December Karim Meeran Mock

Question 1

2. A 50 year­old­man with a history of type 2 diabetes presents with left sided weakness and a headache. Examination reveals brisk reflexes in the left arm. Rank the following differential diagnoses, with 1 being the most likely diagnosis and 5 being the least likely.
A. Migraine
B. Guillain Barre syndrome
C. Brain Tumour
D. Stroke
E. Multiple Sclerosis

Answer 1

Comments for Q2: This patient has hemiparesis and upper motor neurone signs. The first diagnosis that must be excluded is stroke (1) in view of his history of diabetes mellitus. If a timescale was given, it would be sudden onset weakness.

Brain tumour (2) can also present with similar features, but has a slower onset. Once Stroke and brain tumour have been excluded, migraine (3) should be considered. Migraine can present with headache and a range of neurological symptoms and is usually on one side, caused by vascular spasm. Multiple sclerosis (4) is another upper motor neurone disease, but is commoner in females and requires two or more CNS lesions separated in time and space. It usually presents with visual loss and some sensory signs, so is a less likely diagnosis given the history. Guillaine Barre syndrome (5) presents with lower motor neurone signs and is a completely wrong answer.

Question 2

3. A 50­year­old male presents with severe epigastric pain. He has had a similar episode in the past and he admits to drinking an excess of alcohol, and smoking a pack per day. List the differential diagnoses below in order of likelihood, with 1 being the most likely diagnosis, and 5 being the least likely.

A. Cholecystitis
B. Acute Inferior Myocardial Infarction
C. Peptic ulcer disease
D. Basal Pneumonia
E. Acute Pancreatitis

Answer 2

Comments for Q3: In a patient with severe epigastric pain and a history of excess alcohol intake think of acute pancreatitis (1) first. The next likely differential is peptic ulcer disease (2). Both are more common in alcoholics and both cause severe epigastric pain.

Remember that pain perceived as arising in the abdomen may originate from extra-abdominal sites. Acute MI (3) may present with epigastric pain and should be considered, particularly in a smoker. Cholescystitis (4) presents with right upper quadrant or epigastric pain and is often associated with fever. Pneumonia (5) can cause upper abdominal pain but there are no respiratory symptoms or signs reported in this case.

Question 3

4. A 40­year­old man presents with collapse and loss of consciousness witnessed by his wife. The episode lasted 3 minutes. He felt dizzy for a few seconds prior to the event and had some jerky movements during the event. He recovered spontaneously and
   was not confused afterwards. He had no previous cardiac history and in fact had never seen a doctor. Rank the following differential diagnoses of his collapse with 1 as the most likely cause and the 5 as the least likely cause.

Answer 3

Comments for Q4: The differential diagnosis of collapse/ loss of consciousness includes vasovagal attack, cardiac causes (arrhythmia, outflow obstruction e.g. aortic stenosis, postural hypotension) and hypoglycaemia. The sequence of events before, during and after the collapse is crucial to the diagnosis. With no previous cardiac history and the short history reported vasovagal attack (1) is the most likely cause. Remember you can get jerky movements with vasovagal attacks. However, arrhythmias (2) can also present with collapse and should be considered. Seizure (3) would be next on the list, although it is less likely in view of the absence of post-ictal confusion. TIAs (4) usually present with focal neurological signs. Hypoglycaemia (5) is the least likely as the event terminated spontaneously. In addition, there is no suggestion that he is on insulin, as he has not got diabetes, as he has never seen a doctor. While an insulinoma can cause this, insulinomas are very rare.

Question 4

5. A 24 year old female presents with severe right sided back and abdominal pain and a
   fever. She has no other previous medical or travel history. Rank the following
   differential diagnoses in order of likelihood, with 1 being the most likely and 5 being the
   least likely.

Answer 4

Comments for Q5: Acute Pyelonephritis (1) presents with fever loin/flank pain and tenderness, but this is sometimes interpreted as back pain by patients. Cholecystitis (2) also commonly presents with RUQ pain associated with fever. Hepatitis (3) also causes fever and RUQ pain associated with jaundice, and would be more likely if there was a travel history for viral hepatitis. Campylobacter infection (4) presents with fever, cramp-like pain and bloody diarrhoea. Peptic ulcer (5) is the least likely, as it does not usually present with fever.

Question 5

6. A 50­year old woman presents with a severe headache and photophobia. Examination reveals brisk reflexes. Rank the following differential diagnoses, with 1 being the most likely diagnosis and 5 being the least likely.

Answer 5

Comments for Q6: In a patient presenting with severe sudden onset headache and photophobia think of subarachnoid haemorrhage (1) first. There is no history of fever, however, remember that you should treat this patient for meningitis (2) quickly while you are making the diagnosis. Patients with encephalitis (3) have behavioural changes in addition to the headache. Subdural haemorrhage (4) usually has a more subacute/chronic presentation with headache and confusion. Extradural haemorrhage (5) is often due to a fractured temporal/ parietal bone damaging the middle meningeal artery and extradural haemorrhage therefore only occurs after severe trauma.

Question 6

7. A 50­year­old smoker presents with lobar pneumonia. Examination reveals dullness at the right base with increased tactile vocal fremitus. Rank the following organisms in order of likelihood, 1 being the most likely and 5 being the least likely organism.

Answer 6

The commonest cause of community-acquired pneumonia is Strep pneumoniae (1). Haemophilus influenzae (2) is an important cause of pneumonia in elderly adults who have COPD or smoke heavily. Mycoplasma (3) and Legionella (4) are causes of atypical pneumonia. E. coli (5) and other gram negatives are uncommon causes of Community-acquired pneumonia but should be considered in hospital-acquired cases.

Question 7

8. Abdominal examination of a 70­year old breathless man of no fixed abode reveals a palpable spleen. He is known to drink heavily and has had an anterior myocardial infarction previously. Rank the differential diagnoses below with 1 being the most likely and 5 being the least likely diagnosis.

Answer 7

Comments for Q8: The main causes of splenomegaly are portal hypertension, haematological malignancies and infection. In a patient with a history of excess alcohol intake portal hypertension (1) secondary to cirrhosis must be considered. Congestive cardiac failure (2) can cause hepatomegaly and splenomegaly, and is next because the patient is breathless. Tuberculosis (3) is the next likely cause. Other infective causes of splenomegaly include malaria (4) and schistosomiasis (5), but the latter is extremely rare indeed, especially without a travel history.

Question 8

9. A 50­year­old woman presents with left calf swelling and tenderness. She has had a recent fracture and has been immobile. Her past medical history includes osteoarthritis. She has smoked 30/day for the last 30 years, but does not drink alcohol. Rank the differential diagnoses below with 1 being the most likely and 5 being the least likely diagnosis.

Answer 8

The differential diagnosis of unilateral swollen leg includes DVT (1) [which is the most likely in view of the history of recent fracture], cellulitis (2) and ruptured Baker’s cyst (3). Cardiac failure (4) usually causes bilateral leg swelling. Liver failure (5) can also cause peripheral oedema, but there are no features of chronic liver disease stated in the question.

Question 9

10. A 45­year­old woman presents with a 1 day history of dizziness on standing up and vomiting. She had been started on a tricyclic antidepressant by her GP two weeks ago. Her past medical history includes type 2 diabetes diagnosed 4 years ago and treated with metformin. Rank the differential diagnoses below with 1 being the most likely and 5 being the least likely diagnosis.

Answer 9

Comments: Because the patient started a new drug two weeks ago, that is likely to be responsible for any new symptoms. Tricyclic antidepressants (1) are also associated with postural hypotension and may be the cause as they have recently been started. Postural hypotension & dizziness of one days duration can also be secondary to hypovolaemia (2) due to vomiting induced by gastroenteritis. Metformin (3) is a common cause of GI upset and vomiting, but this patient has been stable on the treatment for a while. Patients on metformin are more susceptible to GI upset. Another cause of postural hypotension includes diabetic peripheral neuropathy (4) but is unlikely to be this acute in onset, although it is possible that although it was slowly getting worse, the patient only has noticed recently, and therefore has presented relatively acutely. Amyloid is very unlikely.

Question 10

11. A 35­year­old male intravenous drug abuser is admitted to Casualty with a 3 day history of yellow discolouration of his skin, flu­like symptoms and nausea. On examination, he is cachectic and jaundiced, with smooth, tender hepatomegaly. Rank the following differential diagnoses with 1 being the most likely and 5 being the least likely.

Answer 10

Hepatitis C (1) and HIV (2) are more likely in IV drug abusers. Alcoholic hepatitis (3) isn’t quite the same as chronic alcoholic liver disease, but would be the next most likely diagnosis. Paracetamol (4) overdose can cause acute liver failure. Gilbert’s syndrome (5) simply causes asymptomatic hyperbilirubinaemia, and needs no specific treatment.

Question 11

What is the diagnosis for each of these?

http: //www.ncbi.nlm.nih.gov/books/NBK333/ has got all the answers, as have the 10 minutes of videos that you should watch: https://www.youtube.com/playlist?list=PL-zI9QU3vran9qVDvo03XaAhdfp77xuEp
1. A loud pan-systolic murmur at the apex:
2. An ejection systolic murmur heard:
3. An irregularly irregular pulse:
4. A slow rising pulse:
5. A collapsing pulse:
6. A very loud first heart sound:

Answer 11

1) Mitral regurgitation
2) Aortic stenosis or aortic sclerosis
3) Atrial Fibrillation
4) Aortic Stenosis
5) Aortic regurgitation
6) Mitral stenosis.

Mitral stenosis causes a loud first heart sound because the leaflets are wide apart at the end of atrial contraction. The atrium still isn’t empty when the ventricle starts to contract. Thus the mitral valve is wide open and slams shut. Calcification will quieten the valves. https://www.youtube.com/watch?v=vgpzzPGzs7M

Question 12

7. An early diastolic murmur at the left sternal edge:
8. The closure of which valve causes the first heart sound?
9. The closure of which valve causes the second heart sound?
10. A tapping apex suggests what diagnosis?
11. A 60 year old man complains of breathlessness, and has a third heart sound. What is the cause of a third heart sound?

Answer 12

7) Aortic regurgitation
8) Mitral valve is the best answer. Atrioventricular valve is an alternative name. Although this used to be called the “bicuspid valve”, we can’t really give this full marks, because some other abnormal valves have two cuspids and some patients have bicuspid aortic valves. The name “tricuspid valve” is reserved for and is still the commonly used name for the valve between the right atrium and the right ventricle. Although this contributes to the first heart sound, the pressure is very low, so the valve is very quiet when it closes. The mitral and tricuspid valves should close together, but most of the sound is the mitral valve.
9) The aortic valve is the best answer. The pulmonary valve also contributes, and because the pressure there is lower, the sound is slightly quieter, and the pulmonary valve closes just after the aortic valve, so the second heart sound is “split”. Semilunar valves are another term for the two valves together.
10) A tapping apex is a palpable (hence very loud) first heart sound from a stenosed mitral valve. When the mitral valve is normal, the atrium empties quickly through it into the ventricle, and as there is no more blood to come through the valve, it starts to close BEFORE systole. Thus when systole starts, the valve leaflets are close together. So the first heart sound is of moderate volume normally. If the valve is stenosed then the atrium struggles to empty and at the start of systole, the atrium isn’t yet empty. Thus the valve is wide open when systole starts. Thus when the valve slams shut from being fully open, it is very loud and palpable.
11) A third heart sound is caused by rapid ventricular filling (4 marks) during normal diastole BEFORE the atrium contracts (which would cause a fourth heart sound if there is any stiffness). This occurs when the ventricle is dilated due to cardiac failure (3 marks).

Question 13

12) Examination of the neck reveals Cannon waves. What is the likely diagnosis?
13. A 55 year old smoker complains of severe central crushing chest pain. What is the likely diagnosis?
14. A 65 year old complains of slowly increased swelling of both legs, and slowly worsening breathlessness. Examination reveals a raised JVP. What is the cause?
15. Examination reveals a low pitched rumbling mid diastolic murmur. What is the likely diagnosis?
16. You hear an opening snap. What is the likely diagnosis?

Answer 13

12) Complete heart block or 3rd degree heart block is the correct answer. This occurs because it is the only condition where the atrium can contract when the tricuspid valve is closed (randomly) because the atria and ventricles are contracting at different rates. When they both contract together, the tricuspid valve will be closed and if the atria contract at the same time, the blood of the atrium can only rush upwards. This is much more intense than the v-wave of tricuspid regurgitation (which is thus NOT a cannon wave).
13) The correct answers include acute myocardial infarction, STEMI or angina.
14) Heart failure is the answer. Some of you put in more detail than others. Usually this starts with an ischaemic left ventricle, causing left ventricular failure. This causes breathlessness due to pulmonary oedema. There is then fluid retention and peripheral oedema results from added in right ventricular failure. Congestive cardiac failure describes this. Cor pulmonale is another possibility where the breathlessness is caused by lung disease such as COPD and there is subsequent right ventricular failure.
15) You should have written mitral stenosis. A rarer but a favourite with students is the Austin Flint murmur where aortic regurgitation makes the mitral leaflet close, and thus a pseudo-murmur of mitral stenosis.
16) Mitral stenosis is the correct answer. Calcification makes the opening snap quiet, or absent (http://heart.bmj.com/content/15/2/135.full.pdf page 137) and is thus wrong.

Question 14

17. What causes a fourth heart sound?
18. What murmur do you hear in a patient with mitral regurgitation?
19. What murmur do you hear in a patient with aortic stenosis?
20. What murmur do you hear in a patient with tricuspid regurgitation?
21. What are the ECG changes in first degree heart block?

Answer 14

17) Atrial contraction against a stiffened left ventricle (which is in turn caused by hypertension). Thus the timing is towards the end diastole, with atrial systole, just before the first heart sound. If you got this wrong or want it explained, please watch the 2 minute “Gallop rhythm” video: https://www.youtube.com/watch?v=0ZsCOfKtGLY. There are 4 marks for this question, and 2 marks for partly correct answers.
18) This is a loud pan systolic murmur.
19) This should be an ejection systolic murmur.
20) The same murmur as in mitral regurgitation but much softer, because the right ventricular pressure is a lot lower than the left ventricular pressure. So the answer we are looking for is a soft pan systolic murmur.
21) A prolonged PR interval. All types of heart block are caused by ischaemia of the AV node. When the ischaemia is mild, although the PR interval is prolonged, because conduction is slowed, ALL the P waves are conducted to QRS complexes.

Question 15

22. What are the ECG changes in SECOND DEGREE heart block?

23) What are the ECG changes in third degree heart block?

Answer 15

22) The key point to get full marks is to say that some p waves are not conducted to QRS complexes, or there are some dropped QRS complexes.

There are two variants: Mobitz type 1 second degree heart block occurs where the PR interval slowly lengthens until there is a missed QRS complex every few beats, usually with a regular pattern. Mobitz type 2 second degree heart block occurs where the PR interval is fixed (but may be prolonged or normal) but some QRS beats are missed. The ratio can be 2:1 block, 3:1 block or in fact any number:1 block. 3:1 block for example means that you will have three P waves for each QRS complex. For a 4 minute video explaining this, click on https://www.youtube.com/watch?v=Ytl3lFyCABw

23) This is the same as COMPLETE

Question 16

24. What are the ECG changes in LEFT bundle branch block.
25. What are the ECG changes in right bundle branch block.
26. Examination reveals reduced expansion on the left side with dullness to percussion and increased tactile vocal resonance (when he says “99”).
27. Examination reveals reduced expansion on the left side with dullness to percussion and reduced tactile vocal resonance (when he says “99”).
28. A 25 year old comes to casualty with Expiratory wheezes. What is the likely diagnosis?

Answer 16

24) The correct answer includes a broad complex, or two overlapping complexes resulting in the appearance of a broad complex, with an SRS pattern in lead V1 (or a W shape) and an RSR pattern in V6 (or an M pattern). The word “William” alone is unacceptable. Please see https://www.youtube.com/watch?v=1ztdlEBSyl0 if you need clarification in 4 minutes.
25) The video above explains this also. You wrote M patten in R wave in V1 and W pattern in S wave in V6 and thus scored 4.
26) This is typical of pneumonia, or consolidation caused by pneumonia. A primary malignancy can cause a lobar pneumonia, but it is the pneumonia that is the best answer.
27) This is a typical left sided pleural effusion.
28) The commonest cause of this is acute severe asthma.

Question 17

29. A 45 year old patient complains of a cough that lasts for 3 months every winter for the last three years. What is the likely diagnosis?
30. A 30 year old is on the oral contraceptive pill and becomes suddenly breathless. Examination of the respiratory system is normal.
31. A 45 year old patient complains that they cough up a pot of purulent sputum every day. Examination reveals course crackles.
32. 65 year old complains of breathlessness and has fine crepitations at both bases.
33. A tall 19 year old suddenly complains of breathlessness and left sided chest pain.
34. A 55 year old with known lung cancer complains of a swollen leg and then suddenly becomes breathless.

Answer 17

29) This is the definition of “chronic bronchitis”. Each winter he has an exacerbation of COPD.
30) The OCP is a typical risk factor for a large DVT and resultant pulmonary embolus (PE). Typically a large PE does not leave any signs and examination is usually normal. This is why the diagnosis is often missed. Occasionally you might hear a pleural rub if you get resultant pleurisy over an area of pulmonary infarct.
31) This is typical of bronchiectasis, which may be caused by cystic fibrosis (4 marks). Other infective diagnoses are possible, but don’t usually produce this amount of sputum.
32) Pulmonary oedema (which can be caused by cardiac failure, or left ventricular failure) and pulmonary fibrosis are two completely different conditions that are acceptable answers.
33) This is a typical pneumothorax.
34) Any malignancy can increase coagulability. The swollen leg is likely to be a DVT and the sudden breathlessness occurs when the clot suddenly goes to the lung, forming a pulmonary embolus.

Question 18

35. A 30 year old complains of weight loss and coughs up blood. He has a fever of 38 degrees centigrade and complains of night sweats.
36. Examination reveals a palpable mass in the right hypochondrium.
37. Examination reveals a palpable mass in the left hypochondrium.
38. A forty year old mother of five complains of abdominal pain after eating fish and chips. What is the likely diagnosis?
39. A 40 year old man who drinks a bottle of vodka every night and is known to have chronic liver disease, developed severe abdominal pain with extreme tenderness. Examination revealed a rigid abdomen. What is the likely diagnosis?
40. What single diagnostic confirmatory blood investigation is required for the patient in question 39?

Answer 18

35) This is the typical story of pulmonary tuberculosis. While malignancy is possible with weight loss, this is an unlikely diagnosis given the fever and his young age.
36) This is the position of the liver, so hepatomegaly is what we are looking for.
37) This is the position of the spleen so splenomegaly is the correct answer.
38) When the patient eats a fatty meal, the gall bladder contracts. If the gall bladder is full of gallstones (4 marks), then it hurts immediately after a fatty meal but not at other times. The gallstones here are not inflamed or infected as there is no history given of a fever (cholecystitis =inflamed gall stones). Risk factors for gallstones include being fat, being fair (more common in Caucasians), being female, being fertile, being about forty years old.
39) This is the typical history with a risk factor for acute pancreatitis. The leakage of pancreatic enzymes into the peritoneum causes the rigidity and peritonitis.
40) Amylase is the most common test and lipase is available in some places.

Question 19

41. A 50 year old complains of slowly worsening weakness in his left leg. This started gradually three months ago, and is now making him limp. Examination reveals increased tone, brisk reflexes and weakness in the left leg.
42. A 50 year old complains that he has developed weakness in his left leg when he woke up this morning. He has great difficulty walking. Examination reveals increased tone, brisk reflexes and weakness in the left leg.
43. A 60 year old man complains of drooping of his left eyelid. Examination of his eyes reveals normal eye movements, but his left pupil is smaller than his right pupil.
44. A 50 year old man complains of drooping of his left eyelid, so that his left eye is almost closed. When you hold his left eye open, he complains of double vision, and the left pupil is larger than the right one.
45. Examination of the lower limbs reveals wasting of the muscles of the left calf with absent reflexes on that side.

Answer 19

41) You need to recognise these as upper motor neurone signs. It is slowly progressive, so the likeliest diagnosis is a slowly growing brain tumour. A stroke will have similar signs, but will start SUDDENLY.
42) This is the same as question 41, but sudden onset, or in this case happened suddenly overnight, so this is a typical stroke.
43) This is a typical left sided Horner’s syndrome.
44) This is a typical complete (surgical) 3rd nerve palsy. In a typical diabetic third nerve palsy, the pupil is spared.
45) This is a typical LOWER motor neurone problem. It is in only one leg, so the problem is either pressure on a nerve below the cauda equina or damage to the spine or the nerve roots. Polio used to be a common infection in children, and would damage the ganglion and from then on, the muscles innervated by that nerve would atrophy. Although this infection does not appear in the UK (and the virus may be eradicated in the next few years), patients who had the infection in the 1970s are now well with profound atrophy and lower motor neurone signs forever in the limbs that were infected. Out of 4 marks, your mark reflects how close you are. If you recognise this as a lower motor neurone lesion, then you are pretty close.

Question 20

46. DANISH. Each of these characters is worth 2 points.
47. A patient complains of a tremor when he smokes cigarettes. What is the likely cause if the tremor gets worse when he puts the cigarette into his mouth.
48. What is the diagnosis when a patient complains of a tremor of one hand at rest?
49. A 40 year old patient has brisk reflexes on the right hand side. What do you expect to find when you examine the tone on the same side?
50. Examination of the plantar responses reveals that the right plantar is upgoing and the left plantar is downgoing. What do these findings suggest?

Answer 20

46) The D stands for “Dysdiadochokinesia”.
47. A: ataxia. ”
48. N: Nystagmus.
49. I: Intention tremor.
50. S: Scanning or staccato or Slurred speech.
51. H: Hypotonia (reduced reflexes).

52) This is typical of the ataxia one gets with cerebellar disease, with the past pointing getting worse as you approach the target (either nose, or in this case the mouth). It is truly horrible to witness the difficulty these patients have even smoking.
53) This is likely to be Parkinson’s disease. It starts on one side, so when patients first have symptoms, it is often one sided. At that point the diagnosis might not be very obvious, as it is the patient’s only complaint. However the disease will become bilateral, and the other features will become apparent.
54) Brisk reflexes means upper motor neurone lesion, and this will also cause increased tone.
55) The upgoing plantar is abnormal and suggests an upper motor neurone lesion affecting the right leg. This can be caused by a brain tumour or stroke in the LEFT side of the brain or spinal cord. The downgoing plantar is normal. It is important in summative exams that you are clear as to which side of the brain the problem is on, and also which side of the body is affected.

Question 21

56. A 35-year old woman complains of weight loss, tremor of her outstretched hands and palpitations.
57. A 40 year old woman complains of weight gain, thin skin and is noted to have stretch marks on the abdomen.
58. A 40 year old woman complains of palpitations, and is noted to have a blood pressure of 190/120.
59. A patient with type 2 diabetes is advised on a healthy diet, and to exercise regularly. Three months later, he has an HbA1c of 60 mmol/mol. What drug will you start him on according to NICE guidelines?
60. Three months after that, the patient still does not have adequate glucose control. What class of drug should you add?
61. Name one such drug
62. What CLASS of drug should be prescribed for a patient with diabetes and hypertension who is found to have microalbuminuria?

Answer 21

56) This is typical hyperthyroidism or Graves’ disease.
57) This is typical Cushing’s syndrome.
58) This severe hypertension occurs in patients with phaeochromocytoma (4 marks). The sudden release of adrenaline stimulate beta receptors and can cause palpitations. Conn’s syndrome also causes hypertension, usually with hypokalaemia, which we could presume might cause palpitations, so this is also (just about) acceptable (2 marks). Other plausible answers will get a point.
59) Metformin is the only biguanide available.
60) A sulphonylurea such as Gliclazide was the NICE answer until early December 2015, but now almost any class of drug is acceptable including gliptins. The NICE guidelines in fact put slow release metformin after metformin.
61) Gliclazide, Glibenclamide and Tolbutamide are all possible correct answers amongst others. If you have not used Metformin in Q59, then you can use it now.
62) ACE inhibitors have the most evidence of benefit in preserving renal function. Angiotensin receptor 2 antagonists (ARB) should also have a similar benefit.

Question 22

The next four questions are worth 2 marks each only:

63. Name one such drug:
64. What effect will this drug have on the plasma potassium levels?
65. What effect will this drug have on plasma creatinine levels?
66. What effect will this drug have on the urinary albumin excretion?
67. A patient has a lymph node biopsy which is sent for histology. What is the diagnosis if caseating granulomata are seen?
68. And for non-caseating granulomata:

Answer 22

63) If you put ACE inhibitor for 62, then Enalapril, Lisinopril, Captopril or Ramipril are the most commonly used. Any “PRIL” is correct. If you put Angiotensin 2 receptor antagonist (or ARB), then Candesartan, Losartan, Irbesartan and Valsartan are all correct. Any “ARTAN” is correct.
64) Potassium is increased by ACE inhibitors and ARBs.
65) They will increase.
66) Urinary albumin is reduced, which is why we use ACE inhibitors in any patient with diabetes who has microalbuminuria.
67) Tuberculosis is the commonest cause of caseating granulomata, and is the only important diagnosis for you to think about. A Ziehl Nielsen stain will be useful to see the bacilli.
68) Sarcoidosis.

Question 23

Give an example of the following drugs:

69. A non-steroidal anti-inflammatory drug (NSAID):
70. A corticosteroid:
71. An angiotensin converting enzyme inhibitor.
72. An angiotensin-2 receptor antagonist.
73. A beta blocker.
74. A beta agonist.
75. A calcium antagonist used for hypertension.
76. An alpha blocker used in hypertension.
77. An aldosterone receptor antagonist used for hypertension.
78. A dopamine agonist used for patients with a prolactinoma.
79. A dopamine antagonist that can be used for psychotic disorders or nausea.
80. A macrolide antibiotic.

Answer 23

69. A non-steroidal anti-inflammatory drug (NSAID): You wrote Ibuprofen and thus scored 4.
70. A corticosteroid: You wrote Hydrocortisone and thus scored 4.
71. An angiotensin converting enzyme inhibitor. You wrote Benazepril and thus scored 4.
72. An angiotensin-2 receptor antagonist. You wrote Losartan and thus scored 4.
73. A beta blocker. You wrote atenolol and thus scored 4.
74. A beta agonist. You wrote Salbutamol and thus scored 4.
75. A calcium antagonist used for hypertension. You wrote Amlodipine and thus scored 4.
76. An alpha blocker used in hypertension. You wrote Doxazosin and thus scored 4.
77. An aldosterone receptor antagonist used for hypertension. You wrote Spirinolactone and thus scored 4.
78. A dopamine agonist used for patients with a prolactinoma. You wrote cabergoline and thus scored 4.
79. A dopamine antagonist that can be used for psychotic disorders or nausea. You wrote Reglan and thus scored 0.
80. A macrolide antibiotic. You wrote erythromycin and thus scored 4.

Question 24

Briefly (approx 100 words) explain how one interprets the mean corpuscular volume (MCV) in the full blood count (FBC), and what pattern one sees in a patient with bowel cancer that slowly bleeds, and how this compares to a patient with pernicious anaemia.

Answer 24

Patients who have chronic GI bleeding will become iron deficient, and then go on to have a low MCV. The normal MCV is 76 to 96 fl, and iron deficiency will cause a microcytic anaemia. Pernicious anaemia is caused by lack of intrinsic factor, and this results in B 12 malabsorption. Lack of B12 results in megaloblastic anaemia, where the DNA divides, but the cells do not, so that one has hypersegmented neutrophils. These patients have a high MCV.

Question 25

Briefly (approx 100 words) explain how the pattern of abnormality of liver function tests can give a clue as to the aetiology of jaundice. Illustrate your answer in particular with reference ALT, AST and alkaline phosphatase.

Answer 25

A good answer was: Jaundice can be caused by haemolysis, by liver dysfunction or by physical obstruction of the biliary tree. Haemolysis will result in a high bilirubin with a normal set of liver enzymes, so that ALT, AST and alk phos will be normal. In patients with an inflamed liver, for example caused by hepatitis, the ALT is most raised. Obstructive jaundice is caused by gallstones or pancreatic cancer and in these patients it is the alkaline phosphatase that is most raised.