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Question 1

posterior fossa acute cerebellar hemorrhage

Question 2

A post-marketing observational study

Answer 2

Post-authorisation safety studies (PASS) are observational (non-randomised) studies conducted after a new drug is introduced into clinical use. Their aim is to characterise the adverse-effect profile, particularly in patients not studied during clinical trials, such as those with liver and renal disease, pregnant women, and children.

Question 3

incidential fining with anemia, raised WBC and normal platelet chronic lymphocytic leukaemia

Answer 3

The presence of splenomegaly, anaemia and lymph nodes would make chronic lymphocytic leukaemia the most likely possibility. Acute myeloid leukaemia is unlikely to be diagnosed as an incidental finding and would more likely be associated with thrombocytopenia. Chronic myeloid leukaemia is a possibility, although this is a less common diagnosis and an elevated platelet count would be expected. Myelodysplasia would not usually be associated with a high white count. Myelofibrosis is a possible diagnosis, although the high white count with normal platelet count makes this less likely. It would be expected to request a white cell differential in the clinical setting.

Question 4

AML

Answer 4

Acute myeloid leukemia (AML) is a blood cancer characterized by the rapid accumulation of abnormal white blood cells (myeloblasts) in the bone marrow and blood. Clinically, this manifests as bone marrow failure, leading to symptoms like fatigue, infections, and bleeding. Pathophysiologically, AML arises from genetic mutations in myeloid precursor cells, disrupting normal blood cell development and leading to the accumulation of leukemic blasts.
Clinical Manifestations:
Bone Marrow Failure:
Anemia: Fatigue, weakness, shortness of breath, paleness due to decreased red blood cells.
Neutropenia: Increased risk of infections, fever, and recurrent infections due to low white blood cell counts.
Thrombocytopenia: Easy bruising, bleeding, nosebleeds, bleeding gums due to low platelet counts.
Extramedullary Infiltration:
Hepatosplenomegaly: Enlarged liver and spleen.
Lymphadenopathy: Swollen lymph nodes, though less common.
Skin Involvement: Leukemia cutis (rash), Sweet’s syndrome, or other skin lesions.
Other Symptoms:
Bone pain.
Weight loss.
Swelling in the abdomen.
Swollen lymph nodes in the neck, underarm, or groin.
Loss of appetite.
Fever.
Night sweats.

Question 5

Myelofibrosis

Answer 5

fatigue, anemia, enlarged spleen (splenomegaly), and potential complications like easy bruising, bone pain, and weight loss.

painful splenomegally

Question 6

CLL

Answer 6

enlarged lymph nodes, fatigue, recurrent infections, and night sweats. In some cases, individuals may also experience unintentional weight loss, fever, and abdominal pain due to an enlarged spleen.

disregulated cell death

Answer 7

Typical presentation of IgA vasculitis (also known as Henoch–Schönlein purpura; this eponym is no longer used in the exam) with a rash, arthritis and acute glomerulonephritis. The IgA is seen on immunofluorescence or immunohistochemistry. Foot process effacement is seen in nephrotic syndrome of various types. Linear deposition of IgG on basement membrane in anti-glomerular basement membrane disease, thickened basement membranes are typically seen in Alport, focal and segmental sclerosis seen in focal segmental glomerulosclerosis (FSGS). FSGS describes a lesion seen on biopsy (focal means that some glomeruli are affected and others are not and segmental means that part of the glomerulus is affected and other parts are left unaffected).

Question 8

Antiphospholipid syndrome (APS) is a thrombotic and reproductive disorder caused by autoantibodies that target cell surface phospholipids and phospholipid-binding proteins

Answer 8

She has antiphospholipid syndrome. The livedo reticularis, cognition problems and loin pain are a result of thrombosis. This patient likely has renal vein thrombosis accounting for loin pain and dipstick abnormalities. Anti-centromere is associated with scleroderma, anti-glomerular basement membrane with anti-GBM disease, antimitochondrial with primary biliary cirrhosis and ANCA with ANCA vasculitis.

anticardiolipin

these antibodies, including lupus anticoagulant, anticardiolipin, and anti-B2 glycoprotein I, can lead to thrombosis and recurrent pregnancy loss

Answer 9

This is a typical description of an Adie’s pupil, often associated with reduced or absent deep tendon reflexes. An afferent pupillary defect is due to impaired ipsilateral optic nerve function, causing brief paradoxical pupillary dilatation to light with the “swinging torch” test. Argyll Robertson pupils accommodate but do not react and are typically bilaterally small. A Horner’s would include ptosis with ipsilateral small pupil, and a third cranial nerve palsy might include ipsilateral ptosis and pupillary enlargement.

Question 10

Adie’s pupil

Answer 10

The pathophysiology involves damage to the ciliary ganglion, which controls parasympathetic innervation of the eye, and potentially the dorsal root ganglion, impacting autonomic function. This damage leads to a light-near dissociation, where the pupil constricts poorly to light but reacts more strongly to near vision, and also to loss of deep tendon reflexes

Question 11

Argyll Robertson pupils

Answer 11

Bilateral: Argyll Robertson pupils are typically found in both eyes.
Small Pupils: The pupils are smaller than normal, and their shape may be irregular.
Light-Near Dissociation: The pupils constrict readily when focusing on a near object (accommodation reflex) but do not constrict in response to bright light.

Neurosyphilis:

Answer 12

Von Willebrand disease is the correct answer as this is a relatively common bleeding disorder that can manifest in adults, as excessive bleeding after dental extractions or other minor surgical procedures. On further questioning of female patients, there is often a history of menorrhagia. Factor V Leiden is not correct as this is an inherited disorder that is associated with an increased risk of thrombosis, not bleeding. Factor IX deficiency is an X-linked recessive disorder and would not be expected to affect females or a 38-year-old patient. Factor XII deficiency is a rare autosomal recessive condition that is not associated with a bleeding tendency in the majority of cases, although it is associated with a marked prolongation of the activated partial thromboplastin time and may, incorrectly, be assumed to influence bleeding risk. Primary antiphospholipid syndrome is associated with a tendency to thrombosis, not bleeding.

Answer 13

The history of localised bony pain with significantly elevated serum alkaline phosphatase and normal serum adjusted calcium and serum phosphate in an elderly man is entirely consistent with a diagnosis of Paget’s disease.

The history is not suggestive of insufficiency fracture of the pelvis. In osteomalacia, you would expect to see decreased serum adjusted calcium and serum phosphate alongside the raised serum alkaline phosphatase. While he has pain around his pelvic girdle, the ESR is normal for his age and elevated serum alkaline phosphatase would make polymyalgia rheumatica unlikely. In advanced metastatic prostate cancer, you would expect to see a greater elevation in serum prostate-specific antigen and raised serum adjusted calcium and phosphate. Lower urinary tract symptoms of hesitancy and post-micturition dribbling are very common in this age group.

Answer 14

Angioimmunoblastic T-cell lymphoma is uncommon in this age group and would classically present with more widespread lymphadenopathy and a rash.

Extramedullary plasmacytoma would be unlikely in this age group and would classically present with lesions in the upper respiratory tract, such as the oropharynx.

Follicular B-cell non-Hodgkin lymphoma would be much less likely than Hodgkin lymphoma in this age group, although it could present with asymptomatic lymphadenopathy.

Mantle cell lymphoma is unlikely in this age group and would be expected to present with more widespread lymphadenopathy and splenomegaly.

Question 15

depression and dementia

Answer 16

The most frequent diseases causing haemoptysis are bronchiectasis, tuberculosis, fungal infections and cancer. Causes of bleeding from the large vessels include infectious, cardiovascular, congenital, neoplastic and vasculitic diseases. In cases of severe haemoptysis requiring treatment, the source of bleeding originates from bronchial and pulmonary arteries in 90% and 5% of cases, respectively.

Answer 17

She has acute kidney injury with modest proteinuria and leukocyturia which is in keeping with interstitial nephritis. NSAIDs are associated with interstitial nephritis. Acute tubular necrosis is classically associated with a bland urinalysis. IgA nephropathy is not associated with NSAID use and is therefore less likely. Membranous glomerulonephropathy is more commonly associated with nephrotic range proteinuria (urine PCR >300mg/mmol). Papillary necrosis can be associated with NSAID use but also with flank pain and higher levels of haematuria. A renal biopsy would be required to differentiate between the possible causes for her renal impairment but tubulointerstitial nephritis is the most likely diagnosis based on the information given.

Answer 18

Lichen planus causes violaceous, flat-topped papules, which are often seen on the flexor surfaces of the wrists, lower back and ankles as well as elsewhere on the skin. Lichen planus can koebnerise, which is when the lesions arise at an area of skin that has been traumatised, and the linear pattern on left forearm would be consistent with koebnerisation from scratching. Lichen planus frequently causes a lacy, white pattern on the buccal mucosa, hence involvement of the buccal mucosa is the orrect answer. When lichen planus affects the scalp (i.e. lichen planopilaris), it causes a scarring alopecia, so non-scarring alopecia is unlikely. Conjunctival scarring with lichen planus has been reported but this is uncommon, so is incorrect. Burrows in finger webs are seen in scabies, not lichen planus, so this option is incorrect. Lichen planus does not affect the joints, so is incorrect.

Answer 19

The differential diagnosis for this presentation includes all of the conditions listed. The positive serum IgE and IgG for Aspergillus are indicative of an active inflammatory reaction against it. Aspergillus thrives in poorly drained and avascular cavitary spaces within the lung. Once harbored within a cavitary airspace, it adheres to the wall with its conidia, then germinates and, in the process, evokes an inflammatory reaction. The organism, along with the inflammatory debris, forms an amorphous mass identified as an aspergilloma, and a solid lesion with an adjacent crescentic shaped radiolucency on chest X-ray strongly suggest an aspergilloma within an existing lung cavity. Angio-invasive aspergillosis will not present with a solid mass and only occurs in someone who is immunosuppressed. Patients with allergic bronchopulmonary aspergillosis have proximal bronchiectasis and present with productive cough and wheeze and not likely haemoptysis.

Answer 20

The stem describes multisystem involvement. Investigations show a multisystem inflammatory complement-consuming illness. Systemic lupus erythematosus is the most likely cause for this clinical presentation: it has musculoskeletal, renal and skin symptomatology and systemic manifestation. IgA vasculitis is not common in this age group and pleural involvement is extremely rare. Microscopic polyangiitis would affect the lung parenchyma and not pleura. Mixed cryoglobulinaemia is rare and there are no predisposing illnesses here. Rheumatoid arthritis (RA) is not a complement-consuming condition and would not cause renal involvement at such an early stage; rheumatoid factor is not a diagnostic test or a specific test for RA.

Question 21

Mixed cryoglobulinemia encompasses types II and III cryoglobulinemia

Answer 21

Here’s a more detailed breakdown:
Type II:
This type features a monoclonal IgM (or IgG or IgA) with RF activity, along with polyclonal immunoglobulins.
Type III:
This type is characterized by polyclonal IgM with RF activity, also along with polyclonal IgG, according to the National Institutes of Health (NIH) (.gov).
Mixed Cryoglobulinemia (Type II/III):
The American Society of Hematology and other sources often group types II and III together, referring to them collectively as mixed cryoglobulinemia.

Question 22

Foot drop

Answer 22

causes - L5 Radiculopathy(compressopn at spine) - pain in the buttock, numbness, inversion and iversion both affected

Common peroneal nerve injury - no pain, numbness below the knee, only iversion affected, not inversion

Weakness of inversion is not seen in common peroneal nerve lesion but may be present with L5 lesion (tibialis posterior muscle is supplied by tibial nerve, L4/5). Tinel’s is a weak sign with low positive predictive value.

Question 23

triad for the opioid toxidrome

Answer 23

The combination of reduced conscious level, reduced respiratory rate and small pupils (miosis)

Question 24

Hyertension caused by Thiazide diuretics

Answer 24

Thiazide diuretics act on the distal tubule by blocking the thiazide-sensitive Na+-Cl− symporter. The increased sodium delivery to the distal part of the distal tubule causes increased potassium loss, due to stimulation by sodium of the aldosterone-sensitive sodium pump, thereby enhancing sodium reabsorption in exchange for potassium (and hydrogen) ion.

Question 25

Stroke by anatomy

Answer 25

Dominant parietal lobe lesions can cause a variety of problems including receptive dysphasia, dyslexia, inattention and sensory impairments, and also Gerstmann syndrome, which is characterised by finger agnosia, acalculia, agraphia and left–right limb disorientation

Answer 26

The CSF values are most in keeping with viral meningitis and enterovirus is the most probable cause. It is probably early viral meningitis given that neutrophils are seen in addition to lymphocytes. She has no risk factors for listeria. The CSF in listeria shows high protein, low glucose and lymphocytosis. The CSF in tuberculous meningitis shows very high protein, low glucose and lymphocytosis. The CSF in Neisseria meningitides and Streptococcus pneumoniae shows high protein, low glucose (<50% plasma), and a very high neutrophil count.

Answer 27

There is a wide discrepancy between the peripheral oxygen saturation (98%) and the oxygen saturation by four-wavelength spectrophotometry (55%). The former passes two wavelengths of light to the photodetector and measures only oxyhaemoglobin and deoxyhaemoglobin. It cannot distinguish oxyhaemoglobin from carboxyhaemoglobin, which accumulates in carbon monoxide (CO) poisoning. The four-wavelength spectrophotometer, on the other hand, is able to do so. In CO poisoning, CO avidly binds with haemoglobin to form carboxyhaemoglobin. As a result, the amount of oxyhaemoglobin falls. The four-wavelength spectrophotometer accurately detects this fall of oxyhaemoglobin to 55%, but the two-wavelength peripheral pulse oximeter will give a false elevated reading – 98% being the sum of oxyhaemoglobin and carboxyhaemoglobin, which it cannot measure separately.

Question 28

hypodermis

Answer 28

Lipodermatosclerosis or sclerosing panniculitis is an extensive induration of the skin, often in association with leg ulcers and most commonly related to venous hypertension; it is a chronic inflammation, with fibrous tissue that involves and replaces the hypodermis and, if extensive, the papillary dermis.

Question 29

Waterlow score

Answer 29

age and gender body mass index (BMI) level of continence skin condition (healthy or broken) appetite level of mobility (fully mobile to bed-bound) individual risk factors, e.g. medication, surgery and trauma

Answer 30

This question is testing knowledge of coronary anatomy and corresponding ECG changes. The patient is having a posterior ST-elevation myocardial infarction (STEMI), as noted by the fact there is a dominant R wave in V1–3 and ST depression, which, if posterior leads were applied, it would show ST elevation and Q waves in V1–3 e.g. a mirror image. It is the circumflex that supplies the posterior surface of the heart, via the posterior descending artery in around 15% of people, called a left dominant system; in 85% of people, the posterior descending artery arises from the right coronary artery, called a right dominant system. Of the answers listed, it is only a lesion in the circumflex that could produce these changes, the right coronary artery is not listed as an option; therefore, the answer is circumflex. Of the other answers, first septal branch of the left anterior descending would lead to ST elevation in I and aVL alone; left main stem would lead to widespread ST elevation in most, if not all, leads (or possible ST elevation in aVR and ST depression in the anterior leads); mid-left anterior descending and proximal left anterior descending would lead to anterior ST elevation, in V2-6 and V1-4 ,respectively.

Answer 31

This patient has symptomatic hypercalcaemia with low serum phosphate and slightly elevated plasma parathyroid hormone (PTH). Decreased gastrointestinal absorption could be a cause of this but it is not the most likely cause. Bone resorption releases bound phosphate, so will not cause hypophosphataemia. There is no mention of any actions which could precipitate re-feeding syndrome and, therefore, intracellular shift of phosphate. The phosphate content of vomitus is insufficient to be the most likely cause of this result. Reduced renal absorption of phosphate due to raised PTH is, therefore, the most likely cause of her hypophosphataemia

Answer 32

This is a text-book description of rapid eye movement (REM) sleep behavioural disturbance, with patients acting out their dreams. Patients are usually easily roused from this, unlike non-REM parasomnias. Sleep apnoea is characterised by snoring and apnoeic episodes, non-epileptic attack disorder rarely arises from true sleep, and periodic limb movement disorder is rarely aggressive, although can disturb bed partners. Frontal lobe attacks can be difficult to distinguish, but are rarely associated with dreaming, rarely involve targeted violence, and are less frequent.

Question 34

A 70-year-old woman presented after being found collapsed at home. Examination showed weakness of the lower two-thirds of the left side of her face and a dense left hemiparesis affecting her arm and leg. She had a fixed gaze palsy to the right affecting both eyes. Damage to which area of the brain is most likely to have produced the gaze palsy?

Answer 34

Left hemiparesis with left upper motor neuron facial nerve palsy, implying a right-sided brain lesion. Fixed gaze palsy to the right supports this (the eyes 'look towards' the side of the lesion). These findings are typical of a frontal lobe lesion: Posterior circulation (occipital) stroke would cause ipsilateral cranial nerve signs and contralateral limb signs ('crossed deficit').

Answer 36

The presentation is very strongly suggestive of antiphospholipid syndrome (APLS), although the diagnostic criteria would require the abnormal laboratory tests to be repeated at least 12 weeks later. APLS is diagnosed when both clinical and laboratory features are present. This patient has the clinical features of venous thromboembolism (VTE) and pregnancy loss, as well as the laboratory features of positive anticardiolipin antibodies and a prolonged APTT which is suggestive of a lupus anticoagulant. Long-term anticoagulation would be indicated, and in APLS direct oral anticoagulants should not be used for treatment of VTE as they are less effective than warfarin. Warfarin should not be used in pregnancy, and if the patient were to be planning a pregnancy then low-molecular-weight heparin would be recommended at this time.

Answer 37

Pulmonary vascular resistance (PVR) is mainly generated by arterioles, blood viscosity and lung volume. It is increased by hypoxia, noradrenaline (norepinephrine) and endothelin. The effects of hypocapnia are variable (therefore, not the best answer of the five). PVR is decreased by epoprostenol (prostacyclin).

Question 38

aneuploid diploid haploid monoploid triploid

Question 39

left cavernous sinus left cerebellopontine angle left medulla left midbrain left pons

Question 40

Hodgkin disease

Answer 41

The syndrome described is an anterior mediastinal mass in an individual in the second decade of life. Erythema nodosum, the other presenting feature described, is associated with Hodgkin disease, sarcoidosis and tuberculosis. As a diagnostic test for sarcoidosis, measurement of serum angiotensin-converting enzyme (ACE) levels lacks sensitivity and specificity. Up to 40% of cases of sarcoidosis will have normal serum ACE levels. The normal serum α-fetoprotein and serum β-human chorionic gonadotropin levels make teratoma unlikely. The complex and implied aggressive nature of the growth of the lesion described on CT scan suggests a malignant condition, and coupled with the serum lactate dehydrogenase elevation, make Hodgkin disease the most likely diagnosis.

Answer 42

This is longstanding painless and progressive neck adenopathy in an adolescent. The most likely diagnosis is classical Hodgkin lymphoma. The most appropriate diagnostic investigation is excision biopsy. Fine-needle aspiration is likely to yield insufficient material for diagnostic purposes in Hodgkin lymphoma and, therefore, is likely to be unhelpful and delay diagnosis. Bone marrow examination) and CT scan of head and neck are investigations reserved for staging rather than diagnosis. Mantoux skin test is not likely to be helpful in this setting as Hodgkin lymphoma is the most likely diagnosis.