Formative Flashcards
1
Q
A 70 year old man has pain on chewing his food. He has tenderness in the temporal region and proximal muscle weakness in his arms. Which is the single most appropriate treatment for him? Select one: A. aspirin B. ibuprofen C. hydrocortisone D. methyl prednisolone E. prednisolone
A
The diagnosis is giant cell arteritis and the treatment for this is oral prednisolone.
2
Q
A 93 year old man has a series of falls. He has been progressively forgetful and has had episodic hallucinations over the past year. Which is the single most likely diagnosis? Select one: A. Alzheimer’s disease Incorrect B. diffuse Lewy body disease C. multi-infarct dementia D. multisystem atrophy E. Parkinson’s disease
A
This is a classical description of Diffuse Lewy Body disease – drop attacks and neuropsychiatric symptoms occur early in the disease.
3
Q
A 56 year old obese man has recurrent abdominal pain radiating to his back and made worse by eating spicy foods and bending over. Antacids relieve his pain. Which is the single most appropriate next investigation?
Select one:
A. abdominal x-ray
B. abdominal CT scan
C. double contrast barium meal
D. Helicobacter pylori breath test Incorrect
E. oesophagogastroduodenoscopy (OGD)
A
He should have an OGD – his age makes pathology other than GORD morecommon, this is the recommended course of action for all those over 45 years of age
4
Q
A 79 year old woman has urinary frequency, urgency and urgency incontinence. Which single investigation is most appropriate to arrange next?
Select one:
A. dipstick urinalysis
B. frequency volume chart (bladder diary)
C. multi-channel cystometry
D. renal tract ultrasound
E. video urodynamics
A
A dipstick urinalysis is the next simplest examination to perform; all others either will add nothing to the diagnosis or are unnecessarily invasive.
5
Q
A 65 year old man has a persistent high temperature, profuse diarrhoea and abdominal pain two weeks after finishing antibiotics following an elective hip replacement. There are reddened ulcers and yellowish plaques on his colonic mucosa at sigmoidoscopy. Which is the single most likely diagnosis? Select one: A. Clostridium perfringens enterocolitis B. Crohn’s disease C. pseudomembranous colitis D. ulcerative colitis E. viral gastroenteritis
A
Severe inflammatory changes in the mucosa and antibiotic use suggest pseudoembranous colitis due to clostridium difficile infection.
6
Q
A 87 year old man has a longstanding, non healing ulcer on the side of his nose. It has an opalescent sheen and multiple telangectases running over the surface. The centre is depressed and necrotic. Which is the single most likely diagnosis? Select one: A. basal cell carcinoma B. keratoacanthoma C. melanoma D. solar keratosis E. squamous cell carcinoma
A
The basal cell carcinoma typically has the features as described and may also have a depressed centre.
Features:
- non healing ulcer (often on side of nose)
- opalescent sheen
- multiple telangectases
- centre depressed / necrotic
7
Q
An 80 year old woman inpatient with schizophrenia has a temperature of 38.6oC and increasing rigidity. Which is the single most likely cause of her symptoms? Select one: A. haloperidol and amitriptyline B. haloperidol and diazepam C. haloperidol and flupenthixol D. haloperidol and sertraline E. haloperidol and zopiclone
A
The diagnosis here is neuroleptic malignant syndrome which can be precipitated by either high doses of a single anti-psychotic medication, but more commonly by the use of combinations of anti-psychotic medication (haloperidol and flupenthixol)
8
Q
A 50 year old man with epigastric burning pain has an OGD which shows gastro-oesophageal reflux. Which single oral medication is the most effective for his condition? Select one: A. bismuth B. gaviscon C. magnesium trisilicate D. omeprazole E. ranitidine
A
A PPI is more effective than the H2 antagonist.
Omeprazole
9
Q
A 47 year old man had a history of chronic alcohol misuse. Which single enzyme would most likely be found to be raised in his serum? Select one: A. alcohol dehydrogenase B. alkaline phosphatise C. amylase. D. gamma glutamyl transferase E. pancreatic lipase
A
Gamma GT is commonly raised in patients who consume large amounts of alcohol.
10
Q
A 75 year old man who smokes 20 cigarettes a day has had a worsening productive cough, high temperature, fatigue and shortness of breath for four days. His oxygen saturations is 91% on room air and he has focal coarse crepitations at the left base. Which single organism is the most likely cause of his symptoms? Select one: A. Haemophilus influenza B. Legionella pneumonia C. Mycoplasma pneumonia D. Staphylococcus aureus E. Streptococcus pneumonia
A
the commonest cause of community acquired pneumonia is streptococcus pneumonia
11
Q
A 67 year old woman has had shortness of breath and a productive cough for two days. Her temperature is of 38˚C, pulse rate 100bpm, respiratory rate 26, oxygen saturations 93%, and BP 110/50 mmHg. Her abbreviated mental test score is 6/10. Blood tests show:
Haemoglobin 13.0g/dL
White cell count 15 x 109/L
Urea 9 mmol/L
Creatinine 105µmol/L
Which is the single most appropriate action to take?
Select one:
A. admit to hospital and consider ITU referral
B. admit to hospital for immediate NIV
C. admit to hospital to the medical assessment unit
D. discharge home on oral antibiotics
E. discharge home with home iv antibiotic service
A
she is hypoxic, with altered mentation and evidence of sepsis; she could deteriorate rapidly and so needs urgent high dependency care
The correct answer is: admit to hospital and consider ITU referral
12
Q
A 49 year old woman is waiting for a liver transplant. Which single condition is the most likely indication in this woman? Select one: A. alcoholic liver disease B. chronic active hepatitis C. Hepatitis A liver disease D. Hepatitis E liver disease E. hepatocellular carcinoma
A
hepatitis c, alcoholic liver disease and primary biliary cirrhosis are the commonest indications for liver transplantation in the uk
The correct answer is: alcoholic liver disease
13
Q
A 20 year old woman has repeated episodes of self harm, feelings of emptiness and intense and unstable relationships. Which is her single most likely diagnosis? Select one: A. antisocial personality disorder B. avoidant personality disorder C. borderline personality disorder D. histrionic personality disorder E. narcissistic personality disorder
A
Feedback: typical features of emotional instability, impulse to self harm and inability to form stable relationships
The correct answer is: borderline personality disorder
14
Q
A 50 year old man with schizophrenia takes olanzapine. Which single condition is he more at risk of developing? Select one: A. COPD B. diabetes mellitus C. hypothyroidism D. nephrogenic diabetes insipidus E. pancreatitis
A
olanzapine most of all atypical anti-psychotics cane lead to diabetes, as well as weight gain and metabolic syndrome
The correct answer is: diabetes mellitus
15
Q
A year 4 medical student is shadowing an FY2 on ITU. The FY2 asks the medical student to take blood from an unconscious patient. The patients close family are at the bedside. The medical student has completed her venepuncture training. Which is the single most appropriate action for the medical student to take?
Select one:
A. ask the consultant’s permission before taking blood
B. ask the relatives’ permission before taking blood Correct
C. explain to the FY2 she cannot take the blood as the patient cannot give consent
D. get written consent from the next of kin before taking blood
E. offer to assist the FY2 but not take the blood herself
A
Feedback: getting oral consent from the next of kin is most appropriate
The correct answer is: ask the relatives’ permission before taking blood
16
Q
You are a year 4 student on a clinical attachment. You have been asked to take a history from a 21 year old woman who may have a sexually transmitted infection. Which is the single most appropriate way to introduce the sexual history?
Select one:
A. ask whether she is currently in a relationship.
B. explain that any information she gives is completely confidential.
C. explain that you need to ask about her sexual history, as she may have a sexually transmitted infection.
D. say that you have some routine questions you ask all patients.
E. say you would like to ask some more personal questions.
A
Feedback: this is an open ended approach introducing the subject of more intimate questioning which will include sexual history
The correct answer is: say you would like to ask some more personal questions.
17
Q
A 23 year old university student wakes up in the middle of the night with vomiting, malaise and a high temperature. He is admitted to hospital for observation. Within two hours, he has a stiff neck and convulses. Which is the single most likely diagnosis?
Select one:
A. Haemophilus influenzae type B meningitis
B. Listeria meningitis
C. Meningococcal meningitis
D. Pneumococcal meningitis
E. Tuberculous meningitis
A
meningism in a young patient should alert you to the possibility of meningococcal infection and promt immediate antibiotic treatment before LP
The correct answer is: Meningococcal meningitis
18
Q
A 42 year old obese man is noted by his GP to have glucose in his urine. Two fasting blood glucose levels were 7.3 and 7.4mmol/L. Which is the single most appropriate management option for this man? Select one: A. admit to hospital for insulin therapy B. advice on diet and exercise C. start insulin therapy D. metformin treatment E. sulphonylurea treatment
A
He has impaired glucose tolerance (fasting blood glucose > 7 or random glucose > 11.1) and should be given advice on diet and exercise – he is at risk of developing Type 2 diabetes
The correct answer is: advice on diet and exercise
19
Q
A 34 year old man has fatigue and shortness of breath. His ECG recording is below. He has a cardiac biopsy, and the image is also below. ECG - ST elevation Cardiac biopsy - inflammatory infiltrate What is the single most likely diagnosis? Select one: A. cardiac amyloidosis B. infective endocarditis C. myocardial infarction D. myocarditis E. pericarditis
A
The S-T elevation and neutrophilic infiltration of the myocardium are consistent. ST changes and T wave inversion can occur in myocarditis.
The correct answer is: myocarditis
20
Q
A 64 year old man has central chest pain. Which single set of findings is most likely in the diagnosis of myocardial infarction?
Select one:
A. high troponin T and high creatine kinase (muscle-brain) (CK-MB)
B. high troponin T and high lactate dehydrogenase (LDH)
C. high troponin T and low CK-MB
D. normal troponin T and high LDH
E. normal troponin T and normal CK-MB
A
A. Both Trop and CK-MB indicate myocardial damage in the context of myocardial infarction.
The correct answer is: high troponin T and high creatine kinase (muscle-brain) (CK-MB)
21
Q
A 25 year old woman has a high temperature, haematuria, splenomegaly and splinter haemorrhages. Which is the single most likely diagnosis? Select one: A. Burkitt’s lymphoma B. carcinoid syndrome C. endocarditis Correct D. enteric fever E. pneumococcal pneumonia
A
The combination of features is characteristic of endocarditis
The correct answer is: endocarditis
22
Q
A 68 year old woman had a post mortem. The lungs were heavy and macroscopically had scattered firm grey areas. Histologically, the alveolar spaces were filled with neutrophils. Which is the single most likely diagnosis? Select one: A. adult respiratory distress syndrome B. bronchopneumonia Correct C. chronic obstructive pulmonary disease D. CMV pneumonitis E. tuberculosis
A
The features of neutrophil infiltration are consistent with bronchopneumonia. For those who put ARDS as an answer, the pathologic features of the lung in ARDS derive from severe injury to the alveolo-capillary unit. This leads to a pulmonary oedema due to leakage of protein rich fluid and also cellular necrosis, epithelial hyperplasia, inflammation, and fibrosis.
The correct answer is: bronchopneumonia
23
Q
A 68 year old woman has acute shortness of breath. Which single clinical finding would indicate pulmonary oedema? Select one: A. dry cough B. fine inspiratory crackles Correct C. inspiratory wheeze D. polyphonic wheeze E. prolonged expiration
A
fine, late inspiratory crackles are consistent with pulmonary oedema
The correct answer is: fine inspiratory crackles
24
Q
A 76 year old man has a persistent discharge from his right ear. The image is that seen through the otoscope. Which is the single most likely diagnosis? See mass in ear on otoscope Select one: A. cholesteatoma B. foreign body C. otitis externa D. otitis media E. perforation of ear drum
A
Cholesteatoma occurs if skin from the inner side of the tympanic membrane sloughs off and mixes with ear wax that penetrates to the middle ear and fails to drain through the Eustachian tube. The accumulation of dead skin and wax causes a cyst-like mass, the cholesteatoma. If left untreated the mass can cause serious damage to the eardrum and ossicles. In serious cases, cholesteatomas can erode into the mastoid and can cause cerebral infection.
The correct answer is: cholesteatoma
25
```
A 70 year old man has shortness of breath secondary to a pleural effusion. The protein content of the pleural fluid is 45 g/L. Which is the single most likely cause of his effusion?
Select one:
A. congestive cardiac failure
B. chronic liver failure
C. malabsorption
D. nephrotic syndrome
E. non small cell lung cancer
```
The protein content of the effusion fluid which is high (> 30 g/L)suggests an exudate. The causes of this are chronic inflammation and malignancy. All the other causes are transudates (generally protein content
26
A 26 year old mother of a son with haemophilia A has a third acute haemarthrosis following a relatively minor fall. Which single factor best describes the most likely reason for this?
Select one:
A. a low level of Factor VIII is associated with carrier status in females
B. a high level of Factor VIIIc is associated with carrier status in females
C. a spontaneous mutation of the responsible gene has occured
D. factor VIII resistance is a characteristic feature in mothers of haemophiliacs
E. the mother has a haemophiliac mother
Haemophilia A is due to Factor VIII deficiency and Haemophilia B is due to factor IX deficiency. Both are X linked disorders. This means that an affected X chromosome is commonly paired with an unaffected X chromosome, thus conferring carrier status in females which may lead to low Factor VIII levels.
The correct answer is: a low level of Factor VIII is associated with carrier status in females
27
```
A 38 year old woman has had a cough and malaise for two days. Her chest radiograph is below.
CXR - wedge shape in R middle zone
Which is the single most likely diagnosis?
Select one:
A. atypical pneumonia
B. broncho-alveolar cell carcinoma
C. lobar pneumonia
D. pleural effusion
E. right lower lobe collapse
```
There is consolidation of the right lower lobe along anatomical boundaries – hence lobar pneumonia
The correct answer is: lobar pneumonia
28
```
A 62 year old woman has facial redness and swelling following a superficial wound.
Which is the single most appropriate treatment for this condition?
Select one:
A. intravenous amikacin
B. intravenous benzylpenicillin
C. intravenous ciprofloxacin
D. intravenous erythromycin
E. intravenous flucloxacillin
```
This is erysipelas. It is typically a streptococcal disease – best treated with Benzylpenicillin
The correct answer is: intravenous benzylpenicillin
Erysipelas also known as "Ignis sacer", "holy fire", and "St. Anthony's fire" is an acute infection of the upper dermis and superficial lymphatics, usually caused by streptococcus bacteria. Erysipelas is more superficial than cellulitis, and is typically more raised and demarcated.
Symptoms: high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis. Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen.
29
```
Which is the single major criterion in the diagnosis of rheumatic fever?
Select one:
A. athralgia
B. erythema marginatum Correct
C. fever
D. previous history of rheumatic fever
E. prolonged PR interval
```
Major criteria of rheumatic fever are: Migratory polyarthritis, Carditis, Subcutaneous nodules, Erythema marginatum and Sydenham's chorea.
The correct answer is: erythema marginatum
```
CASES:
Carditis
Arthritis
Sydenham's chorea
Erythema marginatum
Subnutaneous nodules
```
30
```
A 50 year old Caucasian man has a blood pressure of 158/90mmHg. He is a not a smoker or diabetic, with no other significant history other than being overweight. Which is the best initial management?
Select one:
A. advise lifestyle measures.
B. ACE inhibitor
C. beta blocker
D. calcium channel antagonist
E. no treatment required
```
The BP is borderline high, and target for treatment is over 160/100 in patients with no risk factors. The correct thing to do is offer lifestyle advice and repeat the BP measurement
The correct answer is: advise lifestyle measures.
31
A 73 year old man with COPD has an infective exacerbation. His respiratory rate is 12 breaths per minute and arterial oxygen saturation on air 97%. He has no other significant medical history. Which is the single most appropriate antibiotic regime to prescribe him?
Select one:
A. amoxicillin 500mg three times daily by mouth
B. ciprofloxacin 500mg twice daily by mouth
C. co-amoxiclav 625mg thrice daily with clarithromycin 500mg twice daily by mouth
D. flucloxacillin 500mg four times daily by mouth
E. penicillin V 500mg four times daily and trimethoprim 200mg twice daily by mouth
He has mild COPD exacerbation. Amoxicillin is the most appropriate therapy
The correct answer is: amoxicillin 500mg three times daily by mouth
32
A 19 year old woman has an appendicectomy and the surgeon takes care to ensure a good cosmetic appearance of the skin wound when it heals. Which is the single best description of the healed skin incision?
Select one:
A. fibrous repair of both the dermis and epidermis
B. fibrous repair of the dermis, and regeneration of the epidermis
C. granulation tissue in the dermis, and regeneration of the epidermis
D. hyperplasia of both the dermis and epidermis
E. regeneration of both the dermis and epidermis
Mechanisms of wound healing – this is the process where keratinocytes migrate and help regeneration.
The correct answer is: fibrous repair of the dermis, and regeneration of the epidermis
33
```
A 48 year old man has had an inferior myocardial infarction. He has a monitored arrhythmia. His 12 lead ECG is below. Which is the single most likely diagnosis?
Prolongation of PR interval
Select one:
A. atrial fibrillation
B. Mobitz Type 1 atrioventricular block
C. Mobitz Type 2 atrioventriciular block
D. premature ventricular contractions (ventricular extrasystole)
E. Type 1 atrioventricular block
```
Mobitz Type 1 atrioventricular block - prolongation of PR interval
Rather than Mobitz type 2 where there is a dissociation of P waves and QRS complexes. p waves are not conducted
34
A 22 year old woman has tiredness and weight loss. She has a tachycardia, a palpable goitre and a thyroid bruit. Investigations show:
TSH
This woman is hyperthyroid. The TSH is typically suppressed by free T3.
The correct answer is: suppression by free T3
35
A 56 year old woman has chest pain lasting for an hour. Her ECG is below. Which is the single most appropriate treatment?
ECG shows ST elevation in II, III and aVF
```
Select one:
A. aspirin
B. aspirin and streptokinase
C. clopidogrel
D. clopidogrel and aspirin
E. primary percutaneous coronary intervention
```
PCI is now the treatment of choice in myocardial infarction.
| The correct answer is: primary percutaneous coronary intervention
36
```
A 22 year old obese woman has a temperature of 37.8ºC 24 hours after appendicectomy. Which is the single most likely cause?
Select one:
A. pulmonary atelectasis
B. pulmonary embolism
C. pelvic abscess
D. thrombophlebitis
E. urinary tract infection
```
```
Pulmonary atelectasis (enlargement of small airways) may contribute to the development of postoperative pyrexia.
The correct answer is: pulmonary atelectasis
```
37
```
A 30 year old woman has a blood stained nipple discharge associated with a small palpable retro-areolar mass. Which is the single most likely diagnosis?
Select one:
A. cyst
B. fat necrosis
C. fibroadenoma
D. mammary fistula
E. papilloma
```
This is a characteristic description for a papilloma
| The correct answer is: papilloma
38
```
A 35 year old African woman has a haemoglobin level of 6g/dL. A blood film shows microcytic, hypochromic red blood cells with target cells. Which is the single most likely diagnosis?
Select one:
A. anaemia of chronic disease
B. iron deficiency anaemia
C. sickle cell disease
D. sideroblastic anaemia
E. thalassaemia trait
```
The blood film shows iron deficiency, thalassaemia causes microcytosis, but the anaemia is unusual with thalassemia trait.
The correct answer is: iron deficiency anaemia
39
```
A 49 year old woman has had breathlessness for one day. Her chest x-ray is below: Which is the single most likely diagnosis?
CXR - opacity in LLL with meniscus sign
Select one:
A. collapse of the left lower lobe
B. consolidation of the left lower lobe
C. fibrosis of the left lower lobe
D. left sided pleural effusion Correct
E. left sided pulmonary infarction
```
The chest x-ray shows a left sided pleural effusion. There is a meniscus at the fluid- lung interface
The correct answer is: left sided pleural effusion
40
Which single risk scoring system places patients in one of five categories based on general medical history and examination without requiring any specific investigations, and is effective in predicting mortality?
Select one:
A. APACHE Score (Acute physiological chronic health evaluation)
B. American Society of Anaesthesiology (ASA) Score
C. Glasgow Coma Scale
D. Ranson’s score
E. revised trauma score
This is a validated measure of morbidity scoring. ASA stands for American Society of Anesthesiologists. The ASA adopted a five category physical status classification system for assessing a patient before surgery. These are:
A normal healthy patient.
A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a constant threat to life.
A moribund patient who is not expected to survive without the operation.
The correct answer is: American Society of Anaesthesiology (ASA) Score
41
```
A 72 year old man collapses and dies suddenly on the ward, four days after a confirmed anterior myocardial infarction. Which is the single most likely cause of death?
Select one:
A. cardiac rupture
B. mural thrombus
C. pericarditis
D. sub acute bacterial endocarditis
E. ventricular aneurysm
```
A cardiac rupture (due to infracted cardiac muscle) is the most likely cause of sudden death
The correct answer is: cardiac rupture
42
```
A 45 year old hypertensive man has sudden onset of central chest pain, radiating to his left arm, associated with tingling and numbness. The pain radiates to his back and he has nausea, vomiting and sweating. A chest x-ray shows mediastinal widening. Which is the single most likely diagnosis?
Select one:
A. acute myocardial infarction
B. aortic dissection
C. aortic regurgitation
D. pulmonary embolism
E. tension pneumothorax
```
Chest pain radiating to the back is consistent with an aortic dissection, widening of the mediastinum is due to an aortic aneurysm which is a predisposing risk factor
The correct answer is: aortic dissection
43
```
A 67 year old man had a myocardial infarction three days ago. He is now confused with a systolic blood pressure of 70mmHg and an irregular narrow complex tachycardia that has a ventricular rate of 160 beats/minute. Which is the single most appropriate management of his arrhythmia?
Select one:
A. amiodarone intravenously
B. DC cardioversion
C. digoxin intravenously
D. sotolol intravenously
E. verapamil intravenously
```
This man has fast atrial fibrillation with haemodynamic compromise and needs cardioversion
The correct answer is: DC cardioversion
44
A 72 year old man with COPD has reduced lung transfer factor for carbon monoxide (TLCO). Which single factor is measured by the TLCO?
Select one:
A. plasma carbon monoxide concentration
B. pulmonary gas transfer
C. pulmonary transluminal oxygen gradient
D. total lung compliance
E. total lung oxygenation capacity
```
The TLCO (transfer factor) measures the integrity of the alveolar-capillary surface area for gas transfer. It may be reduced in disorders that damage the alveolar walls (septa) such as emphysema, which leads to a loss of effective surface area and in disorders that thicken or damage the walls eg: pulmonary fibrosis.
The correct answer is: pulmonary gas transfer
```
45
A 52 year old man with treated epilepsy is confused and has difficulty in walking. He has some speech difficulty and is drowsy. He recently bought cimetidine for indigestion. His blood results are shown:
haemoglobin 9.8g/dL
MCV 105fL
white cell count 5.5x109/L
platelets 190x 109/L
Which is the single most likely explanation for his phenytoin toxicity?
Select one:
A. impaired absorption caused by achlorhydria
B. impaired elimination caused by folate deficiency
C. impaired metabolism caused by vitamin D deficiency
D. inhibition of metabolism caused by cimetidine
E. non-adherence to medication
cimetidine (a H2 receptor antagonist used to reduce acid production from the stomach), available over the counter, is an inhibitor of hepatic CYP enzymes. This inhibition of enzymes leads to reduced metabolism of other drugs e.g. phenytoin in this case
The correct answer is: inhibition of metabolism caused by cimetidine
46
```
A 36 year old man has unilateral hearing loss and a recurrent discharge from this ear. An image from otoscopy is below. Which is the single most likely diagnosis?
See erythema and discharge in front of ear drum
Select one:
A. acute perforation of the eardrum
B. cholesteatoma
C. otitis interna
D. otitis media Correct
E. otosclerosis
```
This is suppurative otitis media – there is erythema around the middle ear and also discharge.
The correct answer is: otitis media
47
An 81 year old man with COPD has an increase in cough, sputum viscosity, wheeze and breathlessness. He is able to complete short sentences with a respiratory rate of 18 breaths per minute. Which is the single best initial treatment?
Select one:
A. antibiotics, nebulised Beta 2 agonist, nebulised anti-cholinergic, intravenous steroids
B. antibiotics, nebulised Beta 2 agonist, nebulised anti-cholinergic, oral steroid Correct
C. antibiotics, nebulised Beta 2 agonist, oral steroid, montelukast
D. nebulised Beta 2 agonist, montelukast, intravenous steroid, nebulised anti-cholinergic
E. nebulised Beta 2 agonist, nebulised anti-cholinergic, intravenous steroids
The combination should be anbitiotics (amoxicillin), B2 agonist (salbutamol), anticholinergic (atrovent) and oral steroids (prednisolone).
The correct answer is: antibiotics, nebulised Beta 2 agonist, nebulised anti-cholinergic, oral steroid
48
```
A 65 year old woman has palpitations (trace below) and has a pulse rate of 185bpm. By the time she reaches medical help she is better and her pulse is 80bpm and regular.
Which is the single most likely cause for her palpitations?
Select one:
A. atrial fibrillation
B. atrial flutter Incorrect
C. sinus tachycardia
D. ventricular fibrillation
E. ventricular tachycardia
```
Paroxysmal AF is the most common arrhythmia of the older person.
The correct answer is: atrial fibrillation
49
A 70 year old man with known ischaemic heart disease and diabetes has permanent atrial fibrillation with a ventricular rate of 70bpm. He is asymptomatic. Which is the single best management option?
Select one:
A. anticoagulate with 300mg aspirin a day
B. anticoagulate with warfarin
C. direct current cardioversion
D. regular cardiology review
E. rhythm control with amiodarone
He will need anticoagulation with warfarin if in AF as age and diabetes gives him a CHADS-2 score of 2.
The correct answer is: anticoagulate with warfarin
CHADS-2 score
The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF).
CCF -1 point
Hypertension >140/90 - 1 point
Age over 75 - 1 point
DM - 1 point
Stroke / TIA / thromboembolism - 2 points
CHA2DS2-VASc score has been proposed. These additional non-major stroke risk factors include age 65-74, female gender and vascular disease. In the CHA2DS2-VASc score score, 'age 75 and above' also has extra weight, with 2 points.
The European Society of Cardiology (ESC) guidelines recommend that if the patient has a CHADS2 score of 2 and above, oral anticoagulation therapy (OAC) such as warfarin (target INR of 2-3) or one of the new OAC drugs (such as dabigatran) should be prescribed.
50
```
A 27 year old woman has a painless breast lump. It is mobile, with no overlying skin changes. A core biopsy shows an encapsulated lesion containing both epithelial and stromal elements. Which is the single most likely diagnosis?
Select one:
A. benign breast disease
B. ductal carcinoma-in-situ (DCIS)
C. fibroadenoma Correct
D. invasive lobular carcinoma
E. medullary carcinoma
```
Fibroadenomas of the breast are small, solid, rubbery, noncancerous, harmless lumps composed of fibrous and glandular tissue. Microscopically (below) the proliferation forms duct-like spaces. These are surrounded by fibroblastic stroma. There is also normal but proliferating epithelium.
51
```
A 76 year old man has breathlessness and a noisy wheeze over three months. His flow volume loop is below.
reduced PEFR
FEV1 normal
Reduced inspired flows
Preserved expiratory flows
Which is the single most likely diagnosis?
Select one:
A. asthma Incorrect
B. bronchial carcinoma
C. COPD
D. hypertrophy of the tonsils
E. vocal cord paralysis
```
This pattern fits extrathoracic obstruction due to a subglottic tumour or vocal cord problem –see flow volume loops below.
The correct answer is: vocal cord paralysis
52
Which single condition is a recognised complication of essential (primary) hypertension?
Select one:
A. aortic stenosis
B. cerebral infarction
C. chronic glomerulonephritis Incorrect
D. extradural haemorrhage
E. right ventricular outflow tract hypertrophy
Feedback: Hypertension is the most significant risk factor for stroke.
The correct answer is: cerebral infarction
53
```
A 67 year old man has had central chest pain radiating to the jaw and shoulder, with associated nausea and sweating for two hours. What is the single most appropriate initial investigation for his complaint?
Select one:
A. arterial blood gas
B. chest x-ray
C. echocardiogram
D. electrocardiogram
E. ventilation - perfusion (V/Q) scan
```
Feedback: Given the high of this presentation representing ischaemic heart disease, an ECG is the most appropriate thing to do
The correct answer is: electrocardiogram
54
The section below shows tissue from the transplanted heart of a 32 year old with cardiomyopathy. Biopsy was taken six months after transplantation. The section has been exposed to an antibody that detects CD3+ antigen and counterstained with an immunoperoxidase reagent (brown colour = positive).
CD3 detected on section
Which is the single most likely explanation for these findings?
Select one:
A. ciclosporin toxicity
B. cytomegalovirus infection
C. recurrence of viral myocarditis, the cause of the cardiomyopathy
D. rejection episode Correct
E. vasculitis due to immune complex deposition
The positive staining which is CD-3 positive suggests T cell activation associated with acute rejection in transplant tissue.
The correct answer is: rejection episode
55
```
A 65 year old woman who smokes has lobar shadowing on her cest x-ray and rusty coloured sputum. Which single organism is the most likely cause of her pneumonia?
Select one:
A. Haemophilus influenzae
B. Influenza A
C. Mycobacterium tuberculosis
D. Mycoplasma pneumoniae
E. Streptococcus pneumoniae
```
Strep pneumoniae commonest cause of community acquired pneumonia when organisms are isolated.
The correct answer is: Streptococcus pneumoniae
56
A 45 year old man has 48 hours of flu like symptoms and a cough with clinical and radiological signs of consolidation. Which single variable below indicates a poor prognosis from this illness?
Select one:
A. arterial saturation of oxygen on air of 96%
B. blood pressure of 125/90 mmHg
C. plasma urea concentration of 5.1 mmol/L
D. respiratory rate of 35 breaths/min
E. temperature 38.5ºC
CURB 65 score – the R refers to Resp rate > 30
The correct answer is: respiratory rate of 35 breaths/min
CURB 65
Confusion (AMT 7
Resp rate >30
BP 65 years old
57
```
A 68 year old woman has a sudden collapse after a flu like illness lasting seven days. She is cyanotic, hypotensive, and tachycardic with a high jugular venous pressure. Which is the single most likely cause?
Select one:
A. mitral valve prolapse
B. myocardial infarction
C. pulmonary embolism
D. subarachnoid haemorrhage
E. thyrotoxic storm
```
Infections, respiratory or otherwise, have been associated with an increased risk of venous thromboembolism. Thus a sudden collapse as in this case suggests a PE
The correct answer is: pulmonary embolism
58
```
A 57 year old man has palpitations and dyspnoea. He has peripheral cyanosis, an undisplaced tapping apex beat and mid diastolic murmur with an opening snap. Which is the single most likely diagnosis?
Select one:
A. atrial fibrillation
B. atrial myxoma
C. atrial septal defect
D. mitral regurgitation
E. mitral stenosis
```
These are the clinical signs of mitral stenosis. The patient may also be in atrial fibrillation, have a malar flush, often thin, may have a weak or “thready” (low volume) pulse, palpable heart sounds, a RV heave.
The correct answer is: mitral stenosis
59
```
A 70 year old man has bilateral basal fine crackles on auscultation of his chest. He has noticed slight breathlessness on stairs but no other symptoms. There is no significant previous medical or drug history. Which is the single most likely diagnosis?
Select one:
A. asthma
B. bronchiectasis
C. fibrosing alveolitis
D. pneumonia
E. tuberculosis
```
The pulmonary crackles in the absence of other signs of heart failure would suggest a diagnosis of fibrotic lung disease
The correct answer is: fibrosing alveolitis
60
```
A 21 year old asthmatic woman has worsening breathlessness and wheeze over 24 hours. Which single investigation would be most helpful in her initial management?
Select one:
A. chest x - ray
B. full blood count
C. peak expiratory flow rate
D. serum concentration of potassium
E. sputum culture
```
A peak flow would have most value in assessing severity in acute asthma.
The correct answer is: peak expiratory flow rate
61
A 19 year old cleaner in an apiary has developed facial swelling (picture). A provisional diagnosis of a type I immune reaction to bee sting is made.
Which is the single most important future risk from this reaction?
Select one:
A. auto immune uveitis
B. bronchospasm
C. hypertension
D. Reiter’s syndrome
E. Sjogren’s syndrome involving the lacrimal gland
She has been sensitized to the antigen and this is likely to lead to anaphylaxis. Bronchospasm is a feature of anaphylaxis
The correct answer is: bronchospasm
62
A 76 year old woman with repeated falls is investigated with a 24-hour Holter monitor. She dies with the monitor in place. A segment of the trace is below.
trace shows wiggly line - no pattern
```
Which is the single best diagnosis?
Select one:
A. alternating current interference
B. movement artefact
C. torsade des pointes
D. ventricular fibrillation
E. ventricular tachycardia
```
This is a trace of VF
| The correct answer is: ventricular fibrillation
63
An 80 year old woman has weight loss. She has a chest x-ray performed.
Which is the single most important finding?
CXR shows opacity in L lower zone by heart border
```
Select one:
A. abnormal right diaphragmatic shadow
B. enlarged right hilum
C. hyper-expanded lung fields
D. lesion in the left lower lobe Correct
E. normal chest x-ray
```
There is an area of shadowing in the lower zone, with speculated appearances which is consistent with a malignancy
The correct answer is: lesion in the left lower lobe
64
```
A 67 year old woman has worsening breathlessness over 12 months. There is no diurnal variation and except for a productive cough she has no other chest symptoms. She was a smoker of 20/day from the ages of 18 to 63. Which is the single most likely diagnosis?
Select one:
A. anaemia
B. asthma
C. COPD
D. fibrosing alveolitis
E. pleural effusion
```
chronic breathlessness in a longstanding smoker with productive cough suggest COPD. Lack of diurnal variation makes ashma less likely
The correct answer is: COPD
65
```
A 24 year old man has sudden onset stabbing chest pain and breathlessness, he has had one similar episode in the past. He has no other past medical history. Which single diagnosis is most likely to account for his presentation?
Select one:
A. asthma
B. bronchial carcinoma
C. pulmonary embolism
D. pulmonary oedema
E. spontaneous pneumothorax
```
pain and breathlessness would suggest PE or pneumothorax, pleuritic pain would favour PE . The previous episode without risk factors for PE or other thromboembolic features would favour pneumothorax
The correct answer is: spontaneous pneumothorax
66
```
A 37 year old woman has joint pains and shortness of breath. She is known to have asthma. She smokes 4 cigarettes a day and works as a restaurateur. She has mild wheezes throughout the chest. It was noted that she had bilateral erythematous lesions in the legs as shown below. Her chest x-ray is also shown. Which is the single most appropriate next investigation?
Select one:
A. angiotensin converting enzyme level
B. arterial blood gas estimation
C. CT pulmonary angiogram
D. electrocardiogram D
E. ventilation - perfusion (V/Q) scan
```
she has bihilar lymphadenopathy and erythema nodosum, suggesting Sarcoidosis best confirmed by serum ACE
The correct answer is: angiotensin converting enzyme level
67
```
A 43 year old HIV positive man has a cough and haemoptysis. He takes efavirenz, tenofovir and emtricitabine but mentions that he frequently forgets to take his medications. His chest x-ray is shown below. Which is the single most likely infecting organism?
CXR - solid mass in L upper zone
Select one:
A. Aspergillus fumigatus Correct
B. Coxiella burnetti
C. Legionella pneumophilia
D. Mycobacterium tuberculosis
E. Pseudomonas aeruginosa
```
A solid mass within a larger cavity in an immunocompromised patient would suggest aspergillus. Other agents mentioned would cause more diffuse pneumonic involvement
The correct answer is: Aspergillus fumigatus
68
```
A 22 year old man has had asthma for two years. His takes a salbutamol inhaler twice a day. He now has breathlessness during the day and wakes up at night feeling wheezy. A diary of his peak flow shows that measurements average at 450 and a predicted peak flow is 600. Which is the single most appropriate medication to prescribe him?
Select one:
A. inhaled anticholinergic
B. inhaled antimuscarinic
C. inhaled corticosteroid
D. inhaled long acting β2 agonist
E. oral prednisolone
```
poorly controlled asthma despite regular b agonists would require corticosteroids, initially inhaled.
The correct answer is: inhaled corticosteroid
Asthma prescribing
1. inhaled short acting beta 2 agonist
2. + inhaled corticosteroid (400mcg)
3. + LABA
4. If benefit from LABA but not sufficient control, increase corticosteroid to 800mcg/day
If no benefit from LABA - stop
Increase corticosteroid to 800mcg
5. consider trial of leukotriene receptor antag or theophylline
or increase steroid to 2000mcg/day
6. consider oral steroid tablet + 2000mcg inhaled steroid
69
```
A 23 year old intravenous drug user has a temperature of 38.4˚C and rigors. There is an early diastolic murmur. His urinalysis is positive for blood. Which is the single most appropriate investigation?
Select one:
A. coronary angiography
B. dobutamine stress-echocardiography
C. erythrocyte sedimentation rate
D. trans-oesophageal echocardiography
E. ventilation - perfusion (V-Q) scan
```
the likely diagnosis is infective endocarditis with an immune complex glomerulonephritis, which may be confirmed by TOE. He needs blood cultures also
The correct answer is: trans-oesophageal echocardiography
70
```
A 64 year old man with a 50 pack a year history has breathlessness on exertion. His apex beat is displaced by 2 cm laterally and inferiorly. He has an early diastolic murmur, heard loudest at the tricuspid area. Which is the single most likely diagnosis?
Select one:
A. aortic regurgitation
B. aortic stenosis
C. mitral regurgitation
D. mitral stenosis
E. tricuspid regurgitation
```
A displaced apex suggests volume loaded ventricle(MR or AR) and an early diastolic murmur goes with AR
The correct answer is: aortic regurgitation
71
```
A 26 year old woman with asthma attends the Emergency Department with increasing breathlessness, wheeze, a respiratory rate of 40, oxygen saturation 88% on air. Which is the single most appropriate initial management?
Select one:
A. intravenous aminophylline
B. high flow oxygen
C. nebulised ipratropium
D. nebulised salbutamol
E. oral prednisolone
```
he is hypoxic on room air, so the first thing to do is supplement his inhlaed oxygen
The correct answer is: high flow oxygen
72
```
A 87 year old woman attends her GP surgery. She has been getting chest pain which lasts a few minutes, is made worse by walking up the steps or after having a big meal. When she rests it seems to settle pretty quickly. Which is the single most likely diagnosis?
Select one:
A. chronic stable angina
B. myocardial infarction
C. peptic ulcer disease
D. pleurisy
E. pulmonary embolus
```
her symptoms are induced by exertion and resolve with rest, suggestive of angina. There are no features to suggest that this is unstable- prolonged pain at rest or at night.
The correct answer is: chronic stable angina
73
```
A 73 year old woman has three months of palpitations, consisting of a sudden onset of fast chaotic heart beat, with gradual offset after about an hour. She feels a little short of breath and light headed if she walks around during the episodes. She takes bendroflumethazide for high blood pressure. Which is the single most likely cause of her symptoms?
Select one:
A. atrial flutter
B. paroxysmal atrial fibrillation
C. sinus arryhthmia
D. ventricular ectopics
E. ventricular tachycardia
```
Intermittent FAST and chaotic palpitations suggest an irregular tachyarrthymia such as paroxysmal AF, common in elderly patients with IHD.
The correct answer is: paroxysmal atrial fibrillation
74
An 81 year old man has collapsed in the street. His ECG is below. Which is the single most likely diagnosis?
P waves present
Slow rhythm
```
Select one:
A. aystole
B. bigemini
C. complete AV block
D. sinus bradycardia
E. ventricular ectopics
```
he has a slow rhythm, rate of aproximately 42 with clear p waves , demonstrating sinus bradycardia
The correct answer is: sinus bradycardia
75
```
A 67 year old man has had pleuritic chest pain, shortness of breath and a small haemoptysis on three occasions over the past month. Which single investigation is most likely to result in a diagnosis?
Select one:
A. arterial blood gas
B. CT pulmonary angiogram
C. chest x-ray
D. electrocardiogram
E. ventilation-perfusion (V/Q) scan
```
the pleuritic nature of the pain suggests a peripheral lesion, and the haemoptysis would go with a PE, best diagnosed bya V/Q scan as not likeley to be proximal in nature
The correct answer is: ventilation-perfusion (V/Q) scan
76
```
A 36 year old woman has thickening of her skin over her fingers and Raynaud's phenomenon. She has multiple telangiectasia over her face and difficulty swallowing. Which single antibody is most likely to be present?
Select one:
A. anti centromere antibody
B. anti Jo-1 antibody
C. anti topoisomerase antibody
D. c-ANCA
E. high titre of anti-DNA antibody
```
Anti centromere antibody is frequently in limited systemic scleroderma, (CREST Syndrome), and, occasionally are found in the diffuse form of scleroderma
The correct answer is: anti centromere antibody
```
CREST
Calcinosis
Raynaud's
Esophageal dysmotility
Sclerodactyly
Telangiectasia
```
77
```
Which is the single best treatment for the prevention of variceal bleeding in a 43 year old alcoholic man with portal hypertension and varices?
Select one:
A. amlodipine
B. metoclopramide
C. ompeprazole
D. ondansetron
E. propranalol
```
The beta blocker lowers portal blood pressure, bleeding is more likely if this is above 12mmHg
The correct answer is: propranalol
78
```
A 70 year old man has pain on chewing his food. He has tenderness in the temporal region and proximal muscle weakness in his arms. Which is the single most appropriate treatment for him?
Select one:
A. aspirin
B. ibuprofen
C. hydrocortisone
D. methyl prednisolone
E. prednisolone
```
The diagnosis is giant cell arteritis and the treatment for this is oral prednisolone.
The correct answer is: prednisolone
79
A 35 year old man has severe heartburn. Endoscopy confirms severe oesophagitis. Which is the single most appropriate therapy for him?
Select one:
A. amoxicillin and clarithromycin
B. amoxicillin, clarithromycin and lansoprazole
C. lansoprazole
D. no treatment, but repeat endoscopy in 6 weeks time
E. ranitidine
A PPI would be the most effective treatment for oesophagitis
| The correct answer is: lansoprazole
80
```
A 78 year old man has a plasma calcium concentration of 2.50 mmol/L , phosphate of 1.10 mmol/L and alkaline phosphatase of 1120 IU/L on a routine blood screen. Which is the single most likely diagnosis?
Select one:
A. osteomalacia
B. osteopetrosis
C. osteoporosis
D. Paget's disease of bone
E. primary hyperparathyroidism
```
In Paget’s disease there is increased osteoclastic and osteoblastic activity in the bone, but the calcium and phosphate levels are usually normal. However, in the setting of immobilization, hypercalcemia may occur.
The correct answer is: Paget's disease of bone
(enlarged and misshapen bones - excessive breakdown and formation of bones)
```
ALP -protein particularly found in liver, bone and bile ducts.
Elevated in:
Billiary Obstruction
Bone conditions
Osteoblastic bone tumors
Osteomalacia
Liver disease or hepatitis
Leukemia
Lymphoma
Paget's Disease
Sarcoidosis
hyperparathyroidism
```
81
```
A 47 year old woman has bone pain and erythema at the site of an orthopaedic procedure two weeks ago. Which single investigation will best exclude osteomyelitis?
Select one:
A. C reactive protein
B. CT scan
C. leucocyte count
D. magnetic resonance imaging Correct
E. plain x-ray
```
In osteomyelitis, MRI has high sensitivity in the detection of bone marrow changes, it may provide detailed information regarding the extent and activity of the process by allowing the detection of the intramedullary site of infection and its complications. MRI may also be used to distinguish soft tissue involvement, allowing differential diagnosis such as cellulitis.
The correct answer is: magnetic resonance imaging
82
```
A previously well 25 year old man has had bloody diarrhoea associated with mild cramps and lower abdominal pain for three months. He denies recent travel and cannot recall any unusual food items or friends or colleagues with similar symptoms. He has lost weight. He is mildly tender on abdominal palpation with no masses. PR is normal. He is mildly anaemic and stool cultures are negative. Which is the single most likely diagnosis?
Select one:
A. carcinoma of the caecum
B. coeliac disease
C. inflammatory bowel disease
D. irritable bowel disease
E. giardiasis
```
The history of bloody diarrhoea is consistent with inflammatory bowel disease. Carcinoma of the caecum is less likely in a young patient. There is no travel history suggestive of giardiasis.
The correct answer is: inflammatory bowel disease
83
```
A 42 year old man with Crohn’s disease has a full blood count which reveals a macrocytosis and mild anaemia. He is found to be folate deficient. Which is the single most likely mechanism by which this has occurred?
Select one:
A. deficient dietary intake
B. disordered folate metabolism
C. effect of azathioprine therapy
D. failure of absorption
E. increased physiological demand
```
Folate absorption is mostly in the small intestine, thus both Coeliac and crohn’s disease can lead to folate deficiency
The correct answer is: failure of absorption
84
A 38 year old man with alcohol dependence has abnormal liver function tests. A hepatologist performs a liver biopsy. Which is the single most likely microscopic finding in the liver biopsy?
Select one:
A. epithelioid granulomata
B. lymphocytic infiltration of hepatocytes
C. haemosiderin deposits
D. lack of bile ducts in portal tracts
E. steatosis
Fatty liver, or hepatic steatosis, is a reversible condition where large vacuoles of triglyceride fat accumulate in liver cells via the process of steatosis. Fatty liver can occur in those with excessive alcohol intake and those who are obese. Below is the typical appearance of hepatic steatosis.
The correct answer is: steatosis
85
A 76 year old woman has a rash and chronic joint pain. A photograph of her hands is shown below. - very deformed hands
shortened fingers
luxation, phalangeal and metacarpal bone absorption, and skeletal architecture loss in the fingers
Which is the single most likely diagnosis?
```
Select one:
A. osteoarthritis
B. osteogenesis imperfecta
C. psoriatic arthropathy
D. rheumatoid disease Incorrect
E. tophaceous gout
```
She has arthritis mutilans, a severe erosive arthropathy associated with psoriasis
The correct answer is: psoriatic arthropathy
86
```
Which is the single best treatment for severe osteoarthritis of the hip?
Select one:
A. allopurinol
B. gold
C. joint replacement surgery Correct
D. methotrexate
E. prednisolone
```
Joint replacement is a definitive treatment option in OA
| The correct answer is: joint replacement surgery
87
```
A 35 year man has abdominal pains, weight loss and diarrhoea. He has coeliac disease. He has a generalised itchy rash. A picture of the skin is shown below: Which is the single most likely diagnosis?
Select one:
A. erythema marginatum
B. dermatitis herpetiformis
C. erythema chronicum migrans
D. pityriasis rosea Incorrect
E. tinea versicolor
```
Dermatitis herpetiformis is a typical rash (which is pruritic) and associated with celiac disease. The skin changes are erythematous, urticarial plaques; and papules with vesicles.
The correct answer is: dermatitis herpetiformis
88
A 63 yr old woman with type 2 diabetes has severe constant upper abdominal pain. Her pulse is 105bpm, BP 115/75mmHg and temperature 37.5oC. Her abdomen is tender with guarding and reduced bowel sounds. Her blood tests show:
haemoglobin 11.8 g/dL
sodium 145 mmol/L
bilirubin 65 µmol/L
WCC 17x109/dL
potassium 3.9 mmol/L
ALP 105IU/L
platelets 194x109/dL
urea 6.2 mmol/L
ALT 64IU/L
glucose 15.5 mmol/L
creatinine 84 µmol/L
albumin 39g/L
amylase 1310IU/L
Which is the single most likely diagnosis?
Select one:
A. acute cholecystitis
B. acute pancreatitis
C. diabetic ketoacidosis
D. perforated peptic ulcer
E. urinary tract infection
The raised amylase and severe epigastric pain suggests acute pancreatitis
The correct answer is: acute pancreatitis
89
```
A 24 year old woman with systemic lupus erythematosus is under clinic review. Which is the single most likely finding in her serum?
Select one:
A. decreased IgM levels
B. decreased levels of C4
C. decreased levels of Interleukin 1
D. increased levels of C1 inhibitor
E. increased levels of C3
```
In SLE, a decrease in C3 and C4 are both common.
| The correct answer is: decreased levels of C4
90
```
An 83 year old woman has a third osteoporotic vertebral fracture. She is taking calcium and vitamin D supplementation and has oesophagitis. Which is the single most appropriate drug to add to her current regime?
Select one:
A. daily etidronate
B. daily strontium ranelate
C. salmon calcitonin
D. teriparetide injections
E. weekly risedronate
```
Bisphosphonates ( alendronate (Merck) and risedronate) are first line but are known to worsen upper GI symptoms, hence the second line drug for bone protection would be strontium
The correct answer is: daily strontium ranelate
For post-menopausal women raloxifene (selective oestrogen receptor modulator) can be used instead of bisphosphenates
91
A 46 year old woman has pruritis and worsening jaundice. Which single finding would most likely result in a diagnosis of primary biliary cirrhosis?
Select one:
A. presence of a high titre of auto-antibodies against smooth muscle
B. presence of auto-antibodies against aceteldehyde-altered liver cell membrane antigens
C. presence of auto-antibodies against components of the pyruvate dehydrogenase complex
D. presence of auto-antibodies against cytochrome p450
E. raised serum IgG
The pyruvate dehydrogenase complex is located in the mitochondria and the antibody to it is typically found in primary biliary cirrhosis (in clinical practice, an anti-mitochondrial antibody is sent).
The correct answer is: presence of auto-antibodies against components of the pyruvate dehydrogenase complex
92
```
A 60 year old man is admitted with acute decompensation of his alcoholic liver disease. Which single drug would help prevent Wernicke’s encephalopathy and Korsakoff’s psychosis?
Select one:
A. amitriptyline
B. chlordiazepoxide
C. vitamin B1 (thiamine)
D. vitamin B12
E. vitamin C
```
Replacement of thiamine is an important first step in preventing hepatic encephalopathy
The correct answer is: vitamin B1 (thiamine)
93
```
A 31 year old woman has pain in her right arm and difficulty with holding small objects. She has wasting of the muscles of the right hand and her grip is weak. An x-ray of her cervical spine is shown. Which is the single most likely cause of her symptoms?
CXR - no cervical rib
Select one:
A. ankylosing spondylitis
B. cervical rib
C. cervical spondylosis
D. metastatic bony destruction
E. Pancoast tumour
```
The picture in the question does not show a cervical rib.
Cervical ribs are an anomaly that arise from the lowest cervical vertebrae but their relationship to thoracic outlet syndrome (TOS) is not so constant that the two conditions should be seen as synonymous. Perhaps no more than 10% of people who have cervical ribs develop TOS and the syndrome may well occur in the absence of ribs. Diagnosis of TOS may be difficult and depends upon a thorough history and examination together with supportive tests.
94
```
A 36 year old woman has tiredness, joint pain, dry eyes and dry mouth. No joints are swollen and there is no rash. Her blood results show:
Full blood count normal
ESR 96 mm/hr
C reactive protein 10mg/L
Anti-nuclear antibody strongly positive
Rheumatoid factor strongly positive
Anti-CCP negative
Anti-Ro positive
Anti-La positive
Which is the single most likely diagnosis?
Select one:
A. Reiter’s syndrome
B. rheumatoid arthritis
C. Sjögren’s syndrome
D. systemic sclerosis
E. Wegener’s granulomatosis
```
The high ESR, dry eyes and dry mouth, as well as the combination of positive Ro and La makes Sjögren’s Syndrome likely
The correct answer is: Sjögren’s syndrome
95
```
A 36 year old man with type 1 diabetes has an ulcer on his right foot. He develops a hot, red and painful swollen right knee. His temperature is 39oC. His knee is aspirated. Investigation results on peripheral blood are below:
haemoglobin 1.0 g/dL
white cell count 15 x 109/L
platelets 450 x 109/L
serum urate 2.76mmol/L
CRP 67mg/L
Plain radiograph of right knee joint shows no bony abnormality. Which is the single most likely diagnosis?
Select one:
A. gout
B. haemarthrosis
C. pseudogout
D. rheumatoid arthritis
E. septic arthritis
```
A hot swollen knee, raised inflammatory markers and normal urate level suggests septic arthritis.
The correct answer is: septic arthritis
96
```
A 47 year old woman has generalised pruritis, jaundice, dry eyes and mouth. She is otherwise well and drinks no alcohol. She has a markedly raised alkaline phosphatase. Which is the single most useful investigation?
Select one:
A. anti IgM antibody
B. anti-nuclear antibody
C. hepatitis B surface antigen
D. liver function tests
E. mitochondrial antibodies
```
The history and the type of patient suggests primary biliary cirrhosis, (F:M ratio10:1). Anti Mitochondrial antibodies will help to confirm the diagnosis
The correct answer is: mitochondrial antibodies
97
```
A 42 year old woman with tiredness and a macrocytic anaemia has a small bowel biopsy suggesting coeliac disease. Which is the single most sensitive and specific serum antibody which confirms this diagnosis?
Select one:
A. anti endothelial antibody
B. anti gliadin antibody
C. anti intrinsic factor antibody
D. anti mitochondrial antibody
E. anti transglutaminase antibody
```
Anti transglutaminase antibody and anti gliadin antibodies are associated with celiac disease
The correct answer is: anti transglutaminase antibody
98
```
A 46 year old woman requires a blood transfusion but is concerned about the possibility of contracting viral hepatitis. Which single combination of hepatitis viruses are routinely tested for in blood for transfusion?
Select one:
A. hepatitis A and C
B. hepatitis A, B and D
C. hepatitis B and C
D. hepatitis B, C and E
E. hepatitis C and D
```
Hep B and C are routinely tested in blood
| The correct answer is: hepatitis B and C
99
A 65 year old woman has slowly worsening lower back pain. Her investigation results are below. Which is the single most likely diagnosis?
alkaline phosphatise normal
corrected calcium normal
phosphate normal
```
Xray - no mets visible
Vertebral collapse
Select one:
A. bony metastases
B. osteomalacia
C. osteoporosis
D. myeloma
E. Paget's disease
```
There is vertebral collapse on the lateral spine x ray (another example in the arrow below) and normal calcium, which is consistent with osteoporosis.
100
```
A 50 year old man is acutely confused. He drinks excessive alcohol and has an enlarged liver.
His blood tests show:
haemoglobin 8.5 g/dL
MCV 105 fl
WCC 6 x 109/L
platelets 200 x 109/L
INR 2.2
ALT 125IU/L
AST 96 IU/L
ALP 230IU/L
GGT 132IU/L
bilirubin 85µmol/L
Which is the single most likely diagnosis?
Select one:
A. alcoholic hepatitis
B. chronic active hepatitis
C. cirrhosis of the liver
D. hepatocellular carcinoma
E. viral hepatitis
```
The high MCV and mild anaemia combined with the deranged LFTs is consistent with alcoholic hepatitis.
The correct answer is: alcoholic hepatitis
101
```
A 42 year old man felt a sharp pain at the back of his ankle while playing badminton. He thought that somebody may have kicked him from behind. He is now unable to walk normally. Which is the single most likely diagnosis?
Select one:
A. achilles tendon rupture
B. ankle sprain
C. tibialis posterior rupture
D. tibial stress fracture
E. undisplaced ankle fracture
```
The acute pain occurring during a sudden movement is typical of tendon rupture, the anatomy fits an Achilles tendon site.
The correct answer is: achilles tendon rupture
102
```
A 24 year old man has right sided abdominal pain, diarrhoea, poor appetite and weight loss. His temperature is 37.5˚C; he has oral apthous ulcers, and a tender right lower quadrant. Rectal examination is normal. His blood tests show:
haemoglobin 12.5g/dL
white cell count 14 x 109/L
platelets 550 x 109/L
urea 8 mmol/L
creatinine 90 μmol/L
CRP 105 mg/L
Which is the single best test to confirm the most likely diagnosis?
Select one:
A. barium meal and follow through
B. stool cultures
C. surgical laparotomy
D. ultrasound of abdomen
E. upper GI endoscopy
```
The diagnosis is Crohn’s disease, and typically the terminal ileum is affected. This can be imaged with a barium meal and follow through.
The correct answer is: barium meal and follow through
? perhaps colonoscopy would be a better imaging modality
103
```
Which is the single most appropriate initial therapy in a 60 year old man with bilateral knee pain due to osteoarthritis?
Select one:
A. amitriptyline
B. aspirin
C. celecoxib
D. ibuprofen
E. paracetamol
```
The most simple analgesic should be used first, and a step up in therapy following that.
The correct answer is: paracetamol
104
```
In gout, which is the single most likely joint to be inflamed?
Select one:
A. elbow
B. first metacarpo-phalangeal joint
C. first metatarso-phalangeal joint
D. gleno-humeral
E. temporo-mandibular joint
```
The big toe joint is commonly involved in gout.
| The correct answer is: first metatarso-phalangeal joint
105
```
A 22 year asthmatic woman has a painful right hip and inability to weight bear. She is otherwise well. She has had a number of recent admissions during which she needed high dose steroids. Her x-ray shows some destruction of her right femoral head. Which is the single most likely diagnosis?
Select one:
A. avascular necrosis
B. gouty arthritis
C. myositis ossificans
D. osteoid osteoma
E. septic arthritis
```
One of the side effects of steroid therapy is avascular necrosis
The correct answer is: avascular necrosis
106
A 61 year old woman with NYHA stage 4 heart failure is admitted with pneumonia. She is accompanied by her son. She is drowsy and confused and lacks capacity to give consent for treatment. Which is the single most appropriate management option?
Select one:
A. ask the son if his mother had expressed any wishes about treatment
B. gain consent for antibiotic treatment from the son
C. palliate the patient’s symptoms only as curative treatment would not be in her best interests
D. treat the pneumonia as the doctors have a duty to preserve life
E. treat the pneumonia as this would be in the patients’ best interests
before embarking on treatment it is important to ascertain whether the patient had expressed wishes about treatment she should or shouldnt receive.
The correct answer is: ask the son if his mother had expressed any wishes about treatment
107
You are a year 4 medical student on a medical ward. You have been asked to take a history from a 50 year old man with chest pain. Which is the single most effective way to encourage the patient to provide the maximum amount of clinically relevant information during your consultation?
Select one:
A. ask the patient to list all his symptoms at the outset, and say that you will ask about each in turn.
B. empathise with the patient’s concerns about his chest pain.
C. reflect back what the patient says throughout the consultation
D. start with an open ended question.
E. when the patient mentions a symptom, keep asking ‘is there anything else’ until he says there is nothing else.
open ended questions allow for the most information to be forwarded by the patient
The correct answer is: start with an open ended question.
108
A 5 year old boy has acute osteomyelitis affecting his right tibia. He is normally well but his mother reports that he had a severe allergic reaction to amoxicillin two years previously. Which is the single most appropriate management?
Select one:
A. intravenous ceftriaxone plus oral sodium fusidate
B. intravenous co-amoxiclav plus oral sodium fusidate
C. intravenous doxycycline plus oral sodium fusidate
D. intravenous flucloxacillin plus oral sodium fusidate
E. intravenous vancomycin plus oral sodium fusidate
avoid penicllins and cephalosporins and use drugs that will penetrate bone
The correct answer is: intravenous vancomycin plus oral sodium fusidate
109
A 46 year old woman with primary biliary cirrhosis is being considered for liver transplantation. Which is the single most likely indication for the procedure?
Select one:
A. high levels of serum alkaline phosphatase
B. intractable pruritus
C. low serum albumin
D. raised IgM levels
E. rising titre of anti-mitochondrial antibodies
A low serum albumin suggests hepatic failure and usually occurs in patients who have serious illness. The others are features of the PBC and suggest progression.
The correct answer is: low serum albumin
110
```
A 62 year old woman with constipation has pain and bleeding on defaecation. Examination is impossible due to discomfort. Her anus is shown in the picture:
Which is the single most likely diagnosis?
Select one:
A. fissure in ano
B. fistula in ano
C. haemorrhoids
D. perianal abscess
E. pruritis ani
```
A fissure in ano. Haemorrhoids would cause these symptoms but there is either a prolapsed pile or nothing to see in this case
The correct answer is: fissure in ano
111
```
A 74 year old woman has carcinoma of the colon. Which is the single most likely associated condition?
Select one:
A. Crohn's disease
B. familial polyposis coli
C. Hirschsprung's disease
D. sporadic adenomatous polyps
E. ulcerative colitis
```
The majority of carcinoma at this age is due to sporadic polyps.
The correct answer is: sporadic adenomatous polyps
112
```
A 72 year old woman has dysphagia, regurgitation of food and severe halitosis. She has a small mass on the left side of her neck. Which is the single most appropriate investigation?
Select one:
A. barium swallow
B. cervical x-ray
C. MRI of neck
D. oesophagoscopy
E. ultrasound of mass
```
She has a pharyngeal pouch, The best way to delineate this would be by barium swallow.
The correct answer is: barium swallow
113
```
A 43 year old man has pancreatic adenocarcinoma. Which single factor conveys risk in the development of this disease?
Select one:
A. acute pancreatitis
B. chronic gastritis
C. chronic recurrent pancreatitis
D. hepatic steatosis
E. low fat diet
```
Chronic pancreatitis is associated with an increased risk of developing pancreatic carcinoma.
The correct answer is: chronic recurrent pancreatitis
114
```
A 72 year old woman has breathlessness one day after a dynamic hip screw. Her respiratory rate is 25 breaths per minute; pulse rate 90bpm, BP 110/70 mmHg and oxygen saturation 90% on room air. Her heart sounds are normal and her chest is clear. Which is the single most appropriate treatment?
Select one:
A. aspirin
B. clopidogrel
C. low molecular weight heparin
D. unfractionated heparin
E. warfarin
```
The most likely diagnosis is that of pulmonary embolus as this patient has developed the symptoms following surgery. The best treatment at this stage is low molecular weight heparin.
The correct answer is: low molecular weight heparin
115
```
A 22 year old man has bloody diarrhoea and abdominal cramps. He ate chicken the previous night. Which is the single most likely diagnosis?
Select one:
A. Campylobacter enteritis
B. Cholera
C. Clostridium difficile enteritis
D. Coxsackie virus enteritis
E. cryptosporidiosis
```
This is the commonest cause of food borne diarrhoea in the country
The correct answer is: Campylobacter enteritis
116
```
A 42 year old man with active Crohn’s colitis, treated with high dose steroids and azathioprine has severe upper abdominal pain and vomiting. Which is the single most likely diagnosis?
Select one:
A. acute pancreatitis
B. ischaemic colitis
C. perforated peptic ulcer
D. small bowel obstruction
E. toxic megacolon
```
The high dose steroids use in the long term predisposes to peptic ulceration. This acute presentation could be due to a perforated ulcer
The correct answer is: perforated peptic ulcer
117
```
Forty eight hours after undergoing surgery, a 47 year old man becomes slightly jaundiced. His serum bilirubin concentration is 80µmol/L and results of other liver function tests are normal. His urine tests negative for bilirubin. There is no previous history of jaundice. Which is the single most likely explanation?
Select one:
A. idiosyncratic reaction to anaesthetic
B. Gilbert’s disease
C. occult sepsis
D. resorption of haematoma
E. undiagnosed cirrhosis
```
Gilbert’s syndrome is the commonest cause of unconjugated hyperbilirubinaemia. It typically presents with jaundice and no other symptoms. It is has an autosomal dominant pattern of inheritance affecting up to 5% of the population
The correct answer is: Gilbert’s disease
118
```
A 46 year old woman has recurrent episodes of chronic pancreatitis. She has a palpable abdominal mass. The CT scan of her abdomen is shown below.
Which is the single most likely diagnosis?
Select one:
A. carcinoma of the pancreas
B. hydronephrosis
C. pancreatic pseudocyst
D. renal cell carcinoma
E. renal cyst
```
This is the appearance of a pancreatic pseudocyst. If surgical treatment is required then a fistula is created between the cyst and the GI tract to allow drainage. A similar picture pointing to a moderate sized pseudocyst is shown below
119
```
A 58 year old man with mild mitral valve disease is about to undergo cholecystectomy. Which single intervention is required at anaesthetic induction?
Select one:
A. prophylactic intravenous antibiotics
B. salbutamol nebuliser
C. saline nebuliser
D. sedative pre-medication
E. TED stockings
```
DVT Prophylaxis is priority. For uncomplicated cardiac valve lesions, prophylactic intravenous antibiotics are not recommended by NICE guidelines.
The correct answer is: TED stockings
120
A 45 year old man has had an anterior resection for carcinoma of the rectum and received post operative radiotherapy. One year after treatment he has bilateral lower limb oedema. Which is the single most likely cause?
Select one:
A. anastomotic cancer recurrence
B. deep inguinal and para-aortic lymph node recurrence
C. deep venous thrombosis
D. hypoalbuminaemia
E. liver metastasis
This would cause the symptoms described, whereas DVT is unlikely to be bilateral, hypoalbuminaemia occurs late and the symptoms would be a late manifestation of hepatic metastases.
The correct answer is: deep inguinal and para-aortic lymph node recurrence
121
```
A 68 year old woman has an anterior resection of the rectum and sigmoid colon because of bowel obstruction. The surgical specimen is below, opened to show the mucosal surface.
Which is the single most likely pathological diagnosis?
Select one:
A. adenocarcinoma
B. adenoma
C. signet ring carcinoma
D. squamous cell carcinoma
E. transitional cell carcinoma
```
Adenocarcinoma is the most likely colorectal carcinoma
| The correct answer is: adenocarcinoma
122
```
People with which single condition require annual influenza vaccination?
Select one:
A. chronic arthritis
B. chronic renal disease
C. inflammatory bowel disease
D. premature infants
E. thyrotoxicosis
```
Patients who should have vaccination are those with immunosuppression, chronic heart, renal or hepatic disease.
The correct answer is: chronic renal disease
123
```
A 42 year old Bangladeshi man has had low back pain for three months. He sweats at night, and has recently lost weight, x-rays show loss of normal architecture and some collapse of his L3 vertebra. Which is the single most likely diagnosis?
Select one:
A. muscle strain
B. osteoporotic fracture
C. renal stone
D. spondylolisthesis
E. tuberculous infection
```
TB is most likely due to his symptoms of weight loss and night sweats. If this was an elderly patient who had a fall, then osteoporotic fracture would be likely.
The correct answer is: tuberculous infection
124
```
In clinical trials, treatment groups of subjects are often similar with respect to their characteristics at baseline. Which single statement best describes the method which accounts for this?
Select one:
A. blinding
B. informed consent
C. intention to treat analysis
D. placebo effect
E. randomisation
```
This describes the intended effect of randomization
| The correct answer is: randomisation
125
```
A 72 year old man has acute pancreatitis. Which single finding is most likely to be associated with a poor prognosis?
Select one:
A. high PaCO2
B. high serum amylase
C. hyperglycaemia
D. hypoalbuminaemia
E. hypocalcaemia
```
```
All are typically present but hypocalcaemia conveys most risk of a poor outcome. The modified Glasgow criteria is one cretireia for predicting severity - P.A.N.C.R.E.A.S.
PaO2 55 years
Neutrophils (WBC > 15)
Calcium 16 mmol/L
Enzymes LDH > 600iu/L, AST > 200iu/L
Albumin 10 mmol/L
The correct answer is: hypocalcaemia
```
126
```
A 72 year old man with heart failure had uneventful abdominal surgery. Prior to surgery he took bisoprolol,, spironolactone and furosemide. He has been nil by mouth and on intravenous fluids for two days. Bloods taken on the 3rd postoperative day show:
sodium 136 mmol/L
potassium 6.7 mmol/L
chloride 95 mmol/L
bicarbonate 28 mmol/L
urea 9.8 mmol/L
creatinine 134 μmol/L
Which is the single most appropriate explanation for these results?
Select one:
A. acute renal failure
B. adrenocortical failure
C. inadequate blood sample
D. sampling blood from the drip arm
E. spironolactone therapy
```
This sample shows mild hyponatraemia, hyperkalaemia, a normal chloride and bicarbonate concentration with a raised urea and creatinine. An aldosterone antagonist diuretic such as spironolactone is most likely to lead to these features
The correct answer is: spironolactone therapy
127
A 26 year old woman has increased stool frequency with blood and mucus for the past month. There is no recent travel history. Her blood tests show:
haemoglobin 9.8 g/dL
mean corpuscular volume 90fL
white cell count 14.3 x 109/L
platelet 582 x 10 9/L
ESR 86 mm/hr.
She had a flexible sigmoidoscopy and biopsy. The haematoxylin and eosin stained histological section from this biopsy is shown.
Which is the single most appropriate interpretation of the findings?
Select one:
A. amoebae with erythrophagocytosis
B. crypt abscess formation
C. diverticulum formation
D. fissuring ulceration
E. non caseous granulomata
This slide shows the typical appearance of crypt abscesses of ulcerative colitis. Her blood results show an acute inflammatory response
The correct answer is: crypt abscess formation
128
```
A 36 year old carer from an institution is one of several who have an intensely itchy rash. A picture is below:
Which is the single most likely diagnosis?
Select one:
A. contact dermatitis
B. eczema
C. flea bites
D. scabies
E. tinea corporis
```
The correct answer is: scabies
The superficial burrows of scabies usually occur in the area of the hands, feet, wrists, elbows, back, buttocks, and external genitals. Except in infants and the immunosuppressed, infection generally does not occur in the skin of the face or scalp. The burrows are created by excavation of the adult mite in the epidermis.
In most people, the trails of the burrowing mites are linear or s-shaped tracks in the skin often accompanied by rows of small, pimple-like mosquito or insect bites. These signs are often found in crevices of the body, such as on the webs of fingers and toes, around the genital area, and under the breasts of women.
129
```
A 22 year old man has a suspected diagnosis of peritonitis. Which single symptom best describes the patient if the diagnosis is correct?
Select one:
A. abdominal rigidity
B. frequent vomiting
C. hyperactive bowel sounds
D. rolling about in pain
E. tenderness on rectal examination
```
A rigid, tender abdomen is consistent with peritonitis
| The correct answer is: abdominal rigidity
130
Which single fracture around the proximal femur is more likely to develop non union or avascular necrosis of the femoral head?
Select one:
A. displaced fracture of greater trochanter
B. displaced lesser trochanter fracture
C. intertrochanteric fracture
D. intracapsular fracture
E. subtrochanteric fracture
Femoral neck fractures can be divided into intracapsular and extracapsular fractures. Those that are intracapsular may threaten any or all of the three sources of blood to the femoral head (lateral epiphyseal, superior metaphyseal and inferior metaphyseal arteries)
The correct answer is: intracapsular fracture
131
A 21 year old woman has had nausea and abdominal pain for two days. Her abdominal pain was at first generalised although has now localised to the right iliac fossa. Her last menstrual period was four weeks ago. She has localised tenderness and guarding in the right iliac fossa. Blood results showed mildly raised white cell count and CRP. Which is the single most appropriate initial management for her?
Select one:
A. β-HCG urine testing to confirm she is not pregnant -
B. CT abdomen and pelvis
C. proceed to diagnostic laparoscopy
D. reassure her and discharge without further investigation
E. ultrasound abdomen
a missed period may be due to pregnancy which could be extopic explaining her pain, but would also alter next steps of management and investigations
The correct answer is: β-HCG urine testing to confirm she is not pregnant -
132
```
A 35 year old man has ulcerative colitis and increasing abdominal pain. His abdominal x-ray is shown below:
dilated transverse and descending colon
Which single complication is he most likely to have developed?
Select one:
A. hydronephrosis
B. intussusception
C. sigmoid volvulus
D. small bowel obstruction
E. toxic megacolon
```
he clearly has a dilated transverse and descending colon, with bowel wall oedema- suggestive of a toxic megacolon in a patient with UC
The correct answer is: toxic megacolon
133
```
A 32 year old woman has shortness of breath and a large goitre. On chest x-ray there is displacement and compression of the trachea.
Which is the single most appropriate treatment for this problem?
Select one:
A. carbimazole therapy
B. levothyroxine therapy
C. propylthiouracil therapy
D. radio-iodine therapy
E. thyroidectomy
```
In view of the tracheal compression surgery is necessary. None of the other treatments will alleviate the compression by the gland, but rather will only alter production of thyroid hormones.
The correct answer is: thyroidectomy
134
```
A 40 year old woman has painful recurrent sores on the lips and inner sides of the cheeks and sides of the tongue. The lesions seem to resolve after two weeks. On this occasion a single 1cm ulcer is seen on the inner side of the cheek. Which is the single most likely diagnosis?
Select one:
A. aphthous ulcer
B. chancre
C. denture hyperplasia
D. herpetic ulcer
E. infectious mononucleosis
```
recurrent transient aphthous ulcers are common and my be related to other underlying diseases. Other causes may be progressive rather than transient.
The correct answer is: aphthous ulcer
135
```
A 46 year old man has recent 2 stone weight loss one year after a total gastrectomy and Roux-en-Y reconstruction for gastric cancer. At operation, the resection margins were clear of cancer (stage III B). He has been able to tolerate solids and fluids throughout. Which is the single likeliest cause for his weight loss?
Select one:
A. anastomotic stricture
B. brain metastasis
C. depression
D. intra peritoneal recurrence
E. malabsorption
```
weight loss despite eating suggests an inflammatory or malignant condition. Malabsorption would be associated with significant bowel symptoms, while recurrence is the likely diagnosis that should not be missed
The correct answer is: intra peritoneal recurrence
136
A 58 year old man has painless jaundice. Abdominal examination is unremarkable. The urinary bilirubin is raised, urobilinogen is undetectable. The serum activity of aspartate transaminase (AST) is slightly raised and alkaline phosphatase greatly raised. Which is the single most likely diagnosis?
Select one:
A. cholangitis
B. hepatitis B
C. pancreatic carcinoma
D. solitary metastatic deposit in the left lobe of the liver
E. stone within the gallbladder
Painless jaundice with signs of obstructive liver enzymes is suggestive of a malignant blockage to the bile duct, such as a pancreatic carcinoma
The correct answer is: pancreatic carcinoma
137
```
A 70 year old man has a 4 hour history of an acutely painful right lower leg. The leg is pale and he is in atrial fibrillation. What is the single most appropriate immediate investigation?
Select one:
A. chest x-ray
B. duplex scan of the right leg
C. echocardiogram
D. electrocardiogram (ECG)
E. femoral artery angiography
```
```
A pale(cold) painful leg in someone in AF is suggestive of an arterial embolus, diagnosed by arteriography.
The correct answer is: femoral artery angiography
```
138
A 22 year old woman with severe abdominal pain becomes increasingly agitated and disruptive. As the Foundation Year 1 trainee, you note that she has needle tracks on her arms, no accessible veins and markedly dilated pupils. Which single option below denotes the best course of action?
Select one:
A. administer diamorphine
B. administer naloxone
C. ask an anaesthetist to sedate and intubate the woman
D. confine the patient to bed using the sheet
E. notify a senior colleague
This is a complicated situation which may require difficult IV access and for which you are likely to need help.
The correct answer is: notify a senior colleague
139
```
A 71 year old man develops bloody diarrhoea three days after abdominal aortic aneurysm repair. He has a distended, tender abdomen with no active bowel sounds. Which is the single most likely diagnosis?
Select one:
A. bowel perforation
B. campylobacter infection
C. faecal impaction
D. mesenteric ischaemia
E. pseudomembraneous colitis
```
following aortic aneurysm surgery there is a risk of impaired blood supply to other organs, such as the spinal cord, kidneys and gut
The correct answer is: mesenteric ischaemia
140
An 80 year old man has a pale, cold, pulseless leg. He requires an emergency embolectomy. He has dementia and lacks capacity to understand the need for the operation. He is accompanied by a carer from his residential home. Which is the single correct method for obtaining consent?
Select one:
A. carer signs consent
B. family is asked to give consent by phone
C. family is requested to attend to sign the consent form
D. surgeon takes responsibility for consent
E. the clinical hospital director issues consent
this is an emergency situation and urgent surgery is required to save his leg. It is resonable to assume responsibility based on clinical judgement
The correct answer is: surgeon takes responsibility for consent
141
```
An 82 year old man has episodic left sided lower abdominal pain, intermittent diarrhoea and fresh rectal bleeding. A barium enema shows a filling defect in the sigmoid colon. Which is the single most likely diagnosis?
Select one:
A. carcinoma of the colon
B. Crohn’s disease
C. diverticular abscess
D. familial adenomatous polyposis
E. ulcerative colitis
```
change in bowel habit, rectal bleeding and a filling defect suggestive of bowel carcinoma
The correct answer is: carcinoma of the colon
142
A 76 year old man has delirium following abdominal surgery. In addition to treating the delirium, the surgical team wishes to sedate him to prevent him from harming himself. Which single statement best describes the legal position?
Select one:
A. he should only be treated on a psychiatric ward
B. he should be treated under section 3 of the Mental Health Act
C. he should be treated under section 4 of the Mental Health Act
D. he should be treated under section 5 (2)
E. he should be treated under common law
mental health act only allows for treatment of mental health conditions or if there is a lack of capacity and so he must be treated under common law.
The correct answer is: he should be treated under common law
143
```
An 82 year old woman has had constant severe abdominal pain for one day. Her pulse is 120bpm, BP 105/65mmHg, and her whole abdomen is tender with rebound and guarding. Erect chest x-ray shows air under the diaphragm. Which is the single best treatment for this condition?
Select one:
A. endoscopic ulcer repair
B. laparotomy and omental patch
C. octreotide
D. omeprazole
E. partial gastrectomy
```
she has signs of an intra-abdominal perforation which needs to be identified, explored and treated appropriately
The correct answer is: laparotomy and omental patch
144
```
A 59 year old woman has had left sided abdominal pain for four weeks. Over the last seven days she became constipated and has colicky LIF pain when going to the toilet. Her BP is 137/84mmHg, pulse rate 92bpm, respiratory rate 19 and temperature 38. 2°C. Her abdomen is soft, and bowel sounds are present. She is tender with localised guarding in her left iliac fossa and in this area there is also a cylindrical, hard, tender mass. Which is the single most likely diagnosis?
Select one:
A. Crohn’s disease
B. diverticulitis
C. ileus
D. irritable bowel syndrome
E. ulcerative colitis
```
she has signs of infection and localised pain in descending colon with no symptoms of inflammatory bowel disease, making diverticulosis likely
The correct answer is: diverticulitis
145
```
A 58 year old bus driver complains of recurrent bad breath and regurgitation of undigested food. He regularly regurgitates undigested food. He usually takes a sip of water after every bite which seems to calm down his symptoms. Which is the single most likely diagnosis?
Select one:
A. adenocarcinoma of the oesophagus
B. Barrett’s oesophagus
C. Mallory - Weiss syndrome
D. neurosis
E. Zenker's diverticulum
```
a diverticulum would explain the regurgitation of undigested food rather than difficulty swallowing which may be related to strictures or malignancies
The correct answer is: Zenker's diverticulum
146
A 62 year nurse is referred to you at night by a GP with severe abdominal pain for one day. She has nausea and vomiting and has not opened her bowels for three days. She has been previously well apart from a right sided inguinal hernia. She has a hard, swollen and very tender lump in her RIF which is irreducible. Her abdomen is distended and there are ‘tinkling’ bowel sounds. Which is the most appropriate plan of action?
Select one:
A. admission and prescription of laxatives
B. admission for OGD and colonoscopy the next morning
C. contact your senior immediately and make arrangements for emergency surgery
D. control and normalisation of water-electrolyte physiology and NGT aspiration drainage
E. reduction of the lump under sedation
she has signs of an obstructed bowel and a strangulated inguinal hernia which needs emergency decompression by surgery
The correct answer is: contact your senior immediately and make arrangements for emergency surgery
147
A 26 year old man has had vomiting, anorexia and central abdominal pain for one day. He has no urinary or bowel symptoms and no significant medical history. He has a high temperature and generalised abdominal tenderness worse in the right iliac fossa. He has protein + on urinalysis and a raised white cell count. Which is the single most likely diagnosis?
```
Select one:
A. acute appendicitis
B. acute pancreatitis
C. cholecystitis
D. gastroenteritis
E. urinary tract infection
```
he has signs of sepsis and generalised abdominal pain which localises on examination to RIF, highly suggestive of appendicitis
The correct answer is: acute appendicitis
148
```
A 29 year old man has a high temperature, with perianal tenderness, erythema and a fluctuant swelling. Whichis the single most likely diagnosis?
Select one:
A. anal fissure
B. fistula-in-ano
C. haemorrhoids
D. perianal abscess
E. perianal wart
```
there is no pr bleeding but rather signs of an abscess with a fluctuant swelling and inflammation
The correct answer is: perianal abscess
149
```
A 72 year old man with chronic obstructive pulmonary disease is undergoing elective cholecystectomy. Which single preoperative measure is most appropriate in his work-up?
Select one:
A. echocardiogram
B. physiotherapy
C. prophylactic intravenous antibiotics
D. respiratory function tests
E. sedative premedication
```
assessing his respiratory function is imperative with regards anaesthetic risk
The correct answer is: respiratory function tests
150
```
A 75 year old woman with type 2 diabetes is due to have surgery for colorectal carcinoma. Which is the single most appropriate medication to prescribe to control her blood glucose perioperatively?
Select one:
A. intravenous sliding scale insulin
B. oral gliclazide
C. oral metformin
D. oral rosiglitazone
E. subcutaneous long acting insulin
```
although type 2 diabetics are not dependent on insulin, a sliding scale provides the safest way to control blood sugar levels during a prolonged operative and post-operative period.
The correct answer is: intravenous sliding scale insulin
151
```
A 22 year old man with type 1 diabetes has influenza. He is off his food and is worried about the risk of developing hypoglycaemia. Which is the single most appropriate intervention?
Select one:
A. an oral glucose tolerance test
B. change to intravenous insulin
C. gradually reduce the dose of insulin
D. maintain usual insulin regimen
E. stop insulin immediately
```
This man should carry on with his usual insulin regimen, infection will most likely lead to hyperglycaemia
The correct answer is: maintain usual insulin regimen
152
```
A 24 year old woman has right sided colicky abdominal pain and nausea. She has a history of recurrent urinary tract infections. She has intense pain and cannot rest. She is apyrexial, with a pulse rate of 68 beats/min. Urinalysis is positive for blood. What is the single most likely diagnosis?
Select one:
A. acute appendicitis
B. ectopic pregnancy
C. pelvic inflammatory disease
D. pyelonephritis
E. renal colic
```
It can be difficult to distinguish between renal colic and pyelonephritis. The patient is apyrexial and does not have leucocytes in the urine dipstick, hence renal colic fits this scenario better.
The correct answer is: renal colic
153
```
A 30 year old woman has lethargy, dry cough, fevers and palpitations for three weeks. She has a free T4 of 30 pmol/L and TSH of disease
B. iodine deficiency
C. multinodular goitre
D. thyroid carcinoma
E. viral thyroiditis
```
This woman has hyperthyroidism. The transient nature of her symptoms makes a viral thyroiditis the most likely diagnosis. Graves’ disease is the commonest cause of hyperthyroidism in women
The correct answer is: viral thyroiditis
154
```
An 89 year old man fell under a bus, died and underwent a coroner’s post mortem and inquest. A section of his brain is shown.
Depigmentation around basal ganglia.
What is the single most likely diagnosis?
Select one:
A. hepatolenticular degeneration
B. Huntington’s chorea
C. Lewy body dementia
D. Parkinson’s disease
E. stroke
```
Parkinson’s Disease – The dark strip is the pigmented area which are dopamine rich. The specimen on the right is normal but on the left is an example of depigmentation in Parkinson’s disease. In Parkinson’s the dopaminergic pathways degenerate thus leading to depigmentation.
155
```
A 73 year old man has had progressive right sided weakness and speech difficulties for four weeks with a mild headache. He is alert and orientated but dysphasic with a mild right hemiparesis. Which is the single most likely diagnosis?
Select one:
A. brain tumour
B. focal encephalitis
C. haemorrhagic stroke
D. thromboembolic stroke
E. venous infarction
```
Focal signs suggest a localised anatomical lesion. Progressive time course makes a vascular event less likely.
The correct answer is: brain tumour
156
```
A 38 year old woman has painless visual loss, initially in the right eye then the left eye for four weeks. Her visual acuities are reduced to hand movements in the right eye, 6/9 in the left eye with bitemporal field loss. She has poorly controlled asthma and is on long term corticosteroids. Which is the single most likely diagnosis?
Select one:
A. bilateral optic neuritis
B. bilateral retinal detachments
C. optic pathway glioma
D. pituitary macroadenoma
E. steroid induced cataracts
```
The bitemporal hemianopia is characteristic of a pituitary tumour.
The correct answer is: pituitary macroadenoma
157
```
A 75 year old woman with a 60 pack year smoking history has loss of appetite, left temporal headache and malaise for three weeks. Her optic disc margins are sharp and there are no focal neurological signs. Which is the single most appropriate initial investigation?
Select one:
A. carotid ultrasound
B. chest x-ray
C. CT brain
D. ESR
E. lumbar puncture
```
The lack of focal signs and normal optic disc make raised intracranial pressure less likely. Temporal or giant cell arteritis is common in elderly patients and should be excluded first.
The correct answer is: ESR
158
```
A 55 year old man has had a weak right arm and slurred speech for two days. He had similar symptoms last week, lasting for two hours. A carotid doppler reveals an 80% stenosis of the left internal carotid artery. Which is the single most likely diagnosis?
Select one:
A. haemorrhagic stroke
B. in situ thrombotic stroke
C. migraine aura
D. thromboembolic stroke
E. transient ischaemic attack
```
He has had a previous TIA and now has persistent neurological findings, suggestive of an established stroke. The stenosed carotid makes a thromboembolic event highly likely.
The correct answer is: thromboembolic stroke
159
```
A 56 year old teacher has had a tremor in his right hand for six months. This has caused problems writing on the blackboard. He has a rest tremor in his right hand, slowness and stiffness of the right arm and a loss of right arm swing on walking. Which is the single most appropriate initial treatment?
Select one:
A. benzhexol
B. L-Dopa / carbidopa
C. propranolol
D. risperidone
E. ropinirole
```
He has signs suggestive of Parkinson's disease and should start on appropriate dopaminergic agonists.L dopa can lead to many motor side effects and so dopaminergic agonists are used as first line agents
The correct answer is: ropinirole
160
An 18 year old woman collapses at a party. Prior to this she felt light headed, her vision blurred and voices sounded distant. She was prevented from falling by her friends and, after losing consciousness, a few brief jerking movements were seen. Her recovery was rapid and followed by vomiting. She was incontinent of urine. Earlier in the evening she had drunk three glasses of wine. Which is the single most likely diagnosis?
Select one:
A. alcohol associated seizure
B. cardiogenic syncope with anoxic seizure
C. complex partial seizure
D. dissociative attack
E. vasovagal syncope
Her symptoms preceding the fall are suggestive of hypotension, following vasodilatation due to alcohol. Brief jerking may accompany vasovagal syncope, due to the transient hypoxia.
The correct answer is: vasovagal syncope
161
```
A 46 year old woman is admitted with generalised weakness, dysarthria and double vision for three weeks. She has fluctuating symptoms which become worse later in the day. She has proximal weakness, with flexor plantar responses and normal sensation. Which is the single most likely diagnosis?
Select one:
A. acute polymyositis
B. Guillain Barré syndrome
C. lead poisoning
D. motor neuron disease
E. myasthenia gravis
```
The fluctuating symptoms worsening during the day are suggestive of fatigueability, typical of MG, a problem of the neuromuscular junction. Normal sensation rules out a mixed neuropathy and flexor plantars excludes mixed upper and lower motor neuron lesions
The correct answer is: myasthenia gravis
162
```
A 64 year old woman has had progressive change in her voice and swallowing difficulty for six months. Limb examination shows all her reflexes to be brisk and extensor plantar responses. She has a slow moving, wasted tongue with fasciculations. Her jaw jerk is brisk. Which is the single most appropriate initial investigation?
Select one:
A. electromyography of the limbs
B. lumbar puncture
C. MRI scan of the brain
D. MRI scan of the cervical spine
E. serum creatine kinase
```
She has evidence of mixed upper and lower motor neurone abnormalities, therefore nerve conduction or EMG is most appropriate.
The correct answer is: electromyography of the limbs
163
A 48 year old man has weakness of his elbow, wrist and finger extension as well as pronation. In which single distribution would you most expect sensory loss to be detected?
Select one:
A. anatomical "snuff-box"
B. lateral aspect of wrist, flexors, forearm and thumb
C. little and ring fingers
D. medial aspect of forearm
E. middle finger
loss of pronation suggests lesion that influences the median nerve, whose sensory terretory includes the middle finger
The correct answer is: middle finger
164
A 52 year old man with multiple myeloma develops renal impairment. Which is the single most likely underlying pathology associated with myeloma related renal disease?
Select one:
A. an decrease in calcium excretion
B. an increase in erythrocyte sedimentation rate
C. an increased urate excretion rate
D. formation of cellular casts causing renal tubular damage
E. rapid excretion of light chains causing a protein losing nephropathy
Several renal disorders may be present in myeloma. Bence Jones cast nephropathy (BJCN), acute tubular necrosis, and nonspecific tubulointerstitial nephritis are related to nephrotoxic light chains in urine. The tissue deposition of light chains leads to renal AL-amyloidosis or light chain deposition nephropathy (LCDN). There is an increase in calcium excretion, the casts are not cellular, there isn’t a protein losing nephropathy. The increased number and turnover of myeloma cells can lead to the overproduction and excretion of uric acid in the urine.
The correct answer is: an increased urate excretion rate
165
```
A 54 year old man has anaemia. His hands are shown below. Which is the single most likely cause of the anaemia?
Select one:
A. haemolytic anaemia
B. iron deficiency anaemia
C. pernicious anaemia
D. refractory anaemia
E. sideroblastic anaemia
```
This is vitiligo, a single organ autoimmune condition, associated with other similar conditions. Pernicious anaemia (anti-intrinsic factor) is commonly associated.
The correct answer is: pernicious anaemia
166
A 24 year old man with renal failure has a high titre of antibodies against DNase B. Which is the single most likely diagnosis?
Select one:
A. anti glomerular basement membrane disease
B. minimal change glomerulonephritis
C. post streptococcal glomerulonephritis
D. polyarteritis nodosa
E. Wegener’s disease
Increased levels of anti DNAse B may be due to post streptococcal illness or rheumatic fever
The correct answer is: post streptococcal glomerulonephritis
167
```
An 80 year old man has progressive loss of memory associated with focal neurological events. He has a marked loss of short term memory, inappropriate laughing and crying (emotional lability) and a minimal loss of power in his right leg. Which is the single most likely diagnosis?
Select one:
A. Alzheimer’s disease
B. Creutzfeldt Jacob disease
C. diffuse Lewy body disease
D. multi infarct dementia
E. multiple sclerosis
```
The history is suggestive of multiple strokes leading to a “stepwise” deterioration in cognition. C-J disease leads to a rapid deterioration with widespread neurological defect. Alzheimer’s is not usually associated with focal neurology. DLB is characterized by drop attacks and neuropsychriatric features
The correct answer is: multi infarct dementia
168
```
A 66 year old man with type 2 diabetes treated with glibenclamide and metformin. His HbA1c is 6.8% Over the last three months his wife describes episodes of tremulousness, sweating, disorientation and aggression. During these he is abusive when his wife enquired after his well being. On the last occasion he lost consciousness, jerked for a short period and bit his tongue. Which is the single most likely diagnosis?
Select one:
A. epilepsy
B. hypoglycaemia
C. phaeochromocytoma
D. thyrotoxicosis
E. transient ischaemic attack
```
Hypoglycaemia is the most likely cause of his symptoms
| The correct answer is: hypoglycaemia
169
A healthy 78 year old woman has had fits for the last two years. She has no focal neurological deficit. Her CT scan is below.
What is the single most likely diagnosis?
circumscribed lesion near flax cerebri
```
Select one:
A. cerebral abscess
B. glioma
C. meningioma
D. metastatic malignancy
E. subdural haematoma
```
The history suggests a chronic lesion. The circumscribed nature of the lesion along the falx cerebri makes a meningioma most likely.
The correct answer is: meningioma
170
```
A 63 year old man has bruising over his arms and legs, fatigue and dizziness. He has a purpuric rash on his trunk and limbs. Investigations show:
haemoglobin7.5 g/dL
MCV 105 fL
white cell count 7 x 109/L
platelets 100 x 109/L
prothrombin time 20 seconds
fibrinogen 9 g/dL
blood film 50% blast cells
Which is the single most likely diagnosis?
Select one:
A. acute myeloid leukaemia
B. aplastic anaemia
C. haemophilia
D. immune thrombocytopenic purpura
E. sickle cell disease
```
This man has a pancytopenia (anaemia, low white cells, low platelets) and the blood film shows with premature blast cells, suggesting a myeloid leukaemia
The correct answer is: acute myeloid leukaemia
171
```
A 37 year old woman has severe difficulty holding a piece of paper between her thumb and her palm held flat. The palsy of which nerve is the single most likely cause of her symptoms?
Select one:
A. axillary nerve
B. brachial nerve
C. median nerve
D. radial nerve
E. ulnar nerve
```
This action describes adduction of the thumb against the palm, the adductor pollicis is supplied by the ulnar nerve (abductor pollicis is by the median nerve).
The correct answer is: ulnar nerve
172
```
A 68 year old man gives a history of walking into doors unintentionally. A CT scan was performed and it shows a right middle cerebral artery infarct. Which single description best describes his likely visual field defect?
Select one:
A. left homonymous hemianopia
B. left upper quadrantanopia
C. para central visual defect
D. right homonymous hemianopia
E. right upper quadrantanopia
```
The stroke is on the right. The right side of the retina is affected and therefore he will have a left homonymous hemianopia (light travels from the left side to the right side of the retina).
The correct answer is: left homonymous hemianopia
173
An 83 year old woman is found dead in the street. At post mortem, the brain contains the lesion shown in a coronal section of the cerebral hemispheres. Which is the single most likely underlying cause?
Intracerebral haemorrhage
```
Select one:
A. hypertension
B. malignancy
C. ruptured berry aneurysm
D. thromboembolus
E. trauma
```
This is an intracerebral haemorrhage leading to a large area of altered blood, the most likely underlying cause is hypertension
The correct answer is: hypertension
174
```
A 44 year old man has been recently diagnosed with type 2 diabetes. He is noted to have a large tongue, widely spaced teeth and sweaty palms. Which single condition should be considered?
Select one:
A. acromegaly
B. gigantism
C. haemochromatosis
D. Hurler’s syndrome
E. Klinefelter’s syndrome
```
The features are typical of acromegaly. Gigantism occurs before fusion of the epiphyses in adolescence.
The correct answer is: acromegaly
Hurler's = genetic disorder that results in the buildup of glycosaminoglycans due to a deficiency of alpha-L iduronidase, an enzyme responsible for the degradation of mucopolysaccharides in lysosomes. Without this enzyme, a buildup of heparan sulfate and dermatan sulfate occurs in the body. Symptoms appear during childhood and early death can occur due to organ damage.
Klinefelter's = additional X genetic material in males
175
```
A 50 year old woman has had pain in the middle of both feet, back, hips, and metacarpals for five years. She has an elevated serum ferritin, with normal liver function tests and glucose concentration, full blood count, and erythrocyte sedimentation rate. Which is the single most likely diagnosis?
Select one:
A. acute lymphoblastic leukaemia
B. haemochromatosis
C. multiple myeloma
D. sickle cell disease
E. Wilson’s disease
```
This would be a typical description of haemochromatosis, where there is joint involvement, deranged liver function and the serum ferritin is characteristically chronically raised.
The correct answer is: haemochromatosis
176
```
An 82 year old man with type 2 diabetes has a weak arm and leg. Which single sign is consistent with a lower motor neurone lesion?
Select one:
A. clonus
B. dysdiadochokinesis
C. fasciculation
D. hyperreflexia
E. hypertonia
```
Fasciculation and flaccidity are lower motor neuron signs.
| The correct answer is: fasciculation
177
```
An 83 year old woman has had increasing confusion and wandering for eight months. She has no significant past medical history. Which single pathology is most likely to account for her cognitive decline?
Select one:
A. Cushing’s disease
B. diabetes mellitus
C. Gilbert’s syndrome
D. hypoparathyroidism
E. hypothyroidism
```
Thyroid function is one of the tests for a ‘confusion screen’ in the elderly as hypothyroidism is one of the causes
The correct answer is: hypothyroidism
178
```
Which single gastrointestinal infection is best diagnosed by stool microscopy?
Select one:
A. antibiotic associated diarrhoea
B. cholera
C. cryptosporidiosis
D. mesenteric adenitis
E. typhoid
```
Cryptosporidia are protozoa which affect humans typically in the immunocompromised situation. There are many diagnostic tests for Cryptosporidium. They include microscopy, staining, and detection of antibodies. Microscopy can help identify oocysts in fecal matter.
The correct answer is: cryptosporidiosis
179
A 45 year old man with type 1 diabetes and chronic renal failure requiring peritoneal dialysis for a few years. He takes 1-alfa-calcidol replacement. His blood tests show
calcium 3.4 mmol/L
phosphate 0.6 mmol/L
PTH 8.5 pmol/L
```
Which is the single most likely diagnosis?
Select one:
A. hypercalcaemia secondary to vitamin D
B. normal finding in a dialysis patient
C. primary hyperparathyroidism
D. secondary hyperparathyroidism
E. tertiary hyperparathyroidism
```
Secondary hyperparathyroidism is commonly due to hypocalcaemia in chronic kidney disease. This constant stimulation can however lead to autonomous secretion of parathyroid hormone, leading to tertiary hyperparathyroidism which is difficult to treat medically. The definitive treatment is a parathyroidectomy.
The correct answer is: tertiary hyperparathyroidism
180
```
Which is the single commonest cause of blindness in the population of working age in developed countries?
Select one:
A. age related macular degeneration
B. diabetic retinopathy
C. glaucoma
D. thyroid eye disease
E. trachoma
```
The answer is related to the high prevalence of diabetes in the population
The correct answer is: diabetic retinopathy
181
A 42 year old woman with primary hyperparathyroidism develops muscular weakness due to hypophosphataemia. Which is the single most likely reason for this?
Select one:
A. her rate of bone resorption is reduced
B. her serum calcium concentration is raised
C. her serum magnesium concentration is high
D. parathyroid hormone has a renal phosphaturic effect
E. vitamin D activity is impaired in this condition
Low phosphate levels are seen in hyperparathyroidism, causing lethargy.
The correct answer is: parathyroid hormone has a renal phosphaturic effect
182
A 28 year old man has recurrent nose bleeds. He is recovering from an upper respiratory tract infection. His blood count is:
haemoglobin 12.2 g/d
white blood count 9.9 x 109/L
platelets 9 x 109/L
Which is the single most likely diagnosis?
Select one:
A. acute leukaemia
B. disseminated intravascular coagulation
C. haemophilia
D. Hodgkin’s lymphoma
E. immune thrombocytopenia
Idiopathic or Immune thrombocytopenic purpura (ITP) is the likely cause in an young patient with very low platelet counts.
The correct answer is: immune thrombocytopenia
183
```
A 52 year old man has a reduced standard serum bicarbonate concentration. Which is the single most likely cause?
Select one:
A. acute bronchitis
B. acute hyperventilation
C. chronic renal disease
D. potassium deficiency
E. pyloric stenosis
```
The most likely cause of a chronic metabolic acidosis is renal disease
The correct answer is: chronic renal disease
184
```
A 79 year old woman has a resting tremor of her right hand, difficulty walking and falls over the last two years. She has a festinant gait, truncal rigidity and is unable to gaze upwards. Which single diagnosis is the most likely cause of her syptoms?
Select one:
A. diffuse Lewy body disease
B. idiopathic Parkinson’s disease
C. multi-system atrophy
D. progressive supranuclear palsy
E. vascular parkinsonism
```
The clinical description is of one of the “Parkinson’s plus” syndromes. Of these, progressive supranuclear palsy is characteristically associated with a progressive paralysis of upwards gaze.
The correct answer is: progressive supranuclear palsy
185
A 69 year old woman has a pre operative assessment in preparation for a total hip replacement. The results of blood grouping and antibody screening tests are shown. Which single blood group does this woman have?
Typing of patient's red cells
Reaction of patient's serum with red cells
```
Anti-A -
Anti-B -
Anti-A+B -
Anti-D -
A cells ++
B cells ++
O cells -
```
```
Select one:
A. A Rhesus D negative
B. AB Rhesus D negative
C. AB Rhesus D positive
D. O Rhesus D negative
E. Rhesus D positive
```
Look for ABO compatbitility, then Rheus (D) . There is no native AB antigen and the serum reacts with A and B type cells. Patients with O blood group typically have antibodies to both A and B antigens. There is no reactivity to anti – D, hence the patient is rhesus negative.
The correct answer is: O Rhesus D negative
186
```
A 35 year old man with type 1 diabetes has microalbuminuria. Which single treatment should be started?
Select one:
A. atenolol
B. furosemide
C. lisinopril
D. nifedipine
E. prednisolone
```
Feedback: ACE inhibitor treatment is associated with a reduction in proteinuria and delay to renal failure in Diabetes
The correct answer is: lisinopril
187
```
An 87 year old man has a fall. He is unsteady when walking, confused and he has recently become incontinent of urine. His CT head scan is shown below. Which is the single most likely diagnosis?
enlarged ventricles on CT head
Select one:
A. Alzheimer’s disease
B. intracranial haemorrhage
C. lacunar infarction
D. normal pressure hydrocephalus
E. occipital stroke
```
The CT shows large ventricles (hydrocephalus). The clinical triad of gait instability, confusion and urinary incontinence coupled with the CT appearances are characteristic of normal pressure hydrocephalus
The correct answer is: normal pressure hydrocephalus
188
```
A 46 year old woman has disseminated lymphadenopathy. A lymph node biopsy diagnosed non Hodgkins lymphoma. The infection with which single virus is associated with an increased risk of developing the disease?
Select one:
A. cytomegalovirus
B. Epstein Barr virus
C. herpes simplex virus
D. human herpes virus 8
E. varicella zoster virus
```
There are different forms of non Hodgkin’s lymphoma (NHL). One of the forms is Burkitt’s lymphoma which is associated with Epstein Barr virus
The correct answer is: Epstein Barr virus
189
An 89 year old man has Alzheimer's disease and dies. Which is the single most likely macroscopic finding in his brain?
Select one:
A. cerebellar atrophy
B. compression of the lateral ventricles
C. increased volume of the hippocampus
D. narrowing of cerebral gyri and widening of sulci
E. plaques of demyelination in the white matter
Atrophy is not specific to Alzheimer’s disease and there is considerable overlap between the changes associated with ageing.
The correct answer is: narrowing of cerebral gyri and widening of sulci
190
```
A 50 year old woman has numbness in her feet and is found to have a haemoglobin of 9 g/dL and MCV 120 fL. Her serum B12 level is low. Which is the single most appropriate treatment?
Select one:
A. intramuscular iron dextran
B. intramuscular hydroxycobalamin
C. oral cyanocobalamin
D. oral folic acid
E. subcutaneous cyanocobalamin
```
Oral absorption of B12 is poor in the absence of intrinsic factor which may well be in this case so intramuscular administration is used
The correct answer is: intramuscular hydroxycobalamin
191
A 78 year old man with atrial fibrillation and hypertension has a sudden onset of facial numbness, double vision, unsteadiness of gait and left arm and leg numbness. Which is the single most likely diagnosis?
Select one:
A. right anterior cerebral artery infarction
B. right middle cerebral artery infarction
C. right posterior cerebral artery infarction
D. right posterior inferior cerebellar artery infarction
E. right posterior superior cerebellar artery infarction
A right posterior inferior cerebellar artery stroke causes a classical constellation of signs which include a unilateral (right) facial, pharyngeal signs and cerebellar signs but contralateral (left) loss of sensation. Anterior circulation strokes do not normally cause diplopia and ataxia
The correct answer is: right posterior inferior cerebellar artery infarction
192
```
A 21 year old student has meningism and conjunctival petechiae. A lumbar puncture shows turbid cerebrospinal fluid with a high protein level. Microscopy reveals Gram negative diplococci. What is the single most likely cause for her illness?
Select one:
A. Haemophilus influenzae
B. Listeria monocytogenes
C. Neisseria gonorrhoeae
D. Neisseria meningitidis
E. Streptococcus pneumoniae
```
Feedback
Feedback: The description is of menincococcal meningitis.
The correct answer is: Neisseria meningitidis
193
```
A man of 77 has renal papillary necrosis. Which single condition is the most likely predisposing condition?
Select one:
A. diabetes mellitus
B. horseshoe kidney
C. IgA nephropathy
D. renal cell carcinoma
E. renal cortical infarction
```
Feedback: Diabetes, non-steroidal anti-inflammatories, sickle cell and pyelonephritis are the common causes.
The correct answer is: diabetes mellitus
194
A 30 year old woman is seen routinely in the third trimester of pregnancy in the antenatal clinic. She is asymptomatic and there are no concerns but a routine midstream urine examination result shows:
Dipstick: Not performed
Culture: > 105 colony forming units/ml E. coli isolated
The same result is obtained on repeating the specimen. Which is the single most appropriate management?
Select one:
A. five day course of oral cefalexin
B. five day course of oral ciprofloxacin
C. five day course of oral nitrofurantoin
D. no antibiotics unless she becomes symptomatic
E. symptomatic treatment as far as possible – no antibiotics unless she becomes septic
Feedback: UTI may be asymptomatic in pregnancy but can lead to premature labour.Nitrofurantoin can lead to haemolytic anaemia in the fetus and cipro is not recommended in pregnancy
The correct answer is: five day course of oral cefalexin
195
```
A 25 year old woman attends a travel clinic because she intends to spend a month on a backpacking holiday around the Indian subcontinent. Which is the single most appropriate management?
Select one:
A. prophylaxis with oral azithromycin
B. prophylaxis with oral ciprofloxacin
C. prophylaxis with oral metronidazole
D. vaccination against dengue
E. vaccination against Hepatitis A
```
Antibiotic prophylaxis is not necessary to prevent GI disturbance. Hepatitis A is common and preventable by vaccination and good food hygiene
The correct answer is: vaccination against Hepatitis A
196
is known to have mild mitral stenosis. Which is the single best management?
Select one:
A. no antibiotic prophylaxis is indicated
B. prophylaxis with intravenous benzylpenicillin before dental work
C. prophylaxis with oral amoxicillin and intravenous gentamicin before dental work
D. prophylaxis with oral amoxicillin and intravenous gentamicin before dental work, and a further dose of oral amoxicillin 8 hours later
E. prophylaxis with oral amoxicillin before dental work
Feedback: Current guidelines suggest no benefit from antibiotic prophylaxis to prevent bacterial endocarditis
The correct answer is: no antibiotic prophylaxis is indicated
197
```
A 28 year old man has facial swelling, breathlessness on exertion and distended neck veins. A superior mediastinal mass is biopsied and the section shown is stained with haematoxylin and eosin, and with immunoperoxidase using an anti-CD20 antibody. Which is the single most likely diagnosis?
Select one:
A. chronic lymphocytic leukaemia
B. high grade non Hodgkin’s lymphoma
C. Hodgkin’s lymphoma
D. metastatic squamous cell carcinoma
E. multiple myeloma
```
Feedback: Lymphomas are cancer cell lines derived from lymphocytes. The predominance of lymphocytes suggests a lymphoma. Examples of NHL are lymphoblastic lymphoma and Burkitt’s lymphoma. All B cells have the CD20 protein on the outside of the cell and in this case the positive CD20 antibody staining suggests B cell lymphoma which is also a type of NHL. Reed Sternberg cells are multinucleated cells found in Hodgkin’s lymphoma – hence their absence in this case helps to exclude Hodgkin’s lymphoma. CLL is more commonly diagnosed from the blood film or bone marrow biopsy rather than a lymph node biopsy.
The correct answer is: high grade non Hodgkin’s lymphoma
198
```
Six patients and two members of staff on a ward have developed diarrhoea and vomiting over the past 24 hours. Which single virus is most likely to be responsible?
Select one:
A. adenovirus
B. astrovirus
C. enterovirus
D. norovirus
E. rotavirus
```
Feedback: Outbreaks of norovirus infection often occur in areas such as nursing homes, hospitals, prisons, dormitoriesand cruise ships where the infection spreads very rapidly either by person to-person transmission or through contaminated food
The correct answer is: norovirus
199
A 32 year old man has sudden onset of upper abdominal pain radiating to the back. His abdominal x-ray is below.
Bilateral opacities on left and right below diaphragm
Which is the single most likely diagnosis?
Select one:
A. cholecystitis
B. cholelithiasis
C. duodenal ulcer
D. nephrolithiasis
E. splenic infarct
There are bilateral opacities lying within the kidneys. 90% of renal stones are radio-opaque
The correct answer is: nephrolithiasis
200
```
A 28 year old Caucasian man with HIV infection has increasing shortness of breath, a dry cough and decreasing exercise tolerance. Chest x-ray shows bilateral diffuse infiltrates. Which is the single most likely cause?
Select one:
A. adult respiratory distress syndrome
B. lobar pneumonia
C. pulmonary embolism
D. Pneumocystis jeruvocii pneumonia
E. tuberculosis
```
Feedback: The most likely cause of bilateral pulmonary infiltrates in a HIV positive patient. Pneumocystis jerovicii is the pathogen in Pneumocystic Carinii Pneumonia
The correct answer is: Pneumocystis jeruvocii pneumonia
201
```
A 33 year old man has a squamous cell carcinoma of the bladder. Which single risk factor makes this diagnosis more likely?
Select one:
A. being male
B. cystitis cystica
C. schistosomiasis
D. smoking
E. working with aniline dyes
```
Feedback: The major histological cell type of bladder cancer associated with schistosomiasis of the urinary tract is Squamous Cell Carcinoma.The other risk factors are for transitional cell carcinoma.
The correct answer is: schistosomiasis
202
```
A 19 year old contact lens wearer has bilateral red, watery, itchy eyes. Which is the single most likely diagnosis?
Select one:
A. adenoviral conjunctivitis
B. allergic conjunctivitis
C. bacterial conjunctivitis
D. chlamydial conjunctivitis
E. herpetic keratitis
```
Allergic conjunctivitis can be caused by contact lenses.
| The correct answer is: allergic conjunctivitis
203
```
An 87 year old woman complains of sudden painless loss of vision in her left eye. She has been non specifically unwell and has had some pain in her tongue whilst eating. Which is the single most likely diagnosis?
Select one:
A. acute glaucoma
B. basilar migraine
C. cranial (temporal) arteritis
D. optic neuritis
E. retinal detachment
```
Feedback: The age of the patient, the systemic illness and the jaw claudication make a diagnosis of temporal arteritis the most likely
The correct answer is: cranial (temporal) arteritis
204
```
In which single complication of infective endocarditis are no microorganisms identifiable at the complication site?
Select one:
A. cerebral infarct
B. glomerulonephritis
C. mycotic aneurysm
D. splenic infarct
E. valve regurgitation
```
Feedback: This is a complication from immune complex deposition, rather than directly related to the bacterium.
The correct answer is: glomerulonephritis
205
A 38 year old man has renal failure. His arterial pH is 7.23 and his potassium concentration is 6.8mmol/L. An electrocardiogram reveals peaked t waves, wide QRS complexes and ventricular extrasystoles. Which single intravenous intervention is the most appropriate immediate management?
Select one:
A. 10ml 10% calcium gluconate and 50mls sodium bicarbonate
B. 10ml 10% calcium gluconate, 50ml of 50% dextrose with 10 units of actrapid insulin
C. 10ml 10% calcium gluconate and 10 units of actrapid insulin
D. 10ml 10% calcium gluconate, 120mg furosemide and 50ml 50% dextrose intravenously
E. 500ml gelofusin
Feedback: For the treatment of hyperkalaemia with ECG changes, calcium gluconate should be given slowly to stabilise the myocardium and insulin + dextrose drives potassium intracellularly
The correct answer is: 10ml 10% calcium gluconate, 50ml of 50% dextrose with 10 units of actrapid insulin
206
```
A previously healthy 30 year old woman has herpes zoster ophthalmicus (shingles). Which single blood test should be requested?
Select one:
A. cholesterol / lipid profile
B. liver function test
C. serum angiotensin converting enzyme
D. serum protein electrophoresis
E. white cell count and CD4
```
Feedback: a young patient with HZV suggests immunocompromise and this should be tested for
The correct answer is: white cell count and CD4
207
```
A 20 year old woman attends the Emergency Department with thirst, polyuria, weight loss and vomiting for three weeks. Which single bedside test should be performed to confirm the diagnosis?
Select one:
A. arterial blood gas
B. blood culture
C. blood pressure
D. temperature
E. urine dipstick
```
Feedback: These are typical symptoms of diabetes mellitus. Test for glycosuria
The correct answer is: urine dipstick
208
```
A 55 year old hypertensive man has had acute onset of left arm and facial weakness yesterday which resolved within 12 hours. He has a past allergy to aspirin. Which is the single most appropriate drug(s) for him to be started on?
Select one:
A. aspirin
B. clopidogrel
C. dipyridamole
D. ticlopidine
E. warfarin
```
Feedback: Clopidogrel is now fairly standard practice for secondary prevention in TIA and some centres are using aspirin and clopidogrel if high risk. Monotherapy with dipyridamole is not advised, but combined aspirin and dipyridamole can be used.
The correct answer is: clopidogrel
209
```
A 32 year old man has general malaise culminating in a collapse in the street. He is thin and pale but pigmented with marked postural hypotension. Blood chemistry reveals hyponatraemia and hyperkalaemia. Which is the single most likely diagnosis?
Select one:
A. Addison’s disease
B. Conn’s syndrome
C. diabetes mellitus
D. hypothyroidism
E. water intoxication
```
Feedback: Typical clinical features and biochemistry of corticosteroid deficiency
The correct answer is: Addison’s disease
210
```
A 62 year old man has altered bowel habit for three months. There is no nausea or vomiting, loss of appetite, abdominal pain or history of blood per rectum. He has gained weight. There are no abnormal signs and PR shows constipated stool. Faecal samples for occult blood are negative. FBC shows an MCV of 102.5 fL. Which is the most likely diagnosis?
Select one:
A. carcinoma of the descending colon
B. Crohn’s disease
C. hypothyroidism
D. hyperparathyroidism
E. irritable bowel syndrome
```
Constellation of weight GAIN, macrocytosis and constipation suggest low thyroid state
The correct answer is: hypothyroidism
211
A 58 year old man with ischaemic heart disease has recently been prescribed ketoconazole for a fungal infection. His other medications are aspirin, ramipril, atenolol and simvastatin. He now has flu like symptoms and increasing muscular pains and tenderness in the legs, the arms and neck. His muscles are very tender to touch and his urine is much “stronger” than usual. His blood tests show:
```
creatinine 370 µmol/L
potassium 5.9 mmol/L
Which is the single most likely diagnosis?
Select one:
A. glomerulosclerosis
B. polymyalgia rheumatica
C. pyelonephritis
D. rhabdomyolysis
E. systemic lupus erythematosus
```
Muscle tenderness and acute renal failure- after starting statins, suggestive of rhabdomyolysis. Calcium should be low and phosphate high
The correct answer is: rhabdomyolysis
212
```
A 13 year old boy has had recurrent episodes of bone pain which have required hospital admission. X-rays show necrosis of his hip. He also has retinopathy. Which is the single most likely diagnosis?
Select one:
A. multiple myeloma
B. osteopetrosis
C. Paget's disease
D. sickle cell disease
E. thalassemia
```
Feedback: Bone pain and necrosis and retinopathy suggest sickle cell disease. Confirmed on Hb electrophoresis
The correct answer is: sickle cell disease
213
```
A 50 year old man has a hoarse voice. He has a unilateral swelling of the thyroid gland and right recurrent laryngeal nerve palsy. Which is the single most likely diagnosis?
Select one:
A. Graves' disease
B. multinodular goitre
C. single thyroid nodule
D. thyroid carcinoma
E. thyroglossal cyst
```
Feedback: Hoarse voice from laryngeal nerve involvement suggests a infiltrative process, and the signs suggest a thyroid carcinoma
The correct answer is: thyroid carcinoma
214
```
A 55 year old woman was diagnosed with type 2 diabetes three months ago. Despite strict diet control, a random blood sugar is 14 mmol/L. She weighs 80 kg. Which single medication should be started?
Select one:
A. glibenclamide
B. gliclazide
C. insulin
D. metformin
E. troglitazone
```
Feedback: To help lose weight and control BS, metformin is the ideal medication
The correct answer is: metformin
215
A 26 year old Asian man with type 2 diabetes has a persistent blood pressure of 150/90 mmHg. His diabetes is well controlled and his biochemistry is normal. His BMI is 28Kg/m2. Which is the single best antihypertensive medication to start him on?
Select one:
A. alpha blocker
B. angiotensin converting enzyme inhibitor
C. beta blocker
D. calcium channel blocker
E. thiazide diuretic
Evidence that ACEi or ARB are ideal to prevent progression of diabetic nephropathy
The correct answer is: angiotensin converting enzyme inhibitor
216
A 46 year old man has had generalised weakness, a raised temperature and weight loss for two months. There is no past medical history. He looks pale, his temperature is 39ºC, his spleen is palpable 6cm below the left costal margin. His blood test show:
```
haemoglobin 9 g/dL
haematocrit 18%
white cell count 5.3 x 109/l
platelets 89 x 109 /L
blood film tear drop erythrocytes with 4 normoblasts per 100 leucocytes interspersed by myelocytes.
A bone marrow biopsy showed replacement of normal haemopoietic elements by early fibrosis. Which is the single most likely diagnosis?
Select one:
A. amyloidosis
B. Gaucher’s disease
C. myelofibrosis
D. pernicious anaemia
E. primary polycythaemia
```
He has low Hb and platelets with bone marrow fibrosis
| The correct answer is: myelofibrosis
217
A 64 year old woman with long standing type 2 diabetes has had a CT scan of her brain two days ago following admission with an acute hemiparesis. Her renal function has now deteriorated over 48 hours. Which of these agents is the single most likely cause of her renal failure?
Select one:
A. dipyridamole
B. Echo contrast bubbles to investigate the possibility of a patent forman ovale
C. gadolinium contrast medium for magnetic resonance imaging
D. ionic radio contrast medium for computerised tomographic scanning
E. nifedipine
Feedback: Contrast nephropathy due to ionic agents is common and generally temporary. Maybe prevented by fluid resucitation
The correct answer is: ionic radio contrast medium for computerised tomographic scanning
218
```
A 30 year old woman has primary thyrotoxicosis due to Graves’ disease. She has significant tremors. Which single medication should be prescribed to manage her tremors?
Select one:
A. atenolol
B. bisoprolol
C. carbimazole
D. propanolol
E. propylthiouracil
```
Feedback: only non-selective beta blockers will control tremors
The correct answer is: propanolol
219
```
A 15 year old has thalassaemia major. Since he was young he has been on a regular blood transfusion. He is prescribed medications but has become non compliant as he is fed up taking them. Which single complication of this disease is he most likely to develop?
Select one:
A. iron overload
B. massive splenomegaly
C. pulmonary hypertension
D. recurrent infections
E. recurrent venous thromboembolism
```
Feedback: Recurrent transfusions lead to iron overload and require iron chelation therapy
The correct answer is: iron overload
220
A 75 year old man is brought to the Emergency Department following a fall. He has hypertension, and had a stroke four years ago from which he recovered fully; he was also treated with chemotherapy for myeloma three years ago. Since the fall, he has back pain, progressive lower limb weakness and urinary as well and bowel incontinence. Neurology examination of lower limbs confirms the following bilateral signs:
```
Muscle tone reduced
Power 2/5 bilaterally
Coordination normal
Reflexes absent
Anal tone reduced
Which is the single most likely cause of his symptoms?
Select one:
A. osteoarthritis of the spine
B. pathological fracture
C. peripheral neuropathy
D. spinal cord compression
E. stroke
```
Feedback: numerous lower motor neurone defects with bowel and bladder involvement suggest cord pathology, and spinal cord compression is an emergency requiring diagnosis
The correct answer is: spinal cord compression
221
A 60 year old woman starts to bleed profusely from the operation site six hours after undergoing a partial colectomy for rectal carcinoma. She has no prior bleeding history and is not receiving anticoagulation. Her BP is 85/50 mmHg. Her blood tests show:
haemoglobin 5.3 g/dL
platelets 120 x109/L
prothrombin time 27seconds
activated partial thomboplastin time 82seconds
fibrinogen 0.7g/L
She is transfused with 4 units of blood but continues to bleed from the wound. Which is the single most appropriate substance to administer next?
Select one:
A. factor VIII concentrate
B. fresh frozen plasma and cryoprecipitate
C. platelets
D. protamine sulphate
E. recombinant activated factor VII (‘Novoseven’)
Feedback: prolonged PT and APTT with low fibrinogen so multiple clotting factor defects corrected by FFP
The correct answer is: fresh frozen plasma and cryoprecipitate
222
A 29 year old woman with sickle cell disease has had a raised temperature, back and chest pain and dyspnoea for three days. She has a respiratory rate of 35, temperature of 38ºC and oxygen saturations of 85% on air. She has crackles throughout both lung fields. Which is the single most appropriate course of action?
Select one:
A. admit for nebulisers, intravenous antibiotics and oral steroids
B. give analgesia and oral antibiotics and advise she attends her GP if she’s not feeling better within a week
C. start intravenous furosemide and admit for an echocardiogram
D. start low molecular heparin and admit for a CT pulmonary angiogram
E. start oxygen therapy, intravenous antibiotics, analgesia and admit for red cell exchange
Feedback: signs of infection and hypoxia which will precipitate further sickling -this is a sickle emergency
The correct answer is: start oxygen therapy, intravenous antibiotics, analgesia and admit for red cell exchange
223
```
A 53 year old smoker has a three month history of painless microscopic haematuria, frequency and nocturia. Which is the most likely diagnosis?
Select one:
A. acute glomerulonephritis
B. bladder tumour
C. kidney stone
D. urethral stone
E. urinary tract infection
```
painless haematuria with no other urinary symptoms generally excludes stones and in a smoker is highly suggestive of bladder tumour
The correct answer is: bladder tumour
224
A 78 year old man with known prostate cancer develops severe low back pain. Which is the next most appropriate single investigation?
Select one:
A. carcinoma embryonic antigen measurement
B. isotope bone scan
C. prostate specific antigen measurement
D. serum acid phosphatise level
E. transrectal ultrasound guided biopsy of the prostate
he is known to have prostatic cancer and needs an explanation for the back pain, best tested by bone scan to exclude metastases
The correct answer is: isotope bone scan
225
```
The urea and electrolytes of a 26 year old man deteriorate two days following laparotomy for intestinal obstruction. Which single diagnosis is the most likely cause for the problem?
Select one:
A. diabetes mellitus
B. hypertension
C. hypovolaemia
D. pre-existing renal disease
E. renal artery stenosis
```
post operative fluid management is important to get right and there will have been considerable volume loss through the intestinal obstruction, with fluid in the wrong compartment. Fluid resucitation is critical.
The correct answer is: hypovolaemia
226
A 30 year old woman has lethargy, dry cough, fevers and palpitations for 3 weeks. She has a free T4 of 30 pmol/L and TSH of
4. Viral thyroiditis.
The transient nature of her symptoms make a viral thyroiditis the most likely diagnosis. Grave's is the commonest cause of hyperthyroidism in women
227
A 38 year old man with alcohol dependence has abnormal liver function tests. A hepatologist performs a liver biopsy. Which is the single most likely microscopic finding in his liver biopsy specimen?
Choose one answer.
1. epitheloid granulomata
2. lymphocytic infiltration of hepatocytes
3. haemosiderin deposits
4. lack of bile ducts in portal tracts
5.steatosis
steatosis
| this is the typical appearance of hepatic steatosis
228
A 32 year old Bengali man attended hospital with a 2 month hx of cough and blood in his sputum. Further questioning revealed a history of weight loss and night sweats. He is a non-smoker and has no significant past medical history. His CXR is shown below.
What is the most likely diagnosis?
Choose one answer.
a. adenocarcinoma
b. bronchiectasis
c. mycoplasma pneumonia
d. pulmonary embolism
e. TB
Answer: E (Tuberculosis) (Level - Easy)
Explanation: Haemoptysis, fevers, night sweats and weight loss are classical features of TB. Immigrant populations and the immunosuppressed are high-risk groups for TB. BCG vaccination is effective in preventing TB in 70% of cases. The CXR shows cavitating lesions in the right upper lobe-TB commonly affects the upper lobes. Pulmonary embolism, bronchiectasis and adenocarcinoma can all cause haemoptysis but are less likely in this patient.
229
```
A 65-year old man attends his GP for a routine diabetic follow-up. He mentions that he has had a persistent dry cough for the last two months since he was started on a new medication by his GP. Which of the following may be the cause of his cough?
Choose one answer.
a gliclazide
b. metformin
c. ramipril
d simvastatin
e glargine
```
ramipril
Explanation: The anti-hypertensive ramipril is an ACE inhibitor with a common side effect of dry cough due to bradykinin production. Patients are often switched to an Angiotensin receptor antagonist (eg. losartan) which do not cause coughing.
Statins can cause myositis and rhabdomylosis.
Metformin can cause lactic acidosis.
230
A 25-year old man presented to his GP complaining of a three month history of unsightly toenails. The GP examines his nails under a Wood’s lamp and takes some nail clippings. What would be the most appropriate initial management?
a. topical dermovate
b. oral prednisolone
c. topical griseofulvin
d. oral itraconazole
e. oral flucloxacillin
Correct Answer: D (Level - Difficult)
Explanation: The picture shows onychomycosis, fungal nail infection, which is caused by yeasts, dermatophytes and non-dermatophyte molds.
The differential is: bacterial paronychia, thyroid disease, yellow nail syndrome
A) is a topical steroid cream which is inappropriate as there is no inflammation or paronychia.
B) is incorrect as oral steroids are not used to treat fungal nail infections.
E) is the treatment for cellulitis.
C) is a possibility as topical griseofulvin can be used as a treatment for isolated fungal nail infection. However as >50% of the nail plate and more than one nail is affected this makes D) the best answer. Another oral agent often used is terbinafine. Oral treatment lasts for 3 months-LFTs should be monitored monthly.
some fungal conditions will flouresce under UV light (ie. wood's lamp)
231
```
A 42 year-old black American is on work placement in the UK. She develops a painful raised rash over the anterior aspects of the shins. She has no past medical history. In the past year she has visiting Tanzania, Bhutan and Argentina with her work. Which of the following would be the best initial investigation?
Choose one answer.
a, Autoantibody screen
b. blood film
c. cxr
d. skin biopsy
e. USS of abdomen
```
Correct response: CXR
Correct response: C - Level Easy
Rashes over legs are common and need some investigations. We do not have much of a history here other than that of travel. In view of her ethnic background and the rash, we need to rule out sarcoidosis. The question asks for the INITIAL investigation. There is no role for an ultrasound at the present moment and a mantoux test takes days to be interpreted. A simple chest xray may be useful to show us any changes associated with sarcoid. Tuberculosis does not typically present with a painful rash over the legs. Skin biopsy is probably not necessary. Other investigations would be some blood tests looking at specifically inflammatory markers and serum calcium. Sarcoid collections tend to secrete ACE (angio-converting enzyme) so these levels can be monitored.
232
```
A 43 year-old man has developed gynaecomastia.
Which of the following is the most likely cause?
Choose one answer.
a. atenolol
b. bendroflumethiazide
c. bisoprolol
d. digoxin
e. procainamide
```
Correct response: D) Digoxin Level Easy
Gynaecomastia is common. Many causes are idiopathic . Pathological causes of gynaecomastia include hormonal imbalances (such as increased serum o estrogen , decreased testosterone production, androgen receptor defects), chronic illness, chronic kidney and liver disease. Medications cause 10-20% of cases of gynaecomastia. Common drugs causing this are digoxin, cimetidine , spironolactone , finasteride and antipsychotics agents. It is important to examine not only the patient’s breasts but also abdomen and external genitalia.
233
Which one of the following statements about neonates born to hepatitis B infected mothers whose serum contains HBe antigen is correct:
Choose one answer.
a. they are at higher risk of becoming long term carriers than those infected in later life
b. they are highly contagious at birth
c. they are protected from infection if delivered by c. section
d. they should not be given hyperimmune immunoglobulin and vaccine simultaneously
e. they usually develop jaundice
Correct Response: They are at greater risk of becoming long term carriers than those infected in later life.
All pregnant women should be tested for hepatitis B virus early in their pregnancy. Hepatitis B e antigen indicates very active virus replication. Carriers with this marker are highly infectious.
Infection is passed vertically from infected mother to their babies, at or around
the time of birth (Peri-natal transmission). Babies acquiring infection at this time have a high risk of becoming chronic carriers of the virus and have an increased risk of developing chronic liver disease.
Babies born to women with HBV markers should be offered immunisation immediately after birth using the accelerated schedule: initial dose at birth with
further doses at one and two months of age and a fourth dose at 12 months. Babies born to mothers who are high risk should receive hepatitis B immunoglobulin (HBIG) as well. Although immunisation started at birth is 90-95% effective in preventing carrier status, a small number of babies including those who may have been infected earlier in utero, will become carriers.
234
```
A 74 yr old woman presents with weight loss and increasing jaundice over the last 3-4 weeks. On examination she has a palpable gallbladder. Which investigation from the list below is of most value in achieving the diagnosis?
Choose one answer.
a. abdominal xray
b. abdominal USS
c. abdominal CT
d. barium meal and follow through
e. FNA of gallbladder
```
abdominal CT scan
The question asks for the investigation which would be the most valuable in achieving a diagnosis. From the history, we need to exclude a malignant cause. All the investigations listed would be reasonable but the most appropriate has to be chosen. A plain abdominal film is also unlikely to give any specific information. Barium studies can be useful in showing any strictures or narrowing of the duodenum at the level of the pancreatic head. An FNA of the gallbladder is not justified at this stage. Abdominal ultrasound is a reasonable investigation as it may show a dilated common bile duct and could be used to visual a potential mass from these ducts or the pancreas. It would be the investigation of choice to look at gallstones as these can frequently be missed in CT scans unless thin slices are taken. However remember Courvoisier's law which states that in the presence of a palpable gall bladder , painless jaundice is unlikely to be caused by gall stones . We have the option of an abdominal CT scan and this would be the most appropriate investigation as it will clearly show any abdominal masses as well as the organ it is arising from.
235
```
A 40 yr old woman has diabetes and hypertension. She is known to have chronic renal impairment with a creatinine of 160 umol/L. Her potassium is 5.6mmol/L.
Which of the following is the most appropriate option in controlling her potassium?
Choose one answer.
a. low potassium diet
b. administer calcium chloride
c. administer calcium resonium
d. administer insulin and dextrose
e. refer for dialysis
```
low potassium diet
The most pressing concern in a patient with renal failure leading to hyperkalaemia is the possibility of dangerous, sometimes fatal arrhythmias if not treated promptly. However a K of 5.6 is not significantly raised and does not warrant urgent correction (K>6 on the other hand may warrant treatment with insulin/dextrose, cardiac protection with calcium chloride/gluocante, especially in the presence of ECG changes suggestive of instability secondary to high K.)
This lady is known to have renal failure. Her blood results are not bad enough yet to warrant dialysis so conservative management should be sought for as long as possible. Starting dialysis on a patient is life changing as it involves life long trips to the dialysis unit, sometimes up to three times a week. In view of this mildly raised potassium and creatinine, there is currently no need for any aggressive treatment of this, in the form of insulin and resonium. Resonium should be avoided if at all possible as it can cause severe constipation with only a couple of doses. Calcium chloride has no role in lowering a serum potassium level but acts to help stabilise the heart and helps avoid arrythmias. Her drug history list should be rationalised and any offending or nephrotoxic drugs should be changed if at all possible, She should be referred to a dietician and given advice on a low potassium diet.
236
Which one of the following statements regarding colon cancer is correct:
Choose one answer.
a. they are usually preceded by hyper plastic polyps
b. Duke's stage B indicates involvement of local lymph nodes
c. Hereditary non-polyposis colon cancers (HNPCC) preferentially involve the left colon
d. the most frequent sites are distal to the splenic flexure
e. rectal bleeding is a characteristic feature of caecal cancers
Correct Answer D – The most frequent site is the rectum (level – Moderate)
They are usually dysplastic polyps. Hyperplastic polyps are benign protrusions and comprise 90% of all polyps.
'Dukes B' means the cancer has grown into the muscle layer of the colon or rectum. Does not involve rectum (see below)
HNPCC is a result of damage to mis-match repair genes and has a predilection for right sided tumours including mucinous cancers. That is not to say all HNPCC affects the right side of the colon.
2/3 of colon cancer occur distal to the splenic flexure. This question highlights that most tumours are distal, one of the most common sites being the rectum and also explaining why investigations involve PR, rigid and flexible sigmoidoscopy which can quickly assess the distal bowel.
Caecal cancers rarely present with rectal bleeding being more proximal, unlike rectal tumours. Pallor, loss of weight, anorexia, dull ache in right iliac fossa are more usual presentations.
Dukes classification
A - Tumour confined to the intestinal wall
B - Tumour invading through the intestinal wall
C - With lymph node(s) involvement
D - With distant metastasis
237
A 60yr old man has broad complex tachycardia on his ECG. He is hypotensive with a BP of 65/40mmHg.
Which of the following is the most appropriate therapeutic step?
a. carotid sinus massage
b. DC cardioversion
c. IV adenosine
d. IV amiodarone
e. overdrive pacing
Answer B DC Cardioversion
A) Carotid sinus massage is first line for supraventricular tachycardias in patients that are haemodynamically stable, neither of which apply in this station.
B) Patient is haemodynamically compromised (systolic blood pressure
238
```
A 46 yr old presents with severe pain in her thoracic spine 2 years after receiving surgery and adjuvant chemotherapy for breast cancer. Which investigation is most likely to be of diagnostic benefit?
Choose one answer.
a, CT spine
B isotope bone scan
c. MRI spine
d USS spine
e. Xray thoracic spine
```
B: Isoptope Bone Scan (level – moderate)
This patient has a history of breast cancer. The concern is that she has developed metastatic disease, specifically bone disease involving the thoracic spine.
A) When evaluating the spine and spinal cord CT spine is sometimes used when MRI spine is not possible (pacemaker etc). However when specifically looking for bony metastases it is not the best investigation and would not give information on any of the other bones
B) Isotope bone scan will evaluate the entire skeletal system and identify areas of bone production/destruction as is expected in metastatic bone disease. It may also show hot spots where infection is present.
C) MRI spine would provide detailed views of the vertebra, discs and the spinal cord and give information on whether there is evidence of cord compression. However once again it would not give information of metastases in other bones
D) Ultrasound Spine is rarely used to evaluate for bony metastases
E) X-Ray thoracic Spine may sometimes be done, particularly if a patient presents to A+E and can sometimes show destruction of the vertebra involved but sometimes bones can appear normal despite the presence of metastatic bone disease.
239
```
A 43 year-old women presents to surgical outpatients with a painless lump in the neck.
O/E: Single smooth 2 x 2 cm mass in midline.
Thyroid function tests normal.
Which is the investigation of choice?
Choose one answer.
a. CT neck
B fine needle aspiration cytology
c radioisotope scan of the neck
d thoracic inlet views
e USS of neck
```
Correct response: D – fine needle aspiration cytology (level – moderate)
A midline lump in the neck with normal thyroid function must be treated with suspicion. Differentials include lymph nodes and a mass coming from the thyroid/parathyroid.
A – This test is referring to a radioisotope thyroid scan and involves injecting radiolabelled iodine/techtinium and assessing the uptake by the thyroid gland. It may demonstrate ‘hot’ (increased uptake) or ‘cold nodules (little or no uptake). It can also help assess the size of a goitre and assess for any remnants of thyroid tissue post thyroidectomy. Cold nodules should be treated with suspicion as most malignancies have no uptake of the radiolabelled material. It does not offer a definitive diagnosis however!
B + C + E will all give useful information about the size, site and nature of the lump. For example ultrasound would reveal if it is a solid or cystic mass and exact size, CT would also be helpful in delineating the precise location of the lump and its relationship to other structures.
The advantage of D (fine needle aspiration) is that if this is indeed a thyroid cancer aspiration will confirm this as well as the actual type of malignancy allowing for better directed therapy. (This is sometimes done under ultrasound guidance when the lump is deep and more discrete.)
240
A 65 yrs old diabetic presents in a coma. His blood results are:
Na 155mmol/L, K 5mmol/L, Cl 110mmol/L, HCO3 30mmol/L, urea 15mmol/L, glucose 50mmol/L, and arterial pH 7.35.
What is his calculated plasma osmolality?
Choose one answer.
1. 285mOsm/kg
2. 300mOsm/kg
3. 328mOsm/kg
4. 350mOsm/kg
5. 385mOsm/kg
385mOsm/kg
```
Calculated osmolality
2(Na+K) +glucose + urea
2(155+5) + 50 + 15
320 + 50 + 15
=385mOsm/kg
```
Normal range = 275-295
295 – the plasma is more concentrated
This patient has presented with HONK (hyperosmolar, non-ketotic) and is likely to be profoundly dehydrated with a very high sodium and so requires aggressive fluid resuscitation to correct this abnormality.
The plasma osmolality is best interpreted with the urine osmolality, if the plasma is concentrated the urine should be appropriately concentrated and likewise if diluted.
E.g. with SIADH there is elevated ADH and so the urine is more concentrated with more retention of water. This leads to a decreased plasma osmolality (dilute) with an inappropriately raised urine osmolality (concentrated). The body’s appropriate response would be to dilute the urine but this is not possible because of the actions of ADH.
241
Thyroid epithelial cells expressing MHC class II in autoimmune thyroid disease are potentially direct targets for locally activated T cells specific for which one of the following antigens?
Choose one answer.
1. AChR
2. Cardiolipin - 2 - glycoprotein 1 complexes
3. Neutrophil proteinase III enzymes
4. Peroxidase enzymes
5. Pre-synaptic calcium channels
Peroxidase enzymes
```
In autoimmune thyroid disease, MHC class II molecules may be aberrantly expressed on epithelial cells (thyrocytes). These cells present their surface autoantigens to T cells, leading to the induction and maintenance of autoimmunity. Autoimmune thyroid disease (AITD) ranges from hypothyroidism (Hashimoto’s thyroiditis) to hyperthyroidism (Graves’Disease).
Autoantibodies such as thyroid peroxidase (TPO) and thyroglobulin (TG) are found in 90% and 60% of patients with AITD respectively. TPO is found on the apical surface of thyrocytes and is essential in the synthesis of thyroid hormone.
```
242
```
A 63 yr old woman presented with diarrhoea up to 8 times daily, associated with fever. She had been treated for a dental infection with clindamycin.
Which of the following treatments would be most appropriate?
Choose one answer.
a. IV vancomycin
b. oral ciprofloxacin
c. oral metronidazole
d. oral loperamide
e. oral rehydration solution
```
oral metronidazole
This patient has developed clostridium difficile diarrhoea after disruption of the normal colonic microflora through broad spectrum antibiotic (particularly clindamycin) therapy.
First line treatment is oral metronidazole. If a patient doesn’t respond to this or is pregnant, oral vancomycin is an effective alternative. IV Vanc is less useful, as oral vanc can act directly on the gut as it is not absorbed orally and stays on the colonic surface where it is most required.
243
```
A 74 yr old woman presents with weight loss and increasing jaundice over the last 3-4 weeks. On examination she has a palpable gallbladder.
Which diagnosis from the list below describes the likely diagnosis?
Choose one answer.
a. carcinoma of the pancreas
b. cholecystitis
c. coeliac disease
d. gilbert syndrome
e. hep B
```
A) Courvoisier's law states that in the presence of a palpable gallbladder, painless jaundice is unlikely to be caused by gallstones. Gallstones develop over time, resulting in a shrunken, fibrotic gall bladder. Hence enlarged gallbladders are more often as a result of obstruction of the biliary tree typically caused by carcinoma of the pancreas.
244
```
A 55 year-old women with psoriasis is admitted with a deterioration in her condition following the commencement of a new medication by her GP. Which is the likely culprit?
Choose one answer.
a. atenolol
b. bendroflumethiazide
c. fluoxetine
d. amitripptyline
e. diltiazem
```
Atenolol
psoriasis can be worsened or precipitated by drugs such as beta blockers , lithium and anti-malarials
245
A 43 year-old man is referred by his GP with a complaint of double vision worse at the end of the day whilst watching TV.
Which is the best diagnostic test?
a. autoantibody screen
b. CT brain
C. CT chest
d. nerve conduction studies with repetitive nerve stimulation
e. visual evoked responses
Correct response: D
A) Only about 85% of patients with MG test positive for Ach receptor autoantibody by radioimmunoassay.
Another test worth mentioning is the The Edrophonium (tensilon) test. This consists of an acetylcholinesterase inhibitor that works within 60 seconds and lasts 5 minutes. It causes a demonstratable increase in strength which fades within minutes. However, the test can be positive in other conditions, for example with amyotrophic lateral sclerosis and poliomyelitis.
B) CT Brain is not useful in the diagnosis
C) CT
chest is used to screen for thymic tumours, which are associated with MG.
D) This man has myasthenia gravis (MG) which is an autoimmune disorder with antibodies directed against Acetylcholine (Ach) receptors. A reduction in Ach receptors typically leads to progressive muscle weakness as the day progresses. There is a progression of weakness from top down: ocular (causing ptosis and diplopia) → facial and lower bulbar → truncal → limb. These patients can also suddenly develop breathlessness due to respiratory muscle weakness, hence their Forced Vital Capacity should be regularly monitored.
The best diagnostic test is nerve conduction studies with repetitive nerve stimulation (this characteristically leads to a progressive reduction in muscle response, reflecting muscle fatigability).
E) Visual Evoked Responses are used in the diagnosis of Multiple Sclerosis due to slowing of nerve conduction as a result of demyelination.
246
An 18 year old man has acute shortness of breath.
Which single clinical finding supports a diagnosis of a left tension pneumothorax?
a. trachea central, percussion dull, breath sounds normal
b. trachea centra, percussion resonant, breath sounds absent
c. trachea left, percussion dull, bronchial breathing
d. trachea right, percussion resonant, breath sounds absent
e. trachea right, percussion resonant, bronchial breathing
D.
As demonstrated the trachea would be deviated to the right. There would also be absent breath sounds on the Left as the lung collapses down with hyper-resonance on percussion.
Immediate management consists of inserting a cannula into the 2nd intercostal space, mid-clavicular line for immediate decompression followed by aspiration/chest drain according to the BTS guidelines.
247
```
A 40 yr old woman has diabetes and hypertension. She is known to have chronic renal impairment with a creatinine of 160 umol/L. Her potassium is 6.6mmol/L.
Which of the following is the most appropriate next step in her management?
Choose one answer.
a. low potassium diet
b. administer calcium chloride
c. administer calcium resonium
d. admin insulin and dextrose
e. refer for dialysis
```
B
The most pressing concern in a patient with renal failure leading to hyperkalaemia is the possibility of dangerous, sometimes fatal arrhythmias if not treated promptly. A K>6 warrants treatment with insulin/dextrose which pumps K back into cells, cardiac protection with calcium chloride/gluocante , especially in the presence of ECG changes suggestive of instability secondary to high K.)
This lady is known to have renal failure. Her blood results are not bad enough yet to warrant dialysis so conservative management should be sought for as long as possible. Starting dialysis on a patient is life changing as it involves life long trips to the dialysis unit, sometimes up to three times a week. Resonium should be avoided if at all possible as it can cause severe constipation with only a couple of doses. Her drug history list should be rationalised and any offending or nephrotoxic drugs should be changed if at all possible, She should be referred to a dietician and given advice on a low potassium diet.
Calcium chloride has no role in lowering a serum potassium level but acts to help stabilise the heart and helps avoid arrythmias. This should be given first to protect the myocardium - you can then arrange the insulin and dextrose infusion.
248
A 39 year old life-long non-smoking man (arrowed) has recently been diagnosed with severe emphysema. His sister has also been diagnosed with similar problems at the age of 35 years.
Which is the single most likely pattern of inheritance of the condition occurring in this family?
a. autosomal dominant
b. autosomal recessive
c. mitochondrial
d. x-linked dominant
e. x - linked recessive
B
The most likely condition is alpha-1-antitrypsin deficiency which is an autosomal recessive condition.
A) In autosomal dominant conditions one mutated copy of the gene is sufficient for a person to have the disease. If this was an autosomal dominant condition you would expect one of the parents to have the condition in order to pass on the dominant phenotype
B) This is the most likely answer. Both parents must be carriers, which means there is a ¼ chance an off spring will have the disease, ½ chance they will be a carrier and a ¼ chance they will be unaffected
C) Remember mitochondrial inheritance is maternal inheritance. All mitochondrial DNA is inherited from the mother. This means all the offspring of an affected female will have the disease, while all the offspring of an affected male will not be affected.
D) X Linked dominant is caused by mutations to genes on the X chromosome. If the father is affected, all his daughters would be affected as they will definitely inherit is X Chromosome and none of his sons would be affected. If the father is affected, there is a ½ chance that her daughters and a ½ her sons would be affected.
E) X Linked recessive conditions have a greater affect on males as they only have one X chromosome. There is no male to male transmission.
249
A 60 year old man has chest pain and collapses. He has no pulse. His initial rhythm on the monitor is ventricular fibrillation and a 150 Joules biphasic shock has been delivered.
Choose one answer.
a. assess the cardiac rhythm
b. check and correct reversible causes
c. check for a carotid pulse
d. give adrenaline 1mg IV
e. start chest compressions at the rate of 30:2
Answer E- Start Chest compressions Difficulty - Moderate
The latest ALS guidelines focus on maintaining circulation and avoiding any delays in chest compressions. Therefore even after a shock has been delivered to a VF/Pulseless VT the priority is to resume chest compressions for 2 minutes rather than pause to assess rhythm and pulse immediately (see ALS algorithm + guidelines for more in depth explanation).
250
A 78 year old woman has been anticoagulated with warfarin for 2 years as she had a stroke and atrial fibrillation. She was recently reviewed by her GP for cough and dyspnoea and she was treated with erythromycin for suspected pneumonia. She subsequently develops PR bleeding and her INR is found to be markedly prolonged?
What is the explanation for the potentiation of warfarin?
Choose one answer.
a. decreased Vit K absorption
b. displacement of warfarin from albumin binding sites
c. increased sensitivity of hepatic receptors to warfarin
d. increased Vit K absorption
e. reduced metabolism of warfarin
e.
Erythromycin is a cytochrome P450 inhibitor which results in reduced clearance of warfarin and a prolongation of INR.
To name a few inducers/inhibitors:
Enzyme Inducers
PC BRAS
Phenytoin, Carbamazepinem, Barbiturates, Rifampicin, Alcohol (chronic) Sulfapyrazine/St Johns Wort
Enzyme Inhibitors
AO DEVICES
A llopurinol/Azoles/Alcohol (binges), Omeprazole. Disulfiram, Erythromycin, Valproate (Na), Isoniazid, Cimetidine/Chlorpromazine, Sulphonamides
251
A 55 year old man with alcoholic cirrhosis was admitted vomiting fresh red blood. His BP is 90/65 mm/Hg, haemoglobin is 8g/dL (normal 12-16). What is the single most appropriate management plan?
a. blood transfusion, IV pantrazole, IV beta blockers
b. IV fluids, blood transfusion, arrange for urgent endoscopy
c. IV fluids, blood transfusion, insertion of Sengstaken Blakemore tube
d. IV fluids, blood transfusion, IV beta blockers
e. IV fluids , IV pantoprazole, arrange for endoscopy
B
This patient is a known alcoholic and it is important to diagnose and manage possible variceal bleeding. In a non-alcoholic the most common cause of significant upper GI bleed is peptic ulcer disease, whilst in the alcoholic population it is variceal bleeding which invariably has a poor long term prognosis.
Management should follow the ABC approach. In this case he is hypotensive and has had a significant drop in Hb and so he requires urgent IV fluids and blood transfusion.
Emergency endoscopy is the ideal next best step (once stable) in a patient who has been compromised by a likely variceal bleed. This will allow identification of source of bleeding and treatment in the form of banding or sclerotherapy.
Pharmacological management of active varcieal bleeding would involve the use of somatostatin analogues such as octreotide or vasopressin/terlipressin. It reduces splachnic blood flow and thus reducing bleeding.
Beta-blockers have a role in the long term prevention of variceal bleeding but not in active GI bleeding. It reduces portal hypertension in patients with alcoholic liver disease.
Sengstaken Blakemore tube is deployed in active variceal bleeding where either emergency endoscopy is not available and bleeding cannot be stopped or where endoscopy has failed (technically difficult due to obscured vision in active bleed).
IV proton pump inhibitor (omeprazole/pantoprazole) is essential when peptic ulcer disease is suspected and should be commenced in all patients with upper GI bleed until diagnosis is gained (even in the presence of variceal bleeding many gastroenterologists would recommend continuing PPI).
In light of this the best treatment for our patient would be B – fluids, transfusion and urgent endoscopy. The other combinations do not offer the best definite treatment or are not indicated.
252
Which one of the following statements about thrombocytopenia is correct:
a. it is a contraindication of the use of anti-platelet drugs
b. it is defined as a platelet count of less than 20x10 9/l
c. it is a normal finding in pregnancy
d. it is of immune origin in the majority of cases
e. it is physiological in children
A
Bleeding can occur more easily in thrombocytopaenia, particularly with counts
253
```
A 55 yr old patient with known alcoholic liver disease presents with confusion and nystagmus.
Which of the following is the best therapeutic step
Choose one answer.
a. cefuroxime
b n-acetyl cysteine
c. oxygen
d. thiamine
e. vit K
```
D
The symptoms and signs describe wernicke’s encephalopathy which is a triad of
1) encephalopathy – presenting with acute confusion
2) ataxic gait
3) ocular disturbance – nystagmus, nerve palsies
It is a serious disorder of thiamine deficiency, most commonly seen in alcoholics (but also observed in severe malnutrition/AIDS)
In this case the most appropriate treatment would be IV thiamine. Urgency is required whilst the cause is still reversible. Otherwise there is a possibility of the irreversible damage of Korsakoff's psychosis.
254
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A 46 yr old presents with mild pain in her thoracic spine 2 years after receiving surgery and adjuvant chemotherapy for breast cancer. Investigations reveal bone metastases. She has no other comorbidities What is the single best initial treatment option for her pain?
Choose one answer.
a. bisphosphonates
b. codeine phosphate
c. ibuprofen
d. paracetamol
e. radiotherapy
```
Ibuprofen
This patient has metastatic breast cancer which has a poor prognosis. Management should focus on symptom control and delaying disease progression. The question specifically asks for the INITIAL treatment for her PAIN.
A) Bisphosphonates have become a cornerstone in managing metastatic bone disease as it strengthens bone, reduce risk of fracture and helps prevent/treat hypercalcaemia. They can also reduce bone pain but its effects are slow and it can take some weeks/months before the patient notices a difference.
B) Codeine Phosphate is a reasonable choice of analgesia and as a weak opiod enters at level 2 in the analgesic ladder. However as an initial treatment there is a better option listed.
C) Ibuprofen is a simple analgesia and particularly good in bone pain due to its anti-inflammatory effects. Bone pain is thought to be due to oedema within the bone which NSAIDs can help alleviate and bring rapid relief and is a good first choice in mild bone pain and when not contraindicated (renal disease, peptic ulcer disease)
D) Paracetamol would be reasonable, particularly if NSAIDs were contraindicated.
E) This patient is likely to benefit from radiotherapy which proven to reduce bone pain. However radiotherapy is not always instantaneous, requiring referral to oncology services and so pain control measures should be initiated before this.
In cases of severe bone pain you would still use simple analgesia like paracetamol and NSAIDs but may climb up the analgesic ladder quicker using opiod drugs. patches, as well as organising more urgent radiotherapy/bisphosphonates.
255
A 68 year-old women attends A&E with acute, sudden painless onset of loss of vision in the right eye.
O/E: Reduced visual acuity 6/60 right eye.
ESR: 108.
BP: 150/80.
Which step should be taken next?
Choose one answer.
a. administer atenolol 50mg oral
b. administer hydrocortisone 100mg IV
c. administer prednisolone 60mg orally
d. refer to ophthalmology for urgent angiography
e. refer to ophthalmology for urgent laser treatment
C Administer prednisolone 60 mg orally
Level Moderate
Sudden onset vision loss with a raised ESR should raise the possibility of Temporal Arteritis (aka Giant Cell Arteritis). If scalp tenderness/headache was included in the history this would make the diagnosis all the more easier. It is a condition that affects the elderly and is an inflammatory process affecting arteries (inflammatory infiltrate found on biopsy)
Sudden loss of vision is the most alarming symptom and is due to inflammation of the vessels supplying the optic nerve.
In the presence of visual loss urgent treatment with high dose steroids is required (1mg/kg for example).
A) There is no indication for a B Blocker
B) IV hydrocortisone is not required. If an IV route is required (oral route not available) then IV Methylprednisolone is the preferred steroid (greater potency)
C) See above
D) + E) as the underlying pathology is inflammation of the vessels supplying optic nerve there are no specific surgical treatments available. Traetment can be commenced on the basis of visual loss and raised ESR in a patient >50 years of age. The presence of a tender/non-pulsatile temporal artery and abnormal biopsy of an artery would confirm diagnosis.
256
```
A 56 year-old post-menopausal lady is referrred to the rheumatology department following 2 wrist fractures from low impact falls.
Bone profile: normal. DEXA T-score: -3.8. Pelvic radiograph: osteopenia
Which is the preferred treatment option?
Choose one answer.
a. oral bisphosphonate
b. oral calcium supplementation
c. calcitonin injections
d. HRT
e. lifestyle modification
```
A
Dexa T Score ranges
normal BMD: T-score of -1 SD or above
osteopenia: T-score of between -1 and -2.5 SD
osteoporosis: T-score of -2.5 SD or below
This patient has osteoporosis which has predisposed her to fractures.
We have a post-menopausal woman with a diagnosis of osteoporosis based on her DEXA scan with a history of fractures and therefore in a high risk category for further fractures. Such patients should be treated with a bisphosphonates (which is now first line treatment in the secondary prevention of fractures in postmenopausal women)
A) All patients should have adequate calcium and vitamin D supplementation but in this case this alone is not adequate
B) Calcitonin can be used to prevent vertebral fractures in post menopausal osteoporosis but is only considered if bisphosphonates are not tolerated as bisphosphonates have a superior effect.
C) HRT is not recommended for postmenopausal women over the age of 50 years unless other treatments for osteoporosis are contraindicated or not tolerated. HRT has been linked with increased cardiovascular risk, stroke and breast cancer and so no longer routinely prescribed in this situation.
D) Lifestyle modifications such as smoking cessation, responsible alcohol consumption, increased exercise and falls prevention are all important as part of a holistic approach but not the best answer.
Other treatments include raloxifene (Selective oestrogen receptor modulator) and Strontium but these once again are second line to bisphosphonates.
257
```
A 52 year old woman has had a painful unilateral red eye for one day. She has diffuse conjunctival injection and a mid dilated pupil.
What is the single most likely diagnosis?
Choose one answer.
a. acute glaucoma
b. anterior uveitis
c. bacterial conjunctivitis
d. corneal foreign body
e. Herpes simplex
```
A
Patient has a sudden onset acute and painful red eye for which the differential diagnosis includes all of the above. It is the presence of a mid dilated pupil that allows us to make a diagnosis.
A) Acute Glaucoma – A sudden rise in intraocular pressure can present with vision loss, severe pain and hyperaemia (reddening) and a semi dilated, unreactive pupil.
B) Anterior uveitis presents with pain, photophobia, red eye (ciliary injection) and lacrimation but you would not expect pupil changes. It is associated with Ankylosing spondylitis, Behcet’s, IBD, to name a few.
C) Bacterial conjunctivitis is associated with a number of organisms and is usually associated with a purulent discharge, gritty sensation in the eye, and can present bilaterally.
D) Corneal foreign body usually presents with a history of projectile eye injury (drilling etc). Important features are pain, particularly on eye movements and lacrimation
E) Herpes simplex keratitis (dendritic ulcers) is usually suspected if fluorescein staining shows a characteristic ulcer with a branching pattern. There is nothing in the history to suggest this and you would not expect pupil abnormalities.
258
A 57 year old man has a head laceration. He smells strongly of alcohol. He makes grunting noises, demonstrates flexion withdrawal to pain but does not open his eyes. His pulse rate is 90 beats per minute and blood pressure 110/65 mmHg.
What is the most appropriate immediate step in his management?
a. blood alcohol level
b. catheterisation
c. CT scan brain
d. endotracheal intubation
e. mannitol infusion
D
The key to answering this question is considering his GCS
Eyes
Does not open his eyes to pain – 1
Verbal
Grunting – Incomprehensible speech – 2
Movement
Flexion to pain – 3
GCS 6
Anyone with a GCS of 8 or less will require intubation, they cannot protect their own airway (or any suggestion of a compromised airway not responding to simple measures. He is also at high risk of aspiration. An ABCD approach is required (ATLS) and once airway has been managed, breathing has been cleared and circulation stable other management issues can be addressed. He will require catheterisation to monitor fluid balance, a CT brain to rule out haemorrhage (extradural/subdural) and CVA (which can present with head injury).
It is far too early to consider mannitol infusion, the patient requires appropriate work up including urgent CT scan.
GCS
Eyes: 1- does not open 2 - opens in response to pain 3- opens to voice 4. opens spontaneously
Verbal 1- no sounds 2- incomprehensible sounds 3- inappropriate words 4- confused / disorientated 5 - orientated & conversing
Motor - 1-no movements 2 - extension to pain
3- abnormal flexion to pain 4 - flexion / withdrawal to pain 5 - localises painful stimuli 6. obeys commands
259
A 20 year old man has recently returned from the Far East. He has had myalgia, headache, bouts of abdominal pain and diarrhoea for one week. He has a temperature of 390C, blood pressure of 130/ 60 mmHg, pulse rate of 104 beats per minute and oxygen saturations of 92% on air.
What is the single most important investigation to aid diagnosis?
a. CRP & ESR
b. Prolonged culture for brucella
c. serum for virology
d. stool and blood cultures
e. thick and thin blood films
E
The patient has returned from abroad and so tropical disease must be considered in his differential diagnosis. Although Africa/Indian subcontinent is usually associated with Malaria it is also problematic in the Far East. The symptoms and signs described closely match malaria, High fever
Headache
Malaise
Myalgia
Gastrointestinal symptoms
Hypoxia
Malaria is the most common cause of fever in a person returning from the tropics and can be diagnosed with repeat microscopy of thick and thin films (rapid malarial tests are available based on antibody testing).
CRP and ESR may aid in assessing burden/severity of disease as well as having a baseline to guide progress but will not help diagnose.
Prolonged culture for brucella is currently not indicated, results take time to come back but it may be required if symptoms persist without a diagnosis being achieved (pyrexia of unknown origin).
Stool and particularly blood cultures are important and should be done anyway but in the context of this question a diagnosis can be ruled in/out promptly with blood film and so is the best answer.
260
```
A 32 year old woman is concerned about a mole on her calf.
What single major feature would suggest a diagnosis of malignant melanoma?
Choose one answer.
a. bleeding
b. colour change
c. diameter >6mm
d. sensory change
e. surface crusting
```
B
Worrying features of a pigmented skin lesion are
Asymmetry: Half the lesion does not match the other half.
Border irregularity: The edges are ragged, notched, or blurred.
Color variegation: Pigmentation is not uniform and may display shades of tan, brown, or black; white, reddish, or blue discoloration is of particular concern.
Diameter: A diameter greater than 6 mm is characteristic, although some melanomas may have smaller diameters; any growth in a nevus warrants an evaluation.
Evolving: Changes in the lesion over time are characteristic; this factor is critical for nodular or amelanotic (nonpigmented) melanoma, which may not exhibit the classic criteria above.
(i.e. ABCDE ASSYMETRY BORDER COLOUR DIAMETER EVOLVING – S Swetter, emedicine from webmd Jan 2008 http://emedicine.medscape.com/article/1100753-overview))
Although C (>6mm) is worrying, we do not know if it is growing and a diameter
261
```
A 78 year old man has had his electrolytes checked as part of his amiodarone monitoring. The results show:
Sodium 118 mmol/L (Na 135-145)
Potassium 3.8 mmol/L (K 3.5-5)
Urea 6.8 mmol/L (Ur 2.5-6.7)
Creatinine 148 micromol/L (79-118)
Corrected calcium 2.4 mmol/L (2.2-2.6)
Which single drug is most likely to have caused these biochemical findings?
Choose one answer.
a. amiloride
b. bendroflumethiazide
c. felodipine
d. perindopril
e. spironolactone
```
B
The most obvious abnormality is hyponatraemia, in the presence of renal impairment
A) Amiloride – A potassium sparing diuretic that is not associated with a low sodium. Can be used in heart failure and blood pressure control, particularly where hypokalaemia is a problem with conventional diuretics (watch out for hyperkalaemia)
B) Bendroflumethazide is a thiazide diuretic that acts on the distal tubule (chloride-binding sites). It can lead to hypokalaemia, hyponatraemia (as in this case), mild hypercalcaemia, can precipitate gout, as well as affecting diabetic glycaemic control and postural hypotension. The impaired renal function may be due to dehydration secondary to diuretics. Mainly used in hypertension.
C) Felodipine is a calcium channel blocker used in hypertension. It can cause headaches, dizziness, facial flushing and ankle oedema. Not associated with biochemical disturbance
D) Perindopril is an ACE-I used in BP control (particularly in diabetics/renal impairment), IHD and heart failure. It is most commonly associated with a dry cough. Angio-oedema is rare and potassium may rise during treatment. IT is not usually associated with hyponatraemia but as they affect the RAA axis may cause a mild hyponatraemia, particularly if there is also some mild renal impairment.
E) Spironolactone is another potassium sparing diuretic.
262
```
An 80 year old lady has persistent atrial fibrillation, despite having had attempted cardioversion. In view of this she is started on digoxin for rate control and her GP has referred her for consideration for antiocoagulation to reduce her stroke risk. Which single reason would make you withhold warfarin?
Choose one answer
a. concurrent diabetes
b. frequent falls
c. patient taking regular cocodamol
d. patient registered blind
e. patient lives alone
```
B – Recurrent Falls :level easy
There is an increased risk of stroke in patients with atrial fibrillation and therefore careful consideration to anticoagulation is required to manage this risk.
In the elderly the risk of falls have to be assessed. If a patient falls whilst on warfarin there is an increased risk of significant bleeding and this risk has to be weighed up.
Diabetes would make you more inclined to prescribe warfarin due to the greater risk of stroke. Patient living alone and being registered blind in itself does not mean an increase risk of falls.
Taking cocodamol has no bearing on warfarinisation.
263
```
A 76 year old woman has a double contrast barium enema revealing outpounchings in the colonic wall of her sigmoid colon. Several days after this examination the patient is admitted with pain, pyrexia, and constipation. O/E she has a tender mass in the LIF.
What is the most likely diagnosis?
A. acute diverticulitis
B. Colonic perforation
C. Ischaemic colitis
D. Large bowel obstruction
E. Strangulation of colonic polyp
```
A - Acute Diverticulitis Level Easy
Diverticular disease as seen here is generally associated with a western diet that is typically low in fibre. Stools are of low bulk and consequently intraluminal pressures are likely to be higher. To visualise this imagine how much harder it is to get toothpaste out of a tube when it's nearly empty - you have to use much higher pressure and more effort to extract it from the end, than if the tube is full.
It is thought that this increased pressure over time is associated with the outpouchings in the colonic wall. The sigmoid colon is the site most commonly associated with diverticula. These act as blind ended sacs in which faecal matter can collect - providing a convenient substrate for infection to develop. Infection can be self limiting, or the diverticulum in question can perforate. If this is walled off by peritoneum it becomes a diverticular mass - if bowel contents become disseminated around the peritoneal cavity we get a generalised peritonitis and a very sick patient.
264
A 55 year old lady presents to A&E with a 2 day history of right upper quadrant pain and jaundice. In addition her skin feels itchy; her urine has turned dark and her stools slightly pale.
```
Urea 2 (3 - 7)
Creatinine 63 (80-133)
Total bilirubin 72 (3-17)
ALT 63 (8-63)
ALP 349
GGT 94 (11-50)
Albumin 29 (35-50)
Calcium 2.15 (2.2 - 2.8)
Inorganic phosphate 0.95 (0.7 - 1.45)
```
In this lady which of these urinalysis results is most likely to present?
a. conjugated bilirubin increased, urobilinogen absent
b. conjugated bilirubin decreased, urobilinogen present
c. conjugated bill increased, urobilinogen present
d. unconjugated bill increased, urobilinogen absent
e. unconjugated bill increased, urobilinogen present
A
this lady has biliary obstruction and consequently has an extrahepatic cholestatic jaundice. The bilirubin is raised, as is ALP (a ductal enzyme).
Soluble conjugated bilirubin enters the circulation - it is unable to reach the small intestine due to the cholestasis. Low intra-intestinal conjugated bilirubin also means less is converted to urobilinogen. As there is less urobilinogen for reabsorption and subsequent excretion, it may be low or absent in the urine.
The urobilinogen in the intestine (stercobilinogen) is oxidized to stercobilin. This usually gives faeces their brown colour - explaining why they are pale in this situation.
265
```
A 55 year old woman has had right upper quadrant pain and jaundice for two days Her skin feels itchy; her urine has turned dark and her stools slightly pale.
Urea 2 (3 - 7)
Creatinine 63 (80-133)
Total bilirubin 72 (3-17)
ALT 63 (8-63)
ALP 349
GGT 94 (11-50)
Albumin 29 (35-50)
Calcium 2.15 (2.2 - 2.8)
Inorganic phosphate 0.95 (0.7 - 1.45)
What is the single most likely underlying pathology?
A carcinoma of the head of the pancreas
B CBD stones
C malignant porta hepatis lymph nodes
D pancreatitis
E sclerosing cholangitis
```
B
Common bile duct stones are a commonly seen condition, and are found most often in people who are 'fat forty female and fertile.' This patient doesn't necessarily fit all those criteria, but the history combined with the cholestatic picture on the bloods makes this the most likely diagnosis
266
```
A 55 year old woman has had right upper quadrant pain and jaundice for two days Her skin feels itchy; her urine has turned dark and her stools slightly pale.
Urea 2 (3 - 7)
Creatinine 63 (80-133)
Total bilirubin 72 (3-17)
ALT 63 (8-63)
ALP 349
GGT 94 (11-50)
Albumin 29 (35-50)
Calcium 2.15 (2.2 - 2.8)
Inorganic phosphate 0.95 (0.7 - 1.45)
Which of the following investigations would you perform next?
A CT abdo
B endoscopic retrograde cholangiogram
C technetium iminodiacetic acid scan (HIDA)
D Percutaneous transhepatic cholangiogram
E USS liver and biliary tree
```
E
Common bile duct stones are a commonly seen condition, and are found most often in people who are 'fat forty female and fertile.' This patient doesn't necessarily fit all those criteria, but the history combined with the cholestatic picture on the bloods makes this the most likely diagnosis.
The best investigation to confirm this diagnosis is an Ultrasound Scan of the liver/gallbladder and biliary tree. You may or may not see stones, but abnormal dilatation of the common bile duct would indicate an obstruction. ERCP is not first line - you wouldn't do this unless you had first confirmed the diagnosis with noninvasive imaging
267
```
A 65 year old woman was admitted to hospital with symptoms and signs of large bowel obstruction. At laparotomy, there was rectal obstruction, and an anterior resection of the rectosigmoid was performed. The surgical specimen is below, opened to show the mucosal surface.
What is the most likely histological diagnosis?
Choose one answer.
a. adenocarcinoma
b. adenoma
c. signet ring carcinoma
d. squamous cell carcinoma
e. transitional cell carcinoma
```
a
adenocarcinoma is the most common malignancy in the colon
268
```
A 68 year old woman has an anterior resection for sigmoid carcinoma. The pathologist report is "the tumour is moderately-differentiated with expansile margins and few tumour-associated lymphocytes. It invades through the full-thickness of the bowel wall to involve the subserosal fat, although does not reach the serosal surface. 17 lymph nodes are identified, 1 of which contains metastatic carcinoma. The highest lymph node is free from tumour".
What is the the Dukes' stage of this tumour?
Choose one answer.
A
B
C1
C2
D
```
C1
The Duke's staging system was first published in 1932 for rectal carcinomas, and is now used for all colorectal carcinomas.
Duke's A - confined to mucosa/submucosa. 90% 5 year survival
Duke's B - spread into or through muscle layer but lymph nodes negative. 60% 5 year survival
Duke's C - Lymph nodes are involved. Splits into C1 and C2 - the latter means the highest lymph node in the surgical specimen (the one furthest from the tumour in the chain) contains tumour cells. Overall survival for a Duke's C is 30% at 5 years
Duke's D - not part of the original classification, but taken to mean distant metastasis. 5-10% 5 year survival.
269
A 68 year old woman has an anterior resection for sigmoid carcinoma. The pathologist report is "the tumour is moderately-differentiated with expansile margins and few tumour-associated lymphocytes. It invades through the full-thickness of the bowel wall to involve the subserosal fat, although does not reach the serosal surface. 17 lymph nodes are identified, 1 of which contains metastatic carcinoma. The highest lymph node is free from tumour".
What is the histological grade of this tumour?
A 1
B 2
C 3
D 4
E not known
2
```
The grade of a tumour simply refers to the differentiation of the tumour cells. A less well differentiated malignancy is generally more aggressive and resistant to treatment
Grade 1 - Well differentiated
Grade 2 - moderately differentiated
Grade 3 - poorly differentiated
Grade 4 - undifferentiated
```
270
```
A Patient has an adenocarcinoma of the rectosigmoid. Surgical intervention removed the mass successfully. Which of the following tumour markers would it be most useful to measure serologically in the follow up of this patient?
a alpha-fetoprotein
b CA 125
c CA 153
d carcinoembryonic antigen
e lactate dehydrogenase
```
D
CEA is associated with colorectal adenocarcinoma. Here are a few other tumour marker associations:
AFP - hepatoma, testicular teratoma, yolk cell
CA 125 - ovarian
CA153 - breast
CA1909 - pancreatic adenocarcinoma
5-IHAA - carcinoid
acid phosphatase - prostate
HCG - choriocarcinoma, testicular teratoma
paraprotein - myeloma
271
This investigation was performed on a 45year old man with weight loss.
A barium swallow reveals dilatation by the oesopho-gastric junction.
what is the diagnosis?
a. achalasia
b. CHagas disease
c. Diffuse oesophageal spasm
d. infiltrative oesophageal carcinoma
e. scleroderma
A
This is a barium swallow. The oesophagus is the long contrasted structure, and the oesophago-gastric junction can be seen as the thin line of contrast at the inferior end.
Barium should not be used where perforation is suspected as it will cause peritonitis if allowed into the peritoneal cavity. Gastrograffin is used as a substitute in this case, but does not give such good images
This is achalasia of the cardia - a condition where neuromuscular failure of relaxation near the oesophago-gastric junction causes progressively worsening dilatation, uncoordinated peristalsis and hypertrophy of the oesophagus.
Chagas' disease is caused by Trypanosoma cruzi infection - the intermuscular ganglion cells of the oesophagus are destroyed by the parasite. It would look similar on a barium swallow, but it's not going to come above achalasia in your differential list as a UK practitioner.
In achalasia, progressive dysphagia occurs and worsens over months and years. There is sometimes malignant change in the dilated oesophagus.
272
A patient is having an upper GI endoscopy. He suddenly becomes hypotensive, tachycardic and short of breath. His chest-x-ray taken at this time is shown below.
Air visible below diaphragm
```
Which of the following complications is most likely to have occurred?
Choose one answer.
A. ARDS
B. Oesophageal rupture
C. Pneumothorax
D. PE
```
B
This is an oesophageal rupture - there is air under the diaphragm. This is a complication that should be on the consent form for an upper GI endoscopy. The patient will need to be stabilised immediately and the defect closed surgically
273
```
Barium swallow was performed on a 45year old man with weight loss. Which of the following investigations should be performed next?
A CT abdo
B CT thorax and abdo
C endoscopy
D pH manometric studies
E no further investigation necessary
```
Endoscopy is required in this patient to exclude carcinoma, particularly in the presence of weight loss which occurs in both achalasia and oesophageal carcinoma. Although the barium swallow is very suggestive of achalasia it is vital to rule out carcinoma before investigating the possibility of achalasia further with manometric tests (D) (which will reveal a gastro-oesophageal sphincter with a high resting tone that only partially relaxes).
CT scanning is not part of the routine work up of achalasia which is essentially a neuromuscular failure of the lower end of the oesophagus
274
A 26 year old man is brought into A&E via ambulance. He was hit by a car travelling at 45mph while on his motorcycle and has sustained multiple injuries. He is alert and talking, and is on a spinal board with full neck immobilisation. Pulse is 160, BP 90/40, Sats 98% on 12L Oxygen. The ambulance crew have already removed his clothes and you can see that he has an open femoral fracture that is bleeding profusely. Which of the following actions should you perform first?
a. check the GCS
b direct pressure on the site of bleeding
c listen to the patients chest
d obtain IV access using 2 wide bore cannulas into the ant cubital fossae
e urgent spot haemoglobin check
C
Any SBA question that asks what you should do first should be treated with caution. There would normally be several people around in A&E to deal with this major trauma, and several things would be done simultaneously. However, you must understand how to do things in the correct order – in this case ABCDE, as per the ATLS guidelines.
A – he’s talking so his airway is clear, however, you still need to make an assessment of the airway to avoid problems later. It’s not an option here though.
B – In polytrauma there’s a clear risk of pneumothorax. Tension pneumothorax can kill rapidly, and even though the patient is saturating well currently, he is on high flow oxygen. Look and feel for expansion and any injuries, listen for air entry, percuss to check for hyperresonance or dullness.
C – This guy has hypovolaemic shock. He needs rapid fluid resuscitation and you need to stop the blood loss. You know he’s bleeding from the femur, and splintage and direct pressure will help with this. However, don’t assume this is the only source of bleeding. A patient can lose their entire circulating volume into the pelvis if it is fractured, and there’s every chance he has visceral damage as well. This is when you can get cannulae in and send bloods off. The spot haemoglobin will be useful if you can get it at this stage, but it doesn’t come before sorting out breathing
D – You can worry about GCS when you’ve sorted out the above. Disability is also a good time to remember to check the blood glucose level.
E – Full exposure is absolutely essential. Without it you might miss bruising that could alert you to an intra-abdominal trauma, or an overt source of bleeding that you hadn’t seen because the patient’s clothes are apparently soaked from another wound.
275
A 78 year old woman has acute breathlessness and pleuritic chest pain. She has recently been discharged from hospital following a total hip replacement. She had a CTPA, shown below, which confirms the diagnosis.
What is the single most likely finding in her ECG?
VF
S1Q3T3
ST elevation
sinus tachycardia
sinus bradycardia
This woman has had a Pulmonary embolism. Although you do not need to know how to interpret a CTPA you should be aware that PEs are investigated with CTPA or V/Q scans. This CTPA shows a saddle embolus in the pulmonary artery. The most common ECG change in PE is sinus tachycardia. The classical S1Q3T3 associated with PEs is not often seen. Incomplete RBBB is also associated with PE. ST elevation is found in MI and pericarditis but is not associated with PEs. Patient is conscious, VF is not compatible with cardiac output.
276
```
A 17 year old woman has nausea. She took 28 paracetamol tablets (500mg) 5 hours ago after an argument with her boyfriend. She denies taking any other medications and regrets the whole event. She has well controlled epilepsy for which she takes carbamazepine.
Her heart sounds are normal, chest is clear, abdomen is soft, non-tender and there is no focal neurology. Her blood tests show:
HB 13.9
WCC 5.6
platelets 350
sodium 140
potassium 3.9
urea 4.8
creatinine 62
ALT 29
AST 32
ALP 90
Bili 6
INR 1.1
Paracetamol levels 110mg/L
```
Management?
admit for observation and recheck paracetamol levels, LFTs and INR at 8 hours
commence N-Acetylcysteine treatment immediately
discharge pnt and ask her mum to observe her closely for the next 24hrs
Gastric lavage
urgent psychiatry review
Commence N-Acetylcysteine treatment (Difficulty – Moderate)
A) Paracetamol levels should be taken at 4 hours or as soon as the patient arrives if >4 hours as was done in this case. In this case we already have paracetamol levels – see B
B) This patient has levels above the high risk treatment line but below the normal treatment line. Indications to treat as high risk: if on p450 enzyme inducing drugs (antiepileptic medications phenytoin, carbamazepine (our patient), rifampicin, St Johns wort), alcoholics, HIV infection, malnourished (glutathione depeletion)
C) Patient requires treatment with N-acetylcysteine (NAC) due to the high risk of hepatocellular damage in the absence of treatment
D) This would be inappropriate as 5 hours have passed and much of the paracetamol will have been absorbed (generally speaking this option alongside charcoal is only applicable if 1-2 hours post ingestion)
E) This patient will need psychiatric review prior to discharge but only once she is medically stable.
(>150 mg/l is normal treatment line)
Briefly management depends on paracetamol levels and timing of overdose.
4-8 hours – Await paracetamol levels prior to commencing NAC. If significant overdose (>12g) it is usually wise to start treatment
8-16 hours – If significant overdose (>12g) start treatment. If dose unknown better to treat as a high risk overdose and start NAC
>16 hours – At this point it is possible that the window of opportunity has been missed but still wise to start NAC and closely monitor patient for evidence of hepatocellular damange (LFTs + more importantly synthetic function of liver – clotting-INR)
At any stage if severe liver damage is suspected as judge by patient’s clinical condition (ABGs, LFTs, U+Es, glucose, INR) the local liver unit should be consulted on further management,
277
A 50 year old man with hypertension attends the Emergency department with a sudden onset severe headache at the back of his head. He is drowsy and has vomited twice. He has neck stiffness and photophobia but no focal neurological signs were elicited.
An unenhanced CT head was done which is shown below.
What is the single most likely diagnosis?
cluster headache
intracerebral haemorrhage
meningitis
migraine
subarachnoid haemorrhage
Answer: e (difficulty- easy)
a) Cluster headaches usually present as unilateral orbital pain occurring at night. It may be accompanied by lacrimation and miosis.
b) Intracerebral haemorrhage causes 10% of strokes, mostly in hypertensive patients. Vomiting and headache may occur, followed by a focal neurological deficit.
c) Patients with SAH may experience signs of meningism due to irritation of the meninges by subarachnoid blood.
d) Migraines are usually unilateral. One may experience vomiting and photophobia. Neck stiffness/meningism is not a feature.
e) Subarachnoid Haemorrhages (SAH) often present suddenly as “the worst headache of one’s life” at the back of the head. CT is the investigation of choice, showing blood in the subarachnoid space (as demonstrated in the picture above). 70% of SAHs are due to rupture of an aneurysm. If CT is normal, a lumbar puncture looking for xanthochromia is indicated at 12 hours post onset of headache (allows time for red blood cells to degrade to bilirubin). GCS and pupils should be monitored hourly as a drop may signify complications such as rebleeding and hydrocephalus whereby repeat CT is indicated.
278
```
A 43 year old man with a BMI of 32kg/m2 has a fasting glucose of 9 mmol/L despite 3 months of diet and exercise. He has normal renal and liver function.What is the single most appropriate drug treatment to prescribe him?
Choose one answer.
acarbose
gliclazide
insulin glargine
metformin
rosiglitazone
```
Answer: D. Metformin
Difficulty level: Intermediate
Explanation:
He has already had a 3 month trial of diet control and exercise and his fasting glucose remains significantly raised (7mmol/L). He therefore needs pharmacological management.
Metformin is a biguanide which acts to reduce insulin resistance. It is contraindicated in significant renal impairment as it can cause lactic acidosis. It does not cause hypoglycaemia (unlike gliclazide, a sulphonylurea) and is an ideal first choice in obese patients
This patient is obese and therefore gliclazide is unsuitable for this patient as it causes weight gain.
Rosiglitazone acts at the PPAR-γ receptor and is used as an adjunct to biguanides or sulphonylureas.
This patient has type 2 diabetes predominantly due to insulin resistance therefore Insulin glargine is not appropriate as a first line medication.
279
A 51 year old man has had a lack of libido over the past few months. He had planned to travel all over Europe but has not been able to walk very far recently due to shortness of breath and pain in his toes.
He is tanned and has 3 cm hepatomegaly.
His urine dipstick shows: Blood 0
Protein 0
Glucose +++
What is the single definitive investigation which will confirm the underlying diagnosis?
Choose one answer.
blood glucose
CT abdomen
Liver autoantibody screen
liver biopsy
USS abdo
Answer: d= Liver biopsy (level = difficult)
This man exhibits the triad of Haemochromatosis; bronze skin, hepatomegaly and diabetes mellitus. He also demonstrates symptoms of hypogonadism (loss of libido), cardiomyopathy (shortness of breath), and pseudogout (pain in 2nd/3rd toes typically).
A useful screening test for suspected cases of haemochromatosis is Ferritin and Transferrin saturation, which should both be raised.
If the patient has a first degree relative with haemochromatosis then genetic testing for HFE genotype (C282Y mutation) can be used.
The definitive investigation to confirm haemochromatosis is a liver biopsy which will show an increase in iron stores.
280
```
A 71 year old man has increasing drowsiness and worsening headache for 3 days. He has vomited twice and he has a Glasgow Coma Scale of 11. His wife estimates that he drinks 14 pints of beer and 3 bottles of wine a week. She recalls that he has had a few falls within the last six months.
What is the single most likely diagnosis?
Choose one answer.
cerebral abscess
extradural haematoma
subarachnoid haematoma
subdural haematoma
wernickes encephalopathy
```
Answer: d
a) Wernicke’s encephalopathy is due to thiamine deficiency characteristically in alcoholics and results in the triad;
1) Confusion 3) Opthalmoplegia 2) Ataxia
b) Cerebral abscess is unlikely as the patient does not have a fever.
c) Extradural haematomas follow linear skull vault fractures (due to direct injury to the head such as being hit by a baseball bat). There is characteristically a brief moment of unconsiousness followed by a lucid interval and then progressive hemiparesis with subsequent coning.
d) Subarachnoid haemorrhages present acutely with severe sudden onset headache at the back of the head.
e) This patient has had a subdural haematoma which presents typically with headache, drowsiness and fluctuating confusion following a mild head injury days, weeks or months previously. Subdural haematomas should be considered in the elderly, alcoholics and patients with a history of falls or patients on warfarin.
281
```
A 35 year old man who bruises easily has been having epistaxis lately. When he had his wisdom tooth extracted a year ago he bled profusely. His mother and sister have similar symptoms.
What is the single most likely deficiency causing these problems?
Choose one answer.
factor 8
factor 9
vit c deficiency
iron deficiency
von Hillebrand factor
```
```
Answer = e = Von Willebrand Factor (difficulty – moderate)
a + b) Haemophilia A (Factor 8 deficiency) and Haemophilia B (Factor 9 deficiency) have X-linked recessive inheritance so females can only be carriers (therefore this patient’s mother and sister would not have had similar symptoms). There is a clotting defect, hence they more commonly present with HAEMARTHROSIS.
c) Bleeding can cause Iron deficiency anaemia but generally not vice versa.
d) Vitamin C deficiency due to malnutrition causes scurvy. Classically there are perifollicular haemorrhages and bleeding from the gums. Think scurvy in the poor or the pregnant, not middle class pianists.
e) Von Willebrand’s disease (vWD) is the most common bleeding disorder affecting 1% of the population. Type 1 and 2 vWD are Autosomal Dominant.
Von Willebrand Factor (vWF) is a large molecule that attaches platelets to damaged endothelium. It also carries Factor 8 in plasma, stabilising it. Hence vWD leads to a defect in platelet function (causing BLEEDING, particularly EPISTAXIS & menorrhagia).
```
282
A 63 year old man is transferred to intensive care as his condition continues to deteriorate after receiving a blood transfusion. Which is the single most unlikely cause of his transfusion reaction?
Choose one answer.
acute transfusion reaction
transmission of hepatitis c
febrile non-haemolytic transfusion reaction
IgA deficiency
bacteraemia from a contaminated blood pack
Answer B
a) Acute transfusion reaction occurs within minutes of receiving the transfusion.
b) Transfusion related Hepatitis C causes chronic hepatitis in half of all recipients.
c) Febrile non-haemolytic transfusion reaction often occurs within 1-6 hours after the blood transfusion. Typically only fever and dyspnoea is present. This can be managed with paracetamol.
d) Patients with selective IgA deficiency are more prone to experiencing an anaphylactic reaction during transfusion.
e) Bacteraema from a contaminated blood pack may cause sepsis during transfusion.
283
spiking temperature, high pulse and high respiration rate in a 22 year old woman who had a laparoscopic appendectomy for a perforated appendix 5 days ago. She is currently receiving cefuroxime intravenously. Wound sites appear clean.
Which single antibiotic would you start in addition to the cefuroxime?
```
Choose one answer.
Clindamycin
Erythromycin
Gentamycin
Metronidazole
Vancomycin
```
This woman has developed a pelvic abscess as a complication of a perforated appendix. The spiking temperature which she demonstrates is characteristic of this complication. Aerobic and anaerobic organisms could be responsible for the sepsis, and empirical parenteral antibiotics which cover both should be initiated. Cefuroxime covers aerobes and adding metronidazole covers for anaerobes. A pelvic collection of any significant size will need draining, either in theatre or by the interventional radiologists.
284
A 32 year old man who is a known IV drug user has jaundice, malaise, fatigue, arthralgia and right hypochondrial discomfort. Liver function tests suggest an acute hepatitis. Viral serology tests are sent confirming hepatitis B. Which is the single most accurate statement about hepatitis B infection?
 a. Alkaline phosphatase (ALP) levels are likely to be relatively higher than aspartate amnotransferase (AST) levels in acute infection 
 b. IgM antibodies are present in chronic infection 
 c. Chronic infection occurs in the majority of cases 
 d. Presence of antibodies to hepatitis B and Hepatitis B surface antigen indicate vaccination 
 e. Hepatitis B surface antigen if present after six months indicates chronic infection 
Hepatitis B is a DNA virus and is one of the causes of viral hepatitis.
(a) Viral hepatitis causes damage to hepatocytes. AST tends to be relatively more raised when liver cells are damaged as in acute hepatitis as it is found in liver cells (as well as the heart and other muscles). ALP levels are relatively higher when there is obstructive jaundice. ALP is also found in bones.
b) IgM antibodies are characteristic of acute infections. IgG antibodies only arise later. Therefore (b) is false.
c) Chronic infection occurs in only the minority of cases of hepatitis B (5-10%) therefore c is incorrect. It is hepatitis C where the majority of patients (85%) go on to become chronic carriers (Hepatitis C=Chronic). Both Hepatitis B and C can lead to hepatocellular carcinoma.
d) Note that presence of antibodies against HBsAg without the presence of HBsAg indicates vaccination against hepatitis B therefore (d) is false.
e) Assays for hepatitis B infection test for viral antigens (proteins produced by the virus) or antibodies produced by the host (see diagram). HBsAg is most frequently used to screen for the presence of infection it is raised from 1-6months after exposure. The presence of Hepatitis B surface antigen (HBsAg) for more than six months after infection indicates chronic infection so answer (e) is correct. Hepatitis B e antigen increases soon after HBsAg and is present from 1½-3 months after infection traditionally it is associated with a high infectivity.
285
A 42 year old man with polycystic kidney disease attends the Emergency department with severe headache.
His head CT is shown below.
He has an operation and is successfully treated. His routine electrolytes on day 2 post operation are as follows:
Na 123, K 3.7, Urea 8.5, Creatinine 120.
Which is the single most likely cause of his electrolye abnormalities?
acute renal failure
dehydration
diabetes insipidus
inappropriate fluid replacement
syndrome of inappropriate ADH
Answer E) Syndrome of inappropriate ADH (difficulty = moderate)
The CT head scan demonstrates blood within the large left anterior communicating artery aneurysm and blood in the fourth ventricle. Patients with polycystic kidney disease have an increased incidence of cerebral aneurysms which can bleed, causing subarachnoid haemorrhage, as in this case.
A+ B) Urea and Creatinine are within the normal range. They would be raised if these conditions were to be present
C) Diabetes insipidus is due to a lack of ADH production (cranial DI) or a resistance to ADH (nephrogenic DI). Hence patients present with dilute urine relative hypernatraemia.
D) Inappropriate fluid replacement may lead to hypernatreamia (due to too much NaCl) or haemodilution, in which case urea and creatinine may be low.
E) Hyponatraemia commonly occurs in patients with aneurysmal subarachnoid haemorrhage. SIADH can occur for a number of reasons including interruption of neuronal communication and hormonal feedback mechanisms due to intracranial hemorrhage or neurosurgery for aneurysmal repair. This leads to inappropriate release of neuronal ADH.
286
A 62 year old man is suspected to have farmer’s lung. Which is the single most likely cause of this disease?
Choose one answer.
```
aspergillus
hydatid cysts
cryptosporidium
micropolyspora faeni
mycobacterium avium
```
Micropolyspora faeno
Farmer’s lung is a type of extrinsic allergic alveolitis that is caused by micropolyspora. Hydatid cysts are sometimes found as lung (and liver) lesions in sheep farmers. Mycobacterium avium is found in the immunosuppressed (eg. those on steroids or HIV positive). Bird fancier’s lung is associated with avian proteins. Aspergillus occurs in three patters: ABPA (in asthmatics), colonizing cavities or as invasive aspergillosis.
287
```
A new blood test has been developed to detect condition X. It was tested on 200 people. 120 people tested positive for X and 95 actually had the condition. 5 people tested negative for the condition but were actually found to have the condition. The remainder who tested negative were found not to have the condition
Which single value is the positive predictive value of the test?
Choose one answer.
6%
21%
26%
79%
94%
```
For this type of question it may be easier to tabulate the information
```
Condition +ve Condition –ve Total
Test +ve 95 (a) 25 (b) 120
Test –ve 5 (c) 75 (d) 80
Total 100 100
The positive predictive value is the probability that a subject who tests positive for the condition actually has the condition.
It is calculated by
a / (a+b)
Multiple by 100 to get the percentage
95/120 = 79%
```
288
Spiking temperature, high pulse and high RR in a 22 yr old woman who had a laparoscopic appendectomy for a perforated appendix 5 days ago. She is currently receiving cefuroxime intravenously. Wound sites appear clean.
Which single investigation is most likely to establish the diagnosis?
```
Choose one answer.
Blood culture
CXR
Mid stream urine
USS abdo and pelvis
wound swab
```
Answer D
This woman has developed a pelvic abscess as a complication of a perforated appendix. The spiking temperature which she demonstrates is characteristic of a pelvic abscess. Ultrasound should be the initial screening procedure for patients suspected of having abdominal/pelvic abscesses. Ultrasound investigation has high sensitivity and specificity for the detection of such masses.
289
A 54 year old man has recent onset shortness of breath. He has had central chest discomfort with numbness in his left arm for 5 hours. He is a life long smoker and consumes 15-20 pints of beer each week. He does not take any regular medication. He is dyspnoeic, clammy to touch with a pulse of 56bpm, BP 164/84mmHg and oxygen sats of 95% on air, chest has bibasal crackles with normal heart sounds with pitting swelling up to the knees. JVP is difficult to illicit as he is obese.
What would be the single most appropriate initial investigation?
ABG
CXR
ECG
ECHO
Troponin
ECG
A) Patient is not particularly hypoxic and there is no wheeze or cough to suggest COPD exacerbation. He may be prone to Type II respiratory failure in view of his smoking history although the initial management would be high flow oxygen if MI is suspected.
B) Chest X Ray is indicated in order to assess for cardiomegaly and pulmonary oedema/congestion in view of the signs of heart failure but would not be the First investigation
C) This patient has multiple risk factors for IHD and is presenting with central chest discomfort with symptoms in left arm so the priority must be to diagnose/rule out MI or acute coronary syndrome which may have precipitated heart failure.
D) Echo may be indicated in the future management but as part of his acute care it will not influence management.
E) Troponin is indicated but becomes a useful test 12 hours after the onset of symptoms. If acute coronary syndrome (ACS) is suspected in the intervening time you would treat as ACS until a 12 hour troponin became available.
Treatment of acute coronary syndrome (i.e. non-ST elevation MI)
Oxygen
GTN Spray
Diamorphine IV (with metoclopramide)
If pain does not settle with these measures GTN infusion maybe indicated if systolic blood pressure is maintained >100
Antiplatelet therapy – Aspirin + Clopidogrel (if high risk-multiple risk factors) loading dose
Clexane – subcutaneous
MONA – Morphine, oxygen, nitrates, anticoagulation
In proven ACS (troponin positive) and no contraindications start Beta blocker (Atenolol/bisoprolol), ACE-I (ramipril) and statin (simvastatin) over the next 24-48 hours.
290
A 31 year old man with coeliac disease has itchy blisters on his elbows and buttocks. He has been prescribed a drug which has eased the blisters. Since starting this medication he has been tired and has a yellowish tinge to his skin as well as blood in his urine. He had similar symptoms on a trip to Africa last month after starting a prophylactic course of primaquine for malaria .
Investigations: Haemoglobin 7 g/dL,
MCV 105 fL
White cell count 5 x 109/L
Platelets 210 x 109/L
Blood film: Bite cells, Blister cells, Heinz bodies
What is the single most likely diagnosis?
```
G6PD deficiency
malaria
paroxysmal cold haemoglobinuria
paroxysmal nocturnal haemoglobinuria
spherocytosis
```
a) This man has G6PD deficiency which is the commonest enzyme deficiency in the world. It is due to an inability to regulate NADPH and has X-linked recessive inheritance.
The commonest complications are; 1) neonatal jaundice 2) haemolytic anaemia
In this patient haemolysis has been triggered by dapsone (which he has been prescribed for dermatitis herpetiformis) and primaquine (which he took for malaria prophylaxis when he went to Africa).Can also be triggered by infection or ingestion of lava (broad) beans.
Intravascular haemolysis (RBCs destroyed in circulation) causes a triad of;
1) Anaemia; 2) Jaundice; 3) Haemoglobinuria
Deficient glutathione leads to oxidized methemoglobin which precipitates out as Heinz bodies. Bite cells and blister cells can be seen on the blood film.
b) Malaria due to P. Falcifarum can cause blackwater fever which is characterised by intravascular haemolysis and renal failure.
c) Paroxysmal cold haemoglobinuria causes haemolysis due to IgG complement fixing antibodies which lyse red blood cells in the cold. It is associated with measles & mumps.
d) Paroxysmal nocturnal haemoglobinuria causes a triad of;
1) Haemolysis; 2) Thrombosis; 3) Pancytopenia
e) Spherocytosis is an autosomal dominant condition leading to extravascular haemolysis (RBCs destroyed in reticuloendothelial system) which causes:
1) Jaundice ; 2) Anaemia 3) Splenomegaly (NO haemoglobinuria)
291
A 20 year old woman with a BMI of 31kgm2 has headaches and double vision. She is on the oral contraceptive pill.
The picture below shows what is seen on fundoscopy examination.
Which is the single most important investigation to perform next?
 a. Blood test for serum Vitamin A level 
 b. CT head 
 c. Lumbar puncture 
 d. Slit lamp examination 
 e. Visual field testing 
Answer: b (difficulty – moderate)
This is a typical patient with benign intracranial hypertension/ Idiopathic intracranial hypertension. The slide shows papilloedema. It is thought to be due to impaired CSF absorption from the subdural space by arachnoid villi. This condition is associated with OCP, vitamin A and outdated tetracycline use.
a) High vitamin A serum levels (through ingestion) can cause benign intracranial hypertension.
b) CT head must be done urgently in a patient with papilloedema as a space-occupying lesion must be ruled out initially.
c) After a CT scan has ruled out a space-occupying lesion, a lumbar puncture is indicated next. The opening pressure is high.
d) Slit lamp examination is not useful in the diagnosis of benign intracranial hypertension.
e) An enlarged blind spot and peripheral constriction would be seen as this patient has papilloedema.
292
```
A 48 year old woman has had a dry cough and exertional dyspnoea for 4 weeks. She also has joint pain involving both knees, elbows and wrists. She has a 20 pack year smoking history but no other past medical history.She has been dieting recently and has lost 2 stone over the last 6 months. She has mildly tender, swollen knee and elbow joints with minimal effusion clinically. Chest, cardiovascular and abdominal examination are unremarkable. There are small palpable cervical lymph nodes. She has lesions on her lower limbs as shown below .
Her blood tests show:
Sodium 140
Potassium 3.6
Urea 3.8
Creatinine 60
Hb 12.8
WCC 9.4
Platelets 285
Neutrophils 4.4
corrected calcium 2.65
Chest X ray is pending
Which is the single most likely diagnosis?
 A. COPD 
 B. Metastatic lung cancer 
 C. Primary hyperparathyroidism 
 D. Rheumatoid arthritis 
 E. Sarcoidosis 
```
Answer: E (Level - Moderate)
A. Patient is a smoker and complaining of exertional dyspnoea but this does not explain the elevated calcium or joint involvement. There is no mention of wheeze with a clear chest.
B. This is a possibility in view of the respiratory symptoms and smoking history but the weight loss is intentional and so less helpful. It mentions symmetrical joint pain, not bone pain and although this does not rule out metastatic bone disease it is more suggestive of polyarthritis.
C. This would present with hypercalcaemia but would not explain the respiratory symptoms
D. RA can have many presentations and is a multisystem disorder but is not associated with hypercalcaemia
E. The picture shows tender red lesions on the shins i.e. erythema nodosum. The dry cough, joint pain, lymphadenopathy, hypercalcaemia and most specifically erythema nodosum all point to a diagnosis of sarcoidosis. Chest x ray is likely to show bilateral hilar lymphadenopathy. Additional investigations may include checking serum angtionesin-converting enzyme levels (serum ACE). Sarcoidosis can affect multiple systems including skin (EN, lupus pernio), Nervous (CN VII Palsy), Ocular (uveitis, sicca, conjunctivitis), Musculoskeletal (polyarthritis, myositis) and cardiac (CHB, arrhythmias) to name a few. Sarcoidosis is generally treated with steroids depending on the severity of symptoms although individual symptoms may require specific treatment (e.g. symptomatic hypercalcaemia).
293
```
A 22 year old man is in an unexplained coma. His blood results show
Sodium 140 mmol/L
Potassium 5mmol/L
Chloride 100mmol/L
HCO3 5 mmol/L
urea 8mmol/L
arterial pH 7.0
glucose is 30mmol/L
Which single value is his anion gap?
Choose one answer.
20
30
```
40
Anion Gap = [Na+ + K+] - [Cl- + HCO3-] . The anion gap is used to assess the contribution of unmeasured anions in contributing to acidosis. The normal range is 6-16. Unmeasured anions include lactate, ketones, methanol, ethylene glycol, tricyclic antidepressants. A high anion gap results when there is exogenous ingestion of acids or inability to excrete acids. Causes of an increased anion gap include: lactic acidosis, diabetic ketoacidosis, methanol or ethylene glycol poisoning, salicylate poisoning.
294
```
A 38 yr old woman has a firm lump in her right breast. She took the oral contraceptive pill for 4 years in her 20’s and has regular periods.
Which single investigation is of most diagnostic value?
Choose one answer.
 A. Chest X-ray 
 B. CT breast 
 C. FNA of breast lump 
 D. Mammogram 
 E. Ultrasound breast 
```
c
Triple assessment of a breast lump consists of clinical assessment, imaging and biopsy. Imaging of the breast depends on the age of the patient-in younger patients (
295
A 44 year old woman has had a right sided breast lump for 2 months. She has been on HRT since the age of 41 and is concerned as her sister recently died of breast cancer aged 56. She had three children all before the age of 30. Other than a previous alcohol dependency she has no other medical history of note.
Which is the single most accurate statement?
 A. Alcohol consumption has NO relationship with breast cancer 
 B. As she is on HRT her chances of developing breast cancer have lessened 
 C. Having one sister with breast cancer has doubled her risk of developing breast cancer 
 D. Having three children before the age of 30 has increased her risk of developing breast cancer 
 E. Menarche at the age of 12 and menopause at the age of 40 are BOTH risk factors for developing breast cancer. 
A. There is a definite proven link between Breast cancer and alcohol consumption. It may not be a ‘strong’ risk factor but a relationship definitely exists. However there has been no proven association between cigarette smoking and breast cancer.
B. HRT increases the risk of breast cancer by about 2% each year of use. Oestrogen-progesterone combination has a higher risk than oestrogen alone. The oral contraceptive pill also slightly increases the risk in current and past users.
C. This question highlights the importance of taking a thorough family history when assessing for breast cancer. A woman with one affected first degree relative (mother or sister) has approximately double the risk of breast cancer of a woman with no family history of the disease (although 85% of women in this situation never develop breast cancer). When multiple family members affected consider BRCA1/2 gene.
D. Having three children at a young age has lowered her risk of developing breast cancer. The greater the number of children (parity) the greater the protection. There are many reproductive factors that influence breast cancer risk as listed below.
E. An early age of menarche (in this case 12) is associated with an increased risk of breast cancer. However her early age of menopause has decreased her risk i.e. the fewer the menstrual cycles the less risk there is of breast cancer.
Other risk factors:
Protective
Age at first birth -younger the age the more protection
Breast feeding
Increased risk
High BMI/obesity – moderately increases the risk of developing breast cancer in post menopausal women.
High fat diet
Ionising radiation – the younger the age of expose the higher the risk (do not order unnecessary X-Rays/CT!!!!!)
Social status – recognised higher risk amongst the more affluent social class
Personal history of breast cancer – increases risk 2-6 times
296
A new blood test has been developed to detect condition X. It was tested on 200 people. 120 people tested positive for X and 95 actually had the condition. 5 people tested negative for the condition but were actually found to have the condition. The remainder who tested negative were found not to have the condition
Which single value is the specificity of the test?
 a. 5% 
 b. 25% 
 c. 75% 
 d. 80% 
 e. 95% 
```
Answer C - Level - Moderate
For this type of question it may be easier to tabulate the information
Condition +ve Condition –ve Total
Test +ve 95 (a) 25 (b) 120
Test –ve 5 (c) 75 (d) 80
Total 100 100
Specificity is calculated as
true negatives / Total number of patients without the condition
OR
d / (b+d)
Multiple by 100 to get the percentage
75/100 = 75%
```
297
A 40 year old man with hypertension is brought to the Emergency department with a severe headache and a painful left eye, shown below in the picture. (dilated pupil, eye down and out and ptosis)
Which is the single most likely cause of his symptoms?
 a. Diabetic mononeuropathy 
 b. Cavernous sinus thrombosis 
 c. Migraine 
 d. Posterior communicating artery aneurysm 
 e. Weber's syndrome 
Answer: d (Level = Difficulty)
The picture shows a dilated left pupil with is “down and out” and ptosis i.e. a complete third nerve palsy.
a) 3rd nerve palsy ( + Sparing of pupil) = Diabetes/ SLE
b) 3rd, 4th, 5th & 6th nerve palsy = Cavernous Sinus Thrombosis
c) Migranes can cause severe headaches and transient neurological problems such as hemiparesis.
d) Painful 3rd nerve palsy + Dilated pupil =PCA Aneurysm
e) 3rd nerve palsy + Contralateral hemiparesis =Weber’s syndrome (Midbrain infarct)
298
A 41 year old Turkish man has a DVT. He has also had arthritis and diarrhoea for the past few weeks. He has four painless punched-out ulcers on his scrotum and a picture of his mouth is shown below (multiple ulcers). The following day he shows you a papule which has developed overnight at the site of his heparin injection.
What is the single most likely diagnosis?
 a. Behcet's disease 
 b. Crohn's disease 
 c. Reiter's disease 
 d. Systemic Lupus Erythematosus 
 e. Syphilis 
a) Behcet’s is a multisystem vasculitic disease common in Turkish & Japanese populations. It is characterised by the triad of;
1) Oral Ulcers 2) Genital Ulcers 3) Uveitis
The picture above shows multiple oral ulcers. Arthritis and Thrombosis also occur.
The pathergy reaction (skin injury leading to the formation of a papule/pustule within 1-2 days) is highly specific for Behcets disease.
b) Genital Ulcers are not specifically found in SLE or crohn’s disease.
c) Reiter’s syndrome is characterised by the triad of:
1) Urethritis 2) Arthritis 3) Conjunctivitis
d) Genital Ulcers are not specifically found in SLE or crohn’s disease.
e) In syphilis, there is usually a single painless ulcer on the penis called a chancre.
299
A 26 year old man has been hit by a car travelling at 45mph while on his motorcycle and has sustained multiple injuries. He is alert and talking, and is on a spinal board with full neck immobilisation. He has an open femoral fracture that is bleeding profusely. His pulse rate is 160bpm, BP 90/40mmHg, sats 98% on 12L oxygen. Which is the single most appropriate initial action?
Choose one answer.
 a. Obtain IV access using 2 wide bore cannulae in the antecubital fossae 
 b. Listen to the patient’s chest 
 c. Direct pressure on the site of bleeding 
 d. Urgent spot haemoglobin check 
 e. Check the Glasgow Coma Score 
Answer – B - Level Easy
Any SBA question that asks what you should do first should be treated with caution. There would normally be several people around in A&E to deal with this major trauma, and several things would be done simultaneously. However, you must understand how to do things in the correct order – in this case ABCDE, as per the ATLS guidelines which is briefly described below.
A – he’s talking so his airway is clear, however, you still need to make an assessment of the airway to avoid problems later. It’s not an option here though.
B – In polytrauma there’s a clear risk of pneumothorax. Tension pneumothorax can kill rapidly, and even though the patient is saturating well currently, he is on high flow oxygen. Look and feel for expansion and any injuries, listen for air entry, percuss to check for hyperresonance or dullness.
C – This guy has hypovolaemic shock. He needs rapid fluid resuscitation and you need to stop the blood loss. You know he’s bleeding from the femur, and splintage and direct pressure will help with this. However, don’t assume this is the only source of bleeding. A patient can lose their entire circulating volume into the pelvis if it is fractured, and there’s every chance he has visceral damage as well. This is when you can get cannulae in and send bloods off (check Hb, G+S etc).
D – You can worry about GCS when you’ve sorted out the above. Disability is also a good time to remember to check the blood glucose level.
E – Full exposure is absolutely essential. Without it you might miss bruising that could alert you to an intra-abdominal trauma, or an overt source of bleeding that you hadn’t seen because the patient’s clothes are apparently soaked from another wound.
300
Which single condition would be consistent with a low plasma calcium, low phosphate and high alkaline phosphatase?
Choose one answer.
 A. Osteomalacia 
 B. Osteoporosis 
 C. Paget's disease of the bone 
 D. Primary hyperparathyroidism 
 E. Secondary malignant deposits in bone. 
Osteomalacia
Difficulty level: Moderate
Explanation:
Osteomalacia= Low plasma calcium (50%), low phosphate (75%), high ALP (95%). It is the inadequate mineralization of osteoid caused by vitamin D deficiency or defective metabolism. The body responds to a low calcium by producing more PTH which stimulates renal phosphorous loss. The childhood equivalent is rickets.
Osteoporosis= normal bone biochemistry (unless there is a secondary cause for osteoporosis).
Paget’s disease of the bone= High/normal plasma calcium and phosphate, high ALP. Caused by increased osteoclast and osteoblast activity resulting in sclerotic changes. Hypercalcaemia is evident when there is immobilisation.
Primary hyperparathyroidism= High plasma calcium, low phosphate and high ALP. This is caused by parathyroid adenomas or hyperplasia resulting in an increased PTH. PTH acts to raise serum calcium (by renal and osteoclastic reabsorption) and increase renal phosphate excretion.
Secondary malignant bone deposits= high/normal plasma calcium, phosphate and high ALP
301
A 24 year old Afro-Caribbean woman has had painful joints, a dry cough and fever for one month.
She has tenderness of her knee and ankle joints and a painfulr rash on her shins.
Her chest x ray is shown below.
What is the single most likely diagnosis?
 a. Lymphoma 
 b. Tuberculosis 
 c. Sarcoidosis 
 d. Systemic Lupus Erythematosis 
 e. Rheumatoid arthritis 
sarcoidosis
The chest xray shows bilateral hilar lymphadenopathy and the rash described is erythema nodosum. This combination is known as Lofgren’s syndrome (an acute subtype of sarcoidosis) which has a good prognosis as it may spontaneously remit within 6 months to 2 years.
Differential diagnosis of Bilateral hilar lymphadenopathy includes:
1) TB
2) Sarcoidosis
3) Lymphoma
302
A 56 year old man has had type 2 diabetes for twenty years. During routine screening he is noted to have changes consistent with pre-proliferative diabetic retinopathy. Which single statement is not true of diabetic eye disease?
Choose one answer.
 a. Cataracts occurs earlier in patients with diabetes 
 b. Cotton wool spots are characteristic 
 c. Haemorrhages are characteristic 
 d. Patients should be routinely screened every year 
 e. Tortuous arteries with thick shiny walls (silver wiring) are characteristic 
E
Diabetic retinopathy
Diabetic retinopathy is the single largest cause of blindness before old age with a progressive incidence in people with type 2 diabetes and type 1 diabetes. NICE guidelines state that eye screening should occur at or around the time of diagnosis and eye surveillance should then take place annually.
Characteristic changes of diabetic retinopathy include microaneurysms, haemorrhages, exudates, cotton wool spots (infarcts).
Diabetics are also more likely to get early onset cataracts.
Silver wiring is characteristic of hypertensive eye disease so answer (e) is correct.
303
```
A 25 year old woman has a DVT. Previously she has attended the dental clinic for recurrent mouth ulcers and on systemic review informs you of recent ulcers around the genitals. She is in a stable sexual relationship. The nurse informs you that after phlebotomy there was bleeding into the skin. Her coagulation screen is normal.
What is the single most likely diagnosis?
Choose one answer.
 A. Bechet's disease 
 B. Crohn's disease 
 C. Over anticoagulated 
 D. SLE 
 E. Syphilis 
```
Correct response: A Behcet’s
Question category: Rheumatology
Difficulty level:Easy
Explanation: This lady has Behcet’s syndrome, a vasculitis and venulitis that is most commonly found in Mediterranean populations and has an HLA-B5 linkage. It has an equal sex incidence but more severely affects males. Clinical features include: oral and genital ulceration, iritis, thrombophlebitis, pathergy reaction- red papules at the site of pin pricks, erythema nodosum and arthritis. Crohn’s disease causes oral ulceration but not genital ulceration.
304
A 62 year old man has a TURP, and his post-operative full blood count shows Hb 7.5 g/dL, WBC 8.2 x 109/L, platelets 387 x 109/L. A 2 unit transfusion of red cells is requested. His blood group is AB Rhesus D negative, his antibody screen is positive, and an anti-Jka antibody is identified.
Which is the single most appropriate blood type to give him?
Choose one answer.
 a. AB Rhesus D negative Jka positive 
 b. A Rhesus D negative Jka negative 
 c. O Rhesus D negative Jka positive 
 d. O Rhesus D positive Jka negative 
 e. O Rhesus D positive Jka positive  Answer B
A, C, E) Note, only red cells are being transfused, not plasma. As this patient has anti-Jka antibodies, a JKA antigen on red cells can cause an immediate transfusion reaction, hence the cells transfused must be Jka negative.
B) This patient is blood group AB, which means that he has A and B antigens on his red blood cells but no antibodies present in his serum. Hence as red cells are being transfused, not plasma, he can receive any type of ABO red cells.
D, E) This patient has a Rhesus D negative blood group. Rhesus D antigen is immunogenic, hence there is an 80% probability that this man will make Anti-RhD when exposed to the RhD antigen in the transfused blood cells, causing a haemolytic reaction.
305
```
Markers of neoplastic diseases (tumour markers)
A Alpha feto protein
B CA 125
C CA 199
D Calcitonin
E Carcino embryonic antigen
F 5 hydroxy indole acetic acid
G Monoclonal light chains
H Noradrenaline
I Parathyroid hormone related peptide
J Prostatic specific antigen
```
For each of the following circumstances, select the most appropriate
marker.
- After AL amyloidosis has been diagnosed in a renal biopsy.
Monoclonal light chains
AL amyloidosis = Amyloid light-chain amyloidosis
The disease is caused when a person's antibody-producing cells do not function properly and produce abnormal protein fibers made of components of antibodies called light chains. These light chains come together to form amyloid deposits in different organs which can cause serious damage to these organs. Abnormal light chains in blood and urine are sometimes referred to as "Bence Jones protein".
306
```
Markers of neoplastic diseases (tumour markers)
A Alpha feto protein
B CA 125
C CA 199
D Calcitonin
E Carcino embryonic antigen
F 5 hydroxy indole acetic acid
G Monoclonal light chains
H Noradrenaline
I Parathyroid hormone related peptide
J Prostatic specific antigen
For each of the following circumstances, select the most appropriate
marker.
```
When testicular teratoma is suspected.
Alpha feto protein
Some teratomas contain yolk sac elements, which secrete alpha-fetoprotein (AFP). Detection of AFP may help to confirm the diagnosis and is often used as a marker for recurrence or treatment efficacy, but is rarely the method of initial diagnosis.
307
```
Markers of neoplastic diseases (tumour markers)
A Alpha feto protein
B CA 125
C CA 199
D Calcitonin
E Carcino embryonic antigen
F 5 hydroxy indole acetic acid
G Monoclonal light chains
H Noradrenaline
I Parathyroid hormone related peptide
J Prostatic specific antigen
For each of the following circumstances, select the most appropriate
marker.
```
In someone with neuroendocrine carcinoma of ileum.
5 hydroxy indole acetic acid
Since 5-HIAA is a metabolite of serotonin, testing is most frequently performed for the diagnosis of carcinoid tumors of the enterochromaffin (Kultschitzsky) cells of the small intestine, which release large amounts of serotonin.
308
```
Markers of neoplastic diseases (tumour markers)
A Alpha feto protein
B CA 125
C CA 199
D Calcitonin
E Carcino embryonic antigen
F 5 hydroxy indole acetic acid
G Monoclonal light chains
H Noradrenaline
I Parathyroid hormone related peptide
J Prostatic specific antigen
For each of the following circumstances, select the most appropriate
marker.
```
When a cirrhotic patient has a single large mass in the liver.
Alpha feto protein
Hepatocellular carcinoma: alpha-fetoprotein (AFP) levels are abnormal in 80% of patients and exceed 1,000 ng/ml in 40% of affected patients.[1] The level may drop to normal after surgical resection.
309
```
Markers of neoplastic diseases (tumour markers)
A Alpha feto protein
B CA 125
C CA 199
D Calcitonin
E Carcino embryonic antigen
F 5 hydroxy indole acetic acid
G Monoclonal light chains
H Noradrenaline
I Parathyroid hormone related peptide
J Prostatic specific antigen
For each of the following circumstances, select the most appropriate
marker.
```
A possible screening test in the general population.
prostatic specific antigen
| for prostate cancer
310
```
Electrolyte imbalance
A Hypercalcaemia
B Hyperchloraemia
C Hyperkalaemia
D Hypernatraemia
E Hypocalcaemia
F Hypokalemia
G Hypomagnesaemia
H Hyponatraemia
I Metabolic acidosis
J Metabolic alkalosis
For each of the following scenarios, select the most appropriate
metabolic abnormality that you would expect to see.
```
A 37 year old man with acute renal failure and tented Twaves on the ECG.
Hyperkalaemia
tented T waves!
311
```
Electrolyte imbalance
A Hypercalcaemia
B Hyperchloraemia
C Hyperkalaemia
D Hypernatraemia
E Hypocalcaemia
F Hypokalemia
G Hypomagnesaemia
H Hyponatraemia
I Metabolic acidosis
J Metabolic alkalosis
For each of the following scenarios, select the most appropriate
metabolic abnormality that you would expect to see.
```
A 29 year old woman who complains of pins and needles in her hands after a subtotal thyroidectomy for thyrotoxicosis.
Hypocalcaemia
In case parathyroid
312
```
Electrolyte imbalance
A Hypercalcaemia
B Hyperchloraemia
C Hyperkalaemia
D Hypernatraemia
E Hypocalcaemia
F Hypokalemia
G Hypomagnesaemia
H Hyponatraemia
I Metabolic acidosis
J Metabolic alkalosis
For each of the following scenarios, select the most appropriate
metabolic abnormality that you would expect to see.
```
A 76 year old man with lung cancer who presents with confusion, and joint and abdominal pain.
Hypercalcaemia
Hypercalcemia (high blood calcium levels).
Overstimulated parathyroid glands or cytokines
released by the tumor such as tumor necrosis
factor, interleukin-1, transforming growth factor
alpha, and some prostaglandins might recruit too
much calcium from bone into the blood. Another
possible cause of hypercalcemia is invasion of
bone by a tumor.
313
```
Electrolyte imbalance
A Hypercalcaemia
B Hyperchloraemia
C Hyperkalaemia
D Hypernatraemia
E Hypocalcaemia
F Hypokalemia
G Hypomagnesaemia
H Hyponatraemia
I Metabolic acidosis
J Metabolic alkalosis
For each of the following scenarios, select the most appropriate metabolic abnormality that you would expect to see.
```
A 66 year old woman who presents with sepsis secondary to a urinary tract infection. She is severely water depleted but has a normal plasma bicarbonate.
hyponatraemia - worry about in severe volume depletion
314
```
Electrolyte imbalance
A Hypercalcaemia
B Hyperchloraemia
C Hyperkalaemia
D Hypernatraemia
E Hypocalcaemia
F Hypokalemia
G Hypomagnesaemia
H Hyponatraemia
I Metabolic acidosis
J Metabolic alkalosis
For each of the following scenarios, select the most appropriate
metabolic abnormality that you would expect to see.
```
A 17 year old woman with anorexia nervosa who admits to purgative abuse.
hypokalaemia
dehydration and hypokalaemia occur in cases of severe vomiting
