Paper 2 - incorrect MCQ

Question 1

Acute confusion
Which of the following routine blood tests is most likely to indicate a cause
of an elderly patient’s acute confusional state?
A Calcium
B C-reactive protein (CRP)
C Liver function tests
D Sodium
E Urea

Answer 1

B. C-reactive protein (CRP)
The most common cause of acute confusional state in elderly patients is
a chest or urinary tract infection. These may present atypically, without
overt symptoms or a temperature, so looking for a rise in CRP roughly
corresponding with the onset of confusion can suggest that performing a
septic screen (blood cultures, chest X-ray, urine dipstick and culture) would
be of use in fi nding the cause. Uraemia, liver failure, hyponatraemia, and
hyper- or hypocalcaemia can cause acute confusional state, but more rarely
than an infection in older patients.

Question 2

HLA-B27
Which of the following conditions is not associated with HLA-B27?
A Crohn’s disease
B Psoriasis
C Scleritis
D Ulcerative colitis
E Uveitis

Answer 2

C. Scleritis
Inflammatory bowel disease is associated with HLA-B27, as is psoriasis.
Uveitis is inflammation of the iris and associated structures, and causes
acute pain with blurred vision and photophobia with reddening of the iris.
This is associated with both ankylosing spondylitis and HLA-B27. Scleritis
is infl ammation of the sclera, causing pain and a gritty sensation in the eye
with redness of the sclera. This is associated with connective tissue disorders
and rheumatoid arthritis. If left untreated this can cause perforation of the
eye. It is not associated with HLA-B27. Genetic testing for HLA-B27 can be
useful in difficult diagnostic cases for seronegative spondyloarthropathies
and in counselling patients regarding chances of their offspring developing
the same disease.

Question 3

Heart failure (1)
A 69-year-old man presents with a range of signs and symptoms that give
the impression of heart failure.
Which of the following is not a feature of heart failure?
A Hepatomegaly
B Non-pitting oedema
C Pulsus alternans
D Raised jugular venous pressure
E Tricuspid regurgitation

Answer 3

B. Non-pitting oedema
Heart failure is a disease of chronic, insidious onset that can fi rst present
with shortness of breath, persistent cough or insomnia. The heart fails
to maintain adequate cardiac output for a variety of reasons; the harder
it tries, the faster it fails. Occasionally, the left ventricle will weaken to
the point where it cannot empty effi ciently. The subsequent raised enddiastolic
volume causes a pre-stretched ventricle, leading to a more forceful contraction (Starling’s law). This alternating strong–weak pattern can be
seen in the ECG as pulsus alternans (varying amplitudes of the R-wave).
A column of blood builds up proximal to the left ventricle, in the lungs,
causing pulmonary oedema. This creates afterload upon the right ventricle,
which can lead to tricuspid regurgitation. The bottleneck of blood can
extend further, through the right side of the heart and hence JVP is raised
(the heart is unable to pull all the blood from the jugular vein through the
lungs and the left ventricle). Furthermore, close to the right side of the heart,
the inferior vena cava remains full of blood, leading to oedema in the liver
(hepatomegaly). Ankle veins swell with blood as the heart fails to suck the
blood vertically against gravity. The increased hydrostatic pressure results in
fluid extravasation into tissues. The push of a finger is enough to displace
this tissue fluid, hence this ankle oedema is pitting. Causes of non-pitting
oedema include lymphoedema and pretibial myxoedema.

Question 4

Scoring systems (1)
A 57-year-old man with a history of alcohol abuse presents with a 12-hour
history of severe central epigastric pain radiating through to the back.
Blood tests reveal a normal white cell count, amylase 2250 U/ml, LDH 530
IU/L, calcium 2.2 mmol/L, albumin 38 g/dl, urea 12 mmol/L and blood
glucose 14 mmol/L. An arterial blood gas reading demonstrates a pO2 of
10.2 kPa on room air.
What is his Glasgow score?
A 0
B 1
C 2
D 3
E 4

Answer 4

C. 2
The massively raised amylase with this clinical picture supports a diagnosis
of acute pancreatitis. Acute pancreatitis can be a life-threatening condition
for it is an unpredictable disease that can cause quick deterioration. To aid
management, the modified Glasgow criteria were devised to help prognosis
and triage patients to an appropriate level of care. The eight parts of the
Glasgow criteria are as follows (1 point for each):
Age >55 years
White cell count >15 × 103/μL
Urea >16 mmol/L
Glucose >10 mmol/L
Arterial pO2 <8 kPa
Albumin <32 mmol/L
Calcium <2.0 mmol/L
Lactate dehydrogenase >600 mmol/L
This man scores 2 for age and his raised blood sugar, which is a moderate
risk for pancreatitis. A score of 3 and above should indicate to the physician
the need to discuss the case with intensive care as these patients are more
likely to need invasive monitoring of their fluid balance. Patients should
ideally be re-scored 48 hours after admission.

Question 5

Management of hypercalcaemia
A 70-year-old man presents to the emergency department with a cough
productive of blood-stained green sputum and shortness of breath. A chest
X-ray demonstrates a suspicious lesion in the right lower zone associated
with consolidation. On further questioning, he admits to recent weight loss
and back pain. Blood tests show:
Na+ 137 mmol/L
K+ 3.8 mmol/L
Urea 14.5 mmol/L
Creatinine 160 μmol/L
Corrected Ca2+ 3.0 mmol/L
PO4 0.33 mmol/L
Alk Phos 450 mmol/L
Which of the following is NOT appropriate in the management of this
patient?
A Check patient’s urea and electrolyte level and serum calcium level twice
daily
B Consider starting intravenous bisphosphonate
C Consider starting loop diuretics
D Rehydration with intravenous normal saline
E Request an urgent isotope bone scan

Answer 5

E. Request an urgent isotope bone scan
The most common causes of hypercalcaemia are primary hyperparathyroidism
and malignant hypercalcaemia. Patients with hypercalcaemia
present with polyuria, polydipsia, renal colic, nausea, anorexia, lethargy,
dyspepsia, peptic ulceration, constipation, depression, drowsiness and impaired
cognition. Urgent fluid replacement with 0.9% saline is essential
(3–6 L over 24 hours) and the patient’s urea and electrolyte, and calcium
levels should be checked twice daily. Loop diuretics could aid renal clearance
of calcium. Intravenous bisphosphonate (e.g. pamidronate) could
cause a fall in calcium by causing bone reabsorption. Its effect is maximal
at 2–3 days and lasts a few weeks.

Question 6

Nosebleeds
A 55-year-old man is referred to haematology with repeated nosebleeds,
malaise, weight loss and night sweats. Investigations show a raised white
cell count, mainly neutrophils and myelocytes, anaemia, increased urate
and increased alkaline phosphatase. On blood film there are no blast cells.
Genetic studies show a t(9:22) translocation encoding for the BCR-ABL gene.
What is his diagnosis?
A Acute lymphoblastic leukaemia
B Acute myeloid leukaemia
C Chronic lymphoblastic leukaemia
D Chronic myeloid leukaemia
E Non-Hodgkin lymphoma

Answer 6

D. Chronic myeloid leukaemia
The t(9:22) translocation (i.e. a translocation between chromosomes 9
and 22) encoding for the BCR-ABL gene is also known as the Philadelphia
chromosome and is the genetic mutation in over 90% of the cases of chronic
myeloid leukaemia. The mutation is a balanced translocation, which leads to
increased tyrosine kinase activity disturbing stem cell kinetics.
Chronic myeloid leukaemia (CML) is a myeloproliferative disorder. Its
peak incidence is 50–70 years and it is rare in children. There is excessive
proliferation of myeloid cells in the bone marrow. Patients typically have
massive splenomegaly, anaemia, bruising and infection on a background
of generalised illness. A blood film shows myeloblasts (granulocyte
precursors) and granulocytosis. Patients with CML but without the
Philadelphia chromosome have a worse prognosis compared to those with
the translocation. There are three stages of disease in CML: 1) the chronic
phase (which is responsive to treatment), 2) the accelerated phase (where
the disease is difficult to control) and 3) the blast crisis phase (where the
disease progresses into an acute leukaemia, usually AML). The median
survival rate is 5 years. Death usually occurs within months of blast
transformation (from bleeding and infection). Chemotherapy is often
used and allogeneic stem cell transplantation can provide a cure. Having
isolated the gene there is now an effective drug that can block the BCRABL
gene – imatinib mesylate – which can reverse the effects of the protein
and produce remission in 95% of patients with this mutation.

Question 7

Failure to thrive
A 5-month-old girl presents with failure to thrive, pallor and mild
jaundice. The child has frontal bossing of the skull, prominent maxillae
and hepatosplenomegaly.
Which of the following is the most likely diagnosis?
A Congenital biliary atresia
B Congenital hypothyroid
C Hydrops fetalis
D Lead poisoning
E Thalassaemia major

Answer 7

E. Thalassaemia major
Beta-thalassaemia major is an autosomal recessive disorder in which there
is a complete lack of production of the haemoglobin chain beta-globin.
It occurs mainly in Mediterranean and Middle Eastern families and is
due to a point mutation on chromosome 11. Because patients with betathalassaemia
major have mutations on both alleles and cannot synthesise
any beta-globin, they cannot produce functioning adult haemoglobin
(HbA – α2β2). This condition typically presents within the first year of
life, when the production of fetal haemoglobin (HbF – α2γ2) begins to fall.
Affected children become generally unwell and fail to thrive secondary
to a severe microcytic anaemia. Ferritin levels are normal since there is
no iron deficiency. A compensatory increase in the synthesis of HbF and
haemoglobin A2 (HbA2 – α2δ2) occurs, which can be detected on serum
electrophoresis.
Clinical features include failure to thrive, lethargy, pallor and jaundice. On
examination there is often hepatosplenomegaly (secondary to extramedullary
haematopoiesis) with bossing of the skull, maxillary prominence and long
bone deformity (due to excessive intramedullary haematopoiesis). The
treatment of beta-thalassaemia major is with regular blood transfusions, aiming to maintain the haemoglobin concentration above 10 g/dL, or with
allogenic bone marrow transplant. Regular iron chelation therapy (with
desferrioxamine) is required to prevent iron overload and deposition in
vital organs such as the heart, liver and endocrine glands. If untreated, death
is inevitable in the first years of life.
Beta-thalassaemia minor describes people heterozygous for the beta-chain
chromosomal mutation. Affected persons have only mild anaemia and
are usually asymptomatic. Alpha-thalassaemia is common in South-East
Asia. There are four alpha genes, and therefore four variants of alphathalassaemia.
Affected patients can be asymptomatic (one gene corruption),
have mild hypochromic anaemia (two corruptions), have HbH disease
(three corruptions) or can die in utero (all four genes are corrupted). HbH
is a beta-chain tetramer that is functionally useless. Treatment options are
as for beta-thalassaemia.

Question 8

Acute coronary syndrome (2)
A 52-year-old man presents to his GP with chest pain and is afraid he is
having a heart attack. His most significant symptom toward a diagnosis of
acute coronary syndrome (ACS) is:
A Chest pain located just under the left nipple, near the apex beat
B A past medical history of controlled angina
C A sharp chest pain
D Shortness of breath
E Tachycardia

Answer 8

B. A past medical history of controlled angina
ACS typically presents with a central/retro sternal chest pain of a crushing
character. Stable angina can evolve into the unstable angina of ACS.
Tachycardia and shortness of breath are more likely attributed to anxiety
in a patient who is scared. It should be noted that these symptoms should
never be ignored. Patients in the midst of real cardiac pain are also likely to
be anxious and may not necessarily offer textbook characterisations of what
they are experiencing. A brief admission to monitor troponin levels 8–12
hours after symptom onset is the correct course of action for any patient
presenting with possible cardiac chest pain.

Question 9

Antibiotics (1)
From the following list of antibiotics and their predominant cover, which
is incorrect?
A Co-amoxiclav – broad-spectrum Gram-positive and -negative cover
B Flucloxacillin – Gram-positive cover
C Gentamicin – Gram-negative cover
D Metronidazole – anaerobic cover
E Vancomycin – Gram-negative cover

Answer 9

E. Vancomycin – Gram-negative cover
Vancomycin is a glycopeptide antibiotic that binds D-ala-D-ala peptide
sequences to prevent peptidoglycan cell wall synthesis, therefore it is active
against Gram-positive but not Gram-negative bacteria (the peptidoglycan
cell wall is a far more prominent and important feature in Gram-positive
bacteria). Co-amoxiclav has good Gram-positive and -negative cover as well
as much anaerobic cover, so is a widely used antibiotic in many scenarios,
however, its broad-spectrum characteristic means it disturbs the gut flora
and can predispose to Clostridium difficile infection. Flucloxacillin is a
narrow-spectrum antibiotic with only Gram-positive cover and is often
used in staphylococcal infections. Gentamicin has predominantly Gramnegative
cover although it has some Gram-positive cover. Metronidazole
has wide anaerobic cover and is often used in surgery due to the presence of
anaerobes in the bowel.

Question 10

Topical steroids
A 25-year-old man presents with a severe outbreak of a dry erythematous
itchy rash that is now widespread, despite having used a steroid cream
prescribed by his GP. It appears to be eczema, and along with regular
emollients for the dryness, and antihistamines for the itch, you would like
to prescribe some very potent topical steroids for a brief period to attempt
get on top of the outbreak.
Which of the following is classed as a very potent topical steroid?
A Betnovate
B Dermovate
C Eumovate
D Hydrocortisone
E Prednisolone

Answer 10

B. Dermovate
Topical steroids are categorised as mild, moderate, potent, or very potent.
The more potent the steroid, the more likely it is to have side effects such as
skin atrophy, striae and increased risk of infection. Subsequently, the more potent the topical steroid, the less time it should be used for. Hydrocortisone
is a mild steroid, eumovate a moderate steroid, betnovate a potent steroid,
and dermovate is a very potent steroid. Prednisolone is an oral steroid, and
if the dermovate does not get on top of the eczema, there may be a case for
using systemic oral steroids – although they are not normally used in eczema
and carry a greater risk of side effects when used: patients can become
cushingoid, hypertensive, diabetic, immunosuppressed, osteoporotic, and
may develop steroid-induced psychosis.

Question 11

Skin lesion (2)
A 7-year-old boy presents with multiple erythematous patches, over both
sides of his face, head, neck, upper chest and left arm and shoulder, which
appear to be covered in a honey-coloured crust. His mother says that the
lesions have spread, over about a week, starting at the left neck and radiating
outwards. The child appears to be upset and the lesions are itchy. There is
no past medical history and no history of recent infections.
Which of the following diagnoses is most likely?
A Eczema
B Erysipelas
C Impetigo
D Psoriasis
E Staphylococcal scalded skin syndrome

Answer 11

C. Impetigo
Itchy erythematous skin could be due to a number of things, including
eczema and psoriasis, but two features another diagnosis. Firstly, the
spreading from a starting point, rather than patches appearing at the same
time or cropping up in unrelated positions over time, suggests infection.
Secondly, the honey or golden crust is a purulent discharge. Both features are
classical of impetigo. Impetigo is a contagious, superficial infection caused
most commonly by Staphylococcus aureus. The infection spreads when
lesions burst to release an exudate, which spreads the bacteria outwards and
leaves behind the crust. Swabs should be taken for microscopy, culture, and
most importantly sensitivities. In contained infections, topical antibiotics
can be prescribed, but in more widespread disease, systemic antibiotics
should be used. Antibiotics with good activity against Staphylococci, such
as flucloxacillin, should be used pending sensitivities. Antihistamines can
be prescribed to help with itching. Underlying skin disease, such as eczema,
can predispose.
Erysipelas is a superficial form of cellulitis with a well-demarcated edge to the
patch of warm, tender erythema. It can spread more rapidly. Staphylococcal
scalded skin syndrome follows infection with group 2 coagulase-positive
staphylococci, and a circulating toxin causes epidermal splitting in the
granular layer, leading to peeling of the epidermis in large sections. A focus
of infection should be sought, and systemic flucloxacillin should be started.
It normally develops over a period of hours to days.

Question 12

Management of Parkinson’s disease (2)
A 75-year-old man has been recently diagnosed with Parkinson’s disease
and started on levodopa (L-DOPA), which has helped his tremor and
bradykinesia significantly. However, in the past week he had a fall shortly
after getting out of his chair, during which he briefly blacked out, and
afterwards was sweating and felt cold.
Which of the following side effects most likely explains the fall?
A Dyskinesia
B Hallucinations
C Nausea
D None, he actually has multiple system atrophy and not Parkinson’s disease
E Postural hypotension

Answer 12

E. Postural hypotension
The fall happened soon after he stood up, involved a brief loss of consciousness,
and he had an excess sympathetic discharge shortly afterwards. It certainly
sounds like an episode of postural hypotension. Standing up requires
a significant degree of autonomic nervous system function to detect and react to the intravascular volume redistribution. As L-DOPA is a precursor
in the synthesis of not only dopamine but also noradrenaline, excess
peripheral noradrenaline and dopamine can cause widespread autonomic
dysfunction, symptoms of which include nausea and postural hypotension.
Hallucinations can occur with L-DOPA but are unlikely to cause a fall,
and dyskinetic movements could cause a fall but don’t explain the loss of
consciousness. Multiple system atrophy (MSA), a Parkinson-plus syndrome,
indeed includes prominent autonomic dysfunction, however it is extremely
rare and would be less likely to respond well to L-DOPA therapy (as this
man has).

Question 13

Management of skin lesions (2)
A 76-year-old man presents with a vesicular eruption on the left side of his
forehead only. It is severely painful and the vesicles have started to crust
over. On examination, the area affected is well-demarcated. You also note a
red eye with apparent conjunctivitis.
Given the most likely diagnosis, which of the following treatments is the
most appropriate?
A Intravenous aciclovir
B Oral aciclovir
C Topical aciclovir
D Topical antibiotic
E Topical steroids

Answer 13

B. Oral aciclovir
This patient has herpes zoster infection. Herpes zoster is caused by
the varicella zoster virus, which is responsible for chickenpox. After an
episode of chickenpox, the virus resides in dorsal root ganglia and can
be transported retrogradely along the sensory axons to emerge and cause
herpes zoster, most commonly in a dermatomal distribution (although it
can be diffuse, usually in immunosuppressed patients). It appears most
commonly on the trunk and is called “shingles”, however it can affect
branches of the trigeminal nerve, most commonly the ophthalmic, where
it can also cause conjunctivitis, keratitis or iridocyclitis. Concurrent illness
or immunosuppression can trigger zoster, and it is more common in the
elderly. Many episodes will resolve spontaneously after around 2 weeks so the decision to treat depends on severity. Oral aciclovir is usually the first port
of call, although intravenous aciclovir can be used in disseminated zoster.
Topical acyclovir or steroids are unlikely to help, and topical antibiotics are
not indicated unless there is concurrent bacterial infection.

Question 14

Management of asthma (2)
A 28-year-old woman with a past medical history of asthma has been using
her inhaled salbutamol more frequently of late. She is currently on an
inhaled short-acting beta-2 agonist and an inhaled steroid 800 μg/day. She
has been compliant.
What should you do?
A Add inhaled long-acting beta-2 agonist
B Add leukotriene receptor antagonist
C Add oral steroid
D Increase dose of inhaled steroid
E Prescribe inhaled short-acting beta-2 agonist as regular therapy

Answer 14

A. Add inhaled long-acting beta-2 agonist
The pharmacological management of chronic asthma follows a stepwise
approach. There are five steps in the management. In step 1, patients with
mild intermittent asthma are prescribed an inhaled short-acting beta-2
agonist. If there has been an exacerbation of asthma in the last 2 years, if
patient uses inhaled beta-2 agonists three times a week or more, or if patient
reports symptoms three times a week or more, then inhaled corticosteroids
should be added on. In step 3, if the patient‘s asthma control remains poor,
an add-on therapy should be considered such as a long-acting beta-2 agonist.
If the long-acting beta-2 agonist is not working, addition of other therapies
such as leukotriene receptor antagonists or theophylline can be considered.
In step 4, the inhaled corticosteroid can be increased to 2000 μg/day as
well as the addition of a fourth drug (e.g. leukotriene receptor antagonist,
theophylline) if symptoms persist. The final step involves continuous or
frequent use of oral prednisolone. Osteoporosis can be prevented by using
bisphosphonates. Once asthma control is established, the dose of the inhaled
or oral corticosteroid should be titrated to the lowest dose at which effective
control can be achieved.

Question 15

Diagnosis of abdominal pain (2)
A 56-year-old man with a long history of alcohol abuse presents to the
emergency department with abdominal pain. On examination he has a
distended abdomen with shifting dullness and has a temperature of 38.2°C.
What is the most likely diagnosis?
A Bowel obstruction
B Liver cirrhosis
C Mallory–Weiss syndrome
D Perforated peptic ulcer
E Spontaneous bacterial peritonitis (SBP)

Answer 15

E. Spontaneous bacterial peritonitis (SBP)
Patients with ascites are at risk of developing SBP, which usually presents
with severe generalised abdominal pain, worsening ascites, vomiting, fever
and rigors. The most common causative organisms are Gram-negative
bacilli such as Escherichia coli and Klebsiella spp., which enter the systemic
circulation from the intestinal lumen and colonise the ascitic fluid. SBP can
lead to rapid decompensation of liver disease causing hepatic encephalopathy
and death. The diagnosis of SBP is confirmed by paracentesis, which involves
taking a sample of ascitic fluid from the abdomen using a needle. The
aspirated ascitic fluid is analysed for white cell count, glucose and protein.
In addition, the fluid should be sent to microbiology for culture and Gram
staining. If the white cell count is above 250 cells/mm3 the patient requires
intravenous antibiotics (e.g. cefotaxime or ceftriaxone). Some patients
also require human albumin solution to restore their intravascular fluid
volume. Patients who have had a previous episode of SBP, and patients who
are considered to be at high risk of developing SBP, should be considered for prophylactic oral antibiotics (e.g. norfloxacin or ciprofloxacin). The
development of spontaneous bacterial peritonitis corresponds to a poor
long-term prognosis.

Question 16

Investigation of stroke
A 52-year-old man with hyperthyroidism, vitiligo and a 30 pack/year
smoking history, presents to hospital with an acute clumsiness of his right
hand. Neurological examination reveals normal cranial nerves, and the
only abnormal feature on the limb examination is some past pointing
and dysdiadochokinesis in the right hand. Diffusion-weighted magnetic
resonance imaging (MRI) reveals a small right-sided cerebellar infarct.
Which of the following investigations is unlikely to be helpful?
A Carotid Doppler
B Electrocardiogram (ECG)
C Erythrocyte sedimentation rate (ESR)
D Full blood count
E Magnetic resonance angiography

Answer 16

A. Carotid Doppler
The carotid Doppler is unlikely to be helpful as the infarct was clearly in
the posterior circulation territory. The ECG may reveal atrial fibrillation,
which is especially a possibility given his hyperthyroidism. As he is quite
young for a stroke, it is important to be aware of unusual causes; a full
blood count (FBC) may reveal polycythaemia (he is a smoker in his 50s)
or an abnormal platelet reading, and the ESR may be elevated if there is a
vasculitic process behind the infarct – he has a background of autoimmune
disease. Magnetic resonance angiography (MRA) will show if there is an
obvious site of posterior circulation occlusion, and in the absence of any
obvious reason, this may be helpful in guiding further investigation and
management, e.g. intravenous angiography +/– stenting for vertebral artery
dissection.

Question 17

Diagnosis of multiple sclerosis (2)
Which of the following findings on lumbar puncture is most commonly
used to suggest a diagnosis of multiple sclerosis (given a correlative clinical
picture)?
A Autoantibodies to myelin basic protein
B Oligoclonal bands on electrophoresis
C Presence of red blood cells
D Raised lymphocytes
E Raised protein

Answer 17

B. Oligoclonal bands on electrophoresis
Whilst there is sometimes a rise in lymphocytes, this is both mild and rare,
and given the pathology you might not expect to see red blood cells in the
cerebrospinal fluid, which is backed up by observation. The protein level can
be elevated, but this is rather non-specific. Whilst no single specific antigen
has been identified in multiple sclerosis, antibodies to various myelinating
cell-associated proteins have been found in patients with multiple sclerosis,
myelin basic protein among them. However, testing for this autoantibody
alone would not be sensitive enough. Oligoclonal bands on electrophoresis
are found in 50–60% of patients after the first attack, and up to 95% of
patients with established disease. Whilst this isn’t entirely MS specific, being
found in chronic meningitis, neurosarcoidosis and rare infectious nervous
system diseases, they persist indefinitely in MS unlike the other disorders, and
when combined with an appropriate clinical picture are highly suggestive of
multiple sclerosis.

Question 18

Investigation of abdominal pain
A 59-year-old woman with known polycythaemia vera presents to
the emergency department with right upper quadrant pain, tender
hepatomegaly and gross ascites, which has come on suddenly. There is no
jaundice.
What is the next most appropriate investigation?
A Cytomegalovirus (CMV) screen
B Gamma-glutamyl transferase (GGT) levels
C Hepatitis serology
D Hepatic vein Doppler ultrasound scan (USS)
E Human immunodeficiency virus (HIV) testing

Answer 18

D. Hepatic vein Doppler ultrasound scan (USS)
Sudden-onset ascites with tender hepatomegaly in the absence of jaundice
should hold a high degree of suspicion for Budd–Chiari syndrome. This
syndrome describes the effects of hepatic vein outflow obstruction,
commonly by thrombosis or malignant obstruction. Risk factors include
malignancy, thrombophilias, trauma and the oral contraceptive pill. This can
present either acutely or chronically. Diagnosis is made by Doppler scanning
of the hepatic vein or venography. A similar clinical picture is produced by
right-sided heart failure, constrictive pericarditis and inferior vena cava
obstruction, which should also be excluded during your investigations.
Treatment depends on the cause but may involve thrombolysis.

Question 19

Diagnosis of tuberculosis
A 27-year-old man presents with a 3-month history of cough with
some blood streaking, loss of weight and night sweats. You suspect
tuberculosis.
Which of the following chest X-ray findings is not consistent with
tuberculosis?
A Cavitating lesion
B Consolidation of a lobe
C Diffuse 1–2 mm spots of increased opacity
D Perihilar ground-glass changes
E Pleural effusion

Answer 19

D. Perihilar ground-glass changes
A cavitating lesion is not the most common appearance of tuberculosis
on chest X-ray but it could represent a tuberculoma; it could also be a
tumour, abscess or granuloma. Lobar consolidation can be seen and has
a differential of bacterial pneumonia (although the symptoms and their
length differentiate this). The diffuse small opacifications sounds like miliary
tuberculosis, which suggests a blood-borne dissemination that will usually
be more acute in onset and tuberculosis may be affecting other organs.
Tuberculosis can cause pleural effusions, however, the perihilar ground-glass
change does not suggest tuberculosis. Hilar lymphadenopathy can be seen
in tuberculosis. Finally, tuberculosis is diagnosed when the mycobacteria are
seen and multiple sputum samples should be sent for staining and culture.
The absence of classical X-ray changes does not rule it out.

Question 20

Meningitis
A 40-year-old man presents to the emergency department after 8 hours
of a severe frontal headache, photophobia and two episodes of vomiting.
On examination his Glasgow Coma Score (GCS) is 13 (eyes open to voice,
verbal response with confused sentences, and moving freely), he has a
temperature of 38.5°C, a BP of 95/65 mmHg and pulse rate of 105 bpm.
He is photophobic and has neck stiffness. There is no rash and no focal
neurological deficit as far as you can ascertain. His wife is present and is
able to elaborate on the history. He has hit the bottle quite hard since losing
his job 7 months ago and has been drinking 8–10 cans of lager per night. He
has recently been coughing a lot and feeling unwell. He still lives at home
and has not appeared to lose weight recently.
What are you most concerned that this might be?
A Listeria meningitis
B Meningococcal meningitis
C Pneumococcal meningitis
D Tubercular meningitis
E Viral meningitis

Answer 20

C. Pneumococcal meningitis
The sudden onset and severe nature with sepsis precludes viral meningitis.
There seems to be no overt risk of immunocompromise (homelessness,
promiscuity or intravenous drug use) and the onset was acute, thus making
tubercular meningitis unlikely. The lack of likely immunocompromise,
age below 50 and lack of cranial nerve involvement all point away from
Listeria meningitis. Given the alcoholism and recent chest infection,
pneumococcal meningitis seems quite likely and carries a worse prognosis
than meningococcal meningitis – a 20% mortality rather than 10% in
meningococcal disease. His low GCS and sepsis (fever, tachycardia and low
blood pressure) are also bad signs and this man may require intensive care
unit (ITU) admission.

Question 21

Electrocardiogram (2)
A 63-year-old male smoker, on diuretics for essential hypertension, presents
to the emergency department with chest pain. His ECG is presented to you.
Amongst other signs, you notice T-wave inversion.
Which of the following does not cause T-wave inversion?
A Hyperkalaemia
B Left bundle branch block
C Left ventricular hypertrophy
D Myocardial infarction
E Myocardial ischaemia

Answer 21

A. Hyperkalaemia
The T-wave on an ECG denotes the repolarisation of the myocardium after
systole. In the context of a patient presenting with chest pain, an inverted
T-wave is a sign of myocardial infarction (also indicated by ST elevation/
depression and the development of Q-waves). A similar process, to a lesser
degree, occurs in myocardial ischaemia. Left ventricular hypertrophy and
left bundle branch block change the nature of ventricular myocardium
repolarised and hence may also invert the T-wave. Hyperkalaemia will
increase the rate of repolarisation that leads to a peaked or “tented” T-wave,
rather than an inverted one. The accompanying P-wave may reduce and the
QRS complex may broaden. Hyperkalaemia is potentially serious and may
lead to asystole or ventricular fibrillation. Hypokalaemia may flatten the
T-wave and yield subtle U-waves (downward deflections) after the T-wave. Hypokalaemia may lead to cardiac arrhythmias, constipation and fatigue,
and is commonly caused by diuretics.

Question 22

Management of epilepsy
A 24-year-old man presents with two episodes of involuntary clonic beating
of the right arm followed by loss of consciousness with urinary and faecal
incontinence. He then had a headache and confusion for some hours (noone
witnessed any episode). A diagnosis of motor partial seizures with
secondary generalisation is made. He is started on valproate.
Which of the following would you NOT tell him (as it is untrue)?
A Computed tomography (CT)/magnetic resonance imaging (MRI) is
indicated to look for a cause
B No driving for 1 year after the last seizure
C On valproate, blood tests will need to be monitored for liver enzymes and
full blood count
D Valproate may cause gum hypertrophy
E Valproate may cause hair loss

Answer 22

D. Valproate may cause gum hypertrophy
Even when medicated, it is a Driver and Vehicle Licensing Agency (DVLA)
regulation that patients abstain from driving for 1 year after their last attack.
That is, unless they have had seizures only in their sleep for the last 3 years.
Whilst the patient is under 25 years, the focal nature of the attack onset is an
indication for a CT/MRI to look for a structural cause, e.g. tumour or arteriovenous
malformation. Valproate can cause hair loss, thrombocytopenia and
hepatitis, but gum hypertrophy is not a common side effect – it is a side
effect of phenytoin.

Question 23

Diagnosis of HIV-related illness
A 42-year-old woman with known HIV presents with a 3-week history
of dry cough and increasing breathlessness. She is now unable to walk
100 yards without becoming short of breath. You suspect pneumocystis
pneumonia.
Which of the following tests is the best way to confirm the diagnosis?
A Bronchoalveolar lavage
B Chest X-ray
C Computed tomography (CT) of the chest
D Cytology of sputum induced by nebulised hypertonic saline
E Hypoxaemia on arterial blood gas

Answer 23

A. Bronchoalveolar lavage
Pneumocystis pneumonia is the commonest AIDS-defining illness, caused
by the fungus Pneumocystis jiroveci (previously known as Pneumocystis
carinii). Patients present with a dry cough, fever, shortness of breath, weight
loss and night sweats.
Bronchoalveolar lavage involves bronchoscopy and thus is quite invasive,
but it is highly sensitive and 90% specific (95% with biopsy). Radiological
changes can be conspicuously absent early on, but a perihilar ground-glass
pattern of change can be found. Sputum cytology on sputum obtained
by hypertonic saline nebuliser induction is specific although less sensitive than bronchoalveolar lavage – as low as 30% sensitive. Hypoxaemia on
the arterial blood gas is a non-specific finding. The other advantage of
bronchoalveolar lavage is that it will be specific in the diagnosis of other
HIV-related pulmonary diseases such as tuberculosis.
Treatment is with co-trimoxazole (trimethoprim and sulphamethoxazole).
Patients with HIV who have a low CD4 count (<200/μl) receive prophylaxis
for pneumocystis (e.g. co-trimoxazole or dapsone).

Question 24

Management of acne (1)
A 17-year-old girl shuffles awkwardly into clinic with her mother, who
explains that her daughter has suffered from severe acne for the last few
years and nothing that the GP has tried has shifted it. On examination,
as well as several large pustules on her face and comedones, some
scarring is beginning to develop. You would like to start oral isotretinoin
(roaccutane).
When counselling about side effects, which of the following would you
NOT advise the patient?
A Blood tests should be taken to monitor for hyperlipidaemia
B Blood tests should be taken to monitor for raised liver function tests
C Most people feel depressed on isotretinoin
D Parts of the skin and lips often get very dry
E Pregnancy should be avoided as teratogenicity is a risk

Answer 24

C. Most people feel depressed on isotretinoin
Isotretinoin is a vitamin A analogue that markedly reduces the production
of sebum. Increased sebum production is believed to contribute to
the pathogenesis of acne vulgaris, as hair follicles blocked off with
hyperkeratosis, which subsequently have raised sebum production
within, become comedones, and it is here that the conditions are rife for
Proprionibacterium acnes to proliferate and induce an inflammatory
response. When other therapies have failed, when lesions are severe, when
scarring is beginning to form or a patient is psychologically affected,
systemic isotretinoin can be used, and it leads to complete clearance in
90% of patients. Dry lips is an extremely common side effect and other
skin areas can become very dry – this is the mode of action of the drug so
the patient must attempt to put up with as much as possible rather than
cover the dry skin in thick moisturisers. Isotretinoin is highly teratogenic
and therefore with female patients of reproductive age, a frank discussion
should be held regarding contraception. Hyperlipidaemia and raised liver
function tests are common and should be monitored – they often resolve
after termination of therapy.
There are some reports of an increased incidence of depression amongst
patients taking isotretinoin, although these are not consistently reproduced,
and the return of someone’s skin to a normal appearance can often ameliorate
depression rather than cause it. Patients should be warned that there is a
concern that some patients might become depressed when on isotretinoin
and to be vigilant for this, but not that most people feel depressed as this is
untrue.

Question 25

Non-steroidal anti-inflammatories
A 75-year-old woman is suffering from osteoarthritis of the hips and knees
and paracetamol is not touching the pain. You want to consider use of a
non-steroidal anti-inflammatory drug (NSAID).
Which of the following is NOT a relative or absolute contraindication to
NSAID use?
A Asthma
B Concomitant aspirin use
C Concomitant steroid use
D Congestive cardiac failure
E Previous gastric ulcers

Answer 25

C. Concomitant steroid use
NSAIDs can cause bronchospasm and therefore should be avoided in
asthma. NSAIDs commonly cause gastric erosions and ulceration and
therefore should be avoided in aspirin users due to the risk of severe
gastrointestinal bleeding; for the same reason they should be avoided when
there is a significant history of gastric or duodenal ulcers. Anyone taking
long-term NSAIDs should be considered for use of a proton pump inhibitor.
NSAIDs can cause fluid retention and so should be avoided in patients with
moderate or severe heart failure. In diseases such as rheumatoid arthritis,
NSAIDs and steroids are commonly used together.

Question 26

Renal transplantation
Which of the following is NOT a contraindication to renal transplantation?
A Active tuberculosis
B High-pressure urinary tract, e.g. posterior urethral valves
C Malignancy
D Severe arterial disease with stenosed iliac vessels
E Severe ischaemic heart disease with unstable angina and congestive
cardiac failure

Answer 26

B. High-pressure urinary tract, e.g. posterior urethral valves
Active or chronic infection is a contraindication, as the required
immunosuppression could lead to extreme worsening of infection, and
the transplant could become infected or the patient could die. Malignancy
not only could spread to the transplant, but it could become worse with
immunosuppression and the patient is also likely to have a shortened life
expectancy. If the iliac vessels are stenosed, the transplanted kidney is
unlikely to be perfused well enough to function properly (given that the
blood supply to the transplant comes from the iliac vessels). Severe ischaemic
heart disease is a contraindication to renal transplantation. Posterior urethral valves can affect male newborns, and can be mild or
severe in their obstruction of the urinary tract. Without timely intervention,
the urinary tract (including the bladder) can become high pressure and the
kidneys can fail. Transplanting a new kidney onto a high-pressure tract is
likely to accelerate failure of the transplant. This needn’t prevent transplant
and, if it is a severe problem, an ileal conduit or neobladder can be formed
as an alternative to the high-pressure tract.

Question 27

Management of oliguria (2)
An 87-year-old man with a background of Alzheimer’s disease, a previous
stroke, and atrial fibrillation (for which he is on warfarin), is admitted
with increasing amounts of painless haematuria. He is catheterised and
the warfarin stopped. The haematuria reduces and then seems to stop.
Problems with his residential home are delaying discharge. You note 2 days
later that his creatinine level has risen to 250 μmol/L. When you go to see
him, he seems stable, as do his observations. He does seem slightly dry with
reduced skin turgor and delayed capillary refill. The urine output has not
been carefully documented in the last few days, and by your calculations,
100 ml have been passed in the last 24 hours. On examination he appears
to have a mass in his central lower abdomen.
What should be your next step?
A Fluid challenge of 500 ml normal saline over 10 minutes
B Flush the catheter with 50 ml warm saline and then aspirate
C Insert a suprapubic catheter
D Remove the catheter
E Request an ultrasound of the urinary tract

Answer 27

B. Flush the catheter with 50 ml warm saline and then aspirate
The problem that seems to have occurred here, and is quick and easy to
diagnose, is that clots of blood may be being retained and blocking the end
of the catheter (clot retention). Flushing the catheter with some warm saline
and then aspirating may dislodge the clot and allow some urine and smaller clots to pass through the catheter. It may also allow the larger clot to pass
through or disrupt it and allow its fragments to pass through. If this needs to
be done repeatedly, a large-bore three-way catheter (with a separate channel
for irrigation) can be inserted. Removing the catheter alone is unlikely
to resolve the fact that clots are blocking the urinary tract. Insertion of a
suprapubic catheter seems unnecessary at this stage and is associated with
a high morbidity, due to potential perforation of the bowel, and severe
urinary tract infections can occur. Requesting an ultrasound of the urinary
tract would be superfluous at this stage, as clinically there is a likely cause
(a large bladder is felt and there is a history of macroscopic haematuria).
The patient may indeed be slightly dry, but clinically this is not the most
likely cause of the renal impairment. A fluid challenge could be given if an
obstructive uropathy can be ruled out, to see if hypovolaemia was indeed the
cause, and intravenous fluids may still be needed if the catheter can begin
draining with the saline irrigation.

Question 28

The unresponsive patient (2)
A 70-year-old woman presents with hip pain following a fall. The fall appears
to have been related to alcohol ingestion and, whilst the history is vague,
she denies loss of consciousness and does not seem grossly confused, nor is
there evidence of infection. She is a smoker and has a history of ischaemic
heart disease and depression. A hip fracture is ruled out and she is admitted
for rehabilitation purposes. On day 3, however, the nurses report that she is
increasingly sleepy and muddled. On examination, observations are stable,
she is apyrexial, her Glasgow Coma Score (GCS) is 12, and on neurological
examination, she appears to have some mild left arm and leg weakness with
normal or brisk reflexes. There is no hemianopia or other neurological
deficit.
Which of the following is most likely to explain the changes?
A Bacterial meningitis
B Intracerebral haemorrhage
C Lacunar infarct
D Subarachnoid haemorrhage
E Subdural haematoma

Answer 28

E. Subdural haematoma
The first thing to note is that it is possible that the low GCS and confusion
could be due to something separate, e.g. overuse of opioids and an otherwise
asymptomatic urinary tract infection (UTI) – but opioid use is likely to
have been highest on admission with the pain from the injury subsequently
decreasing. Action would be taken to rule out such things but as the defects
have all started together, and an intracranial cause would be the most
worrying explanation, an intracranial lesion must be considered. Whilst
meningitis can give focal neurological defects and a decreased GCS, the
stable observations, lack of a temperature, and lack of reported headache,
neck stiffness or photophobia make this unlikely. A lacunar infarct can
present as a pure motor weakness with no other focal defect, however, this is
likely to come on acutely with decreased reflexes and there is unlikely to be
a drop in GCS. Subarachnoid haemorrhage can present with a drop in GCS
and focal neurology, but more commonly present with unconsciousness,
seizures or thunderclap headache with meningism, which are all absent.
There is no reason in the story why a subarachnoid haemorrhage would
cause deficits to appear at this stage. Strokes do not usually cause a drop
in GCS, although a large intracerebral haemorrhage could by mass effect
– however, the neurology in the patient is subacute, mild and limited.
An intracerebral haemorrhage large enough to drop the GCS would give
more than simply mild motor weakness, and do so more acutely (though
neurology could progress as the haemorrhage and oedema evolved).
This patient is an elderly woman who could have possibly sustained a head
injury and may be an alcoholic – these factors put her at risk of a subdural
haemorrhage. Subdural haemorrhage commonly presents with a subacute development of impaired GCS and focal neurology, and does not always have
a history of head injury and therefore this seems the most likely explanation.
In any case, a computed tomography (CT) scan of the head is indicated and
would show any of the lesions discussed.