SBAs and explanations 1

Question 1

A 43-year-old man presents with a painless lump in his groin that appeared 2 weeks ago. He claims that the lump protrudes on defecation and he also reports becoming constipated recently. On examination, the lump is reduced and a finger is placed over the midpoint of the inguinal ligament. When the patient is asked to cough, the lump reappears. What is the most likely diagnosis?

A Direct inguinal hernia
B Indirect inguinal hernia
C Femoral hernia
D Obturator hernia
E Spigelian hernia

Answer 1

Direct inguinal hernia.

Question 2

Which of the following murmurs is associated with severe aortic regurgitation?

A Austin-Flint
B Graham-Steell C Gibson
D Carey-Coombs E Barlow

Answer 2

Austin-Flint

Question 3

A 67-year-old man is brought into A&E having been involved in a road traffic accident. On examination, he opens his eyes to pain, makes a few grunting noises and withdraws his legs from painful stimuli. What is his GCS?

A 2 
B 4 
C 6 
D 8 
E 10

Answer 3

8.

Question 4

A 2-year-old boy is brought to the GP after his father noticed some swelling around his eyes. On examination, there is periorbital and pedal oedema. A urine dipstick is positive for proteins and negative for blood. What is the most likely diagnosis?

A IgA nephropathy
B Membranous glomerulonephritis
C Rapidly progressive glomerulonephritis
D Minimal change glomerulonephritis
E Henoch-Schӧnlein purpura

Answer 4

Minimal change glomerulonephritis.

Question 5

A 54-year-old man is brought into A&E with a suspected acute coronary syndrome. An ECG is performed, which reveals ST elevation in leads I, aVL, V5 and V6. Which coronary artery has been occluded?

A Left main stem
B Left anterior descending coronary artery
C Left circumflex coronary artery
D Right coronary artery
E Posterior descending artery

Answer 5

Left circumflex coronary artery.

Question 6

A 46-year-old housewife visits her GP complaining of pain in the joints of her hands that has gradually got worse over 3 months. It has started affecting her ability to complete daily tasks such as cooking for her children. Both of her hands are affected equally and the pain and stiffness is worst in the morning but gets better when she starts using her hands. On closer inspection, her hands do not appear to be deformed although her metacarpophalangeal joints and proximal interphalangeal joints appear slightly swollen, warm and tender.
What is the most likely diagnosis?

A Reactive arthritis
B Osteoarthritis
C Rheumatoid arthritis
D Psoriatic arthritis
E Septic arthritis

Answer 6

Rheumatoid arthritis.

Question 7

A 56-year-old man with a history of alcoholism complains of intermittent epigastric pain that radiates through to his back. When questioned, he admits to losing about 3 kg in weight over the past 6 months and says that his stools have become pale and difficult to flush away. Which investigation would you request to aid the diagnosis?

A Serum amylase
B Blood cultures
C Faecal elastase
D CA 19-9
E OGD

Answer 7

Faecal elastase.

Question 8

A 25-year-old female has suffered from shortness of breath over the past 2 months. She gets particularly breathless when she exerts herself, and has had to stop going on her morning jog. She has not experienced a cough, fever or chest pain. She has no past medical history of note, however, her periods have become quite heavy over the past 3 or 4 months. What is the most likely diagnosis?

A Hyperthyroidism 
B Anaemia
C Pneumonia
D COPD
E Asthma

Answer 8

Anaemia.

Question 9

A 46-year-old man, with a history of type 1 diabetes, visits the GP for an HbA1c reading. He has recently been feeling more tired than usual and has noticed that the skin on his hands has become darker over the past few months. On examination, hepatomegaly and a tanned complexion (despite not having been on any recent holidays) are noted. Haemochromatosis is suspected and iron studies are requested. Which set of results would be consistent with haemochromatosis?

A High serum iron, high ferritin, high transferrin, low transferrin saturation, low TIBC
B High serum iron, low ferritin, low transferrin, high transferrin saturation, low TIBC
C High serum iron, high ferritin, high transferrin, high transferrin saturation, low TIBC
D High serum iron, high ferritin, low transferrin, high transferrin saturation, high TIBC
E High serum iron, high ferritin, low transferrin, high transferrin saturation, low TIBC

Answer 9

High serum iron, high ferritin, low transferrin, high transferrin saturation, low TIBC.

Question 10

A 72-year-old woman has recently suffered a fracture of her right distal radius after falling on an outstretched hand. She is at high risk of osteoporosis because she is post-menopausal and has undergone several decades of steroid treatment for her asthma. A DEXA scan is performed. Which result would be diagnostic of
osteoporosis?

A T score of -1.5 or worse
B T-score of -2 or worse
C T-score of -2.5 of worse
D T-score of -3 or worse
E T-score of -3.5 or worse

Answer 10

T-score of -2.5 of worse.

Question 11

A 52-year-old man was watching TV yesterday when he suddenly become very aware of his heart beating rapidly. This lasted around 45 mins and then subsided spontaneously. It has happened several times over the past 2 months. An ECG reveals no abnormalities. However, due to the strong suspicion of atrial fibrillation, the patient is placed on a 24-hr tape, which confirms the diagnosis. Which scoring system should be used to determine the benefit of long-term anticoagulation in this patient?

A QRISK2 score
B ABCD2 Score
C GRACE score
D CHA2DS2-VASc score
E CURB-65 score

Answer 11

CHA2DS2-VASc score.

Question 12

Which of the following is not a feature of background diabetic retinopathy?

A Hard exudates
B Soft exudates
C Microaneurysms
D Blot haemorrhages
E Leakage of lipids from blood vessels

Answer 12

Soft exudates.

Question 13

A 53-year-old man, who has recently recovered from a diarrhoeal illness, comes to A&E with a 1-week history of gradually worsening weakness in his legs. A neurological examination reveals reduced tone, reduced reflexes and impaired sensation in both lower limbs. He adds that the weakness began in his feet and has gradually progressed up his legs. Guillain-Barré syndrome is suspected. Which of the following parameters should be closely monitored in this patient?

A Body temperature
B Serum osmolality
C Serum potassium
D Forced vital capacity
E Urine output

Answer 13

Forced vital capacity.

Question 14

A 14-year-old school boy was diagnosed with asthma 6 months ago. He was
given a salbutamol inhaler to use PRN, however, he continued to have regular
episodes of breathlessness. He was started on a regular inhaled corticosteroid
(beclomethasone) 3 months ago. Although the frequency of his attacks has reduced with the medication, he is still experiencing bouts of breathlessness about 4 times per week. What would be the next most appropriate step in his management?

A Increase the dose of salbutamol
B Add an inhaled corticosteroid
C Add an oral corticosteroid
D Add a long-acting beta agonist
E Montelukast therapy

Answer 14

Add a long-acting beta agonist.

Question 15

Which of the following is the most common cause of chronic kidney disease?

A Hypertension
B Diabetes mellitus
C Glomerulonephritis
D Pyelonephritis
E Polycystic kidney disease

Answer 15

Diabetes mellitus.

Question 16

A 46-year-old woman has been suffering from frequent headaches over the past 4 months, along with some blurring of vision. She also mentions that she has developed a fiercely itchy rash on several occasions, usually occurring soon after she has had a bath. What is the most likely diagnosis?

A Anaemia
B Acute lymphoblastic leukaemia
C Chronic myeloid leukaemia
D Polycythaemia vera
E Myelofibrosis

Answer 16

Polycythaemia vera.

Question 17

A 27-year-old female comes to A&E complaining of severe right iliac fossa pain. She has vomited three times whilst waiting to be seen. On examination, there is rebound and percussion tenderness in the right iliac fossa and the pain gets worse
when the doctor extends the patient’s hip. What is the name of the sign being elicited?

A Murphy’s sign
B Cope sign
C Rovsing’s sign
D Psoas sign
E Aarons sign

Answer 17

Psoas sign.

Question 18

A 74-year-old man presents with a skin lesion on his left cheek, which has gradually grown over 4 months. On closer examination, the lesion has raised, everted edges with an ulcerated centre revealing a keratotic core. What is the most likely diagnosis?

A Basal cell carcinoma
B Squamous cell carcinoma
C Melanoma
D Keratoacanthoma
E Actinic keratosis

Answer 18

Squamous cell carcinoma.

Question 19

A 53-year-old man presents to A&E with severe pain in his right flank that radiates to his right groin. Ureteric colic is suspected and a CT-KUB is requested. The CT-KUB confirms the diagnosis but it also shows an abdominal aortic aneurysm with a diameter of 4.7 cm. When questioned, the patient denies any back pain (other than the pain caused by ureteric colic) or symptoms of vascular disease. What is the most appropriate management option for this patient?

A Reassure and discharge
B Surveillance with an ultrasound scan every 1 year
C Surveillance with an ultrasound scan every 6 months
D Surveillance with an ultrasound scan every 3 months
E Surgical repair of the aneurysm

Answer 19

Surveillance with an ultrasound scan every 3 months.

Question 20

A 38-year-old man is complaining of excessive thirst and frequent urination over the past month. He describes the thirst as being ‘insatiable’, and claims to drink about 8-12 litres of water every day. He undergoes a water deprivation test, which revealed the following results:
Urine osmolality
2 hr : 212 mOsm/kg 4 hr: 227 mOsm/kg
6 hr : 221 mOsm/kg 8 hr: 242 mOsm/kg
Following administration of 2 mg IM desmopressin (DDAVP) : 278 mOsm/kg (normal
> 600 mOsm/kg).
What is the most likely diagnosis?

A Diabetes mellitus type 1
B Central diabetes insipidus
C Nephrogenic diabetes insipidus
D Psychogenic polydipsia
E Hyperparathyroidism

Answer 20

Nephrogenic diabetes insipidus.

Question 21

A 37-year-old man visits the GP because his partner has recently noticed some dark patches on his back. On examination, there are multiple painless red papules on his back, some of which have merged to form purple plaques. He was diagnosed with HIV 8 years ago. What is the most likely diagnosis?

A Discoid lupus
B Guttate psoriasis
C Kaposi’s sarcoma
D Shingles
E Chronic mucocutaneous candidiasis

Answer 21

Kaposi’s sarcoma.

Question 22

A 16-year-old school girl has been suffering from depression for 6 months. Last night (12 hours ago) she decided to end her life and ingested 40 paracetamol tablets. She has since decided that she has made a mistake and does not want to end her life. She appears reasonably well when she presents to A&E, only complaining of some mild nausea. What is the most appropriate treatment option?

A N-acetylcysteine
B Naloxone
C Flumezanil
D Atropine
E Sodium bicarbonate

Answer 22

N-acetylcysteine.

Question 23

A 7-year-old girl has had severe, bloody diarrhoea with cramping abdominal pain for the past 3 days. She has also been emptying her bladder less and less frequently. Blood tests, including a blood film, are performed which revealed a low
Hb, low platelets and the presence of schistocytes. U&Es are also performed: Creatinine : 182 micromol/L (baseline = 92 micromol/L)
Urea : 9.2 mmol/L (2.5-6.7)
A stool culture identifies E. coli O157. What is the most likely diagnosis?

A Microangiopathic haemolytic anaemia
B Haemolytic uraemic syndrome
C Thrombotic thrombocytopaenic purpura
D Disseminated intravascular coagulation E Gastroenteritis

Answer 23

Haemolytic uraemic syndrome.

Question 24

A 37-year-old plumber presents to his GP with a week-long history of headache, diarrhoea and fever. In the last 2 days, he has also developed a dry cough and his wife has commented that he has appeared to be quite confused recently. What is the most appropriate investigation?

A CT head scan
B Urinary antigens
C Stool culture
D LFTs
E U&Es

Answer 24

Urinary antigens.

Question 25

Which system is used to stage prostate cancer? ``` A Breslow thickness B Gleason staging C GRACE score D W ells score E Dukes’ staging ```

Answer 25

Gleason staging.

Question 26

A 28-year-old woman presents with a 5-day history of urinary frequency, dysuria and mild suprapubic pain. Urine dipstick is positive for nitrites and leucocytes. A urinary tract infection is suspected and an MSU is taken and sent to the lab. Whilst awaiting culture and sensitivities, which empirical treatment option is best for this patient? ``` A Trimethoprim B Benzylpenicillin C Vancomycin D Metronidazole E Levofloxacin ```

Answer 26

Trimethoprim.

Question 27

A 68-year-old male visits his GP complaining of constipation, rectal bleeding and itchiness around his anus. He often feels ‘a lump’ hanging out after defecating which he has to push back in himself. On examination, anal tone is weak and a protruding mass is felt which has palpable muscular rings. What is the most likely diagnosis? ``` A Grade 3 haemorrhoids B Grade 4 haemorrhoids C Perianal abscess D Type 1 rectal prolapse E Type 2 rectal prolapse ```

Answer 27

Type 2 rectal prolapse.

Question 28

A 54-year-old man is complaining of sharp, central chest pain that has arisen over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He also has a low-grade fever. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis? ``` A Viral pericarditis B Constrictive pericarditis C Cardiac tamponade D Dressler syndrome E Tietze syndrome ```

Answer 28

Dressler syndrome.

Question 29

A 66-year old man has been experiencing pain in his right calf for the last 6 months. Initially, the pain would come about whenever he went for a walk, and it would be relieved by rest. However, over the last few weeks he has experienced pain during rest. The pain is particularly bad at night, and he gets some relief from dangling his leg over the end of the bed. Recently, he has noticed a small, elliptical ulcer appear in between his toes on his right foot. He has a past medical history of ischaemic heart disease, and underwent a CABG 8 years ago. What is the most likely diagnosis? ``` A Intermittent claudication B Critical limb ischaemia C Acute limb ischaemia D Leriche syndrome E Chronic deep vein thrombosis ```

Answer 29

Critical limb ischaemia.

Question 30

A 3-year-old boy is brought, by his father, to see his GP because he has had a fever for the past 4 days and has cried in pain every time he has tried to eat. On examination, the patient’s gums look red and swollen and there are small vesicles and ulcerations along the gumline. The GP suspects gingivostomatitis. What is the most likely cause? ``` A Varicella B Primary HSV1 infection C Reactivation of HSV1 D HSV2 infection E Infectious mononucleosis ```

Answer 30

Primary HSV1 infection.

Question 31

What does the inguinal canal contain?

Answer 31

Spermatic cord in males, round ligament in females.

Question 32

Where does the inguinal ligament run?

Answer 32

From the ASIS to the pubic tubercle, forming the floor of the inguinal canal.

Question 33

Where does the inguinal canal begin and end?

Answer 33

The canal begins at the deep inguinal ring (located just above the midpoint of the inguinal ligament) and ends at the superficial inguinal ring (located just superior and medial to the pubic tubercle).

Question 34

Where do direct inguinal hernias arise?

Answer 34

Direct inguinal hernias arise from a weakness in the posterior wall of the inguinal canal, allowing abdominal viscera to protrude ‘directly’ through the back of the inguinal canal.

Question 35

Where do indirect inguinal hernias arise?

Answer 35

In indirect inguinal hernias, the abdominal contents pass through the deep inguinal ring and along the inguinal canal.

Question 36

What is the similarity between direct and indirect inguinal hernias?

Answer 36

The hernial sacs in both conditions will protrude through the superficial ring and produce a swelling in the groin.

Question 37

How do you distinguish between direct and indirect inguinal hernias?

Answer 37

These two types of hernia are differentiated on examination by reducing the hernia, placing a finger on the deep inguinal ring and asking the patient to cough. As you are blocking the deep inguinal ring with your finger, an indirect inguinal hernia should not reappear as a groin lump when the patient is asked to cough. Therefore, if the hernia appears again when the patient increases their intra-abdominal pressure (by coughing), it suggests that it is a direct inguinal hernia. This test is very crude and error prone – definitive diagnoses are often made in theatre.

Question 38

Where do Spigelian hernias occur?

Answer 38

Spigelian hernias occur when abdominal contents herniate through the linea semilunaris, typically occurring inferior and lateral to the umbilicus.

Question 39

Where do obturator hernias occur?

Answer 39

Obturator hernias occur through the obturator canal and they present with inner thigh pain when the hip is internally rotated (Howship- Romberg sign).

Question 40

What is an Austin-Flint murmur?

Answer 40

Aortic regurgitation is normally associated with an early diastolic murmur. However, severe aortic regurgitation leads to the regurgitated blood applying pressure on the mitral valve and causing a physiological mitral stenosis. This produces a low-pitched, rumbling mid-diastolic murmur, also known as an Austin-Flint murmur.

Question 41

What is a Graham-Steell murmur?

Answer 41

A Graham-Steell murmur is a high-pitched early diastolic murmur best heard at the upper left sternal edge. It is associated with pulmonary regurgitation.

Question 42

What is a Gibson murmur?

Answer 42

A Gibson murmur is a continuous ‘machinery’ murmur that is associated with patent ductus arteriosus.

Question 43

What is a Carey-Coombs murmur?

Answer 43

A Carey-Coombs murmur is a mid-diastolic murmur caused by turbulent blood flow over a thickened mitral valve. It is associated with acute rheumatic fever.

Question 44

What is a Barlow murmur?

Answer 44

A Barlow murmur is a mid-systolic click and an end-systolic murmur heard best at the apex and is associated with mitral valve prolapse.

Question 45

What is minimal change disease?

Answer 45

Minimal change disease is a type of non-proliferative glomerulonephritis which causes nephrotic syndrome in young children. Light microscopy shows no visible changes to the glomerulus (hence, minimal change), but electron microscopy shows diffuse loss of the processes of the podocytes in the Bowman’s capsule.

Question 46

What is membranous glomerulonephritis?

Answer 46

Membranous glomerulonephritis is a type of non-proliferative glomerulonephritis and is a cause of nephrotic syndrome in adults.

Question 47

What is the most common cause of glomerulonephritis?

Answer 47

IgA nephropathy, tends to occur a few days after upper respiratory tract infections.

Question 48

What is Henoch-Schönlein purpura?

Answer 48

A type of IgA nephropathy that tends to affect older children and presents with a triad of abdominal pain, arthritis and purpuric rash.

Question 49

What do IgA nephropathy and Henoch-Schönlein purpura both cause?

Answer 49

Nephritic syndrome. Haematuria is more prominent than proteinuria.

Question 50

What is rapidly progressive glomerulonephritis?

Answer 50

An acute nephritic syndrome characterised by rapid loss of kidney function within weeks to months.

Question 51

Which coronary artery is implicated in anterior MI?

Answer 51

Left anterior descending coronary artery.

Question 52

Which coronary artery is implicated in lateral MI?

Answer 52

Left circumflex coronary artery.

Question 53

Which coronary artery is implicated in inferior MI?

Answer 53

Right coronary artery.

Question 54

Which coronary artery is implicated in posterior MI?

Answer 54

Posterior descending artery.

Question 55

What is reactive arthritis and how does it present?

Answer 55

Reactive arthritis is a sterile arthritis that tends to occur days or weeks after a GI or urogenital infection. It presents with a triad of arthritis, uveitis and urethritis. Other extra-articular features of reactive arthritis include circinate balanitis and keratoderma blennorrhagicum.

Question 56

What is osteoarthritis and how does it present?

Answer 56

Osteoarthritis is a degenerative disease of the cartilage, usually occurring in weight-bearing joints such as the knees and hips. It is usually asymmetrical and the stiffness gets worse with activity.

Question 57

What is rheumatoid arthritis and how does it present?

Answer 57

Long-term pain and stiffness in both hands with swollen joints is an early presentation of rheumatoid arthritis (RA). RA is a chronic autoimmune inflammatory disease characterised by symmetrical polyarthritis, joint deformity and certain extra- articular manifestations (e.g. subcutaneous nodules, pulmonary fibrosis and episcleritis). Patients may also experience a degree of constitutional upset, such as weight loss, fatigue and a low-grade fever. On examination, tenderness and warmth of the metacarpophalangeal and proximal interphalangeal joints is often observed. The distal interphalangeal joints are spared. As the disease becomes more severe, the hands will become very deformed. Deformities that are typically seen in RA include radial deviation of the wrist, ulnar deviation of the fingers, Z deformity of the thumb swan neck deformity, Boutonnière deformity and trigger finger.

Question 58

What is hereditary haemochromatosis?

Answer 58

Hereditary haemochromatosis (HH) is an autosomal recessive disorder of iron metabolism caused by excessive intestinal absorption of dietary iron. This results in iron deposition in tissues and organs (e.g. skin, joints, liver, pancreas and adrenal glands). Iron is absorbed in the duodenum where it is either stored intracellularly bound to ferritin or transported out of the cells by ferroportin, a transmembrane protein. It then binds to transferrin in the blood stream. Hepcidin is a protein that inhibits ferroportin, thereby regulating the amount of iron entering the blood. 90% of cases of HH are caused by a mutation that leads to a deficiency of hepcidin, resulting in unregulated absorption of iron in the intestines.

Question 59

How is hereditary haemochromatosis investigated, and what results would you expect?

Answer 59

It is investigated using iron studies – typical results in HH: High Serum Iron – a deficiency of hepcidin leads to increased iron transport into the blood via ferroportin High Ferritin – increased serum iron leads to an increase in ferritin in a compensatory attempt to increase intracellular iron storage Low Transferrin – increased serum iron leads to decreased transferrin levels to prevent more iron from becoming plasma protein bound in the blood High Transferrin Saturation – due to high serum iron and low transferrin Low Total Iron Binding Capacity (TIBC) – this is a measure of the blood’s capacity to bind iron to transferrin. As transferrin is low, it is more difficult for iron to bind to transferrin.

Question 60

What is osteoporosis?

Answer 60

Osteoporosis is characterised by reduced bone mineral density (BMD) resulting in bone fragility and increased fracture risk. Osteoporosis can be a primary bone disorder of unknown cause. Secondary causes of osteoporosis include Cushing’s syndrome, hyperthyroidism and hypogonadism. Post-menopausal women are at increased risk of osteoporosis due to the loss of the protective effect of oestrogen over bone. DEXA (dual energy X-ray absorptiometry) scans are the gold standard for diagnosing osteoporosis. It quantifies BMD based on the T-score (the number of standard deviations between the normal BMD for a young, healthy 30-year-old and the patient’s BMD). T-scores are interpreted as follows: 0 to -1 = Normal. -1 to -2.5 = Osteopaenia (at risk of developing into osteoporosis). -2.5 or worse = Osteoporosis.

Question 61

What is the CHA2DS2-VASc score and what is it used for?

Answer 61

The CHA2DS2-VASc score is used to assess the risk of stroke in patients with atrial fibrillation, and, hence, determine the benefit of long-term anticoagulation. It is based on the following factors: Congestive heart failure Hypertension Age > 75 yrs (2 points) Diabetes mellitus Stroke/TIA symptoms previously (2 points) Vascular disease (e.g. peripheral artery disease) Age 65-74 yrs (1 point) Sex category (Female = 1 point). Guidelines recommend that patients with a score of 2 or more should be offered anticoagulation with warfarin or a NOAC (novel oral anticoagulant).

Question 62

What is the QRISK2 score used for?

Answer 62

QRISK2 is used to predict the risk of cardiovascular disease based on traditional risk factors such as blood pressure and smoking status. It is used to decide whether to give primary prevention (e.g. statins).

Question 63

What is the ABCD2 score used for?

Answer 63

ABCD2 predicts a patient’s risk of stroke in the days following a TIA. This allows triaging of TIA patients and guides specialist referrals.

Question 64

What is the GRACE score used for?

Answer 64

GRACE score is used for risk assessment and triaging of patients with ACS.

Question 65

What is the CURB-65 score used for?

Answer 65

CURB-65 is used to assess severity of community-acquired pneumonia. A score of 2 warrants hospital admission. A score of 3 or more is considered ‘severe’ pneumonia and should be considered for ITU admission.

Question 66

What is the sequence of diabetic retinopathy?

Answer 66

Background retinopathy. Pre-proliferative retinopathy. Proliferative retinopathy.

Question 67

What causes diabetic retinopathy?

Answer 67

Progressive damage to blood vessels in the back of the eye.

Question 68

What is maculopathy?

Answer 68

A separate subtype of diabetic retinopathy when the disease affects the macula (centre of retina, responsible for central high-resolution vision). In maculopathy, hard exudates are found near the macula. This can threaten direct vision.

Question 69

What are the features of background diabetic retinopathy?

Answer 69

Background retinopathy, the first in the continuum of diabetic retinopathy, features hard exudates (leaked lipid contents from blood vessels creating a cheesy yellow appearance), microaneurysms and blot haemorrhages.

Question 70

What are the features of pre-proliferative diabetic retinopathy?

Answer 70

Pre-proliferative retinopathy is characterised by the presence of soft exudates – regions of retinal ischaemia.

Question 71

What are the features of proliferative diabetic retinopathy?

Answer 71

In proliferative retinopathy, new blood vessels begin to form in response to retinal ischaemia. If these vessels form near the macula, they can affect acuity and colour vision. Furthermore, they are fragile and prone to bleeding.

Question 72

What is Guillain-Barre syndrome, and what is it important to monitor in patients presenting with this condition?

Answer 72

Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy that often occurs a few weeks or months after an infection (e.g. Campylobacter jejuni). It results in ascending symmetrical muscle weakness. It is important to monitor forced vital capacity (FVC) using spirometry because GBS can cause respiratory muscle weakness, resulting in respiratory failure and, ultimately, death.

Question 73

What are the BTS guidelines for asthma management?

Answer 73

STEP 1: Inhaled short-acting beta agonist (e.g. salbutamol). STEP 2: Inhaled corticosteroid (e.g. beclomethasone). STEP 3: Inhaled long-acting beta agonist (e.g. salmeterol) + consider increasing dose of inhaled corticosteroid. STEP 4: Consider trials of theophylline, oral beta agonists, oral leukotriene. STEP 5: Oral corticosteroids.

Question 74

What are the causes of chronic kidney disease?

Answer 74

Diabetes mellitus (most common), hypertension, idiopathic, glomerulonephritis, pyelonephritis, vasculitides, polycystic kidney disease, reflux nephropathy and obstructive nephropathy.

Question 75

What is polycythaemia and how does it present?

Answer 75

Polycythaemia refers to an abnormally high haemoglobin concentration. There are two main types - polycythaemia vera (a rare type of bone neoplasm resulting in a clonal proliferation of myeloid cells) and secondary polycythaemia (secondary to, for example, chronic hypoxia, renal tumours and erythropoietin abuse in athletes). The symptoms of polycythemia include headaches, tinnitus, blurred vision, history of thromboses, angina and, perhaps the most memorable symptom, pruritus after a hot bath.

Question 76

What is myelofibrosis and how does it present?

Answer 76

Myelofibrosis is a disorder characterised by progressive bone marrow fibrosis, resulting in reduced bone marrow output, extramedullary haematopoiesis and massive splenomegaly. Myelofibrosis is often asymptomatic, however, there is a strong association between myelofibrosis and polycythaemia vera.

Question 77

What is psoas sign?

Answer 77

Achieved by lying the patient on their left-hand side, straightening their right leg and then passively extending their right hip. If pain is elicited, this suggests that the appendix is retrocaecal.

Question 78

What is Rovsing's sign?

Answer 78

Rovsing’s sign is when palpation of the left iliac fossa causes pain in the right iliac fossa.

Question 79

What is Cope's sign?

Answer 79

Cope’s sign is pain on flexion and internal rotation of the hip and indicates that the appendix lies close to the obturator internus.

Question 80

What is Aaron's sign?

Answer 80

Aaron’s sign is referred epigastric pain when pressure is applied over McBurney’s point.

Question 81

What is Murphy's sign?

Answer 81

Murphy’s sign is the cessation of inspiration when two fingers are placed below the right costal margin in the midclavicular line and the patient is asked to take a deep breath in. This is suggestive of cholecystitis.

Question 82

What is appendicitis and what might cause it?

Answer 82

A young patient presenting acutely with right iliac fossa pain and vomiting is typical of appendicitis. Appendicitis is inflammation of the appendix that occurs following obstruction of the lumen of the appendix by a faecolith (calcified stone of faeces), foreign body, tumour, lymphoid hyperplasia or filarial worms.

Question 83

What is squamous cell carcinoma and how does it present?

Answer 83

A squamous cell carcinoma (SCC) is one of the most common types of skin cancer. It is caused by malignant proliferation of keratinocytes. SCCs typically arise in sun- exposed areas and have raised, everted edges with an ulcerated centre and a keratotic core. A keratoacanthoma is a variant of SCC which grows rapidly but does not metastasise.

Question 84

What is a basal cell carcinoma and how does it present?

Answer 84

Basal cell carcinomas are the most common type of skin cancer. A skin lesion with raised pearly edges and fine telangiectasia on the surface. It grows across the skin but rarely metastasises.

Question 85

What is melanoma and how does it present?

Answer 85

Melanoma is the worst type of skin cancer and is often associated with a poor prognosis as it grows rapidly and metastasises early. It usually presents as an asymmetrical pigmented skin lesion with an irregular border. An actinic keratosis is a very common, non-malignant skin lesion that occurs due to sun damage. It has a thick, crusty surface.

Question 86

What is the normal diameter of the aorta?

Answer 86

2cm.

Question 87

In which patients is surgical intervention, either by open repair or EVAR, considered?

Answer 87

AAA diameter > 5.5 cm or a rapidly expanding AAA (> 1 cm per year).

Question 88

What is the management plan for patients with an AAA diameter of 3-4.5cm?

Answer 88

Regular surveillance, every year.

Question 89

What is the management plan for patients with an AAA diameter of 4.5-5.5cm?

Answer 89

Regular surveillance, every 3 months.

Question 90

What is Kaposi's sarcoma and how does it present?

Answer 90

Kaposi’s sarcoma is a systemic disease caused by infection with human herpesvirus 8 (HHV-8), presenting as cutaneous tumours. It is an AIDS-defining illness that is often the first AIDS-related complication in HIV patients. Lesions appear mainly on the extremities, but can occur on the trunk, back, face and mucous membranes. Organ involvement is sometimes present in the gastrointestinal and respiratory tract and can result in death.

Question 91

List some important AIDS-defining illnesses.

Answer 91

``` Kaposi's sarcoma. Candidiasis (of the oesophagus, trachea, bronchi or lungs). Cervical cancer. Burkitt's lymphoma. Cytomegalovirus retinitis. Mycobacterium avian complex. Pneumocystis jiroveci pneumonia. Toxoplasmosis. ```

Question 92

What is the antidote to paracetamol overdose?

Answer 92

N-acetylcysteine.

Question 93

What is the antidote to opiate overdose?

Answer 93

Naloxone.

Question 94

What is the antidote to benzodiazepine overdose?

Answer 94

Flumezanil.

Question 95

What is the antidote to organophosphate poisoning?

Answer 95

Atropine.

Question 96

What is the antidote to aspirin overdose?

Answer 96

Sodium bicarbonate.

Question 97

What is haemolytic uraemic syndrome, when does it occur and how does it present?

Answer 97

Haemolytic uraemic syndrome (HUS) is a triad of microangiopathic haemolytic anaemia (MAHA), acute renal failure and thrombocytopaenia. It most often occurs following a diarrhoeal infection by E. coli O157 in children. HUS results from endothelial injury leading to activation of platelets and the clotting cascade, which, in turn, leads to small-vessel thrombosis. Glomeruli are particularly vulnerable, hence why HUS leads to acute renal failure. The small vessel thromboses also cause intravascular haemolysis by exerting shear forces on the blood cells. Schistocytes in the blood film (red cell fragments) indicate intravascular haemolysis. A significant rise in creatinine indicates acute renal failure. N.B. the clotting screen is normal in HUS.

Question 98

What is thrombotic thrombocytopaenic purpura (TTP)?

Answer 98

Thrombotic thrombocytopaenic purpura (TTP) has the same features as HUS with the addition of fever and fluctuating neurological signs.

Question 99

What is disseminate intravascular coagulation (DIC)?

Answer 99

Disseminated intravascular coagulation (DIC) is widespread activation of the clotting cascade resulting in low platelets, low Hb and low fibrinogen with a high APTT/PT.

Question 100

What is atypical pneumonia and how does it present?

Answer 100

Atypical pneumonia is a type of pneumonia that is not caused by the ‘typical’ pathogens and does not present like a ‘typical’ pneumonia. It tends to present with vague symptoms such as malaise, headache and diarrhoea. The three main causes of atypical pneumonia are Legionella pneumophila, Mycoplasma pneumoniae and Chlamydia psittaci. L. pneumophila is found in bodies of water kept at temperatures below 60°C, such as air conditioning units, and it is associated with causing confusion. L. pneumophila also produces antigens that are excreted in the patient’s urine. Mycoplasma pneumoniae causes red cell agglutination and is associated with transverse myelitis. Chlamydia psittaci is primarily found in birds but can cause an atypical pneumonia, known as ‘Psittacosis’, in humans that are exposed to birds.

Question 101

What is Breslow thickness used for?

Answer 101

Prognostic indicator for melanoma based on the depth to which tumour cells have invaded surrounding tissues.

Question 102

What is the Wells score used for?

Answer 102

Assessment of pre-test probability in patients with a suspected pulmonary embolism.

Question 103

What is Dukes' staging used for?

Answer 103

Colorectal cancer.

Question 104

How are haemorrhoids graded?

Answer 104

Grade 1: no prolapse. Grade 2: prolapse on defecation but reduces spontaneously. Grade 3: prolapse requires manual reduction. Grade 4: remain persistently prolapsed and cannot be reduced.

Question 105

What are the different types of rectal prolapse and how do they present?

Answer 105

Type 1 rectal prolapse occurs when only the rectal mucosa protrudes through the anus and type 2 occurs when all layers of the rectum protrude through the anus, creating a mass which has palpable, concentric muscular rings. Some patients report constipation, but fecal incontinence is more common due to the lax anal tone. Some also report a mucus discharge.

Question 106

What are the 2 main causes of rectal prolapse?

Answer 106

Lax anal tone (usually due to pudendal nerve damage) and prolonged straining.

Question 107

What is Dressler's syndrome and how does it present?

Answer 107

Dressler’s syndrome is a type of pericarditis that arises 2-10 weeks after an MI. It is thought that injury to the myocardium during an MI stimulates the production of autoantibodies against heart muscle. These autoantibodies cause pericardial inflammation many weeks later. It presents in the same way as viral pericarditis – pleuritic chest pain that is relieved by sitting forward, fever and a pericardial rub. Dressler’s should not be confused with a simple post-MI pericarditis which occurs within 2-4 days of an MI.

Question 108

How is Dressler's syndrome treated?

Answer 108

Dressler’s is treated with analgesia and anti-inflammatories (e.g. NSAIDs). It may cause a pericardial effusion, which may require pericardiocentesis.

Question 109

What is Leriche syndrome?

Answer 109

Leriche syndrome is a type of intermittent claudication resulting in buttock claudication, erectile dysfunction and weak distal pulses, due to aortoiliac stenosis.

Question 110

How does herpes simplex virus 1 (HSV1) infection present?

Answer 110

Most HSV1 infections are acquired during early childhood and the infection is lifelong. Primary infection is mostly asymptomatic, but may cause pharyngitis, gingivostomatitis and herpetic whitlow (digital blisters/pustules). Following primary infection, HSV1 becomes dormant, classically in the trigeminal ganglia. Reactivation may occur due to physical or emotional stress or immunosuppression, and presents as herpes labialis (cold sores).

Question 111

How does herpes simplex virus 2 (HSV2) infection present?

Answer 111

HSV2 is almost exclusively sexually transmitted and it causes genital herpes (presenting with genital or anal blisters, often with dysuria, fever and malaise).

Question 112

What is Varicella and how does it present?

Answer 112

Varicella (chickenpox) is a primary infection with varicella zoster virus. It causes an intensely itchy and spreading rash affecting mainly the face and trunk.

Question 113

What causes infectious mononucleosis and how does it present?

Answer 113

Infectious mononucleosis (glandular fever) is an infection caused by Epstein-Barr virus, presenting with sore throat, fever, lymphadenopathy, tonsillar enlargement and splenomegaly.

Question 114

What are the clinical features of hereditary haemochromatosis?

Answer 114

Bronze skin, diabetes and hepatomegaly, due to iron deposition in the skin, pancreas and liver, respectively.