Formative 3

Question 1

A 18 year old woman has 6 hours of severe dizziness and nausea. She says that the room is constantly spinning round and she has vomited several times. The dizziness is worse when she opens her eyes. She reports that her hearing has not changed.
She has nystagmus with the fast phase to the left, which does not fatigue.

Which is the most likely diagnosis?
A. Benign positional vertigo
B. Cerebellar tumour
C. Ménière’s disease
D. Vestibular migraine
E. Vestibular neuronitis

Answer 1

E. Vestibular neuronitis

The most likely diagnosis is vestibular neuronitis as this is a single episode in an 18-year-old. The diagnoses of vestibular migraine and benign positional vertigo would not be considered unless the attacks were recurrent.

Question 2

A 91 year old woman is admitted from a nursing home with a 3 day history of vomiting and diarrhoea.
Her pulse rate is 110 bpm. Her BP is 116/66 mmHg lying in bed, with a postural BP drop of 30 mmHg when sitting.
Investigations:
Sodium 130 mmol/L (135–146)
Potassium 4.0 mmol/L (3.5–5.3)
Bicarbonate 20 mmol/L (22–29)
Urea 25.6 mmol/L (2.5–7.8)
Creatinine 177 μmol/L (60-120)

Which is the most appropriate initial intravenous fluid?
A. 0.9% sodium chloride
B. 1.4% sodium bicarbonate
C. 1.8% sodium chloride
D. 4% glucose, 0.18% sodium chloride
E. 5% glucose

Answer 2

A. 0.9% sodium chloride

If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130 to 154 mmol/l, with a bolus of 500 ml over less than 15 minutes (NICE CG174)

https://www.nice.org.uk/guidance/cg174/resources/composition-of-commonly-used-crystalloids-table-191662813

Question 3

A 28 year old woman returns to the dermatology clinic 2 weeks after surgery to excise a 1.1 cm pigmented lesion on her right lower leg.
The histopathological report states that the lesion is a superficial spreading melanoma with a Clark level 3, Breslow depth 0.9 mm, mitotic index of 1/mm2and no ulceration. It has been completely excised.

Which feature provides the most important pathological prognostic indicator?
A. Breslow depth
B. Clark level
C. Diameter of lesion
D. Melanoma subtype
E. Mitotic index

Answer 3

A. Breslow depth

A complete full-thickness excisional biopsy of suspicious lesions with 1 to 3 mm margin of normal skin and part of the subcutaneous fat should be performed. Tumour thickness is the single most important prognostic factor for patients with localised melanoma. This is measured as the Breslow depth or thickness.

Question 4

An 88 year old woman has recurrent falls. She says that she cannot feel where her feet are.
There is reduced pinprick sensation up to the level of her mid calf and joint position sense is impaired in the feet. Knee reflexes are brisk, but ankle reflexes are absent.
Investigations:
Haemoglobin 91g/L (115–150)
White cell count 3.5 × 109/L (3.8–10.0)
Platelets 130 × 109/L (150–400)
MCV 116fL (80–96)

Which is the most likely deficiency?
A. Folate
B. Iron
C. Pyridoxine
D. Thiamine
E. Vitamin B 12

Answer 4

E. Vitamin B 12

This is a typical presentation of B12 deficiency. The most common neurologic findings are symmetric paraesthesias or numbness and gait problems. This is much less common with folate deficiency.

Question 5

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

Answer 5

E. Right temporal lobe

He has focal onset impaired awareness seizures, the aura implicates one of the temporal lobes. In the seizure itself he waves his left arm, suggesting spread to the right frontal lobe (though the origin is elsewhere).

Question 6

A 75 year old man visits his GP with one episode of visible haematuria.
His temperature is 36.2°C and BP 142/80 mmHg. Urinalysis shows blood 2+, leucocytes negative, protein negative, nitrite negative.

Investigations:
Midstream urine: red blood cells and epithelial cells, no microbial growth

Which is the most appropriate next step?
A. Arrange an ultrasound scan of renal tract
B. Arrange CT urography
C. Check serum prostate specific antigen
D. Refer for urology opinion
E. Repeat midstream urine sample for culture and sensitivity

Answer 6

D. Refer for urology opinion

This is because the patient may have transitional cell carcinoma of the bladder and thorough investigation of haematuria is urgent to rule this out.

Question 7

A 53 year old woman has 6 months of worsening tiredness.
She has jaundice, xanthelasma and 7 cm non-tender hepatomegaly.
Investigations:
INR 1.2 (1.0)
ALT 60 IU/L (10–50)
ALP 302 IU/L (25–115)
Bilirubin 50 μmol/L (<17)
Antinuclear antibodies 1:40 (negative at 1:20)
Antimitochondrial antibodies 1:320 (negative at 1:20)
Ultrasound scan of abdomen hepatosplenomegaly, no biliary dilatation

Which is the most appropriate treatment?
A. Azathioprine
B. Lamivudine
C. Prednisolone
D. Thiamine
E. Ursodeoxycholic acid

Answer 7

E. Ursodeoxycholic acid

The clinical picture fits a diagnosis of primary biliary cirrhosis (raised ALP, AMA positive with no evidence of obstruction.

There is good evidence that Ursodeoxycholic acid should be prescribed for all patients with this diagnosis. A biopsy is not required to make the diagnosis.

Question 8

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

Answer 8

C. Lumbar spinal stenosis

This patient gives a typical history of neurogenic claudication coming on with walking and better leaning forwards (including when riding a bike).

Question 9

A 17 year old girl has a florid skin rash for 24 hours. She has been feeling unwell for the past week with intermittent abdominal pain.
She has a palpable, purpuric rash on her lower limbs and buttocks. Her temperature is 37.2°C, pulse rate 70 bpm and BP 122/80 mmHg. Her urinalysis has blood 3+, protein 2+, nitrites negative, leucocytes negative.
Investigations:
Haemoglobin 122 g/L (115–150)
White cell count 8.9 × 10^9/L (3.8–10.0)
Platelets 320 × 10^9/L (150–400)
Urea 3.2 mmol/L (2.5–7.8)
Creatinine 60 μmol/L (60–120)

Which is the most likely diagnosis?
A. IgA vasculitis (Henoch–Schönlein purpura)
B. Meningococcal septicaemia
C. Microscopic polyangiitis
D. Postinfectious glomerulonephritis
E. Systemic lupus erythematosus

Answer 9

A. IgA vasculitis (Henoch–Schönlein purpura)

Classic presentation of HSP with a purpuric (vasculitic) rash and an active urinary sediment. Abdominal and joint pain may also occur. Renal function is usually normal. With meningococcal sepsis the patient would be much more unwell. Postinfectious GN would follow a clear- cut infection, particularly streptococcal sore throat. SLE would normally have a longer history, does not typically give a vasculitis rash and would be associated with other features of SLE e.g. alopecia, arthralgia, skin rash, cytopenias, mouth ulcers. Microscopic polyangiitis (ANCA associated normally) is less common in this age group and usually has a longer history.

Question 10

A 54 year old woman has reduced urine output 24 hours after admission with right lower lobe consolidation due to community-acquired pneumonia. She has been treated with intravenous amoxicillin and clarithromycin, but remains breathless. Her creatinine was 82 μmol/L (60–120) on admission.
Her temperature is 38.0°C, pulse rate 106 bpm, BP 102/50 mmHg and oxygen saturation 95% breathing 4 L/min oxygen via nasal prongs. Her urine output is 250 mL over the past 12 hours. Her urinalysis has protein 1+.
Investigations:
Haemoglobin 119 g/L (115–150)
White cell count 16.9 × 10^9/L (3.8–10.0)
Platelets 95 × 109/L (150–400)
Urea 15.5 mmol/L (2.5–7.8)
Creatinine 160 μmol/ (60–120)

Which is the most likely cause of her acute kidney injury?
A. Drug-induced interstitial nephritis
B. Haemolytic uraemic syndrome
C. Infection-related glomerulonephritis
D. Renal hypoperfusion
E. Systemic vasculitis

Answer 10

D. Renal hypoperfusion

The patient has ongoing sepsis with hypotension which is leading to pre-renal AKI. This clinical pattern may ultimately lead to acute tubular necrosis/tubular injury. None of the other diagnoses fit the clinical picture. Interstitial nephritis would normally not appear until 4-7 days of antibiotic exposure and is relatively rare. Infection related glomerulonephritis is uncommon with pneumonia and there is no evidence of non-visible haematuria. The same applies to systemic vasculitis. Haemolytic uraemic syndrome would have a different clinical picture with marked anaemia and a lower platelet count.

Question 11

A 53 year old man has increasing abdominal swelling over several weeks, with severe abdominal pain developing over the past 12 hours. He drinks one to two bottles of vodka per day.
He has jaundice, and has spider naevi and prominent veins on his abdominal wall. His temperature is 37.6°C. His abdomen is diffusely tender.
Investigations:
Haemoglobin 136 g/ (130–175)
White cell count 9.6 × 10^9/L (3.8–10.0)
Platelets 160 × 10^9/L (150–400)
INR 1.2 (1.0)
ALT 350 IU/L (10–50)
AST 140 IU/L (25–115)
Bilirubin 78 umol/L (<17)

Ultrasound scan of abdomen shows ascites with mild hepatosplenomegaly.

Which is the most appropriate next step?
A. Ascitic tap
B. CT scan of abdomen
C. Hepatitis serology
D. Percutaneous liver biopsy
E. Ultrasound scan of abdomen

Answer 11

A. Ascitic tap

Spontaneous bacterial peritonitis (SBP) should be suspected in patients with ascites due to cirrhosis who develop symptoms such as fever, abdominal pain or tenderness, and confusion. The signs and symptoms are more subtle compared with those seen in patients with standard bacterial peritonitis. It is important not to miss SBP as delayed recognition is associated with a high mortality.

Question 12

A 70 year old woman has an ulcer above the left medial malleolus. She has a history of type 2 diabetes mellitus. She smokes 10 cigarettes per day.
Her BMI is 34. The ulcer is 10 × 5 cm and superficial. She has brown discolouration of both lower legs. The skin has a thickened, waxy feel.

Which ulcer type is the most likely?
A. Arterial
B. Inflammatory
C. Malignant
D. Neuropathic
E. Venous

Answer 12

E. Venous

The site and presence of hyperpigmentation or lipodermatosclerosis are suggestive of venous ulceration. The classic location for these is by medial or lateral malleolus and they are not associated with significant pain.

Question 13

A 60 year old woman is found drowsy and confused. She has been unwell for 2–3 days with diarrhoea and vomiting. She has a history of bipolar disorder. Her regular medication includes lithium, risperidone and co-codamol.
Her temperature is 37.3°C, pulse rate 94 bpm, BP 122/70 mmHg, respiratory rate 14 breaths per minute and oxygen saturation 99% breathing high-flow oxygen. Her GCS score is 12/15. She has coarse tremor in her arms and jerking movements of her legs.

Which is the most likely diagnosis?
A. Hypernatraemia
B. Lithium toxicity
C. Neuroleptic malignant syndrome
D. Opioid toxicity
E. Subdural haematoma

Answer 13

B. Lithium toxicity

The patient displays classic features of lithium toxicity (confusion, coarse tremor, jerking leg movements), likely precipitated by dehydration secondary to diarrhoea and vomiting.

Question 14

A 73 year old man has 3 months of increasing weakness of his right hand with reduced sensation of the forearm.
There is wasting of all the intrinsic muscles of the right hand. There is weakness of finger abduction and adduction, and thumb adduction. Finger flexion is normal. There is mild altered light touch sensation along the ulnar aspect of the forearm. The biceps, supinator and triceps reflexes are normal. The lower limbs and the left arm are normal.

Where is the most likely site of the lesion causing his symptoms?
A. Median nerve in the forearm
B. Median nerve in the wrist
C. Spinal cord C8 level
D. T1 nerve root
E. Ulnar nerve at the elbow

Answer 14

D. T1 nerve root

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

Question 15

An 18 year old man has 3 weeks of malaise, fever and headaches and 1 week of a sore throat.
He has large tonsils with exudate, a petechial rash on the palate, and axillary and inguinal lymphadenopathy. His temperature is 37.6°C, pulse rate 84 bpm, BP 120/82 mmHg and respiratory rate 12 breaths per minute.
Investigations:
White cell count 11.2 × 10^9/L (3.8–10.0)
Lymphocytes 5.5 × 10^9/L (1.1–3.3)
ALT 72 IU/L (10–50)
AST 45 IU/L (10–40)
Alkaline phosphatase 91 IU/L (25–115)
Bilirubin 16 μmol/L (<17)

Which is the most appropriate investigation to confirm the diagnosis?
A. Anti-streptolysin O titre
B. Blood cultures
C. Epstein–Barr virus serology
D. Hepatitis A serology
E. Throat swab

Answer 15

C. Epstein–Barr virus serology

This is a typical clinical picture of glandular fever in the usual age group. Epstein-Barr virus (EBV)-induced infectious mononucleosis (IM) should be suspected when a young adult complains of sore throat, fever, and malaise and also has lymphadenopathy and pharyngitis. The presence of palatal petechiae is also characteristic. Lymphocytosis is usually seen in the FBC. The diagnosis can be confirmed through EBV specific antibodies.

Question 16

A 67 year old woman becomes unwell whilst attending the diabetes foot clinic. She is anxious and noticeably tremulous as she drinks from her water bottle.
She is sweaty but apyrexial. Her pulse rate is 98 bpm, BP 128/76 mmHg and oxygen saturation 96% breathing air. Her capillary blood glucose is 2.1 mmol/L.

Which is the most appropriate next step in management?
A. Intramuscular glucagon
B. Intravenous 10% glucose
C. Intravenous 20% glucose
D. Oral glucose gel (GlucoGel ® )
E. Oral glucose tablets

Answer 16

E. Oral glucose tablets

She is alert enough to swallow so does not need to be given glucogel but the tablets. JBDS guidelines (March 2010).

Question 17

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

Which is the most likely diagnosis?
A. Cardiac tamponade
B. Fat embolism syndrome
C. Opiate toxicity
D. Pulmonary embolus
E. Subdural haematoma

Answer 17

B. Fat embolism syndrome

Classic presentation of fat emboli. Multiple fractures followed by early onset (within 24 hours) of hypoxia, dyspnea, and tachypnea are the most frequent findings. Neurologic manifestations range from the development of an acute confusional state and altered level of consciousness to seizures and focal deficits and usually follow respiratory symptoms. A petechial rash is the last component to appear and only appears in about a third of cases. Patients with PE may present in the same time frame (ie, 24 to 72 hours), but neurologic abnormalities are not explained by this.

Question 18

A 42 year old woman has a 3 month history of weight loss, insomnia, and palpitations. She has a fine resting tremor and bilateral proptosis.
Which is the most likely underlying pathological mechanism?
A. Antibody directed against the thyroid stimulating hormone receptor
B. Antibody directed against thyroid peroxidase
C. Autonomous activity of thyroid follicular cells
D. Destruction of thyroid cells by lymphocytes
E. Excess production of thyroid stimulating hormone

Answer 18

A. Antibody directed against the thyroid stimulating hormone receptor

The clinical picture fits with Grave’s; disease. It is caused by autoantibodies to the thyroid stimulating hormone receptor (a.k.a thyrotropin receptor antibody, TRAb) that activates the receptor, stimulating thyroid hormone synthesis and secretion and a goitre.

Question 19

A 68 year old man has eight weeks of back pain. It sometimes wakes him at night, and he is feeling increasingly tired. He has no history of back problems and has no history of recent trauma.
He has tenderness over L3 and L4 vertebrae.
Investigations:
Haemoglobin 137 g/L (130–175)
Erythrocyte sedimentation rate 55 mm/hr (< 20)
Creatinine 72 μmol/L (60–120)
Calcium 2.5 mmol/L (2.2–2.6)
Serum protein electrophoresis: no paraprotein

Which is the most appropriate next investigation?
A. CT scan abdomen and pelvis
B. DEXA scan
C. HLA-B27 antigen
D. Isotope bone scan
E. X-ray lumbar spine

Answer 19

E. X-ray lumbar spine

Being woken from sleep is a red flag symptom, as is the duration. At this age and with the persistence of symptoms, spinal tenderness and an elevated ESR it is reasonable to perform imaging. Plain X- rays are appropriate initially, although if negative an MR scan would be indicated.

Question 20

A 45 year old man with pain caused by cancer has been using opioids to control his pain very successfully. He is taking a regular dose of MST Continus® 60 mg 12-hourly orally. He has been using three breakthrough doses (oral morphine 20 mg) per day for the past week.

Which is the most appropriate opioid prescription?
A. Diamorphine 60 mg subcutaneously over 24 h by syringe driver
B. Morphine 90 mg subcutaneously over 24 h by syringe driver
C. MST Continus ® 60 mg 12-hourly and morphine 30 mg as required (up to 4- hourly) orally
D. MST Continus ® 90 mg 12-hourly and morphine 20 mg as required (up to 4- hourly) orally
E. MST Continus ® 90 mg 12-hourly and morphine 30 mg as required (up to 4- hourly) orally

Answer 20

E. MST Continus ® 90 mg 12-hourly and morphine 30 mg as required (up to 4- hourly) orally

The breakthrough dose should be one-sixth of the total daily dose. The current daily morphine dose is 180 mg, hence MST continus at 90 mg 12 hourly and the breakthrough at morphine 30 mg.

Question 21

A 62 year old man has 1 year of intermittent heartburn and difficulty in swallowing. An endoscopic biopsy of the oesophagus 5 cm above the anatomical gastro- oesophageal junction is reported as showing ‘columnar epithelium containing goblet cells and Paneth cells’.

Which is the most appropriate pathological description of the features noted?
A. Hyperplasia
B. Hypertrophy
C. Intestinal metaplasia
D. Intraepithelial neoplasia
E. Squamous metaplasia

Answer 21

C. Intestinal metaplasia

This is because the combination of goblet cells and Paneth cells is characteristic of (small) intestinal metaplasia.

Question 22

A67yearoldmanhas3weeksofworseningankleoedema.Hehasahistory of hypertension, treated with amlodipine. He is a lifelong heavy smoker and drinks 12 units of alcohol per week.
His BP is 125/85 mmHg and oxygen saturation 98% breathing air. His JVP is 4 cm above the sternal angle. He has marked bilateral pitting ankle oedema. He has dull percussion note at both bases with reduced breath sounds.
Investigations:
Creatinine 85 μmol/L (60–120)
Fasting glucose 5.7 mmol/L (3.0–6.0)
Total cholesterol 9 mmol/L (<5.0)
Albumin 15 g/L (35–50)
Urinary protein:creatinine ratio 568 mg/mmol (<30)
Urine microscopy: no cells, no casts

Which is the most likely diagnosis?
A. Cardiac failure
B. Nephritic syndrome
C. Nephrotic syndrome
D. Rapidly progressive glomerulonephritis
E. Renovascular disease

Answer 22

C. Nephrotic syndrome

The combination of hypoalbuminaemia, proteinuria, oedema, hypercholesterolaemia etc. is characteristic of nephrotic syndrome. The most likely causes in the age group (without diabetes) would be membranous nephropathy, minimal change or FSGS. Myeloma would also need to be considered. A renal biopsy would be required to confirm the diagnosis

Question 23

A 46 year old man has a cardiac arrest in the Emergency Department after an episode of chest pain. He remains in ventricular fibrillation after three DC shocks, and he is treated with a bolus of intravenous adrenaline/epinephrine.

Which other drug treatment should be administered at the same time?
A. Alteplase
B. Amiodarone hydrochloride
C. Atropine sulfate
D. Lidocaine
E. Magnesium sulfate

Answer 23

B. Amiodarone hydrochloride

If VF/VT persists after a third shock, resume chest compressions immediately and then give adrenaline 1 mg IV and amiodarone 300 mg IV while performing a further 2 min CPR (as per ALS guidelines 2015)

Question 24

The association between low birth weight babies and maternal smoking during pregnancy is studied by obtaining smoking histories from women at the time of their first prenatal visit, then assessing birth weight at delivery and analysing according to the smoking histories.

Which is the best description of this type of study?
A. Case control
B. Case series
C. Clinical trial
D. Cross-sectional
E. Prospective cohort

Answer 24

E. Prospective cohort

A prospective cohort study is a longitudinal cohort study that follows over time a group of similar individuals (i.e. babies) who differ with respect to certain factors under study (i.e. maternal smoking history), to determine how these factors affect rates of a certain outcome (i.e. birth weight).

Question 25

A 42 year old woman has 12 hours of colicky central abdominal pain, vomiting, abdominal distension and increased bowel sounds. She had a ruptured appendix aged 20 years.

Plain abdominal X-ray: enlarged loops of small bowel

Which is the most appropriate initial management?
A. Flatus tube insertion
B. Intravenous antibiotics
C. Laparoscopy
D. Laparotomy
E. Nasogastric tube insertion

Answer 25

E. Nasogastric tube insertion

The patient has small bowel obstruction due to adhesions from her previous appendicitis. This is treated conservatively with fluid resuscitation and nasogastric decompression of the gut. The stomach contents should be aspirated using a syringe, following which the bag should be placed on free drainage. Further aspiration may be needed if required. Conservative management is successful in 65-80% of cases and surgical intervention is only considered for those patients who do not improve with conservative management. Surgically dividing adhesions creates further raw surfaces on which adhesions may form during the healing process and hence is avoided wherever possible. Intravenous antibiotics are not indicated in cases managed conservatively. Upper GI endoscopy has no role in the management of this case.

Question 26

A 46 year old woman attends the Emergency Department with fever, headache and confusion, which have developed over several hours. She finds it impossible to lift her head from the pillow and resists the doctor’s attempts to feel her neck.
Her temperature is 38.1°C, pulse rate 105 bpm and BP 110/60 mmHg. Her GCS score is 14.
A CT scan of her head is normal. A lumbar puncture is performed. Which are the most likely observations in the cerebrospinal fluid?

A. High pressure, normal protein, excess red cells
B. High pressure, raised protein, excess neutrophils
C. Normal pressure, normal protein, excess lymphocytes
D. Normal pressure, raised protein, excess neutrophils
E. Normal pressure, normal protein, no cells

Answer 26

B. High pressure, raised protein, excess neutrophils

This is because she has typical bacterial meningitis- fever, neck pain, confusion. A high pressure acute inflammatory exudate is typical.

Question 27

A 60 year old man visits his GP as he wants to start training for a 5 km race for charity. He plans to run 3 to 5 km three times per week. He describes occasional central chest tightness when he walks up hills. He has a history of type 2 diabetes mellitus and COPD for which he is taking metformin and using an as-required salbutamol inhaler.
His BP is 162/94 mmHg. His BMI is 32.

Which aspect of his clinical background is a contra-indication to his training plan?
A. BP >160/90 mmHg
B. COPD
C. Exertional chest tightness
D. Obesity
E. Type 2 diabetes mellitus

Answer 27

C. Exertional chest tightness

The presence of exertional chest pain indicates a high likelihood of undiagnosed ischaemic heart disease. Vigorous exercise runs the risk of a significant ischaemic event including a myocardial infarct or arrhythmia.

Question 28

A 38 year old man has a 3 month history of a cough with bloodstained sputum. A sputum analysis is positive for Mycobacterium tuberculosis. He is treated with quadruple antituberculous therapy. Two weeks later he reports that he is passing orange urine.
Which is the medication most likely to be responsible for his orange urine?
A. Ethambutol
B. Isoniazid
C. Pyrazinamide
D. Pyridoxine
E. Rifampicin

Answer 28

E. Rifampicin

Rifampicin typically causes an orange or red- orange discolouration of body fluids (including urine, sweat, saliva, and tears). The patient should be warned of this possibility.

Question 29

A 70 year old woman develops pyrexia and reduced oxygen saturation 2 days after an elective subtotal gastrectomy. Her postoperative pain control has been difficult, which has limited her ability to have chest physiotherapy and to mobilise.
Her temperature is 37.8°C, pulse rate 84 bpm and oxygen saturation 92% breathing 35% oxygen. Her BMI 36. There is reduced breath sounds at both lung bases. Her abdomen is soft, with tenderness around her wound. Her drain has serous output.
Which is the most likely postoperative complication?
A. Anastomotic leak
B. Atelectasis
C. Pneumothorax
D. Pulmonary embolism
E. Wound infection

Answer 29

B. Atelectasis

The development of a fever in the early postoperative period, in combination with reduced oxygen saturation, is most likely to be due to the development of bibasal atelectasis, especially in a patient who has undergone an abdominal procedure and is experiencing pain.

Question 30

A 30 year old man has 3 months of intermittent but worsening headaches. His only medications is paracetamol and ibuprofen as required. His BP is 220/130 mmHg.
Investigations:
Sodium 144 mmol/L (135–146)
Potassium 3.0 mmol/L (3.5–5.3)
Urea 7.0 mmol/L (2.5–7.8)
Creatinine 92 μmol/L (60–120)

Which is the most likely underlying diagnosis?
A. Addison’s disease
B. Chronic kidney disease
C. Cushing’s disease
D. Phaeochromocytoma
E. Primary aldosteronism (Conn’s syndrome)

Answer 30

E. Primary aldosteronism (Conn’s syndrome)

Conn’s is the commonest endocrine cause of hypertension and much more common than Cushings/Phaeo. The classic presenting signs of primary aldosteronism are hypertension and hypokalemia, although the later is not present in all cases. The diagnosis should also be considered in those with severe hypertension (>150/100 mmHg), hypertension with sleep apnoea and hypertension with a family history of early onset hypertension.

Question 31

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

Answer 31

B. It prevents the passage of gastric contents into the airway

Justification for correct answer(s): The cricoid cartilage is a complete ring; pressure on the front is transmitted to the back, and this seals the oesophagus, preventing gastric contents in a patient who is not fasted or has abdominal problems from passing higher up and possibly entering the airway. None of the others are true - in fact, it can make intubation more difficult.

Question 32

A 59 year old woman has loin pain and dysuria.
Her temperature is 39°C, pulse rate 108 bpm, BP 90/60 mmHg and
respiratory rate 18 breaths per minute.
Investigations:
Haemoglobin 130 g/L (115-150)
White cell count 22.0 × 10°L (3.8-10.0)
Platelets 40 × 109/L (150-400)
PT 20 seconds (10-12)
aРТТ 60 seconds (22-41)
Fibrinogen 1.0 g/dL (1.5-4.0)

Which is the most likely explanation for her thrombocytopenia?
A. Disseminated intravascular coagulation
B. Haemophilia B
C. Immune thrombocytopenic purpura
D. Vitamin B 12 deficiency
E. von Willebrand disease

Answer 32

A. Disseminated intravascular coagulation

The clotting abnormalities are consistent with acute DIC due to complicated urosepsis. typically patients have thrombocytopenia, prolonged PT and aPTT, low plasma fibrinogen and an elevated plasma D-dimer. There may also be microangiopathic abnormalities on the blood smear.

Question 33

A 65 year old man reports sudden onset of visual disturbance with flashing lights, floaters and loss of vision in the upper outer quadrant of his right eye. He has a history of hypertension but reports no previous visual disturbances.
Which is the most likely diagnosis?
A. Acute glaucoma
B. Central retinal artery occlusion
C. Central retinal vein occlusion
D. Retinal detachment
E. Vitreous haemorrhage

Answer 33

D. Retinal detachment

Patients with retinal detachment typically complain of an increasing number of floaters in one eye. As detachment progresses the separating vitreous will tug on the surface of the retina and create a mechanical depolarization of the axons running through the nerve fibre layer of the retina. This leads to flashing lights.

Question 34

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

Answer 34

E. Oxybutynin

Oxybutynin is an anticholinergic and a frequent cause of constipation.