Right conductive deafness
E. Right sensorineural deafness

Answer 39

Right Conductive deafness
Air is meant to be louder than bone. If bone loder then it is Conductive hearing loss.

Weber locates the deafness on the patient whether it is right or left.

Question 40

A 68 year old man collapses when rising from a chair and is seen in the emergency department 45 minutes later. He is conscious but has reduced strength in his left arm (3/5) and leg (4/5) and slurring of speech. He has a history of COPD and hypertension. He smokes 10 cigarettes per day. He has bilateral scattered wheeze and carotid bruits on auscultation.
Which is the most appropriate initial radiological investigation?
A. Cerebral angiography
B. CT cerebral venogram
C. CT scan of head
D. MR scan of brain
E. Ultrasound scan of carotid arteries

Answer 40

CT scan of head ->This is a CVA and this needs A CT head

Question 41

A 79 year old woman has 3 months of a left leg venous ulcer that is slowly healing. Ankle–brachial pressure Indices are 0.9 on the left side and 1.1 on the right side (0.8–1.2).
Which is the most appropriate management?
A. Compression stockings
B. Diagnostic biopsy
C. Full-length graduated compression bandaging
D. No further management required
E. Repeat ankle–brachial pressure indices in 3 months

Answer 41

Compression stockings -> despite gradual improvement this venous ulcer would be best managed with stockings

Question 42

A 55 year old man has had lower back pain and fatigue for 3 months. Investigations: Haemoglobin 110 g/L (130–175) White cell count 5.8 × 109/L (3.8–10.0) Platelets 120 × 109/L (150–400) Corrected calcium 2.90 mmol/L (2.2–2.6) Albumin 29 g/L (35–50) Serum electrophoresis: monoclonal Ig kappa peak Bone marrow biopsy: foci of plasma cells, which account for 18% of all haematopoietic cells
Which is the most likely diagnosis?
A. Acute lymphoblastic lymphoma
B. Chronic lymphocytic leukaemia
C. Extramedullary plasmacytoma
D. Multiple myeloma
E. Waldenström’s macroglobulinaemia

Answer 42

Multiple myeloma
CRAB -> High calcaium, renal failure, anaemia + Bones(pain,osteoperosis)

MGUS - IgM spike is < 30g/L

Smouldering MM&raquo_space;

Question 43

A 54 year old woman has reduced urine output 24 hours after admission with right lower lobe consolidation due to community-acquired pneumonia. She has been treated with intravenous amoxicillin and clarithromycin, but remains breathless. Her creatinine was 82 μmol/L (60–120) on admission. Her temperature is 38.0°C, pulse rate 106 bpm, BP 102/50 mmHg and oxygen saturation 95% breathing 4 L/min oxygen via nasal prongs. Her urine output is 250 mL over the past 12 hours. Her urinalysis has protein 1+. Investigations: Haemoglobin 119 g/L (115–150) White cell count 16.9 × 109/L (3.8–10.0) Platelets 95 × 109/L (150–400) Urea 15.5 mmol/L (2.5–7.8) Creatinine 160 μmol/L (60–120)
Which is the most likely cause of her acute kidney injury?
A. Drug-induced interstitial nephritis
B. Haemolytic uraemic syndrome
C. Infection-related glomerulonephritis
D. Renal hypoperfusion
E. Systemic vasculitis

Answer 43

Renal hypoperfusion
Patient has sepsis leading to pre-renal AKI

This will lead to acute tubular necrosis.

Interstitial nephritis presents 4-7 days of post antibiotics exposure and its relative care.

This isnt nephritic syndrome so infectious glomerularnephritis is less likely

HUS would have marked anaemia and low platelet count

Question 44

A 68 year old man has eight weeks of back pain. It sometimes wakes him at night, and he is feeling increasingly tired. He has no history of back problems and has no history of recent trauma. He has tenderness over L3 and L4 vertebrae. Investigations: Haemoglobin 137 g/L (130–175)Erythrocyte sedimentation rate 55 mm/hr (< 20) Creatinine 72 μmol/L (60–120) Calcium 2.5 mmol/L (2.2–2.6)Serum protein electrophoresis: no paraprotein
Which is the most appropriate next investigation?
A. CT scan abdomen and pelvis
B. DEXA scan
C. HLA-B27 antigen
D. Isotope bone scan
E. X-ray lumbar spine

Answer 44

**X-ray lumbar spine ** -> Waking up at night is a red flag symptom as it is a sign of bone pain that could suggest malignant causes.

Question 45

An 82 year old woman has constipation and passes infrequent, hard stools. She has hypertension, overactive bladder symptoms and type 2 diabetes mellitus. She takes amlodipine, doxazosin, gliclazide, metformin and oxybutynin.
Which medication is most likely to be worsening her constipation?
A. Amlodipine
B. Doxazosin
C. Gliclazide
D. Metformin
E. Oxybutynin

Answer 45

Oxybutynin -> This is an anticholinergic and a frequent cause of constipation.

Question 46

A 69 year old man has 6 months of intermittent weakness and numbness in both legs. The symptoms comes on during walking, typically after about 100 metres, and settle after a few minutes with rest. He has found that leaning forwards whilst walking can prevent the symptoms. He can ride a bike slowly without provoking the symptoms. He has diet-controlled type 2 diabetes mellitus. He is an ex-smoker with a 40 pack-year history. His BP is 178/95 mmHg. He has weakness of hip flexion bilaterally. His peripheral pulses are palpable.
Which is the most likely diagnosis?
A. Diabetic amyotrophy
B. Lumbar disc prolapse
C. Lumbar spinal stenosis
D. Osteoarthritis of hips
E. Peripheral arterial disease

Answer 46

Lumbar spinal stenosis -> it is worsenedd by walking but it improves when leaning forward is charateristic of this conditions.

Question 47

A 62 year old man presents to the Emergency Department following a road traffic collision. He has severe bruising of the right upper shoulder from the seat belt, but no other injuries. Chest X-ray (performed to exclude a pneumothorax) shows a 2 cm mass in the right upper zone.
Which is the most appropriate next investigation?
A. CT scan of chest
B. Lateral chest X-ray
C. MR scan of chest
D. PET scan of chest
E. Technetium bone scan

Answer 47

CT scan of chest -> Mass on CXR as an incidental leads to likely cancer of lung cancer based on age an prescence of mass and so a CT scan would be the next most appropriate.

Question 48

A 19 year old woman requires an urgent appendicectomy. The anaesthetist explains that the patient will need to breathe oxygen from a face mask before induction of anaesthesia, and that she will feel some pressure on the front of her neck as she goes to sleep. The patient asks why.
What is the purpose of the cricoid pressure?
A. It facilitates endotracheal intubation
B. It prevents the passage of gastric contents into the airway
C. It reduces the haemodynamic response to endotracheal intubation
D. It reduces the risk of vomiting
E. It stabilises the neck in a neutral position

Answer 48

It prevents the passage of gastric contents into the airway -> pressure is placed on the cricoid cartilage to seal the oesophagus in order to stop the passage of gastric contents.

Question 49

A 45 year old man with pain caused by cancer has been using opioids to control his pain very successfully. He is taking a regular dose of MST Continus® 60 mg 12-hourly orally. He has been using three breakthrough doses (oral morphine 20 mg) per day for the past week.
Which is the most appropriate opioid prescription?
A. Diamorphine 60 mg subcutaneously over 24 h by syringe driver
B. Morphine 90 mg subcutaneously over 24 h by syringe driver
C. MST Continus ® 60 mg 12-hourly and morphine 30 mg as required (up to 4-hourly) orally
D. MST Continus ® 90 mg 12-hourly and morphine 20 mg as required (up to 4-hourly) orally
E. MST Continus 90 mg 12-hourly and morphine 30 mg as required (up to 4-hourly) orally

Answer 49

MST continous 90 mg 12 hourly and morphine 30 mg as required upt to 4 hourly orally -> breakthrough dose should be 1/6th of total dose. And as the pain is not managed then there is a need to increase the long acting dose.

Question 50

A 73 year old man has 3 months of increasing weakness of his right hand with reduced sensation of the forearm. There is wasting of all the intrinsic muscles of the right hand. There is weakness of finger abduction and adduction, and thumb adduction. Finger flexion is normal. There is mild altered light touch sensation along the ulnar aspect of the forearm. The biceps, supinator and triceps reflexes are normal. The lower limbs and the left arm are normal.
Where is the most likely site of the lesion causing his symptoms?
A. Median nerve in the forearm
B. Median nerve in the wrist
C. Spinal cord C8 level
D. T1 nerve root
E. Ulnar nerve at the elbow

Answer 50

T1 nerve root ->

The intrinsic hand muscle wasting suggests T1. The normal reflexes and normal other arm are against a cord lesion. The sensory loss on the forearm excludes median and ulnar nerve lesions. T1 dermatome is often thought to be higher in the arm medially.

Question 51

A 53 year old woman has 6 months of worsening tiredness. She has jaundice, xanthelasma and 7 cm non-tender hepatomegaly. Investigations: INR 1.2 (1.0) ALT 60 IU/L (10–50) ALP 302 IU/L (25–115) Bilirubin 50 μmol/L (<17) Antinuclear antibodies 1:40 (negative at 1:20) Antimitochondrial antibodies 1:320 (negative at 1:20) Ultrasound scan of abdomen hepatosplenomegaly, no biliary dilatation
Which is the most appropriate treatment?
A. Azathioprine
B. Lamivudine
C. Prednisolone
D. Thiamine
E. Ursodeoxycholic acid

Answer 51

Ursodeoxycholic acid -> PBC This is treated with UDCA

Question 52

A 30 year old man has 3 months of intermittent but worsening headaches. His only medications is paracetamol and ibuprofen as required. His BP is 220/130 mmHg. Investigations: Sodium 144 mmol/L (135–146)Potassium 3.0 mmol/L (3.5–5.3) Urea 7.0 mmol/L (2.5–7.8) Creatinine 92 μmol/L (60–120)
Which is the most likely underlying diagnosis?
A. Addison’s disease
B. Chronic kidney disease
C. Cushing’s disease
D. Phaeochromocytoma
E. Primary aldosteronism (Conn’s syndrome)

Answer 52

Conn’s Syndrome -> This is more likely. Additionally the hypokalaemia with HTN or HTN with Sleep apnoe or HTN with FHx are all suggestive

Question 53

A 24 year old man has acute shortness of breath and lightheadedness. He was admitted 24 hours ago following a car accident. He had multiple pelvic fractures and compound fractures of both tibia. These required surgical fixation. He is on intravenous morphine via a patient-controlled analgesia device, prophylactic low molecular weight heparin, intravenous flucloxacillin and intravenous 0.9% saline at 120 mL/hour.He is confused and disorientated. His temperature is 36.4°C, pulse rate 100 bpm, BP 110/60 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 85% breathing 4 L/min oxygen via nasal prongs. His chest is clear.
Which is the most likely diagnosis?
A. Cardiac tamponade
B. Fat embolism syndrome
C. Opiate toxicity
D. Pulmonary embolus
E. Subdural haematoma

Answer 53

Fat embolism -> Multiple fractures followed by early onset (within 24 hours)
PRESENTs with
* Hypoxia dysppnoea, and tachypnea.
* Neurological manifestations -> They may appear confused or have an altered state of conscoiusness.
* Finally petichial rash is the last component and only appears in a third of cases.

Question 54

A 46 year old man has a cardiac arrest in the Emergency Department after an episode of chest pain. He remains in ventricular fibrillation after three DC shocks, and he is treated with a bolus of intravenous adrenaline/epinephrine.
Which other drug treatment should be administered at the same time?
A. Alteplase
B. Amiodarone hydrochloride
C. Atropine sulfate
D. Lidocaine
E. Magnesium sulfate

Answer 54

Amiodarone -> Need to look at the guidelines.
Justification for correct answer(s): If VF/VT persists after a third shock, resume chest compressions immediately and then give adrenaline 1 mg IV and
amiodarone 300 mg IV while performing a further 2 min CPR. As per ALS guidelines 2015.

Question 55

A 74 year old man is brought to the Emergency Department after falling down the stairs. He has no pain. He has a history of atrial fibrillation and takes apixaban. He has significant bruising to the left side of his face and left arm. His pulse rate is 80 bpm, irregular, BP 150/95 mmHg and oxygen saturation 96% breathing air. His GCS score is 14.
Which is the most appropriate next step in management?
A. Cervical spine immobilisation
B. Chest X-ray
C. CT of head
D. Intravenous prothrombin complex
E. Intravenous vitamin K

Answer 55

Cervical Spine immobilisation

Airway -> Cervical spine immobilisation (Collar) -> Ix

This is because sequence of care for potential trauma patient is airway and cervical spine. There is no mention of a collar so this should be applied. This would need to be done before any of the other options. A CT scan head will be required and a chest X-ray likely. Vitamin K would not have a role and the use of prothrombin complex or other reversal agents would depend on the results of subsequent investigations.

Question 56

A 17 year old boy has repeated episodes characterised by a funny ‘racing’ sensation in his abdomen, followed by loss of awareness. His girlfriend describes that he has a vacant stare and waves his left arm around in a writhing manner during these attacks.
Which is the most likely site of origin of these episodes?
A. Cerebellum
B. Right frontal lobe
C. Right occipital lobe
D. Right parietal lobe
E. Right temporal lobe

Answer 56

Right temporal lobe -> He has focal imparied awareness seizures

The funny racing sensation is an aura and is suggestive of a temporal lobe lesion

Question 57

A 62 year old man has 1 year of intermittent heartburn and difficulty in swallowing. An endoscopic biopsy of the oesophagus 5 cm above the anatomical gastro-oesophageal junction is reported as showing ‘columnar epithelium containing goblet cells and Paneth cells’.
Which is the most appropriate pathological description of the features noted?
A. Hyperplasia
B. Hypertrophy
C. Intestinal metaplasia
D. Intraepithelial neoplasia
E. Squamous metaplasia

Answer 57

Intestinal metaplasia -> this means that it is creating intestinal cells. It does not describe the site of the metaplasia…

Aka squamous metaplasia would mean that the cells are turning from x to squamous cells.

Question 58

A 61 year old woman is admitted with 2 days of confusion. She has a history of hypertension and takes nifedipine. She smokes 20 cigarettes per day. She is confused but has no focal neurological deficit. Her pulse rate is 75 bpm, BP 139/87 mmHg and JVP 2 cm above the sternal angle. Investigations: Sodium 117 mmol/L (135–146) Potassium 4.2 mmol/L (3.5–5.3) Urea 1.9 mmol/L (2.5–7.8) Creatinine 57 μmol/L (60–120) Serum osmolality 252 mOsmol/kg (285–295) Urine osmolality 585 mOsmol/kg (100–1000)
Which mechanism best explains the development of hyponatraemia?
A. Increased sodium secretion in the distal tubule
B. Increased water absorption in the collecting duct
C. Increased water ingestion
D. Reduced cortisol secretion
E. Reduced sodium reabsorption in the proximal tubule

Answer 58

Increased water absorption in the collecting duct -> The tests reveal that this is SIADH.

Question 59

A 60 year old man visits his GP as he wants to start training for a 5 km race for charity. He plans to run 3 to 5 km three times per week. He describes occasional central chest tightness when he walks up hills. He has a history of type 2 diabetes mellitus and COPD for which he is taking metformin and using an as-required salbutamol inhaler. His BP is 162/94 mmHg. His BMI is 32.
Which aspect of his clinical background is a contra-indication to his training plan?
A. BP >160/90 mmHg
B. COPD
C. Exertional chest tightness
D. Obesity
E. Type 2 diabetes mellitus

Answer 59

Excertional chest pain -> highly indicative of ischaemic heart disease. therfore vigrous training is contraindicated due to risks of IHD.

Question 60

A 48 year old man has 1 day of severe right upper quadrant pain. He has vomited five times. He smokes 10 cigarettes per day and drinks 31 units of alcohol per week. He is tender in the epigastrium and right upper quadrant, and there is voluntary guarding. His temperature is 37.8°C, pulse rate 90 bpm and BP 140/84 mmHg. He is tender in the epigastrium and right upper quadrant, and there is voluntary guarding.

Investigations:
White cell count 15 × 109/L (3.8–10.0)
ALT 41 IU/L (10–50)
Alkaline phosphatase 125 IU/L (25–115)
Bilirubin 14 μmol/L (<17)
Amylase 222U/L (<220)
CRP 42 mg/L (<5)

Which is the most likely diagnosis?

A. Acute cholangitis
B. Acute cholecystitis
C. Acute hepatitis
D. Acute pancreatitis
E. Biliary colic

Answer 60

Acute cholecystitis -> History and Ix fit this diagnosis.

Acute pancreatitis is not right because amylase is not high enough

Biliary colic will not have ana inflammatory response -> They wont have a raised temperature of tachycardia.

Bilirubin will be higher in acute cholangitis

Question 61

A 24 year old man develops low back pain the day after falling while playing tennis. He is usually well and takes no regular medication. He is a laboratory technician.
Which is the most appropriate advice?

A. Avoid work until the pain has completely settled
B. Back strengthening exercises
C. Bed rest until pain improves, then gradual mobilisation
D. Continue usual activity
E. Self referral for physiotherapy

Answer 61

Continue usual activity ->
If you are a fit person with an acute history of lower back pain then it is fine to continue usual activity.

Question 62

A 67 year old man presents to the Emergency Department feeling generally unwell with no specific symptoms. He is being treated with neoadjuvant chemotherapy for bowel cancer. He underwent the third cycle 8 days ago. His temperature is 38.6°C, pulse rate 97 bpm, BP 132/68 mmHg, respiratory rate 12 breaths per minute and oxygen saturation 95% breathing air. Examination is otherwise unremarkable. Blood tests have been taken, but results are not yet available.
Which is the most appropriate next step in management?
A. Admit to medical receiving unit
B. Await blood results before taking further action
C. Discuss with local oncology team for advice
D. Give intravenous broad-spectrum antibiotics
E. Give intravenous fluid therapy

Answer 62

Give broad spectrum Abx -> This is suggestive of neutropenic sepsis. There is an importance to start treatment asap soo this is the most approapriate.

Question 63

A 63 year old woman has episodes of irregular palpitations, lasting several days and occurring once a month. She has a history of ischaemic heart disease and type 2 diabetes. Her ECG confirms atrial fibrillation. The patient wants to discuss the risks before starting anticoagulation (see image).
Which is her lifetime risk of having a stroke related to her atrial fibrillation?
A. 3%
B. 15%
C. 20%
D. 30%
E. 60%

Answer 63

60% I am a genius-> need to know that the life expectancy is arround 80 so she has 20 more years of life…

Then need to calculate the CHADSVASC score which is 3

so the percent is 3.2 * 20 = around 60

1 for diabetic
1 for female
1 for IHD

Question 64

The surgical registrar is running late due to a fault with their car. She asks the surgical Foundation Year 1 doctor (FY1) to obtain written consent from the patients on the afternoon list to avoid a delayed start and possible cancellations. The list is three dupuytren’s contracture releases. The FY1 has not assisted with this operation on this rotation.
Which is the most appropriate action for the FY1 to take?
A. Ask the consultant to consent the patients
B. Consent all of the patients
C. Consent all of the patients and ask the registrar to countersign the forms
D. Only consent the patients without significant medical conditions
E. Refuse to consent the patients

Answer 64

Ask the consultants to consent the patient -> The FY1 does not have the ability to take informed consent as such should organise someone who has that ability to take it.

Question 65

A 63 year old man presents to his GP for review following addition of chlortalidone to maximal-dose ramipril for BP control. He also has type 2 diabetes mellitus and chronic kidney disease and takes metformin. His creatinine 1 month ago was 115 μmol/L (60–120). His BP is 133/85 mmHg. Investigations: Sodium 135 mmol/L (135–146) Potassium 4.6 mmol/L (3.5–5.3) Urea 9.0 mmol/L (2.5–7.8) Creatinine 150 μmol/L (60–120) eGFR 44 mL/min/1.73 m2 (>60)
Which is the most appropriate management?
A. Stop metformin
B. Repeat urea and electrolytes in 2 weeks
C. Stop chlortalidone
D. Stop ramipril
E. Switch chlortalidone to amlodipine

Answer 65

Repeat U+Es in 2 weeks

The drop in Creatinine is < 30 % increase in creatinine. There is no indication to change treatment with this level of results,

Honselty a dumb qs the rise is greater than 30% doesnt even explain what it would be if it was greater than 30% and I have no clue what this is or what it is testing.

The pic below is from Zeeshan being legend… wait for it, and i hope you arent lactose intolerant becuase the 2nd half of that sentence …dairy

^^^ delirium lads and lass and others

Question 66

A 62 year old Indian woman visits her GP for an NHS health check. Her BMI is 34 kg/m2. Her BP is 110/84 mmHg. Urinalysis is normal. Investigations: Glycated haemoglobin 45 mmol/mol (20–42)
Which is the most appropriate next step in management?
A. Advise a low sugar diet
B. Prescribe metformin
C. Prescribe ramipril
D. Refer her to the Diabetes Prevention Programme
E. Send off a fasting plasma glucose

Answer 66

Refer her to the diabetes prevention programme

Basically, patients who are chinese or south asian which a BMI > 23 are at risk of diabetes and they should have a HbA1c. Hence why this patient had one. After this if they are pre diabetic which this person is because the result is between 42 and 48 they are at high risk of progressing to T2DM.

At this point a referral should be made to the Diabetes prevention programme.

If they were above 48 then it suggests they have t2DM and so need a repeat test if they asymptomatic to confirm diagnosis.

If they had a HBA1c of less than 42 they are still moderate risk because of ethnicity and BMI, as such you will give then education on what they can do to reduce risk and potentially ask if they will be interested in a weight loss programme.

Question 67

A 76 year old man has nausea, fever and rigors. He has foul smelling urine . He was discharged 3 days ago after being treated for a PE. He has been having low molecular weight heparin injections twice daily since the diagnosis. He had a cholecystectomy 12 years ago. His temperature is 39.7°C, pulse rate 100 bpm and BP 92/41 mmHg. Investigations: APTT 43 seconds (22–41) PT 18 seconds (10–12)
Which is the most likely cause of the prolonged prothrombin time?
A. Disseminated intravascular coagulation
B. Liver disease
C. Low molecular weight heparin
D. Lupus anticoagulant
E. Vitamin K deficiency

Answer 67

DIC ->
Diagnosis->
* >= 1 known underlying cause (SEPSIS in this case) + abnormal global coagulation tests:
* low plat, increase PT +APTT + increased fibrin( d-dimer or fibrin degeneration products) + Decreased fibrinogen

Question 68

A 62 year old man has a right-sided hearing loss. There has been slow deterioration over the previous two years, and he is now also troubled by non-pulsatile, right-sided tinnitus that prevents him from sleeping. A pure-tone audiogram shows a right-sided high-frequency hearing loss. He has normal tympanometry bilaterally.
Which is the most appropriate diagnostic investigation?
A. Cerebral angiography
B. CT of head
C. CT of petrous temporal bones
D. MR imaging of internal acoustic meatus
E. PET–CT of brain

Answer 68

MRI internal Acoustic meatus
With Unilateral sensorneural hearing loss it is vital to exclude the presence of a vestibular schwannoma or other neoplasms… Ix of choice is MRI.

Question 69

A 65 year old woman has had bloody diarrhoea six times each day for the past 4 weeks and is feeling unwell. She has noticed urgency to pass stool and has to get up in the night to pass stool. Her left eye has been red, but not painful. Her temperature is 38.5°C, pulse rate 109 bpm, BP 110/70 mmHg and respiratory rate 22 breaths per minute. Investigations: Stool culture: negative
Which is the most likely diagnosis?
A. Adenocarcinoma of the colon
B. Crohn’s disease
C. Irritable bowel syndrome
D. Microscopic colitis
E. Ulcerative colitis

Answer 69

Ulcerative colitis -> has the bloody diarrhoea and GI symptoms… The urgency is also suggestive of UC more than Crohns I believe. And the extraintestinal manifesations of eye symptoms… Could also have been erythema nodosm or arthritis etc.

Question 70

A 28 year old man presents to his GP with 7 weeks of right iliac fossa pain, weight loss of 3 kg and diarrhoea five times a day. He previously opened his bowels once daily. He has not travelled abroad. He lives with his partner, who is well. Rectal examination is normal. Investigations: Haemoglobin 129 g/L (Men: 135-180 g/l Women: 115-160 g/l) Albumin 32 g/L (35–50) White cell count 11.4 × 109/L (3.8–10.0) Platelets 450 × 109/L (150–400) Erythrocyte sedimentation rate 60 mm/hr (<20) ALT 10 IU/L (10–50) ALP 110 IU/L (25–115) Bilirubin 15 μmol/L (<17)
Which is the most appropriate next investigation?
A. Antimitochondrial antibodies
B. Anti-tissue transglutaminase antibodies
C. Faecal calprotectin
D. Faecal occult blood testing
E. Stool cultures

Answer 70

Stool cultures -> NICE guidelines apparently suggests that stool cultures need to be sent first in primary care before refferral to the secondary care doctors when there is suspicion of IBD,

Question 71

A 58 year old woman has 6 months of worsening right-sided hip pain caused by osteoarthritis. Her pain is partially controlled by regular paracetamol and ibuprofen gel. She remains active. She has peptic ulcer disease and heart failure. Her medication includes bisprolol fumarate, aspirin and simvastatin. She has crepitus on active and passive movements of both hips. Her BMI is 30 kg/m2.
Which is the most appropriate management?
A. Add celecoxib
B. Add oral ibuprofen and lansoprazole
C. Refer for acupuncture
D. Refer for knee replacement surgery
E. Switch paracetamol to regular co-codamol

Answer 71

Swith the paracetamol to regular co-codamol

this or the addition of NSAIDs would be the next step in the management of this pain but as this patient is suffering from ulcer the NSAIDs is a relative contraindicaiton.

Question 72

A 37 year old man has 4 weeks of pain on the radial side of his left wrist. The pain is worse when he plays the piano. He has no history of trauma. He has swelling and tenderness over the distal end of the left radial styloid. The pain is exacerbated by ulnar deviation of the wrist when the thumb is clasped in the palm.
Which is the most likely diagnosis?
A. de Quervain tendinopathy
B. Ganglion cyst
C. Intersection syndrome
D. Osteoarthritis of the trapeziometacarpal joint
E. Scaphoid fracture

Answer 72

de querviain tendinopathy ->
The above is associated when there is pain that is not associated with a traumatic injury. Additionally the description of the localised pain at the site of the tendon as well as pain when passively stretching the tendon is suggestive of tendinopathy,

Question 73

A 48 year old man has 8 months of a painful, stiff left shoulder. The pain is dull and worse at night. There is no history of trauma. He has type 1 diabetes mellitus. He has reduced passive and active range of movement in the left shoulder with pain at extremes of range of motion. Neck movements are normal. Power and sensation are normal. Investigations: CRP 6
Which is the most likely diagnosis?
A. Adhesive capsulitis
B. Glenohumeral osteoarthritis
C. Polymyalgia rheumatica
D. Rotator cuff tear
E. Subacromial bursitis

Answer 73

Adhesive capsulitis -> there is overall reduction in movement. Additional features that may be described include worse pain on external rotation and flexion of the shoulder. managed by physio and if that doesnt work then steroids intrarticularly. the above is more liekly in patients < 40 years old. This is also more common in diabetics

if > 70 then rotator cuff injuries or glenohumeral osteoarthritis is possible

Sobacromial pathology often present with a history of repeated movements above the shoulder level and lifting heavy objects maybe atheletic or occupation based.

Both rotator cuff injury and sobacromial bursitis will present with activity related pain and problems performing ussual activities.

Question 74

A 52 year old woman has a brief episode of dizziness on standing . She has had 4 days of dysuria, loin pain and fever. She has been feeling tired for 4 months and has lost 3 kg in weight. Her temperature is 37.4°C, pulse rate 90 bpm, BP 100/55 mmHg lying and 90/50 mmHg sitting, respiratory rate 18 breaths per minute and oxygen saturation 95% breathing air. Her JVP is not visible. Investigations: Haemoglobin 106 g/L (115–150) White cell count 14 × 109/L (3.8–10.0) Platelets 201 × 109/L (150–400) Sodium 130 mmol/L (135–146) Potassium 5.6 mmol/L (3.5–5.3) Urea 9.5 mmol/L (2.5–7.8) Creatinine 98 μmol/L (60–120) Random plasma glucose 3.2 mmol/L 12-lead ECG sinus rhythm
Which is the most appropriate additional investigation?
A. CT of head
B. CT pulmonary angiography
C. Echocardiography
D. Plasma cortisol and adrenocorticotropic hormone
E. Urinary and serum osmolality

Answer 74

Plasma cortisol and adenocorticotrophic hormone -> This person has addisons this meanse they are not producing cortisol, aldosterone. This leads to a high potassium and low sodium.

These patients often present with lethargy + Wt loss

If they asked about approapriate management you would start steroids before waiting for results.

CT head would be suggestive of cerebral disease that this patient doesnt have

CTPA would be suggestive of PE which again this pt doesnt have

the hypotension is unlikley to be due to cardiac disease

Urine and plasma osmolality is not required as there is more likely cause for hyponatraemia….

Question 75

A 55 year old man is brought to the Emergency Department with 2 hours of severe left sided chest pain. A pre-hospital ECG shows left bundle branch block, for which paramedics gave aspirin and glyceryl trinitrate spray. On arrival at hospital, he is sweating and distressed . His pulse rate is 85 bpm, BP 99/54 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 96% breathing air. His GCS score is 15/15.
Which is the most appropriate management?
A. Continue breathing air
B. Start 28% oxygen via a Venturi mask
C. Start 40% oxygen via a Venturi mask
D. Start oxygen 2 L/min via nasal cannulae
E. Start oxygen 15 L/min via a non-rebreathe mask

Answer 75

Continue breathing air -> only really needed if O2 less than 94 and for this patient it is not.

Question 76

A 30 year old woman is brought to the resuscitation room of the Emergency Department after after being kicked by a horse . She is 28 weeks pregnant. Her cervical spine is immobilised. She is conscious and asks about her baby. Her temperature is 37°C, pulse rate 100 bpm, BP 78/56 mmHg and oxygen saturation 99% breathing 40% oxygen . Fluid resuscitation has been started and bloods have been sent.
Which is the most appropriate next step?
A. Image the long bones and pelvis, and orthopaedic review
B. Perform a full primary survey
C. Scan the baby and arrange fetal monitoring
D. Transfer to theatre for immediate delivery of baby
E. X-ray cervical spine

Answer 76

Full primary survey -> This is an acute sceario and the treatment s main focus is the mother. With the tachycardia and the hypotension there is need to look at the management doing a primary survey to determine any other life thereatening injuries the mother is facing.

Question 77

A 59 year old man presents to the GP for review. He has type 1 diabetes mellitus, hypertension, ischaemic heart disease and CKD stage 4 [recent eGFR 25 mL/min/1.73 m2(> 60)]. He is taking insulin, lisinopril, metoprolol tartrate and aspirin. His BP is 160/96 mmHg. He has pitting oedema to the mid shin.
Investigations:

Sodium 144 mmol/L (135–146)
Potassium 5.4 mmol/L (3.5–5.3)
Urea 19.2 mmol/L (2.5–7.8)
Creatinine 237 μmol/L (60–120)
eGFR 26 mL/min/1.73 m2 (>60)
Urinalysis: protein 2+

Which is the most appropriate therapeutic change?
A. Add indapamide
B. Add furosemide
C. Add spironolactone
D. Stop lisinopril
E. Switch lisinopril to losartan

Answer 77

Add furosemide -> HTN is not managed… there is also peripehral oedema and so furosemide would be useful. It also would help with the hyperkalaemia.

The raised K+ is not high enough to stop the lisinopril

ARB would not provide more benefit

Spiro is relatively contraindicated in hyperkalaemia

Question 78

A 38 year old woman has abdominal pain 7 days after a laparoscopic sleeve gastrectomy for weight loss. Her temperature is 36.5°C, pulse rate 110 bpm, BP 120/72 mmHg and oxygen saturation 96% breathing oxygen 4 L/min via nasal prongs. She has reduced breath sounds in both bases. She has abdominal tenderness with guarding and reduced bowel sounds.
Which is the most appropriate diagnostic investigation?
A. Abdominal X-ray
B. Barium enema
C. CT of abdomen
D. Erect chest X-ray
E. Point-of-care FAST scan

Answer 78

CT abdomen -> Investigation of choice for acute abdomen post surgery is a CT scan. It will also most likely be a contrast CT.

FAST this is for trauma and it is at point of care not post surgery. It can be used in RTA.

Question 79

A 62 year old man becomes increasingly breathless 3 hours after the removal of a chest drain. This was inserted to drain a right-sided pleural effusion secondary to lymphoma . Three litres of bloodstained fluid were drained before removal.
Which is the most likely diagnosis?
A. Aspiration pneumonia
B. Pneumothorax
C. Pulmonary embolism
D. Pulmonary oedema
E. Recurrence of effusion

Answer 79

Pneumothorax -> Iatrogenic cause of pneumothorax

I dont really know why it cant be refractory pulmonary oedema due to pleural effussion removal… I presume the delay in presentation ???

Question 80

Answer 80

Hypoalbuminaemia

SLE nephritis causes nephrotic syndrome that causes the hypoaluminaia that leads to the pulmonary oedema

Question 81

Answer 81

second degree heart block type 1

The p-r intervals keeps getting longer then drops… This is regularly irregular.

Question 82

Answer 82

Oesophageal ulceration

This is the descriptioon of a ulcer in endoscopy.
Additionally the pain on swallowing in the lower chest is also suggestive of ulcers…

Question 83

Answer 83

Granulomatosis with polyangitis

Has the classic triad with nose, lung and kidney involvement

Question 84

Answer 84

ERCP

Question 85

Answer 85

Herpes simplex virus

Question 86

Answer 86

Repeat US every 12 months

Question 87

Answer 87

Acute ischaemic optic neuropathy

If the red reflex was absent then it would be more suggestive of retinal detachement or vitreous haemorrhage

Question 88

Answer 88

USS kidney -> This is PCKD

For this to be diagnosed there is a need to visualise the kidney and this is done with an USS.

CTKUB is needed with a renal colic and that is likely if there was colicky pain, however this patient has constant pain.

RCC is more common at the age of 65, this patient is quite young. In this presentation you would consider PCKD before RCC

Question 89

A 36 year old man has recurrent episodes of collapse over 4 months. When laughing, his muscles feel limp and he falls to the floor, but remains conscious. He has a history of anxiety and depression and takes citalopram. His father died from an ischaemic stroke aged 59 years.
Which is the most likely diagnosis?
A. Cardiogenic syncope
B. Cataplexy
C. Cough syncope
D. Dissociative (non-epileptic) seizures
E. Epilepsy

Answer 89

Cataplexy
This presents with a loss of skeletal loss function when you feel immense emotion.

EMOTIONAL DAMAGE = cataplexy