PTS SBA 3

Question 1

2. A 74-year-old female attends General Practice complaining of no longer being able to get comfy in bed. For the past 2 months she has noticed she needs more and more pillows under her head and often wakes up in the middle of the night ‘gasping for breath’. On examination, you notice bilateral oedematous legs. Which of the following is the most appropriate first line investigation?
   A. Chest X-ray.
   B. CT chest.
   C. NT-proBNP (BNP) levels.
   D. ECG.
   E. Echocardiogram.

Answer 1

C. NT-proBNP (BNP) levels.
(A) CXR shows signs of heart failure (ABCDE) but is not diagnostic and not first line

Question 2

5. A 62-year-old male attends his General Practice complaining on worsening dyspnoea. He has a past medical history of heart failure. The GP wants to investigate him further and orders a chest x-ray. Which of the following is not a sign associated with heart failure on chest x-ray?
   A. Interstitial oedema
   B. Cardiomegaly
   C. Dilated bronchioles
   D. Prominent upper lobe vessels.
   E. Pleural effusion.

Answer 2

Question 5- Answer C- Dilated Bronchioles
Chest Xray signs for heart failure are ABCDE (Alveolar oedema, Kerley B lines (interstitial oedema), Cardiomegaly, Dilated upper lobe vessels, pleural Effusion). Therefore C- dilated bronchioles is incorrect.

Question 3

. A 55-year-old male is invited by his local practice to undergo an NHS health check. During the check the healthcare professional uses a risk calculator in order to determine his 10– year probability of suffering from a cardiovascular event. What is the name of this risk calculator?
A. CHA2DS2–VaSc
B. QRisk3
C. ABCD2
D. Wells’ score
E. Modified Duke Criteria

Answer 3

B. QRisk3

Question 4

8. A 67-year-old male is referred to a cardiologist due to detection of a new pansystolic murmur on examination. The cardiologist suspects a diagnosis of mitral regurgitation. What is the most appropriate investigation to confirm the diagnosis?
   A. Echocardiogram
   B. ECG
   C. Troponin-T
   D. NT-proBNP (BNP) levels
   E. Chest X-ray

Question 5

0. A 19-year-old male collapses whilst playing a football match for his local team. Paramedics arrive rapidly and find him in cardiac arrest and attempt to defibrillate him. His brother who was playing football with him tells you that he’s normally fit and well but for the past few months he had been experiencing some chest pain, palpitations and unexplained syncope. His brother also mentions that their dad died at a young age due to “some heart problems”. What is the most likely cause of this patient’s cardiac arrest?
   A. Atrial fibrillation.
   B. Aortic stenosis.
   C. ST elevation myocardial infarction (STEMI).
   D. Non-ST elevation myocardial infarction (NSTEMI).
   E. Hypertrophic cardiomyopathy.

Answer 5

E. Hypertrophic cardiomyopathy.
Hypertrophic cardiomyopathy is most likely given that he’s young and has a +ve family history of young cardiac death. Other diagnoses are unlikely due to his young age.

Question 6

14. Earlier today Betty, a 67-year-old lady, had a fall. She was sitting in her chair for most of the morning but on standing up she immediately collapsed to the floor. She did not lose consciousness but did hit her head. She is brought to A&E where a reassuring CT scan shows no abnormalities or bleed. You perform a lying and standing blood pressure, diagnose postural hypotension and appropriately reduce some of her anti-hypertensive medications. Which of the following BP results reflect those recorded in Bettys notes?
    A. Lying 118/82, standing 138/98
    B. Lying 120/110, standing 107/93
    C. Lying 137/103, standing 109/88
    D. Lying 147/99, standing 137/96
    E. Lying 150/102, standing 140/9

Answer 6

(A) Normal lying and standing BP response- 118/82 then increased to 138/90
(B) Narrow pulse pressure- 120/110 seen in aortic stenosis
(C)Postural hypotension- 137/103 to 109/88 because 137-109= drop of 28mmHg. (D) Stage 1 hypertension- 147/99 (BP>140/90= stage 1)
(E) Wide pulse pressure- 150/102 seen in aortic regurgitation

If there is a systolic drop >20mmHg or if the systolic BP drops to less than 90 (from any original starting point) the patient is diagnosed with postural hypotension
. Pharmacological management includes medications such as fludrocortisone 1st, midrodine 2nd.

Question 7

16. Which of the following signs is most likely to indicate that a patient is in septic shock?
    A. Apyrexial
    B. Bradycardia
    C. Bounding Pulse
    D. Reduced airway entry
    E. Paraesthesia

Answer 7

Answer C- Bounding Pulse
(A)- septic shock is caused by wide-spread infection in the blood therefore the patient will be pyrexic. (B)- bradycardia -a classical sign of cardiogenic shock- septic shock most likely to be tachycardic. (D)- reduced airway entry- anaphylactic shock because of swelling of the airways. (E) Paraesthesia isn’t a common feature of any type of shock. Therefore, the answer is C- bounding pulse.

Question 8

17. Which of the following is least likely to cause hypovolaemic shock?
    A. Gastrointestinal Bleed
    B. Severe Diarrhoea and Vomiting Secondary to Gastroenteritis
    C. A 3rd degree burn to the torso
    D. Pancreatitis
    E. Pulmonary Embolism

Answer 8

Answer E- Pulmonary Embolism.
PE does not cause any form of fluid/blood loss.
Hypovolemic shock is caused by blood/ fluid loss. (A) GI bleeding causes loss of blood. (B) severe diarrhoea/vomiting would cause loss of fluid. (C) burns cause loss of fluid. (D) pancreatitis is a known cause of hypovolaemic shock.

Question 9

20. An 84-year-old lady is rushed into A&E with sudden onset epigastric pain which radiates to the back. Vital signs: HR: 112, BP: 92/63, RR: 36, O2: 89%, Temperature: 37C. Her hands are cold and clammy. What investigation is it important to do first?
    A. Chest Xray
    B. Coagulation screen
    C. MRI
    D. Troponin I
    E. Ultrasound scan

Answer 9

Question 20- Answer E- Ultrasound Scan
From the history of sudden onset epigastric pain and her vital signs indicating shock one diagnosis to work to exclude is a ruptured abdominal aortic aneurysm (AAA). This is done by performing a rapid USS of the aorta, if confirmed it requires immediate surgical repair.

Question 10

21. Which of the following is not a typical symptom of a patient with hyperthyroid disease?
    A. Diarrhoea
    B. Polyuria
    C. Increased appetite
    D. Irritability
    E. Weight loss

Answer 10

B. Polyuria

Question 11

23. A 38-year-old lady has noticed that she has become increasingly tired, put on 6kg of weight in the last month and is feeling depressed. Which of the following Thyroid Function Tests would most likely fit with this patient’s clinical picture?
    A. High TSH, Low T3 and Low T4
    B. High TSH, High T3 and Low T4
    C. Low TSH, High T3 and High T4
    D. Low TSH, Low T3 and Low T4
    E. Normal TSH, Normal T3 and Normal T4

Answer 11

A. High TSH, Low T3 and Low T4

Question 12

25. What is the most common cause of secondary hypoadrenalism?
    A. Autoimmune disorder
    B. Cessation of corticosteroid treatment
    C. Long term corticosteroid usage
    D. Pituitary Surgery
    E. TB

Answer 12

C. Long term corticosteroid usage

Question 13

Which of these is not a cause of Syndrome of Inappropriate secretion of ADH (SIADH)?
A. Alcohol withdrawal
B. Dehydration
C. Head injury
D. Pneumonia
E. Small cell lung cancer

Answer 13

B. Dehydration

Question 14

34. A serious complication of peptic ulcers is erosion into nearby vessels causing intra- abdominal bleeding. Which vessel would be mostly likely to bleed as a result of a duodenal wall eroding posteriorly?
    A. Gastroduodenal artery
    B. Left gastric artery
    C. Short gastric artery
    D. Superior mesenteric artery
    E. Superior pancreaticoduodenal artery

Answer 14

A. Gastroduodenal artery

Question 15

35. In a patient with appendicitis, where is the initial pain usually felt?
    A. Left iliac region
    B. McBurney’s point
    C. Peri-umbilical region
    D. Right hypochondrium
    E. Right lumbar region/flank

Answer 15

Answer C- Peri-umbilical region
Visceral pain is poorly localised and so inflammation of appendix (right iliac region) is referred to umbilical region. Only when the inflammation becomes more serious and touches the parietal peritoneum does the pain localise to McBurney’s point/right iliac region
(B) McBurney’s point- specific point of pain seen in PTs with appendicitis after inflammation has reached parietal peritoneum. Pain shifts here from umbilical region. Point is located 2/3 from umbilicus to ASIS

Question 16

36. Which of these would you not generally see in a patient with Coeliac disease?
    A. Angular stomatitis
    B. Aphthous ulcers
    C. Loss of appetite
    D. Steatorrhoea
    E. Unintentional weight loss

Answer 16

Answer C- Loss of appetite
Loss of appetite is not a typical symptom of coeliac disease, there isn’t a direct loss of appetite. Patients have weight loss but this isn’t due to decreased appetite, it’s due to malabsorption (A) Angular stomatitis: soreness at corners of lips, seen in severe cases of coeliac disease
(B) Aphthous ulcers: mouth ulcers, commonly seen in more severe cases
(D) Steatorrhea: classic symptom of coeliac disease, stinking/fatty/loose stools (E) Unintentional weight loss: malabsorption due to villous atrophy

Question 17

37. Jane, a 49-year-old lady, has recently been diagnosed with gastro-oesophageal reflux disease and has come to see the GP for a review of her medications. She is otherwise fit and well. Which of the following medications is least likely to be prescribed to alleviate her symptoms?
    A. Alginates
    B. Antacids
    C. Antibiotics
    D. Histamine receptor antagonists
    E. Proton-pump inhibitors

Answer 17

Answer C- Antibiotics
Antibiotics are not used to alleviate GORD. They are used for infections or commonly as part of triple therapy management of H.pylori peptic ulcers (PPI + Metronidazole + Clarithromycin)
(A) Alginates: form a physical barrier and work by forming neutral floating gel raft on top of the stomach to prevent acids from backing up into the oesophagus
(B) Antacids: work by neutralising the HCL in the stomach
(C) Histamine receptor antagonists: histamine binds to H2 receptors of parietal cells to trigger acid production, if these receptors have antagonists bound, histamine cannot bind meaning less acid is produced
(D) Proton-pump inhibitors: inhibit gastric acid secretion by blocking H+/K+ ATPase enzyme

Question 18

38. What is the most common cause of small bowel obstruction?
    A. Malignant tumours
    B. Meckel’s diverticulum
    C. Strictures from Crohn’s disease
    D. Surgical adhesions
    E. Volvulus

Answer 18

Answer D- Surgical Adhesions
Surgical adhesions: scar-like tissue that form between organs, these can compress the small intestine, these are the most common cause of small bowel obstruction
(A) Malignant tumours- most common cause of large bowel obstruction, can also cause small bowel obstruction but not the most common cause
(B) Meckel’s diverticulum: congenital disorder resulting in outpouching of small intestine, can cause obstruction, not most common cause as only present in 2% of population
(C) Strictures from Crohn’s disease: can also cause small bowel obstruction
(E) Volvulus: loop of bowel twists round itself, one of the main causes of large bowel obstruction

Question 19

39. Which of these clinical features would not affect a patient with oesophageal carcinoma?
    A. Enlarged Virchow’s node
    B. Lymphadenopathy
    C. Progressive dysphagia
    D. Retrosternal chest pain
    E. Weight loss

Answer 19

Answer A- Enlarged Virchow’s node
Enlarged Virchow’s node (Trosier’s sign)- enlargement of left supraclavicular node commonly associated with gastric cancer, NOT oesophageal cancer
(B) Lymphadenopathy- enlargement of lymph nodes is a sign of many malignancies, could indicate metastasis to lymph tissues
(C) Progressive dysphagia- classic symptom of oesophageal carcinoma. Initially PT has difficulty swallowing solids, but dysphagia for liquids follows as tumour grows
(D) Retrosternal chest pain- may be experienced by PTs with oesophageal carcinoma, epigastric pain more associated with gastric cancer
(E) Weight loss- common symptom observed in most malignancies

Question 20

40. Which of these is an example of a first-line treatment for mild ulcerative colitis?
    A. Colorectomy
    B. IV hydrocortisone
    C. Mesalazine
    D. NSAIDs e.g. Ibruprofen
    E. Oral Prednisolone

Answer 20

Answer C- Mesalazine
Mesalazine- member of 5-ASA drug group that is used for mild UC
(A) Colectomy- definitive surgical removal of colon, only used when severe UC + other treatments exhausted
(B) IV Hydrocortisone- corticosteroids used for severe UC
(D) NSAIDs e.g. Ibuprofen- NSAIDs tends to aggravate the GI tract, do not use in treatment of UC (E) Oral prednisolone- corticosteroid used for moderate UC

Question 21

41. Which of the following is not a cause of macrocytic anaemia?
    A. Alcohol excess
    B. Bone Marrow infiltration
    C. B12/Folate deficiency
    D. Chronic disease
    E. Hypothyroidism

Answer 21

Answer D- Chronic Disease
Chronic disease is classically associated with Normocytic or Microcytic anaemia. The rest impair meiosis and cell division, hence the cells that are produced are larger than they would ordinarily be i.e. macrocytic cells.

Question 22

6. Thomas Jones, a 17-year-old male, presents to his GP with a large, non-tender lump on his neck. He is referred to a haematologist and diagnosed with Hodgkin’s Lymphoma. Which of the following is least likely to be found in a patient with Hodgkin’s Lymphoma?
   A. Anaemia
   B. Hepatosplenomegaly
   C. Pruritis (itching)
   D. Raised white cell count
   E. Reed-Sternberg cells on blood film

Answer 22

Answer D- Raised white cell count
In Hodgkin’s Lymphoma white cells are not typically raised. Pruritis can occasionally be the only presenting symptom in Hodgkin’s lymphoma. Reed-Sternberg cells are diagnostic if found on a blood film. It is counter intuitive that the WCC is not raised and it can be easy to be caught out.

Question 23

48. An 80-year-old lady is diagnosed with polycythaemia rubra vera and is treated with hydroxycarbamide and aspirin. Which of the following is not an identified feature or complication of PCV?
    A. Dizziness
    B. Itching
    C. Haemorrhage
    D. Weight Loss
    E. Thrombosis

Answer 23

48- Answer D- Weight loss
Weight loss (D) is not a known complication or feature of PCV.
PCV is a condition in which the bone marrow over produces blood cells caused in 95% of cases by a JAK2 mutation. Dizziness (A) occurs because the blood is overly viscous causing various CNS abnormalities. Itching (B) occurs because the abnormal numbers of RBC’s stimulate histamine. Haemorrhage (C) can occur due to defective platelet function.

Question 24

52. Which of the following is not part of the definition for acute liver failure?
    A. INR greater than 1.5
    B. Onset of less than 26 weeks duration
    C. Low albumin levels
    D. Mental alteration without pre-existing cirrhosis
    E. No previous liver disease

Answer 24

Answer C- Low albumin levels
According to the European Association for the Study of the Liver any of the definitions are applicable with the exception of low albumin levels.

Question 25

54. Abdul, a 72-year-old gentleman, is admitted to the ward from surgical outpatients. For the last 3 months, he has noticed a progressively deepening yellow discolouration of the skin. He denies any abdominal pain although he notes his clothes have become looser. He has also noticed that his stools have become pale and his urine has become darker. His stools are difficult to flush. What is the most likely diagnosis? A. Acute pancreatitis B. Cancer of the pancreatic head C. Cholangiocarcinoma D. Chronic Liver Failure E. Hepatocellular carcinoma

Answer 25

Answer B- Cancer of the pancreatic head Painless jaundice is a red flag, especially in a 72-year old man. Jaundice there is something wrong with the hepatobiliary system. The fact that his stool and urine colour has been affected suggests that this is an obstructive jaundice which rules out Chronic Liver Failure and Hepatocellular carcinoma although you can get colour changes although less likely. Pancreatitis is not correct as he is not in any pain. In theory, a cholangiocarcinoma is possible although it is rare in the Western world. A cancer in the head of pancreas can obstruct the Common Bile Duct, causing obstructive jaundice and is therefore the correct answer.

Question 26

55. Which of the following is not a risk factor for liver cancer? A. Hepatitis B infection B. Chronic alcohol use C. Aflatoxin exposure D. Benzene exposure E. Non-alcoholic Fatty Liver Disease

Answer 26

Answer D- Benzene exposure Benzene exposure is a risk factor for Renal cell carcinoma and therefore, it is the correct answer. Hepatitis B and chronic alcohol use are both big risk factors for liver cancer because of the associated cirrhosis risk. Non-alcoholic fatty liver disease can also cause cirrhosis, although it is less common and also causes liver cancer. Aflatoxin is a type of toxin produced by fungi such as Aspergillus and can cause liver cancer.

Question 27

67. What nutrient agar is used to grow Mycobacterium tuberculosis? A. Blood B. Charcoal C. Chocolate D. Lowenstein-Jensen E. MacConkey

Answer 27

Question 67- Answer D- Lowenstein-Jensen Lowenstein-Jensen is used to culture mycobacterium tuberculosis Blood agar is used to culture anaerobes such as fusobacteria. Charcoal agar is used to grow campylobacter jejuni. Chocolate agar is used to grow aerobes such as strep. pneumonia. MacConkey is used to grow gram negative bacilli

Question 28

71. Fred is a 75-year-old gentleman with known COPD. He has recently been seen by his GP due to worsening of his symptoms. Fred notes that he now has to stop to catch his breath when walking 100m on flat to go to the local corner store. The GP is writing a referral to respiratory medicine. On the referral what grade does Fred fall under on the Medicine Research Council (MRC) dyspnoea scale? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4 E. Grade 5

Answer 28

Question 71- Answer D- Grade 4 This MRC scale is commonly used in General Practice and respiratory medicine. I would develop a good idea of most of the commonly used scales/scores ( MRC dyspnoea, NYHA scale, GCS, CURB-65). It is easily examined and described below: Grade 1: Breathless with strenuous exercise. Grade 2: Short of breath when hurrying or when walking up hill. Grade 3: Walks slower than people of the same age or stops for breath when walking at own pace on flat. Grade 4: Stops for breath after walking 100m on flat. Grade 5: Too breathless to leave the house/ Breathlessness on changing clothes.

Question 29

79. You see a 50-year-old man on the ward who has a bronchiectasis diagnosis. Which of the following on the list is not a cause of bronchiectasis? A. Bronchogenic carcinoma B. Cystic fibrosis C. Immotile ciliary syndrome D. Left ventricular failure E. Pneumonia

Answer 29

Question 79- Answer D- Left Ventricular Failure Left ventricular failure (D) is not a cause of bronchiectasis. Bronchiectasis= chronic infection leading to permanent dilatation of the airways. Bronchogenic carcinoma, cystic fibrosis and immotile ciliary syndrome (aka kartagner’s syndrome) all predispose the airways to infection and hence can cause bronchiectasis. Pneumonia is an infection of the airway and pneumonias can cause bronchiectasis too. The main infective organisms involved in bronchiectasis include: Pseudomonas aeruginosa, Haemophilus influenzae, Staph aureus, Strep Pneumoniae .

Question 30

80. An elderly gentleman with known COPD attends clinic with persistent SOB. He has quit smoking and is struggling to manage with his salbutamol inhaler. Spirometry performed earlier today show FEV1 at 65% of predicted value. Oxygen sats are 95% on air, respiratory rate =18 and he is apyrexial. What is the next best step in his management? A. Add a long-acting β2 agonist inhaler B. Add oral theophylline therapy C. Forty (40) mg daily oral prednisolone for 5 days D. Start inhaled corticosteroid therapy E. Start long-term oxygen therapy

Answer 30

Follow link to BNF for full outline of COPD management, beneath is a brief summaryhttps://bnf.nice.org.uk/treatment-summary/chronic-obstructive-pulmonary-disease.html In this patient case as we have not yet confirmed whether the patient is steroid responsive or not we should add in a LABA as this treatment is indicated in both. When steroid responsiveness has been confirmed you can then add the subsequent medication. First thing to do is always stop smoking and vaccinate (influenza and pneumococcal) 1) SABA / SAMA 2) *If steroid responsive/asthmatic = Add LABA + ICS 2) *If not steroid responsive / non-asthmatic= Add LABA + LAMA 3) Oral theophylline 4) Long term oxygen therapy SABA= Short-acting beta agonist, LABA= Long-acting beta agonist, SAMA= short-acting muscarinic antagonist, LAMA= long-acting muscarinic antagonist (Note: do not prescribe together- if started on LAMA, remove SAMA) ICS= Inhaled corticosteroid

Question 31

87. What is the diagnostic investigation for sarcoidosis? A. Bronchoalveolar lavage B. Blood Tests C. Chest X-ray D. Lung function tests E. Tissue biopsy

Answer 31

Question 87- Answer E- Tissue Biopsy A tissue biopsy is diagnostic for Sarcoidosis- showing a non-caseating granuloma. A bronchoalveolar lavage will show a)increased lymphocytes in active disease b)increased neutrophils if pulmonary fibrosis present but is not diagnostic. Blood tests are good for assessing the extrapulmonary manifestations of the condition. Chest X-ray is used for staging. Lung function tests give an indication of the effects of the condition and how it is affecting the patient.

Question 32

94. A 14-year-old girl, Anna, presents to A&E. Her mum says she has had a ‘seizure’ approximately an hour ago. Her mum, who witnessed the incident, says Anna told her she felt ‘weird’ whilst they were watching TV together. Anna then appeared to stare into the distance and was unresponsive to her mum’s voice, whilst picking at her clothes and chewing. Afterwards, Anna was ‘confused’. What is the most likely diagnosis? A. Frontal lobe seizure B. Occipital lobe seizure C. Parietal lobe seizure D. Psychogenic non-epileptic attack E. Temporal lobe seizure

Answer 32

Question 94- Answer E- Temporal Lobe Seizure (A) Frontal lobe seizure- Seizures in the frontal lobe may cause ‘Jacksonian motor seizures’ (Proximal spread of clonic jerking- begins in finger / toe / corner of mouth, spreads proximally as abnormal epileptic discharge moves along motor cortex). Post-ictal Todd’s paralysis- Affected limb(s) may remain temporarily weak (B) Occipital lobe seizure=typically cause floaters / flashes in the eyes. (C) Parietal lobe seizure- typically cause non-specific sensory symptoms (tingling / pain / numbness / prickling) (D) Psychogenic non-epileptic attack- Complex (but probably more common than people think). No abnormal electrical brain activity. Factors favouring: female, pelvic thrusting, hx of childhood physical/sexual abuse, PTSD, depression. (E) Temporal lobe seizure:  Pre-seizure aura- rising epigastric sensation, fear / anger, déjà vu, hallucinations - olfactory / gustatory  Seizure- Automatisms: lip smacking, chewing, grimacing, fidgeting, picking at clothes  Post-ictal confusion= common Location Typical seizure type Temporal lobe (HEAD) Hallucinations (auditory/gustatory/olfactory) Epigastric rising / Emotional Automatisms (lip smacking/grabbing/plucking) Déjà vu / Dysphasia post-ictal Frontal lobe (motor) Head/leg movements Posturing Post-ictal weakness Jacksonian march Parietal lobe (sensory) Paraesthesia Occipital lobe (visual) Floaters/flashes

Question 32

89. What type of hypersensitivity reaction is hypersensitivity pneumonitis? A. Type 1 B. Type 2 C. Type 3 D. Type 4 E. Type 5

Answer 32

C is the correct answer, it is a type 3 hypersensitivity reaction. The allergic response to the inhaled antigen involves both cellular immunity and the deposition of immune complexes (TYPE 3 HYPERSENSITIVITY. Some of the inhaled antigen may directly activate the alternate complement pathway. Both these mechanisms attract alveolar and interstitial macrophages. Prolonged exposure to the antigen eventually leads to pulmonary fibrosis.

Question 33

95. A 19-year-old man presents to A&E with a fever, headache, vomiting, photophobia, and drowsiness. On examination, neck stiffness and a positive Kernig’s sign are elicited. Given the patient’s reduced GCS and as a highly proficient FY1, you order a CT head to rule any intracranial pathology / raised ICP before conducting a lumbar puncture. You send both blood and CSF samples to be cultured. After 24 hrs of successful empirical treatment, the lab reports the results of the CSF gram stain: Gram positive diplococci seen. Given the most likely diagnosis and the histopathology, which pathogen is most likely responsible for his symptoms? A. Coxsackie B virus B. Haemophilus influenzae type B C. Herpes simplex virus D. Neisseria meningitidis E. Streptococcus pneumoniae

Answer 33

Question 95- Answer E- Streptococcus Pneumoniae (A) Coxsackie B virus- causes an aseptic meningitis – negative culture / staining. Viral meningitis tends to be less serious – i.e. not likely to have reduced GCS (drowsiness) (B) Haemophilus influenzae type B- gram-negative coccobacillus – catalase and oxidase positive. Note it is less common cause due to HiB inclusion in UK vaccination schedule (C) Herpes simplex virus- more commonly a cause of encephalitis, detected on PCR not gram stain. (D) Neisseria meningitidis-gram negative diplococcus, ‘reddish-pink’ (E) Streptococcus pneumoniae- gram positive diplococcus, ‘blue’, causes severe meningitis

Question 34

97. A 75-year-old man presents to his GP two days after right-sided arm and leg weakness. He says he did not seek medical attention at the time as the symptoms resolved after 30 minutes. He has had no other symptoms since this incident. You suspect the patient has had a TIA. As a diligent junior doctor, you refer him to the specialist TIA clinic. What pharmacological therapy should be immediately initiated in the meantime? A. Aspirin 300mg daily B. Aspirin 300mg + clopidogrel daily C. Clopidogrel daily D. Dipyridamole daily E. Warfarin daily

Answer 34

Question 97- Answer A- Aspirin 300mg daily (A) Aspirin 300mg daily: NICE guidelines state that if a patient presents within 7 days of suspected TIA: aspirin 300mg daily – immediately, specialist review within 24 hrs, advise Ptx not to drive. Note that if >7 days, as above but with specialist review within 7 days (B) Aspirin 300mg + clopidogrel daily- 1st line long-term anti-thrombotic therapy in TIA (as in stroke) is clopidogrel monotherapy. This is given after specialist review has been conducted + TIA confirmed (rather than suspected, in this case) (C) Clopidogrel daily- see b) (D) Dipyridamole daily- aspirin + dipyridamole dual therapy is 2nd line long-term anti-thrombotic therapy if clopidogrel is not tolerated. (E) Warfarin daily- warfarin increases the risk of stroke within 30 days of ischaemic symptoms

Question 35

98. Graham, a 60-year-old gentleman, presents to A&E with a history of lower back pain and increasing weakness and numbness in both lower limbs. Two days earlier, he had pain shooting down both his legs after moving heavy boxes at home. There was no history of incontinence or impotence. On examination, power in the right lower limb was reduced, power in the left lower limb was normal. Reflexes of the right lower limb were absent but normal on the left. Anal sphincter tone was also reduced. Sensation was broadly reduced on the right side, but normal on the left. What is the most likely diagnosis? A. Brown-Sequard syndrome B. Cauda equina syndrome C. Conus medullaris syndrome D. Spinal cord compression at T10 E. Syringomyelia

Answer 35

Question 98- Answer B- Cauda Equina Syndrome (A) Brown-Sequard syndrome (lateral hemisection of the spinal cord). Features: ipsilateral weakness below lesion, ipsilateral loss of proprioception + vibration, contralateral loss of pain + temperature. (B) Cauda equina syndrome- note that cauda equina begins at L1/2 – level at which the spinal cord terminates. LMM signs only. Lower back pain, LMN weakness (decreased power and reflexes), sphincter disturbance (urinary hesitancy / impaired sensation of flow / retention, foecal incontinence). Impotence, saddle paraesthesia, decreased anal tone. (C) Conus medullaris syndrome- similar to cauda equina but UMN features. (D) Spinal cord compression at T10- mixture of UMN + LMN features. LMN at level of lesion (T10) → sensory level (umbilicus). UMN below level of lesion→UMN (spastic) weakness +  reflexes. Note you get UMN + LMN here because the spinal cord has not yet terminated – in cauda equina, it has (E) Syringomyelia = central cord syndrome. Weakness upper limb affected > lower limb. ‘Cape-like’  pain / temperature caused by spinothalamic tract damage. Normal proprioception / vibration