Paper 4

Question 1

Airway management
You fi nd an 80-year-old man collapsed in the street. He is unresponsive
and is making a snoring sound. An ambulance has been called but has yet
to arrive.
Which of the following is the best course of action?
A Cricothyroidotomy
B Do nothing till the ambulance arrives
C Finger sweep
D Head tilt chin lift
E Place in the recovery position

Answer 1

D. Head tilt chin lift

Question 2

2. Management of pulmonary embolism
   A 26-year-old woman presents to the emergency department with an oxygen
   saturation reading of 80% on air with a background history of increased
   breathlessness on exertion over the course of a week. She has not travelled
   abroad recently and does not have a family history of thromboembolism.
   On examination, there is elevation of the jugular venous pressure and
   accentuation of the pulmonary component of the second heart sound.
   A chest examination is unremarkable. A chest X-ray is normal and a
   subsequent CT angiography demonstrated a pulmonary embolism.
   Which of the following management is NOT appropriate?
   A Request an echocardiogram
   B Request a thrombophilia screen
   C Request tumour markers
   D Start treatment dose low-molecular-weight heparin
   E Start warfarin treatment

Answer 2

C. Request tumour markers

Question 3

3. Skin manifestations of systemic disease (1)
   A 34-year-old woman presents to the GP complaining of a new rash. The
   skin under her arms and on the back of her neck is dark and velvety in
   texture. She has a past medical history of diabetes for which she takes
   insulin.
   What is the most likely diagnosis?
   A Acanthosis nigricans
   B Diabetic dermopathy
   C Erythema ab igne
   D Hyperhidrosis
   E Xanthelasma

Answer 3

A. Acanthosis nigricans

Question 4

Scoring systems (3)
Which of the following scoring systems can be used to assess the risk of an
adverse outcome following an upper gastrointestinal bleed?
A Breslow score
B CURB (Confusion, Urea, Respiratory rate, Blood pressure, Age) score
C Ranson’s criteria
D Rockall score
E Waterlow score

Answer 4

D. Rockall score

Question 5

Diagnosis of abdominal pain (4)
A 64-year-old man presents to the emergency department with a large rectal
bleed and left-sided abdominal pain. He has a long history of constipation.
He has a temperature of 38.4°C and a heart rate of 110 bpm.
What is the most likely cause?
A Angiodysplasia
B Bowel malignancy
C Diverticulitis
D Haemorrhoids
E Pseudomembranous colitisC

Answer 5

C. Diverticulitis

Question 6

Investigation of hepatomegaly
A 55-year-old man is being investigated for irregular heart rhythms. He has
a medical history of diabetes mellitus. He explains that exercise is diffi cult
for him due to joint pains. During the examination it is noted that he has
tan skin pigmentation and hepatomegaly.
Which of the following investigations could reveal the aetiology of his
symptoms?
A Haematinics
B Serum caeruloplasmin
C Short synacthen test
D Alpha-1 antitrypsin
E Gamma-GT

Answer 6

A. Haematinics

Question 7

Substance use (1)
A 64-year-old woman is an inpatient on a surgical ward following an aboveknee
amputation. The nursing staff said she vomited earlier and she has
been unresponsive since her operation a few hours ago. On examination,
you noticed her pupils are small and she has a respiratory rate of 5 breaths/
min.
Which of the following is the most likely reason for this clinical picture?
A Alcohol withdrawal
B Opiate use
C Opiate withdrawal
D Sedative use
E Sedative withdrawal

Answer 7

B. Opiate use

Question 8

Home oxygen
A 66-year-old man with a 10-year history of chronic obstructive pulmonary
disease is assessed in the respiratory clinic for eligibility for long-term
domiciliary oxygen therapy.
Which of the following is NOT a criterion for prescription of long-term
oxygen therapy?
A No exacerbation of chronic obstructive pulmonary disease (COPD) for
the previous 5 weeks
B Patient has stopped smoking
C Patient has chronic hypoxaemia with PaO2 <7.3 kPa
D Presence of pulmonary hypertension with PaO2 <8.0 kPa
E Two arterial blood gases showing PaO2 <7.3 kPa within 7 days

Answer 8

E. Two arterial blood gases showing PaO2 <7.3 kPa within 7 days

Question 9

Management of chest pain (2)
A 68-year-old woman is recently not coping at home. She is now
experiencing episodes of central, choking chest pain and shortness of
breath on exertion. Her ECG is normal, as are her bloods and chest X-ray.
Which of the following will NOT help her during her next episode?
A Bisoprolol
B Glyceryl trinitrate (GTN) spray
C Morphine
D Oxygen
E Salbutamol nebulisers

Answer 9

E. Salbutamol nebulisers

Question 10

Antibiotics in pregnancy
A 33-year-old woman who is 10 weeks’ pregnant develops increased
frequency of urination and dysuria. Urine dip is positive for nitrites.
Which of the following antibiotics could be used to empirically treat the
urinary tract infection?
A Ciprofloxacin
B Co-amoxiclav
C Doxycycline
D Trimethoprim

Answer 10

B. Co-amoxiclav

Question 11

Left ventricular hypertrophy
An 80-year-old man attends the general practice for an annual check-up
of his hypertension. He gingerly tells you all about his “left ventricular
hyperthingummy”. You check him and his records for confirmatory signs
and symptoms.
Which of the following is NOT a sign of left ventricular hypertrophy?
A Inverted T-waves
B Left axis deviation
C Pansystolic murmur
D R-wave in V6 >25 mm
E The sum of the magnitude of the S-wave in V1 and R-wave in V5 >35mm

Answer 11

C. Pansystolic murmur

Question 12

Shortness of breath (4)
A 79-year-old woman who was admitted to hospital with a fractured right
neck of femur 1 week ago suddenly becomes acutely unwell on the ward
6 days after her operation. She complains of sudden-onset of shortness
of breath and chest tightness. The pain is exacerbated by deep breathing.
She has a past medical history of hypertension, hypercholesterolaemia and
asthma. Her observations include temperature 37.8°C, pulse rate 108 bpm,
blood pressure 96/66 mmHg, respiratory rate 26/min and saturations 89%
on room air. On examination, her chest is clear to both auscultation and
percussion. An electrocardiogram (ECG) shows sinus tachycardia without
bundle branch block.
What is the most likely diagnosis?
A Acute exacerbation of asthma
B Myocardial infarction
C Pneumonia
D Pneumothorax
E Pulmonary embolism (PE)

Answer 12

E. Pulmonary embolism (PE)

Question 13

Polycystic kidney disease (1)
A 43-year-old man presents with intermittent haematuria. On examination
of the abdomen, bilateral masses are felt and an ultrasound reveals
polycystic kidneys. You explain the syndrome to him. He is concerned that
his son may develop the disease. He does not believe his wife suffers from
the condition.
What is the probability that his son will develop the disease?
A Negligible
B One in two
C One in four
D One in a thousand
E One in two thousand

Answer 13

B. One in two

Question 14

Management of status epilepticus
A 35-year-old homeless man presents to the emergency department
unconscious and fitting. You estimate that he has been fitting now for 35
minutes. He smells of alcohol and looks dishevelled. He has an adequate
airway and is breathing 10 L/min O2. His pulse and blood pressure are
within normal range, and his capillary glucose is normal.
What should your immediate management be?
A Diazepam 2 mg intravenously
B Diazepam 2 mg intravenously and Pabrinex intravenously
C Lorazepam 4 mg intravenously and Pabrinex intravenously
D Lorazepam 8 mg intravenously
E Lorazepam 8 mg intravenously and Pabrinex intravenously

Answer 14

C. Lorazepam 4 mg intravenously and Pabrinex intravenously

Question 15

Overdose and antidotes (2)
A 17-year-old female has taken 20 paracetamol tablets 3 hours ago in an
attempt to end her life after an argument with her mum. She has now
attended hospital with regret and is asking for treatment.
Which of the following should be administered?
A Atropine
B Desferrioxamine
C Digibind
D N-acetylcysteine
E Sodium bicarbonate

Answer 15

D. N-acetylcysteine

Question 16

Murmur (2)
You are examining a tearful young child who has fractured her arm. On
auscultation you hear an ejection systolic murmur. There is no cyanosis.
Which of the following prevents you reassuring her calm dad that his
daughter has no serious heart problem?
A A history of cyanosis
B The fracture needs to heal first
C The second heart sound is split
D The murmur disappears on sitting up
E The murmur is soft

Answer 16

A. A history of cyanosis

Question 16

Management of shortness of breath (2)
A 60-year-old man presents to the emergency department with shortness
of breath for 3 hours and chest pain. He also complains of a right calf pain
that he has had for 2 weeks. He has a past medical history of hypertension,
recent stroke and disseminated lung cancer. His observations include
temperature 37.0°C, pulse rate 112 bpm, blood pressure 100/54 mmHg,
respiratory rate 26/min and saturations 87% on room air. There is no
significant finding on chest examination. An electrocardiogram (ECG)
shows sinus tachycardia and new right bundle branch block. A computed
tomography (CT) pulmonary angiography confirmed massive pulmonary
embolism.
What is the most appropriate initial treatment?
A Intravenous caval filters
B Oral warfarin
C Prophylactic dose of low-molecular-weight heparin
D Thrombolysis
E Treatment dose of low-molecular-weight heparin

Answer 16

E. Treatment dose of low-molecular-weight heparin

Question 17

Helicobacter pylori infection
A 55-year-old man is found to have a gastric ulcer following an endoscopy
for left upper quadrant pain. A rapid urease test is positive for H. pylori
infection.
What treatment does this man need?
A H2 antagonist plus metronidazole and clarithromycin
B Metronidazole, clarithromycin and amoxicillin
C PPI plus metronidazole and clarithromycin
D PPI plus H2 antagonist plus an antibiotic
E Steroids + PPI + metronidazole

Answer 17

C. PPI plus metronidazole and clarithromycin

Question 18

Management of hyperglycaemia (2)
A 55-year-old man presents to his GP with increasing lethargy and
polyuria. He has a past medical history of ischaemic heart disease and
congestive cardiac failure. He smokes 30 cigarettes per day and drinks
alcohol occasionally. He has a body mass index (BMI) of 32. His random
blood glucose is 14.0 mmol/L and fasting blood glucose level is 9.0
mmol/L.
Which of the following management is NOT appropriate in this patient?
A Advise the patient to change his diet and stop smoking
B Metformin should be considered as the first-line oral treatment option
for overweight patients
C Sulphonylureas and metformin could be considered as a combined
therapy if glycaemic control is not optimal
D Sulphonylureas should be considered if patient is intolerant to metformin
E Thiazolidinediones can be added to metformin and sulphonylurea
combination therapy if control is not optimal

Answer 18

E. Thiazolidinediones can be added to metformin and sulphonylurea
combination therapy if control is not optimal

Question 19

Drug administration
A 79-year-old woman is started on high-dose steroids for giant cell arteritis.
As therapy will likely be maintained for at least a year, she needs bone
protection. The decision is made to start alendronate 70 mg once weekly.
How would you advise her to take the tablet?
A Take it in bed at least half an hour before rising for breakfast
B Take it whilst sitting or standing just before breakfast
C Take it whilst sitting or standing upright at least half an hour after
breakfast with minimal sips of water
D Take it with plenty of water whilst sitting or standing upright at least half
an hour after breakfast
E Take it whilst sitting or standing upright at least half an hour before
breakfast with plenty of water

Answer 19

E. Take it whilst sitting or standing upright at least half an hour before
breakfast with plenty of water

Question 20

Arterial blood gases (2)
A 59-year-old man is admitted to the emergency department following a
fall. He complains of increased tiredness and jerking movement of his legs,
which led to his fall from the staircase. He is a smoker. On arrival, he has
an oxygen saturation level of 76% in air, and an arterial blood gas reading
demonstrates: pH 7.40, PaO2 6 kPa, PaCO2 9.3 kPa, HCO3
− 35 mmol/L on
room air. His respiratory rate was 20/min.
What does this blood gas result show?
A Acute type 1 respiratory failure
B Acute type 2 respiratory failure
C Compensated chronic type 2 respiratory failure
D Metabolic acidosis
E Respiratory alkalosis

Answer 20

C. Compensated chronic type 2 respiratory failure

Question 21

Fluid therapy
A 55-year old man fractures his ankle attempting to replicate the latest
dance fad he has seen his children do. He is otherwise fit and well and
is haemodynamically stable. The fracture requires open reduction and
internal fixation. The trauma registrar has said that he needs to be nil-bymouth
from midnight, however the operating list is always changing and
new emergencies may come in. There are at least three cases that are likely
to get done before him. Your request that he have breakfast as he is likely
to be done later in the day is met with derision. He will need physiological
fluid replacement when he is nil-by-mouth. He weighs 70 kg.
Which of the following regimens is closest to physiological needs?
A 1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose
in 24 hours
B 1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose
with 20 mmol potassium in 24 hours
C 2 × 1 L 0.9% normal saline with 20 mmol potassium and 1 L 5% dextrose
in 24 hours
D 2 × 1 L 0.9% normal saline with 20 mmol potassium and 1 L 5% dextrose
with 20 mmol potassium in 24 hours
E 3 L Hartmann’s in 24 hours

Answer 21

B. 1 L 0.9% normal saline with 20 mmol potassium and 2 ¥ 1 L 5%
dextrose with 20 mmol potassium in 24 hours

Question 22

Haemolytic anaemia
In haemolytic anaemia which is the correct pattern of investigations that
you would expect to see?
A Low haemoglobin, low unconjugated bilirubin, high haptoglobin
B Low haemoglobin, high unconjugated bilirubin, high urinary
urobilinogen, and low haptoglobin
C Microcytic anaemia, normal bilirubin, high transferrin, low ferritin
D Normocytic anaemia, normal bilirubin, low iron, low TIBC, normal
ferritin
E Normal haemoglobin raised conjugated bilirubin, normal haptoglobin

Answer 22

B. Low haemoglobin, high unconjugated bilirubin, high urinary
urobilinogen, and low haptoglobin

Question 23

Basic life support
You are the designated driver on Saturday night and are soberly walking to
your car with your friends. You spot an elderly man lying on the ground.
He is not breathing and has no pulse although he is warm. You ask a friend
to call 999. His airway is clear. Your praecordial thump fails.
The most likely way for his heart to resume beating is:
A Adrenaline
B Defibrillation
C Cerebral reoxygenation
D Chest compressions
E Recovery position

Answer 23

B. Defibrillation

Question 24

Causes of tremor
Which of the following diseases is the most common reason for misdiagnosis
of Parkinson’s disease?
A Corticobasal degeneration
B Essential tremor/familial tremor
C Progressive supranuclear palsy
D Pugilist encephalopathy
E Wilson’s disease

Answer 24

Causes of tremor

Question 25

Biological therapies
A 46-year-old woman has been diagnosed with rheumatoid arthritis and
has been on methotrexate for over a year, but sadly her disease is not under
control. She wants to know about the new drugs used for rheumatoid
arthritis that she heard about at a patients’ association.
Which of the following statements about biological disease-modifying
anti-rheumatic drugs (DMARDs) is NOT true?
A A chest X-ray should be taken before starting to rule out latent tuberculosis
(which could be reactivated)
B If the patient’s disease gets worse whilst on biological therapy, switching
from one biological DMARD to another is unlikely to produce an
improvement
C Injection site reactions for subcutaneously injected agents are common
D The more commonly used agents target and inhibit tumour necrosis
factor alpha (TNF-alpha)
E They can be used in combination with methotrexate

Answer 25

B. If the patient’s disease gets worse whilst on biological therapy,
switching from one biological DMARD to another is unlikely to produce
an improvement

Question 26

Cognitive impairment (1)
A 55-year-old woman presents with mild cognitive impairment and
disinhibition without significant mood change. She also has falls and
urinary incontinence. She has no major past medical history or medications,
and has never smoked or drank much alcohol. On examination, there are
no cranial nerve or arm defects, however the legs appear to have increased
tone, upgoing plantars and clonus bilaterally with some weakness of hip
and knee flexion bilaterally.
Which of the following diagnoses may explain the picture?
A Alzheimer’s disease
B Benign intracranial hypertension
C Lewy body dementia
D Normal pressure hydrocephalus (NPH)
E Vascular dementia

Answer 26

D. Normal pressure hydrocephalus (NPH)

Question 27

Complications of blood transfusion
A 45-year-old man is having his second transfusion following blood loss
from a road traffic collision. During the transfusion he developed a fever of
38.5°C and rigors.
What should your immediate action be?
A Contact haematology for urgent advice
B Give steroids and antihistamines and continue transfusion
C Start antibiotics
D Stop the transfusion, take blood cultures and provide supportive measures
E Take blood cultures and continue transfusion

Answer 27

D. Stop the transfusion, take blood cultures and provide supportive
measures

Question 28

Diagnosis of numbness
A 32-year-old woman presents to her GP complaining of tingling and
numbness around her mouth for 1 week. Occasionally, she also develops
painful carpal spasm. She has a past medical history of Graves disease for
which she just recently had subtotal thyroidectomy.
What is the most likely diagnosis?
A Hypercalcaemia
B Hypermagnesaemia
C Hypocalcaemia
D Hypophosphataemia
E Hypothyroidism

Answer 28

C. Hypocalcaemia

Question 29

Diagnosis of postural hypotension
A 62-year-old woman presents to the emergency department with collapse.
She felt dizzy when she tried to stand up from a sitting position. She did
not lose consciousness. She denied any visual disturbances, headache or
head injury. She also complained of fatigue over the past month. She takes
only omeprazole and paracetamol. An ECG showed normal sinus rhythm.
Blood pressure was 102/50 mmHg with a postural systolic drop of 30
mmHg. Blood test showed revealed Na+ 126 mmol/L, K+ 6.5 mmol/L, urea
10.0 mmol/L, creatinine 139 μmol/L.
Which of the following will be most useful in establishing the diagnosis?
A Low-dose dexamethasone suppression test
B Random cortisol level
C Renal ultrasound scan
D Short synacthen test
E Water deprivation test

Answer 29

D. Short synacthen test

Question 30

Management of delirium
A 70-year-old man, admitted two days previously with a mechanical fall
and needing rehabilitation, becomes increasingly anxious and agitated on
the ward. He has been pestering the nurses for some “moonshine”, and he
is now disorientated in place and time. He claims to have seen little gnomes
dashing between patients’ beds. You suspect delirium tremens.
Which of the following represents best management?
A Intravenous Pabrinex
B Oral Pabrinex
C Reducing dose chlordiazepoxide
D Reducing dose chlordiazepoxide and intravenous Pabrinex
E Reducing dose chlordiazepoxide and oral Pabrinex

Answer 30

D. Reducing dose chlordiazepoxide and intravenous Pabrinex

Question 31

Liver function tests
Which of the below results is the best indicator of poor liver function?
A Raised alanine transferase
B Raised albumin
C Raised alkaline phosphatase
D Raised bilirubin
E Prolonged prothrombin time

Answer 31

E. Prolonged prothrombin time

Question 32

Diagnosis of cough (6)
A 60-year-old woman presents to her GP with a chronic cough associated
with thick, yellow sputum for the past year. Sometimes, the sputum is
blood-tinged. She had been prescribed multiple courses of antibiotics
but they did not seem to help. She had a past medical history of severe
pneumonia that required admission to the intensive care unit for 20 days.
On chest examination, there are inspiratory crackles throughout the lung
fields, with normal vesicular breath sounds.
Which of the following is the most likely differential diagnosis?
A Bronchial carcinoma
B Bronchiectasis
C Chronic pulmonary obstructive disease
D Idiopathic pulmonary fibrosis
E Pneumonia

Answer 32

B. Bronchiectasis

Question 33

Diagnosis of skin lesions (1)
A 31-year-old man presents with a 1-month history of a growing round,
flat, erythematous lesion on the left thigh. The border is slightly more
erythematous than the rest of the lesion and has some flakiness of the
skin. The lesion itches. The patient also has had long-standing itchy scales
between his toes.
Which of the following investigations would help confirm the most likely
diagnosis?
A Excisional biopsy
B Incisional biopsy
C Punch biopsy
D Skin scrapings to be sent for microscopy culture and sensitivities
E Skin swab to be sent for microscopy culture and sensitivities

Answer 33

D. Skin scrapings to be sent for microscopy culture and sensitivities

Question 34

Electrocardiogram (4)
A 56-year old man has a myocardial infarction the day after a hernia repair.
You request an ECG and then compare it to his pre-admission trace. You
notice ST-segment changes in leads II, III and aVF.
In which part of the myocardium is the infarct?
A Anterior
B Anterolateral
C Anteroseptal
D Inferior
E Posterior

Answer 34

D. Inferior

Question 35

Diagnosis of neurological dysfunction (2)
A 19-year-old female university student presents with problems in both
arms and difficulty walking. Since starting her course she has had difficulty
writing, typing, and other such activities, and thus has struggled to keep
up with the workload. She says the arms have “felt unusual” for around 6
months. She describes finding small burns and blisters on her arms that she
can’t remember getting in the first place. In the last few weeks she has also
fallen twice when walking up the stairs. The only other thing she describes
is some mild occipital headaches that have increased in frequency lately.
She is otherwise fit and well.
On examination, there is a loss of pinprick sensation found throughout
the arms and on the back to around T3 level. Her hands appear to have
some element of small muscle wasting and there is some loss of power
throughout the arms. Reflexes are hard to elicit or possibly absent. In the
legs, there is some mild symmetrical weakness, and the knee reflexes appear
brisk. Plantars appear equivocal.
What is the most likely diagnosis?
A Cervical spondylosis
B Multiple sclerosis
C Psychogenic neurological symptoms
D Syringomyelia
E Viral transverse myelitis

Answer 35

D. Syringomyelia

Question 36

Management of ischaemic stroke
A 74-year-old woman presents to hospital with an acute right-sided
hemiparesis, and is found to have a left middle cerebral artery infarct
on diffusion-weighted magnetic resonance imaging (MRI). It is her first
stroke. Her past medical history is unremarkable. Her blood pressure
is normal and her electrocardiogram (ECG) shows sinus rhythm with
occasional ventricular ectopics. Blood tests show normal cholesterol and
normal glucose. On carotid Doppler she is found to have an 85% stenosis
of the left carotid.
Which of the following treatments will NOT benefit her?
A ACE-inhibitor
B Aspirin
C Left carotid endarterectomy
D Statin
E Warfarin

Answer 36

E. Warfarin

Question 37

Malignant melanoma (1)
A 24-year-old woman who has been travelling to India on a gap year
presents to clinic as she is concerned about a “funny-looking mole” on her
leg. She is unsure how long it has been there.
Which of the following is not a concerning feature of a mole when
considering a diagnosis of malignant melanoma?
A Asymmetry
B Bleeding
C Border irregularity
D Colour different to that of other moles on patient
E Itching

Answer 37

D. Colour different to that of other moles on patient

Question 38

Nipple discharge
A 42-year-old woman presents to her GP with a 2-month history of nipple
discharge from her left breast. The discharge is milky in colour. No blood
is noted. She has a past medical history of hypertension, type 2 diabetes
mellitus and depression. She has been taking regular medication for
these conditions. She has been amenorrhoeic for 6 months. A provisional
diagnosis of hyperprolactinaemia is made.
What of the following is NOT appropriate management?
A Breast examination
B Serum prolactin
C Stop antidepressants
D Thyroid function tests
E Urgent computed tomography (CT) of the brain

Answer 38

E. Urgent computed tomography (CT) of the brain

Question 39

Palpitations (1)
A 52-year-old woman presents to the GP with intermittent palpitations
and breathlessness that has occurred over the last few weeks. She denies
chest pain. Her electrocardiogram (ECG) shows sinus tachycardia and she
does not appear to be anaemic.
Which blood test would be of most use in confirming the diagnosis?
A Haematinics
B Lactate
C No blood test required
D Thyroid function tests
E Troponin

Answer 39

D. Thyroid function tests

Question 40

Diagnosis of endocrine disease
A 33-year-old man presents to his GP complaining of worsening headaches
and tiredness for the last 2 months. He denies drinking alcohol and smokes
occasionally. He has a good appetite and has gained 3 pounds over the past
month. He also noticed that he has difficulty in biting his food, and has a
reduced libido. On examination, he is tall, with an oval-shaped face, large
hands and prominent lower jaw.
Which of the following tests is the most useful in the initial diagnosis?
A Growth hormone levels during an oral glucose tolerance test
B IGF-1 levels
C MRI scan of pituitary fossa
D Pituitary function test
E Random growth hormone levels

Answer 40

A. Growth hormone levels during an oral glucose tolerance test

Question 41

Emollient use
In which of the following circumstances would use of emollients be illadvised?
A Acne vulgaris
B Contact dermatitis
C Eczema
D Psoriasis
E Wound healing

Answer 41

A. Acne vulgaris

Question 42

Medications in acute renal failure
An 83-year-old man is admitted with acute confusion. He has an extensive
medical history including atrial fibrillation, type 2 diabetes, osteoarthritis,
hypertension and some mild congestive cardiac failure, for which he takes
several medications. He appears clinically dry, with a pulse of 115/min, dry
mucous membranes and a capillary refill rate of 4 seconds. He is noted
to have a reduced urine output with concentrated urine. His creatinine is
235 μmol/L.
Which of the following medications does not need be reduced or stopped?
A Amlodipine
B Diclofenac
C Digoxin
D Furosemide
E Metformin

Answer 42

A. Amlodipine

Question 43

Rectal bleeding (2)
A 27-year-old woman presents to the GP complaining of intense sharp pain
on passing stools, accompanied by bright red bleeding noticed on the toilet paper. She has no fever and is otherwise well in herself. She recently had a
course of codeine phosphate following a sprain injury to her ankle.
What is the most likely diagnosis?
A Anal abscess
B Anal carcinoma
C Anal fissure
D Crohn’s disease
E Haemorrhoids

Answer 43

C. Anal fissure

Question 44

Signs of liver disease (2)
A 15-year-old girl is being investigated for behavioural changes and is
found to have a green–yellow discolouration around her iris on slit lamp
examination.
What is the name of this feature?
A Arcus senilis
B Caput medusae
C Kayser–Fleischer rings
D Lens dislocation
E Xanthoma

Answer 44

C. Kayser–Fleischer rings

Question 45

Indications for haemodialysis in acute renal failure
Which of the following is NOT an indication for haemodialysis in patients
with acute renal failure?
A Acidosis with a pH <7.2
B Hypertension >220 mmHg systolic or 160 mmHg diastolic
C Persistent potassium of >7 mmol/L
D Refractory pulmonary oedema
E Uraemic pericarditis

Answer 45

B. Hypertension >220 mmHg systolic or 160 mmHg diastolic

Question 46

Sexually transmitted infections (3)
A 43-year-old woman attends the GP with a 3-month history of a grey–white
vaginal discharge which she says has a “fishy” odour. She is systemically
well and has no menstrual abnormalities.
What is the most likely diagnosis?
A Bacterial vaginosis (BV)
B Candida
C Chlamydia
D Gonorrhoea
E Syphilis

Answer 46

A. Bacterial vaginosis (BV)

Question 47

Systemic lupus erythematosus (2)
A 35-year-old woman has had a diffuse mild arthralgia with a fluctuating
time course for the last year. There is never much synovitis to be seen on
examination and inflammatory markers are only mildly raised. ANA is
positive.
Which of the following would make a diagnosis of systemic lupus
erythematosus (SLE)?
A Anterior uveitis
B Anti-ribonucleoprotein antibodies
C Erosions on X-rays of affected joints
D Painful palpable purple lumps on the shins
E Red rash across the cheeks, worse in summer

Answer 47

E. Red rash across the cheeks, worse in summer

Question 48

Uraemia
Which of the following is NOT a sign of uraemia?
A Clouding of consciousness
B Hiccoughs
C Lemon yellow skin tone
D Spider naevi
E Twitching

Answer 48

D. Spider naevi

Question 49

Urinary frequency (1)
A 30-year-old man presents to the medical assessment unit with a history
of excessive drinking and urination. He has been going to the toilet about
7–8 times per day for 1 month. His random blood glucose is 9.3 mmol. His
results on admission show:
Na+ 130 mmol/L
K+ 3.5 mmol/L
Urea 2.4 mmol/L
Creatinine 80 μmol/L
Corrected Ca2+ 2.34 mmol/L
Plasma osmolality 609 mOsm/kg
Urine osmolality 145 mOsm/kg
Water deprivation test – urine osmolality 296 mOsm/kg after DDAVP 2 μg
administered intramuscularly
What is the most likely diagnosis?
A Acute tubular necrosis
B Cranial diabetes insipidus
C Nephrogenic diabetes insipidus
D Primary polydipsia
E Type 2 diabetes mellitus

Answer 49

B. Cranial diabetes insipidus