Which of the following is NOT a cardiac feature of Marfan's syndrome?
(a) Aortic dissection
(b) Aortic regurgitation
(c) Mitral regurgiation
(d) Aortic aneurysm
(e) Mitral valve prolapse
The correct answer is (c) Mitral regurgitation.
The cardiac features of Marfan's syndrome are dilatation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm (d), aortic dissection (a) (leading cause of death), Aortic regurgitation (b) and mitral valve prolapse (e) (75%, murmur is a systolic click with late systolic murmur)
Which of the following is NOT an acceptable, normal ECG variant for an athlete?
(a) Sinus Bradycardia
(b) Junctional rhythm
(c) First degree heart block
(d) Second degree heart block, Mobitz I (Wenckebach)
(e) Second degree heart block, Mobitz II
The correct answer is (e) Second degree heart block, Mobitz II. All the other options are normal ECG variants found in athletes.
Which of the following would be consistent with a diagnosis of primary sclerosing cholangitis?
(a) Reversible with treatment of ursodeoxycholic acid
(b) Restriction of disease to intra-hepatic ducts
(c) Associated osteoporosis
(d) p-ANCA antibodies
(e) Presence of non-caseating granulomas on biopsy
The correct answer is (d) p-ANCA antibodies.
In terms of (a) treatment with ursodeoxycholic acid improves cholestasis only in PSC.
(b), (c) and (e) are all features of primary biliary cholangitis(PBC), not PSC. PSC involves intra and extra-hepatic ducts, the bile duct is destroyed by chronic granulomatous inflammation leading to cirrhosis, with fibrous, obliterative cholangitis seen on biopsy, strongly associated with p-ANCA autoantibodies. Conversely, PBC involves intrahepatic ducts only, chronic biliary obstruction leading to secondary biliary cirrhosis, with non-caseating granulomas seen on biopsy, strongly associated with anti-mitochondrial antibodies.
Which of the following is NOT a feature of Wilson's disease?
(a) Fanconi anaemia
(b) Basal ganglia degeneration
(e) Renal tubular acidosis
The correct answer is (a) Fanconi anaemia. Instead, Wilson's disease is associated with Faconi syndrome, a variant of renal tubular acidosis.
All other options are associated with Wilson's disease along with hepatitis, cirrhosis, speech and behavioural problems, asterixis and kayser-fleischer rings, haemolysis and blue nails.
Name two respiratory, cardiac and gastrointestinal causes of clubbing.
Respiratory causes are bronchial carcinoma, mesothelioma, empyema, bronchiectasis, cystic fibrosis, pulmonary fibrosis and TB.
Cardiac causes are infective endocarditis, atrial myxoma and congenital cyanotic heart disease.
GI causes are cirrhosis, crohn's disease, ulcerative colitis, coeliac and GI lymphoma.
Which of the following is a parathyroid hormone mediated cause of hypercalcaemia?
(a) Vitamin D toxicity
(b) Multiple endocrine neoplasia (type 1 and 2a)
(c) Milk alkali syndrome
(d) Hypercalcaemia of malignancy
The correct answer is (b) Multiple endocrine neoplasia (type 1 and 2a).
Causes of hypercalcaemia can be categorised into PTH mediated and PTH independent causes.
PTH mediated causes – Multiple endocrine neoplasia (type 1 and 2a)(b), familial isolated hyperparathyroidism and tertiary hyperparathyroidism.
PTH independent causes – Vit D intoxication(a), hypercalcaemia of malignancy(d), chronic granulomatous disorders (sarcoidosis(e), TB), drugs (thiazides, lithium, theophilline toxicity), others (immobilisation, milk alkali syndrome(c), parenteral nutrition)
Regarding herpes encephalitis, which of the following statements is correct?
(a) Haemorrhagic encephalitis of the temporal lobe is a rare presentation.
(b) If left untreated it can have a mortality rate as high as 25%
(c) Focal fits occur early in the disease process
(d) There is no treatment aside from supportive
(e) Brain biopsy is unhelpful in diagnosis
The correct answer is (c) Focal fits occur early in the disease process.
With regards to (a), haemorrhagic encephalitis of the temporal lobe is a common presentation. If left untreated it can have a mortality rate as high as 75%, not 25%(b) Treatment(d) is aciclovir, and if treated early it has shown great improvement in outcomes. Brain biopsy (e) is useful in getting a definite diagnosis.
Which of the following is best first-line management of stable chronic bronchiectasis or pulmonary fibrosis?
(a) Inhaled salbutamol
(b) Inhaled corticosteroid
(d) Air clearance physiotherapy
(e) Oral steroids
The correct answer is (d) air clearance physiotherapy.
Order the following five investigations of diagnosing asthma according to 1st line, second line and so on.
Exhaled Nitric Oxide
Spirometry with reversibility
The correct order is as follows:
Spirometry with reversibility - first line
Exhaled Nitric oxide - second line
PEFR - this and histamine challenge are roughly equal but due to ease and cost of PEFR diary I'd put this third.
HRCT - Not really an investigation you'd do to diagnose asthma.
If a patient experiences sensory loss in the dorsum of their great toe what dermotome is affected?
The correct answer is (b) L5
A 54 year old female patient comes to the GP complaining of long-term dysphagia with both solids and liquids, with a small amount of weight loss and reflux, especially at night. She feels especially unwell at the moment and on examination she has crackles at the right lung base.
What is the most likely cause of her symptoms?
(a) Hiatus hernia
(b) Post cricoid web
(e) Pharyngeal pouch
The correct answer is (d) Achalasia.
Achalasia is due to a degeneration of the myenteric plexus which leads to decreased peristalsis and a failure of the lower oesophageal sphincter to relax. It's usually idiopathic but can be secondary to oesophageal carcinoma or chagas disease.
Patients will usually have a longer history of intermittent dysphagia, characteristically for both solids and liquids from the onset. Regurgitation of food from their dilated oesphagus occurs, particularly at night and aspirational pneumonia is a common complication (what this lady has). Weight loss is not usually massive. Gives a classical "bird beak" appearance on barium swallow with a narrow stricture in the lower third of the oesophagus and dilatation proximally. Manometry shows failure of relaxation of the LOS and decreased peristalsis. CXR may show widened mediastinum. An OGD is required to exclude malignancy.
Mx is CCBs and nitrates, interventionally can be an endoscopic balloon dilatation or botulinum toxin injection, or surgically a Heller's cardiomyotomy (open or endo).
As for the other answers, both a hiatus hernia (a) and GORD (c) present with retrosternal burning chest pain worse on bending or lying flat, especially following a meal. Regurgitation of acid into the mouth may be observed (water brash). Usually relieved by OTC medication.
A post-cricoid web (b) is a thin membranous tissue flap covered with squamous epithelium which may produce dysphagia. Found in Plummer-Vinson syndrome when coupled with iron deficiency anaemia in women.
A pharyngeal pouch (e) (also known as a Zenker's diverticulum, who knew?) corresponds with weak areas called Killian's dehiscence, May be associated with a palpable lump on the left side of the neck. Food caught in the pouch may cause compression and subsequent dysphagia. May also complain of regurgitation, gurgling sounds or halitosis. Perforation is a risk factor with endoscopy. Can be associated with aspiration of food contents at night. Mx is excision or endoscopic stapling.
A 63 year old male comes to his GP complaining of being hard of hearing. The Rinne's test had bone conduction louder than air conduction on the left, and air conduction louder than bone conduction on the right. Weber's lateralised to the left.
What do these findings demonstrate?
(a) Normal hearing
(b) Left sided sensorineural hearing loss
(c) Left sided conductive hearing loss
(d) Right sided sensorineural hearing loss
(e) Right sided conductive hearing loss
The correct answer is (c) Left conductive hearing loss.
Just to recap (as I was not clear on this myself) these are the findings you'd expect to see for the following:
Normal hearing: Positive Rinne's with air conduction louder than bone conduction and Weber's does not lateralise.
Conductive hearing loss: Negative Rinne's with bone conduction louder than air conduction and Weber's lateralises to the affected ear (as in this case)
Sensorineural hearing loss: Positive Rinne's with air conduction louder than bone conduction and Weber's lateralises to the unaffected ear. So Rinne's would be positive in both ears, but if Weber's lateralised to the right ear, it indicates sensorineural hearing loss on the left.
54 year old woman presents with ascites and a right swollen leg, on a background of lethargy and recent weight loss. Where is the site of the malignancy in this woman?
The correct answer is (c) Ovarian.
Pelvic masses can cause localised compression of the large veins and subsequent oedema of a unilateral limb. Of the malignancies listed only ovarian cancer occupies the pelvis, and is also commonly associated with ascites (Meig's syndrome)
A 24 year old man presents to his GP with a firm, painless swelling arising from the lower pole of the testis. On examination you can get above the mass but it does not transilluminate.
What is the likely diagnosis of this scrotal lump?
(a) Testicular tumour
(c) Epididymal cyst
The correct answer is (a) Testicular tumour.
First question to answer when diagnosing a scrotal lump is whether it is painful or not:
Causes of a painful scrotal lump - Torsion(of testis or testicular appendage), epididymo-orchitis, strangulated inguinal hernia.
Causes of a painless scrotal lump - Inguinal hernia, testicular tumour, hydrocele, varicocele, epididymal cyst, spermatocele.
Testicular tumour (a) - a mass in the testes which you can get above and cannot transilluminate is likely to represent a testicular tumour. Check AFP (for a teratoma) and beta-HCG. Seminomas are radiosensitive and respond well to radiotherapy, teratomas are less radiosensitive so require chemotherapy.
A 75 year old woman on the care of the elderly ward has deteriorated quickly over the past 12 hours, with a fever of 38.6, abdominal pain and bloody diarrhoea. On examination she is clinically dry and confused. She has a background of T2DM and hypertension and was admitted following a fall. Whilst in hospital she developed a hospital acquired pneumonia which was successfully treated with levofloxacin several days earlier.
What is the cause of this patient's condition?
(a) Ischaemic colitis
(c) NSAID use
(d) Clostridium difficile infection
(e) Autonomic neuropathy
The correct answer is (d) Clostridium difficile infection.
This is a common situation with an elderly patient in hospital, particularly following a course of quinolone antibiotics.
Main risk factors for c. diff infection are antibiotics such as clindamycin, cephalosporins, co-amoxiclav, quinolones (cipro and levofloxacin), elderly, long stay in hospital, contact with c. diff and PPI use.
Presentation would be as in this case, but can also present with mucous PR.
Investigations: Pseudomembranes (yellow plaques) can be seen on flexi sig. Blood tests will reveal increased CRP, WCC, decreased albumin and U&Es in keeping with dehydration. You can do a stool cultuire and if you're super keen you can do ELISA for the c. diff toxins.
Treatment is metronidazole 400mg TDS PO for 10-14 days first line.
Second line is vancomycin 125mg QDS for 10-14 if metronidazole therapy failed.
If severe infection then vancomycin up to 250mg QDS with metro IV (note metro is less bioavailable IV so need 500 not 400mg added).
-Urgent surgical intervention in the form of a colectomy may be needed if => Toxic megacolon, increasing LDH or deteriorating condition
Final point, if there is a recurrence then it is treated with a repeat course of metro 10-14 days, then vancomycin if there are further relapses.
A patient presents with dysphagia for liquids and solids from the very start. Which of the following options is least likely to be the cause of the dysphagia?
(b) Bulbar Palsy
(d) Myasthenia Gravis
(e) Systemic Sclerosis
The correct answer is (c) Plummer-Vinson.
Plummer-Vinson is a benign, mural, stricture with an oesophageal web. The reason that it's the least likely cause in this case is that the patient presented with dysphagia of both solids and liquids from the beginning. That points to a motility disorder being the cause of the dysphagia (which a,b,d,e all are) rather than a mechanical block or stricture such as Plummer-Vinson.
What is prescribed as part of first-line eradication therapy of H. Pylori in a patient with NKDA?
7 day course of lansoprazole 30mg BD, amoxicillin 1g BD and clarithromycin 500mg BD.
If eradication unsuccessful or penicillin-allergic then second line treatment is 7 days of lansoprazole 30mg BD, metronidazole 400mg BD and clarithromycin 250mg BD.
If second line was unsuccessful there are treatment options including a regimen with bismuth and tetracycline added but a referral for more specialist/senior consult would be appropriate.
A 35 year old male smoker presents with epigastric pain which is worse on eating and relieved by antacids. He is diagnosed with a peptic ulcer.
Which of the following options describes where this patient's ulcer is most likely to be?
(a) Lesser curve of the gastric antrum
(b) Greater curve of the gastric antrum
(c) First part of duodenum
(d) Second part of the duodenum
(e) Fundus of the stomach.
The correct answer is (a) Lesser curve of the gastric antrum.
There are two parts to this question, firstly deciding whether it is a duodenal or gastric ulcer. Smoking is a risk factor for both, duodenal ulcers are more common in M>F, but importantly the clinical presentation of epigastric pain which is worse on eating and relieved by antacids indicate this is gastric pathology. Gastric ulcers can also present with weight loss. Conversely a duodenal ulcer presents with epigastric pain before meals and at night which is relieved by eating, or drinking milk.
With the diagnosis of gastric ulcer the most likely location is the lesser curve of gastric antrum. A key learning point here is that ulcers elsewhere in the stomach are often malignant.
Duodenal ulcers are most commonly found in the first part of the duodenum.
Give five differential diagnoses for a patient presenting with haematemesis.
Haematemsis causes can be remembered with the mnemonic VINTAGE.
Inflammation => Peptic ulcer disease (duodenal ulcer most commonly) and oesophago-gastro-duodenitis.
Neoplasia => oesophageal or gastric Ca
Trauma => Mallory weiss tear, boerhaave's syndrome
Angiodysplasia + HHT and dieulafoy lesion
Generalised bleeding => warfarin, thrombolytics, chronic renal failure
A 25 year old man is brought in by his concerned mother who says he's become increasingly withdrawn, depressed, and more recently, forgetful. As you go to shake the young man's hand you notice he has a resting tremor and he suffers from random jerks of his body. He demonstrates bradykinesia and ataxia, and you elicit spasticity on your examination. Other examination of note is marked bowing of the legs and an enlarged liver. As you are doing so the patient starts to respond to a voice only he can hear.
What is the cause for this man's symptoms and signs?
(a) Hodgkin's Lymphoma
(b) Wilson's Disease
(c) Paranoid Schizophrenia
(d) Sporadic CJD
(e) Drug use
The correct answer is (b) Wilson's disease.
This unfortunate gentleman has a host of different symptoms and signs, which individually point to a lot of different diagnoses. However, all together, given the young age of the patient they indicate Wilson's disease.
Clinical features of Wilson's disease can be remembered by the mnemonic CLANKAH (bit clunky I know)
Cornea - Kayser-Fleischer rings (70%, may need slit-lamp)
Liver disease- Children usually present with acute hepatitis, fulminant necrosis may occur, can progress to cirrhosis
Arthritis - Chondrocalcinosis and osteoporosis
Neurology - Parkinsonism: Bradykinesia, tremor, rigidity
-Chorea, tics, dysarthria, dysphagia and ataxia
-Depression, dementia and psychosis
Kidney - Fanconi's syndrome (type 2 renal tubular acidosis)=>Osteomalacia
Haemolytic anaemia - Coombs' negative
For each of the following options choose whether it applies to Crohn's disease, Ulcerative colitis or both.
(a) Slightly more common in females than males
(b) Presence of fibrosis and granulomas on histopathology
(c) Can cause fistulae formation
(d) Can potentially lead to development of a toxic megacolon
(e) Presentation is usually with blood diarrhoea, with blood and mucous on DRE.
(f) Associated with apthous ulcers and glossitis
(a) Slightly more common in females than males - this is true for both UC and Crohn's.
(b) Presence of fibrosis and granulomas on histopathology - this is true for Crohn's
(c) Can cause fistulae formation - this is true for Crohn's
(d) Can potentially lead to development of a toxic megacolon - This is true for both but is much more common with UC than Crohn's.
(e) Presentation is usually with blood diarrhoea, with blood and mucous on DRE - This describes UC's classical presentation. Crohn's does not usually present with bloody diarrhoea.
(f) Associated with apthous ulcers and glossitis - This statement describes Crohn's
Which of the following features would indicate tubular pathology rather than glomerular?
(c) Red cells
(d) Red casts
(e) White cell casts
The correct answer is (e) White cell casts.
(a,b,c,d) all indicate a glomerular pathology.
Other features of tubular pathology aside from white cell casts are small protein or leukocyturia
What are 6 causes of renal disease?
Classify or die!
-Vascular - RAS, toxins (NSAIDs, ACEi), thrombosis, hepatorenal syndrome
-Acute tubular necrosis
-Diseases of renal papillae, pelvis, ureters, bladder or urethra.
Posterior urethral valves
Infection: TB, schistosomiasis
Neuro: Post-op, neuropathy
A 74 year old man is brought into A&E via ambulance. He complains of feeling nauseated, and about a metallic taste in his mouth, and has been hiccoughing since he was admitted. He is confused, and clinically appears overloaded, with pale, sallow skin. On examination of his chest you auscultate a pleural rub as well as bilateral fine crackles in the lung bases. Abdomen is soft non-tender. PMH includes type 2 diabetes mellitus, well-controlled hypertension and osteoarthritis which has been causing him a lot of grief the past few months. Before you can site a peripheral cannula the patient starts to fit.
What is the cause of this patient's condition?
(a) Subdural haematoma
(b) Renal failure
(d) Colorectal carcinoma
(e) Congestive cardiac failure
The correct answer is (b) Renal failure.
This patient has a wide constellation of symptoms, the mainstay of which are related to a uraemia (N&V, confusion, metallic taste, hiccoughs, pale sallow skin, pleural rubs and fits). On top of that there are signs of protein loss with the oedema. Given the history of DM(massive risk factor for renal failure, well controlled hypertension (Use of ACEi can contribute to renal failure) and symptomatic OA (which is probably taking NSAIDs for) there are several risk factors for renal failure, which is what this patient has.
The prevalance of this disease is 1:40,000. It causes renal cysts and congenital hepatic fibrosis in infancy.
Which of the following options does this describe?
(a) Autosomal dominant polycystic kidney disease
(b) Autosomal recessive polycystic kidney disease
(c) Medullary sponge kidney
(d) Tuberous Sclerosis
(e) Bartter's syndrome
The correct answer is (b) autosomal recessive PKD.
Conversely autosomal dominant PKD(a) has a prevalance of 1:1000, affecting adults 40-60years old. Pathology is large cysts arising from all parts of nephron with a progressive decline in renal function, 70% with end stage renal failure by 70.
Medullary sponge kidney (c) is a disease with multiple cystic dilatations of the collecting ducts in the medulla, which typically presents in 20-30s and is commoner in females. It's often asymptomatic, but predisposes to hypercalciuria and nephrolithiasis, recurrent UTIs and pyelonephritis and haematuria. Renal function is usually normal.
Tuberous Sclerosis (d) (also referred to as bourneville's disease) is an autosomal dominant condition with hamartomas in skin, brain, eye and kidney. Skin manifestations are nasolabial adenoma sebaceum, ash-leaf macules, peri-ungual fibromas, neurologically they are low IQ, and have epilepsy. Renal - cysts and angiomyolipomas.
Bartter's syndrome (e) is a tubular disease unlike the others, and is one of the hereditary hypokalaemic tubulopathies which block the NaCl reabsorption in loop of henle causing RAS activation causing hypokalaemia and metabolic alkalosis with a normal BP. It is similar to Gitelman syndrome, the way to remember them, is Bartter's syndrome mimics the action of furosemide, and Gitelman's syndrome mimics the action of a thiazide.