MSAKT paper qs bank 2023 Flashcards
Answers are uptodate and defo correct
A 67 year old man is found to have an ejection systolic murmur. He is otherwise well. His pulse rate is 72 bpm and BP 128/84 mmHg. His chest is clear. Investigations: ECG shows sinus rhythm. Echocardiography shows aortic stenosis, valve gradient 50 mmHg. Left ventricular (LV) diastolic dysfunction, LV ejection fraction 45% (>55).
Which is the most appropriate management?
A. Clinical review and echocardiography in 6 months
B. Reassure and discharge
C. Refer for aortic valve replacement
D. Start bisoprolol fumarate and advise review if symptomatic
E. Start lisinopril and advise review if symptomatic
Refer for aortic valve replacement
>= 50mmhg valve gradient is where Aortic valve replacement should be considered.
Mild LV dysfunction is also reason to consider valve replacement. A and B will not be safe to do and medical management will not help with valve disease progression.
Asymptomatic aortic valve replacement referral should be made if:
* valve area < 0.6 cm2
* LVEF < 55%
* BNP or proBNP more than 2 uln
* symptoms during exercise.
Considered if during stress echo:
* LVEF < 50 + valve pressure gradient >40 + aortic valve < 1cm 2
A 60 year old man has 6 months of dry cough and increasing shortness of breath on effort. He was previously fit and well, and is a non-smoker. His temperature is 36.8°C, pulse rate 60 bpm and oxygen saturation 89% breathing air. He has finger clubbing. Cardiac examination is normal, and chest examination reveals bibasal crepitations.
Which is the most likely diagnosis?
A. Bronchiectasis
B. Extrinsic allergic alveolitis
C. Idiopathic pulmonary fibrosis
D. Lung carcinoma
E. Pulmonary tuberculosis
Idiopathic Pulmonary Fibrosis -> All the answers are causes of cough finger clubbing and increasing breathlessnes but IPF is most likely
Lack of smoking hx means that Lung cancer is less likely, additionally symptoms are more likely to be unilateral
EAA is possible but again is less common that IPF also EAA is often associated with a specific trigger antigen
Pulmonary TB is less likely as there is no fever and the cough dry
A 65 year old man attends the anticoagulant clinic. He has had a metal mitral valve replacement and atrial fibrillation. He takes warfarin 7 mg daily. There are no signs of bleeding. His pulse rate is 70 bpm, irregularly irregular, with a mechanical second heart sound. His INR is 5.1.
Which is the most appropriate next step in management?
A. Continue warfarin at lower dose
B. Continue warfarin at same dose
C. Give vitamin K intravenously
D. Give vitamin K orally
E. Withhold warfarin for 2 days then restart at lower dose
Withold Warfarin for 2 days and restart at a lower dose ->
A 52 year old man has three days of severe epigastric pain, radiating to his back, but no chest pain. He has vomited several times. He was previously well. He drinks approximately 60 units of alcohol a week and smokes 20 cigarettes per day. There is epigastric tenderness but his abdomen is not distended, and bowel sounds are present.
Which test would confirm the most likely diagnosis?
A. Abdominal X-ray
B. Gastroduodenoscopy
C. Serum alkaline phosphatase concentration
D. Serum amylase concentration
E. Ultrasound scan of abdomen
Serum Amylase -> Acute pancreatitis a lot of risk factors present suggesting pancreatitis.
This is an important diagnostic test early in pancreatitis.
A 55 year old man is rescued from a collapsed building where he has been trapped for 12 hours without water.His temperature is 35.6°C, pulse rate 100 bpm and BP 90/42 mmHg. His JVP is not visible. His abdomen is non tender.
Investigations:
Haemoglobin 168 g/L (130–175)
Sodium 148 mmol/L (135–146)
Potassium 6.0 mmol/L (3.5–5.3)
Urea 25.1 mmol/L (2.5–7.8)
Creatinine 184 μmol/L (60–120)
Creatine kinase 840 U/L (25–200)
Which is the most likely cause of this biochemical picture?
A. Bladder outflow obstruction
B. Direct renal trauma
C. Hypovolaemia
D. Rhabdomyolysis
E. Sepsis
Hypovolaemia -> Low BP and high HR additionally there is evidence of an AKI and the most common cause of this is hypovolaemia.
There is no reason for Sepsis to have developed in this scenario and no temperatire.
Ther Creatinine Kinase will be near 10,000 or in the 10,000s for rhabdomyolysis.
A 24 year old woman has diarrhoea. She is HIV positive and has been working in Namibia. Investigation:
Faeces microscopy (following modified Ziehl–Neelsen stain): protozoa
Which is the most likely causative organism?
A. Acanthamoeba
B. Cryptosporidium parvum
C. Entamoeba coli
D. Plasmodium falciparum
E. Schistosoma mansoni
Cryptosporidium Parvum -> This is a protozoa, It is a common causative organism that is associated with HIV and Nambia and causes Diarrhoea
IT is found in contaminated water sources and is a signigicant cause of diarrhoea in developing countries
The others can also cause diarrhoea the HIV and the Nambia makes Parvum more likely.
A 67 year old man has difficulty chewing and speaking. He underwent carotid surgery 2 days ago. His tongue deviates to the right when he is asked to protrude it.
Which nerve has been damaged?
A. Left glossopharyngeal nerve
B. Left hypoglossal nerve
C. Left vagus nerve
D. Right glossopharyngeal nerve
E. Right hypoglossal nerve
Right Hypoglossal nerve -> The motor function of the Hypoglossal is the movement of the tongue.
The Tongue deviates Towards the lesion
The UvulA deviates Away from the lesion -> it is also associated with a lesion in the vagus nerve
(it might be glossopharyngeal but i think it is vagus.)
A 72 year old woman has had 4 months of progressive difficulty walking. She describes numbness and tingling in her feet and has fallen on several occasions. On examination of her lower limbs, she has normal tone, moderate weakness of ankle dorsiflexion and plantar flexion, normal knee jerks, but absent ankle jerks and extensor plantars. Romberg’s test is positive. She has reduced vibration sense, and joint position sense is impaired up to the ankle joints.
Temperature and pinprick sensations are normal.
Which investigation is most likely to confirm the diagnosis?
A. HbA 1c
B. Serum folate
C. Serum protein electrophoresis
D. Serum vitamin B 12
E. Serum vitamin D
Vitamin B12
A deficiency in B12 causes subacute combined degeneration of the cord
Presents with UMN and LMN signs as well as glove and stock loss of sensation I think anyway
BELOW IS WHAT WAS EXPLAINED ON THE WEBSITE…
The clinical picture is consistent with subacute combined degeneration of the cord, giving a mixture of upper motor neurone (extensor plantars) and lower motor neurone (absent ankle jerks) features. The sensory ataxia (positive Romberg test and absent position sense in the ankles) is most likely due to dorsal column dysfunction from vitamin B12 deficiency, and this can be confirmed by serum vitamin B12 measurement. Vitamin B12 deficiency of this severity is usually caused by pernicious anaemia.
A 34 year old woman has a recurrent itchy rash which lasts for several hours before resolving (see image). She has not identified any triggers. She is systemically well. She is a firefighter and says that she does not want any treatments that may affect her level of alertness.
Which is the most appropriate treatment to control her symptoms?
A. Oral chlorphenamine maleate
B. Oral loratadine
C. Oral prednisolone
D. Topical aqueous cream
E. Topical hydrocortisone
Oral Loratadine -> first line management of uritcaria is non-sedative anti histamines as there are less adverse effects. An example of this is oral Loratadine…
Oral Chlorophenamine maleate is also an anti histamine but this is sedative
oral pred - Steroids may be approapriate in a severe outbreak
Topical steroids are ineffective and so should not be used.
Topical Aqueous cream is an alternative to soap and has no place in the manafement of uritcaria
A 29 year old woman has 2 days of marked loss of vision and acute pain in her left eye. The pain is worse when she changes her gaze direction. Her eyes appear normal on general inspection. Her vision is ‘count fingers only’ in the affected eye. The swinging flashlight test shows that the left pupil dilates when a bright light is moved from the right eye to the left eye. The optic discs are normal on fundoscopy.
Which is the most likely diagnosis?
A. Acute closed angle glaucoma
B. Giant cell arteritis
C. Idiopathic intracranial hypertension
D. Migraine with aura
E. Retrobulbar optic neuritis
Retrobulbar Optic neuritis -> Acute onset eye pain, marked loss off vision as well as a relative afferent pupillary defect = Optic neuritis
The optic disc swelling along with the above suggests retrobulbar lesion
Acute angle glaucoma -> can present similarly but there is sometimes mention of vominting, headaches, red eye with dilated pupils.
Giant cell arthritis would present with more systemic features which are not present here as well as malaise and jaw claudication
Idiopathic intracranial HTN -> Does not tend to cause pain with eye movement
Migraine with aura can have visual disturbance but not associated with RAPD
A 45 year old woman develops an intensely painful eruption around her right eye. The illness started with pain 5 days previously, followed by the appearance of a few vesicles, which has now developed into the rash (see image). She has no significant medical history. Treatment is started.
Which is the most likely long-term outcome?
A. Complete resolution with no sequelae
B. Corneal ulceration
C. Extensive scarring of the right temple
D. Partial ptosis
E. Reduced visual acuity
Complete Resolution with no sequelae -> This herpes zoster ophthalmicus. this is chicken pox that represents on the V1 distribution. Most of the time this has a complete resolution with no sequelae.
A 48 year old woman has rheumatoid arthritis. She takes regular paracetamol and has no drug allergies. She is due to commence methotrexate weekly.
Which additional treatment should be prescribed?
A. Calcium carbonate
B. Folic acid
C. Pyridoxine hydrochloride
D. Thiamine
E. Vitamin D
Folic acid -> Methotrexate is an Anti folate and so to reduce the adverce effects folic acid is needed.
Methotrexate is taken ONCE a week
Thiamine is Vitamin B1 and is needed in alcohol patinets.
Calcium carbonate is often used if there is hypocalcaemia
Pyrodoxine -> I believe is used to treat B6 deficiency in patients that are being treated with RIPE for tuberculosis as the Isonazid causes a depletion of B12
A 61 year old man has had 2 months of ankle swelling. He has hypertension and a 30 year history of seronegative polyarthritis. His medication includes ramipril, sulfasalzine, hydroxychloroquine sulfate and diclofenac. His BP is 156/90 mmHg. He has pitting oedema to mid thigh and signs of chronic deforming polyarthropathy in his hands, but no joint tenderness. His optic fundi show silver wiring and arteriovenous nipping. Urinalysis: protein 4+, no other abnormalities.
Investigations:
Sodium 133 mmol/L (135–146)
Potassium 5.4 mmol/L (3.5–5.3)
Urea 9.0 mmol/L (2.5–7.8)
Creatinine 119 µmol/L (60–120)
Albumin 21 g/L (35–50)
CRP 43 mg/L (<5)
Urinary protein:creatinine ratio 1100 mg/mmol (<30)
Which is the most appropriate initial treatment?
A. Candesartan cilexetil
B. Furosemide
C. Indapamide
D. Prednisolone
E. Prednisolone and cyclophosphamide
Furosemide -> This is nephrotic syndrome there is HTN and there is peripheral oedema as well as protein in urine. This is a loop diuretic and can cause hyponatreaemia and hypokalaemia
The patient needs to be referred but would be started on furosemide for the time being,
A 75 year old woman has had 5 months of a 2 cm red plaque on her leg. Investigation: Skin biopsy: Bowen’s disease
Which is the most appropriate topical treatment?
A. 5-fluorouracil (Efudix® ) cream
B. Betamethasone valerate (Betnovate® ) cream
C. Diclofenac (Solaraze® ) gel
D. Isotretinoin gel
E. Salicylic acid gel
5-Fluorouracil -> This is the topical treatment that is used in the management of Bowen’s disease.
5 fluorouracil is also used to treat acitnic keratosis
Bowen’s disease is a type od squamous cell carcinoma
Diclofenac can be used in the management Acitinic keratoisis but not Bowen’s disease
Isoretononin is used in the management in ACNE.
Salicycic acid is used in the treatment of hyperkeratototic lesions such as warts and acitinic keratosis. -> Even though there is hyperkeratosis in Bowen’s disease it does not treat the underlying dysplasia.
A 32 year old woman has had palpitations and hot flushes for 4 weeks. She has noticed a painless swelling in her neck over the same time and her weight has decreased by 2 kg. She gave birth 4 months ago after a normal pregnancy. She is not breastfeeding. Her pulse rate is 120 bpm and BP 140/90 mmHg. She is tremulous and restless. She has a large smooth non-tender goitre. Investigations:
Free T4 35.6 pmol/L (9–25)
Free T3 10.8 pmol/L (4.0–7.2)
TSH <0.01 mU/L (0.3–4.2)
Thyroid peroxidase antibodies >1600 IU/L (<50)
Thyroid stimulating antibodies <1.0 IU/L (<1.75)
Which is the most appropriate initial treatment?
A. Carbimazole
B. Propranolol
C. Propylthiouracil
D. Thyroidectomy
E. Thyrotropin alfa
Propanolol -> this is the most approapriate initial management. This can be done to manage the HTN and the High HR while further ix and management is initiated.
An 80 year old man has an ulcer over the left heel and reduced mobility. He has a loss of appetite. He has type 2 diabetes mellitus and has previously had a myocardial infarction. The ulcer is 3 cm in diameter and deeply penetrating. Sensory testing shows reduced vibration sense but normal sensation to light touch. His Doppler ratio (ankle brachial pressure index) on the left is 0.68 and on the right is 0.98 (normal value 1.00).
Which is the most likely mechanism of his ulcer?
A. Arterial
B. Neuropathic
C. Nutritional
D. Vasculitic
E. Venous
Arterial -> There is sig hx for vascular disease. There is normal sensation and so neuropathic is not possible.
A 76 year old woman with hypertension is taking amlodipine 10 mg daily. A 24 hour BP measurement shows a mean BP of 168/90 mmHg. Investigations: Sodium 135 mmol/L (135–146) Potassium 4.0 mmol/L (3.5–5.3) Urea 7 mmol/L (2.5–7.8) Creatinine 100 μmol/L (60–120) eGFR 68 mL/min/1.73 m2(>60) Urinary albumin : creatinine ratio 50 mg/mmol (<3.5)
Which class of antihypertensive should be added?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Loop diuretic
E. Thiazide-like diuretic
ACE i -> In terms of Standard HTN management ACEi would be next anyway.
However, in this caes the fact that the Albumin to creatinine ratio was >30 mg/mmol meant that it would benefit to be on ACEi as it delays the progression of end stage renal failure.
There is no other medication that is shoud to reduce protienuria and thus CVS risk
A 76 year old woman has progressive breathlessness with right-sided pleuritic chest pain and weight loss over 6 months. She is a retired mechanic and has a 25 pack-year smoking history. Investigations: Chest X-ray: marked volume loss in right hemithorax CT scan of chest: see image
What is the most likely diagnosis?
A. Asbestosis
B. Chronic hypersensitivity pneumonitis
C. Lung cancer
D. Malignant pleural mesothelioma
E. Tuberculosis
Malignant pleural mesothelioma -> The wt loss is more suggestive of a cancer disease
The thickening of the pleura in the CT is more suggestive a proble with the mesothelium, hence a diagnosis of mesothelioma.
No fever points away from the diagnosis of TB
The chronic hypersensitivity pneumonitis and Asbestosis will both present with both likely present with bilateral symptoms and crackles hear at the area of abnormality. Additionally the CT will show changes within the lung fields not in the pleura. That being said pleural plaques may be present in Aesbestosis.
Lung cancer tends not to be painful and will not look like this on CT.
A 64 year old woman has thumping palpitations and says that she sometimes feels her heart ‘gives a sudden jump’. Her husband recently died due to myocardial infarction. Her pulse rate is 70 bpm, BP 136/80 mmHg. Her heart sounds are normal. Her 12-lead ECG is shown in the tracing.
Which is the most likely cause of her palpitations?
A. Atrial fibrillation
B. Premature supraventricular beats
C. Premature ventricular beats
D. Sinus arrhythmia
E. Ventricular tachycardia
Premature Ventricular beats -> this can be differentiated from premature supraventricular beats because this is wide qrs complex and so the beat origniates from the ventricles so not from above. The common jumps and thumping palpitation is a common description of ectopic beats.
