SMURF SBA

Question 1

Q6. What is the embryological origin of the pulmonary artery?

First pharyngeal arch
Second pharyngeal arch
Fifth pharyngeal arch
Fourth pharyngeal arch
Sixth pharyngeal arch

Answer 1

sixth pharyngeal arch

Question 2

Q7. A 50 year old female patient presents to you with SOB, when you ask her more details about her shortness of breath she tells you it predominantly comes on when she is hurrying for the bus along the road, which is level.

Using the MRC scale, what grade of breathlessness is this best describing

Grade 1
Grade 2
Grade 3
Grade 4
Grade 5

Answer 2

Q7. B - grade 2

Question 3

Q9. A patient is taking medication for a known respiratory condition. They are now worried as their partner has noticed that when they are carrying a cup of tea, they sometimes spill some due to a new tremor. What medication is most likely to have caused this.

Hydrocortisone
Salbutamol
Salmeterol
Ipratropium bromide
Beclomethasone

Answer 3

SABA use can cause a fine tremor

Question 4

Q10. A 22 year old male patient presents to you in your GP practice and tells you that they have become progressively short of breath over the last few years. After referral to the hospital and a biopsy is taken of the airway, you are able to see goblet cell hyperplasia, inflammation of the airway causing narrowing.

What is the most likely cause of these symptoms

G6PD deficiency
COPD due to smoking
Alpha 1 antitrypsin deficiency
Asthma
Sarcoidosis

Answer 4

C - alpha 1 antitrypsin deficiency - COPD in a young patient raises the possibility of Alpha 1 antitrypsin deficiency

Question 5

Q11. A 24-year-old female presents to the A&E department having taken 20 paracetamol tablets all at once 3 hours ago. How do you proceed?

A. Wait 1 hour and measure plasma paracetamol levels
B. Wait 5 hours and measure plasma paracetamol levels
C. Administer activated charcoal
D. Immediately administer N-Acetyl Cysteine
E. Refer to transplant services

Answer 5

Ingestion less than 1 hour ago + dose >150mg/kg: Administer
activated charcoal
Ingestion <4 hours ago: Wait until 4 hours to take a level and
treat with N-acetylcysteine based on level
* Ingestion within 4-8 hours + dose >150mg/kg: Start N-
acetylcysteine immediately if there is going to be a delay of 28
hours in obtaining the paracetamol level
Ingestion within 8-24 hours + dose >150mg/kg: Start N-
acetylcysteine immediately
Ingestion >24 hours: Start N-acety
Staggered overdose: Start N-acetylcysteine immediately

Question 6

when should N- acetyl- cysteine be administered immediately in paracetamol overdose?

Answer 6

• jaundice
• RUQ pain
• Staggered overdose
• elevated ALT
• INR> 1.3
• Detectable paracetamol concentration

Question 7

Q13. A 43-year-old overweight woman presents to A&E with a temperature of 38C and severe abdominal pain, localised to the right upper quadrant. You note she does not have jaundice. What is the most likely diagnosis?

A. Acute cholecystitis
B. Ascending cholangitis
C. Biliary colic
D. Cholangiocarcinoma
E. Pancreatitis

Answer 7

Fever & RUQ pain in the absence of jaundice should raise the suspicion of acute cholecystitis
If there is jaundice (completing Charcot’s triad), suspect ascending cholangitis

Question 8

Q14. You are an F1 doctor working on SAU. You have been asked to clerk a patient who has presented with fatigue and pruritus. Upon examination, you note hepatosplenomegaly. His past medical history includes ulcerative colitis. Which malignancy is most closely linked to the most likely diagnosis here?

A. Hepatocellular carcinoma
B. Adenocarcinoma of the small bowel
C. Renal cell carcinoma
D. Osteosarcoma
E. Cholangiocarcinoma

Answer 8

E. Cholangiocarcinoma
.The most likely diagnosis here is Primary Sclerosing Cholangitis (biggest giveaway is the PMH of ulcerative colitis). These patients are at an increased risk of cholangiocarcinoma. Patients with PBC are at an increased risk of hepatocellular carcinoma

Question 9

Q15. Which of these describes Zollinger-Ellison Syndrome best?

A. Upper oesophageal web, post-cricoid dysphagia and iron deficiency anaemia
B. Passage of a gallstone through the Ampulla of Vater into the small bowel, leading to small bowel obstruction
C. Splenomegaly, rheumatoid arthritis and neutropenia
D. Gastrinoma uncontrollably releasing gastrin leading to several ulcerations within the stomach and duodenum
E. Diabetic symptoms due to invasion of cancerous cells into the tail of the pancreas

Answer 9

D. A=Plummer Vinson Syndrome, B=Gallstone ileus, C=Felty’s syndrome and E is a late sign of pancreatic cancer

ZES is characterised by a tumour (often in the head of the pancreas or duodenum) uncontrollably releasing gastrin. Gastrin triggers an increased release of gastric acid, which leads to ulceration of the stomach and duodenum. These patients as a result often present with GI haemorrhage (melaena/haematemesis).

Question 10

Q16. Patients with T1DM often suffer from gastroparesis due to autonomic neuropathy. Which of these best describes gastroparesis?

A. Intermittent abdominal pain after eating
B. Delayed gastric emptying
C. Late satiety
D. Impaired absorption of protein
E. Rapid gastric transit of food

Answer 10

b

Question 11

Q17. When shadowing the F2 doctor in A&E, you are asked to take a history from a patient presenting with ‘black poo and red vomit’. You establish that they have had a drinking problem for some years now, consuming over 50 units a week for the last 5 years. On examination, they have gross ascites and scleral icterus. A gastroscopy reveals oesophageal varices that are actively bleeding. This cannot be controlled with band ligation. What is the next best step in management?

A. Adrenaline injection
B. Propranolol
C. Sengestaken-Blakemore Tube
D. Transjugular-Intrahepatic Portosystemic Shunt (TIPSS)
E. Escalate to end of life care

Answer 11

C. Sengestaken-Blakemore Tube
C. Adrenaline injections are used for smaller bleeding lesions, such as angiodysplasias or ulcers. Propranolol can be used as prevention of bleeding varices. Sengestaken Blakemore tubes are used to tamponade bleeding varices temporarily. TIPPS can be used as a preventative method for bleeding varices where propranolol and band ligation fail.

Question 12

Q18. Considering the patient from Question 7, what is his total weekly intake of alcohol if he drinks the following:
8 pints (568mL) of 5.5% beer daily
1 bottle (750mL) of 37.5% vodka daily
1 bottle (750mL) of 8% wine daily

A. 185.086
B. 59.117
C. 53.117
D. 108.32
E. 94.56

Answer 12

B. 59.117
B:
Beer- (8x568x5.5)/1000=24.992
Vodka- (750x37.5)/1000=28.125
Wine- (750x8)/1000=6
Units are calculated by multiplying the volume (mLs) and concentration (ABV%) and dividing by 1000

Question 13

Q19. Which of the following is NOT a cause of a high serum albumin ascitic gradient?

A. Nephrotic syndrome
B. Budd-Chiari syndrome
C. Heart failure
D. Cirrhotic liver disease
E. Constrictive pericarditis

Answer 13

A. Nephrotic syndrome

Causes of High SAAG
Liver failure
Cirrhosis
Constrictive pericarditis
Heart Failure
Budd-Chiari syndrome

causes of low SAAG
TB
Pancreatitis
Peritoneal cancer
Nephrotic syndrome

Question 14

Q20. You are working as a junior doctor in a GP practice. During your clinic, a patient presents with jaundice. They deny abdominal pain, fever or any other symptoms. However, they do state that they have recently had an extremely stressful period in which they sat their GCSE exams, which coincided with the jaundice. They also state that their father suffered from something similar to this. What is the most likely differential?

A. Autoimmune hepatitis
B. Primary Biliary Cholangitis
C. Hereditary haemochromatosis
D. Gilbert’s syndrome
E. Pancreatic cancer

Answer 14

. D. Gilbert’s syndrome is a condition where someone has a deficiency in UDPGT, the enzyme needed to conjugate bilirubin. With a lack of conjugation, the build up of unconjugated bilirubin can lead to jaundice. These episodes of jaundice are often seen in times of physiological stress, such as stressful periods of life or infections.

Question 15

Q21. A 53-year-old man presents to the nephrology clinic after a total nephrectomy for malignant renal cell cancer. His kidney has undergone histological analysis.
What histological type is his cancer most likely to be?

A. Chromophobe renal cell cancer
B. Clear cell carcinoma
C. Papillary renal cell carcinoma
D. Renal medullary carcinoma
E. Sarcomatoid renal cell cancer

Answer 15

1. B. Clear cell carcinoma is the correct answer as 75% of renal cell cancers are of the clear cell histological type. Renal cell cancer is more common in middle-aged men, smokers, tuberous sclerosis, von Hippel-Lindau syndrome and autosomal polycystic kidney disease patient.

Question 16

Q22. A 72-year-old woman presents to the endocrinology clinic with a history of muscle cramps, headaches, and lethargy. Her observations in the clinic are heart rate 82/min, respiratory rate 16/min, blood pressure 152/102 mmHg, temperature 36.2ºC, saturations 98% on air. An abdominal CT scan shows an adrenal mass.
Given the likely diagnosis, where is the hormone responsible for these symptoms produced?

A. Adrenal medulla
B. Juxtaglomerular apparatus
C. Zona fasciculata
D. Zona glomerulosa
E. Zona reticularis

Answer 16

D. Zona glomerulosa. Patient is suffering from symptoms of hyperaldosteronism (Conn’s syndrome). Aldosterone is produced in the zona glomerulosa

Question 17

Q23. A 4-year-old boy is admitted with abdominal pain and painless haematuria. On examination, there is a mass on palpation of the left flank. What is the most likely diagnosis?

A. RCC
B. Wilm’s tumour
C. UC
D. cystitis
E. appendicitis

Answer 17

23. B. Wilms tumour. The most common form of renal carcinoma in children is WIlms’ tumour.

Question 18

Q24. A 34-year-old single mum has been referred for genetic testing following her 8-months-old son being diagnosed with congenital nephrogenic diabetes insipidus. She is asymptomatic and is not aware of any family history of this condition.
Which of the following structure of the kidney is most commonly affected in this condition?

A. Vasopressin receptor
B. Angiotensin II receptor
C. Epithelial sodium channel
D. Sodium-chloride co-transporter
E. Aquaporin 1 channel

Question 19

Q25. A 70kg 55-year-old male is recovering from a community acquired pneumonia in hospital. His blood tests are consistent with AKI stage 2.
What is the most important drug to stop on this patient’s drug chart?

A. Co-amoxiclav
B. Diclofenac
C. Morphine sulphate
D. Paracetamol
E. Tramadol

Answer 19

B. Diclofenac NSAID

Question 20

Q26. A 45-year-old male is returned to a surgical ward following a renal transplant. 90 minutes after the transplantation, diuresis suddenly decreases. The patient is immediately transferred back to surgery where the transplanted kidney shows signs of hyperacute rejection and is removed. Histopathological examination is consistent with hyperacute rejection.
This patient has experienced which of the following types of hypersensitivity reaction?

A. I
B. II
C. III
D. IV
E. V

Answer 20

B. Hyperacute transplant rejection is an example of type II

Question 21

Q27. A 27-year-old female presents with recurrent urinary tract infections. As part of the history you find out that she is 14 weeks pregnant.
What medication should the patient be given?

A. Amoxicillin
B. Trimethoprim
C. Rifampicin
D. Flucloxacillin
E. Nitrofurantoin

Answer 21

E. Nitrofurantoin is indicated here as trimethoprim is teratogenic during the first trimester.

Question 22

Q29. A woman is admitted with left-sided weakness and collapse. She is brought in with her husband, who explains that she has no drug allergies and a past medical history of diabetes, hyperthyroidism and autosomal dominant polycystic kidney disease.
A CT scan of the head shows a large, right-sided intracerebral bleed.
What is the most likely cause of the bleed?

A. Hypertension
B. Poorly controlled diabetes
C. Ruptured berry aneurysm
D. Atherosclerotic disease
E. Paradoxical embolism

Answer 22

C. Adult polycystic kidney disease increases the risk of brain haemorrhage due to ruptured berry aneurysms

Question 23

34) Most common cause of small bowel obstructions?
A) Malignancy
B) Diverticular disease
C) Surgical adhesions
D) Volvulus
E) Hernia

Answer 23

C) Surgical adhesions

Question 24

36) Which of the following is not an insufficient absorptive area cause of malabsorption?
A) Lactose intolerance
B) Gluten sensitivity
C) Crohn’s disease
D) Small intestine resection
E) Bacterial infections

Answer 24

A – lactose intolerance, all the other affect the size of the surface area that is available for absorption

Question 25

7) A patient enters A and E complaining of stomach pain that has been occurring for several hours. They had had very spicy food last night and have recently been to India to see family. They also tell you that in the last half an hour the pain has begun to spread to downward and to the right-hand side of their abdomen. Based on your most likely diagnosis what is your first line investigation?
A) CT abdomen
B) Ultrasound
C) Urine dip
D) Pregnancy test
E) Colonoscopy

Answer 25

B – ultrasound, the pain travelling to the lower right quadrant from the stomach suggests appendicitis, while there are better investigations for this here, this is the first line

Question 26

38) Mr Kerton, a 67-year-old male, presents to you, his GP, complaining of some blood in his poo in recent weeks. He says that he can he see it in his bowels, and it looks quite dark. He said that he also has lost weight recently which has surprised him as he has been eating normally. Based on the likely diagnosis what is the first line investigation?
A) Digital examination
B) Endoscopy
C) Stool sample
D) Gastroscopy
E) Abdomen x-ray

Answer 26

D) Gastroscopy

Question 27

39) Alex enters A and E complaining of stomach pains, heartburn and dyspepsia as well as dark, foul smelling bowel movements. When asked about his social history he tells you that he has recently returned from Malaysia, he is a smoker, binge drinks alcohol regularly and is allergic to penicillin and insulin. Based on your likely diagnosis, what would be your treatment plan?
A) Omeprazole and amoxicillin
B) Metronidazole, clarithromycin and omeprazole
C) Amoxicillin, omeprazole and clarithromycin
D) Metronidazole and amoxicillin
E) Metronidazole, clarithromycin, amoxicillin

Answer 27

B – the history of travel with the symptoms presented suggests a H. Pylori infection, as he is allergic to penicillin this is the course of treatment

Question 28

40) Which of these is the least likely cause of peptic ulcers?
A) Mucosal ischaemia
B) Autoimmune gastritis
C) H.Pylori
D) Increase in stomach acid production
E) Repeated NSAID use

Answer 28

B) Autoimmune gastritis

Question 29

41) Margaret is a 76 y/o lady with hypertension that is still not controlled despite being on the highest doses of amlodipine (10mg) and ramipril (10mg) and indapamide (2.5mg). She has her Urea and Electrolytes (U&Es) checked and her potassium is measured at 4.2 mmol/L so she is started on 25mg of spironolactone. What is the mechanism of action of spironolactone?

A) Inhibits Angiotensin Converting Enzyme (ACE) primarily in the lungs preventing Angiotensin-I being cleaved to Angiotensin-II. In turn this has an antagonistic effect on the Renin-Angiotensin-Aldosterone-System (RAAS)

B) Competitively binds to mineralocorticoid receptors on aldosterone-dependent sodium-potassium channels in the distal convoluted tubule and collecting ducts leading to increased amounts of sodium and water to be excreted whilst sparing potassium

C) Inhibits reabsorption of Cl- ions at the distal tubule via the Na-Cl co-transporter resulting in an increase in the excretion of sodium, chloride and water and also causes vasodilation

D) Dihydropyridine Calcium Channel Blocker; inhibits the influx of calcium ions into vascular smooth muscle resulting in vasodilation and leading to a reduction in peripheral vascular resistance

E) Competitively binds to AT1 receptors in vascular smooth muscle and the adrenal glands in place of Angiotensin-II leading to vascular smooth muscle relaxation and leading to a reduction in peripheral vascular resistance

Answer 29

B) Competitively binds to mineralocorticoid receptors on aldosterone-dependent sodium-potassium channels in the distal convoluted tubule and collecting ducts leading to increased amounts of sodium and water to be excreted whilst sparing potassium

Question 30

45) Rose is a 30 year old lady presenting to A&E with a 1 hour history of palpitations following a 10km run. She has never experienced this before. Her observations are as follows:
SpO2 - 97% on room air
BP - 115/76
HR - 210bpm and regular
RR - 20 b/min
Temp - 37.1°C

You perform an ECG and note the following features:
Narrow QRS complex
Normal isoelectric line
No discernible P waves
Regular rhythm and fast rate at 180bpm

You check her medical records and find an old ECG from 1 year ago which is normal. You decide to initiate treatment by getting her to forcefully blow into a 20ml syringe for 20 seconds and just before she releases you tilt her back to lie flat on the bed and lift her legs in the air. You check her heart rate and it is now back to her normal baseline of 70bpm.

What cardiac rhythm did she experience:

A) SVT - Atrioventricular Re-Entry Tachycardia (AVRT)
B) Ventricular Tachycardia (VT)
C) Atrial Fibrillation
D) SVT - AV Nodal Re-entry Tachycardia (AVNRT)
E) Sinus Tachycardia

Answer 30

Q45) D) SVT - AV Nodal Re-entry Tachycardia (AVNRT)

AVRT - a type of SVT due to an anatomical accessory pathway such as the Bundle of Kent seen in Wolf-Parkinson-White Syndrome
VT - is a broad complex tachycardia
AF - irregularly irregular rhythm
Sinus Tachycardia - P wave followed by QRS complex, maximum heart rate (in sinus rhythm) can be calculated with 220 - age so for Rose this would be 190, this rhythm is unlikely to be sinus tachycardia as it is too fast

Question 31

42) Which of the following is not a cause of atrial fibrillation:

A) Myocardial Infarction (MI)
B) Thyrotoxicosis
C) Diltiazem
D) Infection
E) Hypertension

Answer 31

C) Diltiazem
C) Diltiazem; Diltiazem is a non-dihydropyridine calcium channel blocker (cardioselective) and is a Class IV anti-arrhythmic. It is one of the first line rate control treatments for AF.

The causes of AF can be remembered with the mnemonic Mrs SMITH (not an exhaustive list):
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension

Question 32

46) Which of the following statements is correct:

A) Abdominal aortic aneurysm (AAA) screening is offered at age 60 and consists of a single Magnetic Resonance Angiogram (MRA)

B) Abdominal aortic aneurysm (AAA) screening is offered at age 60 and consists of a single abdominal ultrasound scan

C) Abdominal aortic aneurysm (AAA) screening is offered at age 65 and consists of a single Magnetic Resonance Angiogram (MRA)

D) Abdominal aortic aneurysm (AAA) screening is offered at age 65 and consists of a single CT Angiogram

E) Abdominal aortic aneurysm (AAA) screening is offered at age 65 and consists of a single abdominal ultrasound scan

Answer 32

E) Abdominal aortic aneurysm (AAA) screening is offered at age 65 and consists of a single abdominal ultrasound scan

Question 33

Q47) Joe is a 54 y/o gentlemen who has presented to A&E with recurring fevers, feeling generally unwell and weakness. On examination you note that his temperature is 39.2°C and on auscultation of his chest, you hear normal vesicular breathing over the lung fields but notice a new loud murmur heard best at the apex. Joe states that he has never been told about that before and there is no mention of valvular pathology in his medical records. You also notice that Joe has obvious dental caries and he mentions he can’t remember the last time he went to the dentist.

You take several sets of peripheral blood cultures. The microbiologists report they have grown an organism that appears purple on gram staining with round-shaped bacteria organised in chains. In blood agar, they noticed a green discolouration surrounding the colonies cultured and after placing an optochin disc into the medium, no zone of inhibition forms around it.

Which of the following is the most likely causative organism:

A) Staphylococcus aureus
B) Streptococcus viridans
C) Enterococci species
D) Streptococcus bovis
E) Staphylococcus epidermidis

Answer 33

B) Streptococcus viridans

Q47) B) Streptococcus viridans; most common organism implicated in patients with poor dental hygiene. It is an optochin resistant, alpha-haemolytic, gram positive cocci, seen in chains
Purple gram stain - gram positive
Round shape - cocci
Chains - gram +ve cocci in chains points to streptococcal species instead of staphylococcal which are in clusters
Green discolouration - alpha haemolysis (partial haemolysis)
No zone of inhibition around optochin disc - optochin resistant

Staph. aureus - most common cause of IE in the developed world
Strep. bovis - important cause of IE as it is associated with colorectal cancer (pt would be considered for colonoscopy +/- biopsy)
Staph. Epidermidis - common cause of prosthetic valve endocarditis

*Important note - fever + new murmur is always Infective Endocarditis until proven otherwise

Question 34

Q49) Which of the following correctly describes the formation of foam cells?

A) Fatty infiltration of the subendothelial space by low-density lipoproteins (LDL)
B) Endothelial cell damage secondary to super-oxide anions, CO, free radicals, nicotine, shearing forces, glycosylation products and LDL
C) Macrophages phagocytose LDL and increase in size
D) Smooth muscle proliferation and migration from the tunica media into the tunica intima forming a fibrous cap over the fatty plaque
E) Monocytes migrate form the blood into the subendothelial space where they differentiate into macrophages

Answer 34

C) Macrophages phagocytose LDL and increase in size

Question 35

55.) Sickle-Cell Anaemia is caused by a single point mutation in the beta-globin gene which causes sickling of erythrocytes at low O2 tension. On which chromosome does this point mutation occur?
A. Chromosome 9
B. Chromosome 5
C. Chromosome 14
D. Chromosome 22
E. Chromosome 11

Answer 35

E. Chromosome 11

Question 35

56.) A 48 year-old female presents to her GP with exertional chest pain and SOB. She also complains of feeling more tired lately and felt dizzy when coming into surgery today. You suspect anaemia. Antibody testing shows the presence of Intrinsic Factor antibodies. What would be your 1st-line treatment?
A. Hydroxocobalamin
B. Blood transfusion
C. Hydroxycarbamide
D. Folic Acid
E. Ferrous Sulphate

Answer 35

A. Hydroxocobalamin

Question 36

60.) A 67 year-old female patient presents with increased bruising as well as increased excoriation marks across her skin due to excessive itching. She also complains of a headache as well as a ringing in her ears. What gene might you a see a mutation in following genetic testing?
A. HLA-DQ2
B. BCR-ABL
C. JAK2
D. G6PD
E. HLA-B27

Answer 36

C
· Polycythaemia Rubra Vera is a cancer caused by the clonal proliferation of haematopoietic progenitor cells causing an increase in the red cell mass
· Mostly all cases of polycythaemia rubra-vera are linked to an acquired mutation of Janus Kinase 2 (JAK2) - a tyrosine kinase important in cell signalling pathways
i. HLA-DQ2: Coeliac Disease
ii. BCR-ABL: Chronic Myeloid Leukaemia
iii. G6PD: deficiency would present with more anaemia-like symptoms
iv. HLA-B27: spondyloarthropathies (Ankylosing Spondylitis)

Question 37

62.) A 42-year-old male presents with hypertension, tachycardia is very sweaty and looks pale. You complete serum metadrenalines and normetadrenalines to help you with your diagnosis which come back raised supporting your differential. The patient is deemed unfit for surgery. What should be your initial management?

Amlodipine
Atenolol
Co-amoxiclav
Phenoxybenzamine
Ramipril

Answer 37

Phenoxybenzamine
This patient has a phaeochromocytoma which should first be treated with an alpha-blocker followed by a beta-blocker to prevent reactive vasoconstriction

Question 38

64.) When measuring patients blood pressure, you notice their hand and wrist start to curl up towards themselves. Last year the patient had a full thyroidectomy. What is the name of this sign?

Babinski’s
Chvostek’s
Lhermitte’s
Murray’s
Trousseau’s

Answer 38

Trousseau’s

Question 39

66.) Which of these is not released by the anterior pituitary?

Adrenocorticotropic hormone
Follicle-stimulating hormone
Growth Hormone
Prolactin
Vasopressin

Answer 39

Vasopressin

Question 40

68.) Kyle visits you in the hypertension clinic. He complains of new problem with needing the toilet more frequently. You conduct some tests and find he is hypokalaemia. You suspect Conn’s disease.
Which area of the kidney is responsible for secreting the hormone responsible for Conn’s disease?

Cortex
Medulla
Zona fasciculata
Zona glomerulosa
Zona reticularis

Answer 40

Zona glomerulosa

Question 41

70.) What is the correct MOA of carbimazole?

Blocks synthesis of T4, which decreases the production of T3
Increases the release of TSH, therefore stimulating the release of T3 and T4
Makes PTH more sensitive to calcium
Prevents the conversion of T4 to T3
Synthetic form of T4

Answer 41

Blocks synthesis of T4, which decreases the production of T3 Blocks synthesis of T4, which decreases the production of T3

Question 42

71. Which of the following is not a feature of Huntington’s Disease?

Anticipation
Associated with cell loss in the basal ganglia
Characteristic symptoms include chorea, dystonia and seizures
Autosomal dominant inheritance pattern
Associated with increased dopamine levels

Answer 42

Associated with increased dopamine levels

Question 43

72. A 57 year old male patient presents to A&E with diplopia, vomiting and ataxia. Whilst in the waiting room his symptoms stop without treatment. What could have caused these symptoms?

TIA in the basilar arteries
Hypoglycaemia
Webers syndrome
Posterior circulation stroke
TIA in the internal carotid artery

Answer 43

TIA in the basilar arteries
72. A - symptoms resolve within 24 hours, so it is a TIA (hypoglycaemia would need treatment). Basilar arteries perfuse occipital lobes, brainstem and cerebellum, so could cause these symptoms, unlike the internal carotid artery

Question 44

73. A 22 year old female patient presents to A&E reporting symptoms of a worsening headache, confusion, nausea and drowsiness over the last 6 hours since she was hit in the head by a stray cricket ball.

What would the result of her investigation show?

Crescent shaped haematoma hypodense to surrounding tissue on CT
Biconcave hyperdense shape on CT
Subarachnoid bleeding on CT
Crescent shaped haematoma hyperdense to surrounding tissue on CT
Increased electrical activity on EEG

Answer 44

Crescent shaped haematoma hyperdense to surrounding tissue on CT

Question 45

75. A 14 year old female patient presents to her GP after suffering 4 bad headaches in the last month. During the headaches she tries to avoid bright lights and loud noises. They normally last around 12 hours.

Which of these would the GP prescribe for use during the next headache?

Codeine
Naproxen
Propranolol
Topiramate
Mannitol

Answer 45

Naproxen
B - NSAIDS like naproxen are used in acute attacks, alongside triptans, paracetamol and antiemetics. Codeine is an opioid which should not be used in migraines, propranolol and topiramate are prophylactic measures, mannitol is just wrong

Question 46

78. A 30 year old patient reports feeling numb all over their body, with muscle weakness on both sides of their body and double vision. They report they have never had any incidents like this before and have been in good health apart from a case of food poisoning 3 weeks ago.

What is their likely diagnosis?
Motor neurone disease
Multiple sclerosis
Guillain-Barre syndrome
Charcot Marie Tooth syndrome
Brown-sequard syndrome

Answer 46

Guillain-Barre syndrome
GBS as symptoms match and followed a case of food poisoning

Question 47

79. A 63 year old male patient enters your GP surgery. You notice he is walking with small steps, nearly falls as he turns to sit, and has a tremor when he is sitting down.

What is causing his condition?

Increased GABA levels
Increased acetylcholine levels
Decreased glutamate levels
Decreased serotonin levels
Decreased dopamine levels

Answer 47

Decreased dopamine levels
the patient has symptoms of Parkinson’s disease, which is caused by decreased dopamine levels

Question 48

80. The above patient goes on to suffer with fluctuating cognitive ability and visual hallucinations.

What is a feature of the condition he has developed?

Sudden onset
Deposition of abnormal proteins
2 attacks disseminated in time and space
Classified using WHO histology grading
Positive Babinski sign

Answer 48

Deposition of abnormal proteins
this is a feature of Lewy Body dementia, which is associated with Parkinson’s

Question 49

81. A male patient presents to you with a high fever after visiting the dentist. When you listen to their chest, you hear a murmur. When you examine the patients hands there are red line under the patients nails and dots on their hands that hurt when they are pressed. Given the most likely diagnosis, what is the best description of the most likely causative organism

Gram negative, catalase negative alpha haemolytic, optochin resistant
Gram positive catalase negative, alpha haemolytic optochin sensitive
Gram negative catalase positive
Gram positive, catalase negative beta haemolytic
Gram positive, catalase negative, gamma haemolytic

Answer 49

Gram negative, catalase negative alpha haemolytic, optochin resistant

Question 50

82. What is the mode of action of vancomycin

Inhibits protein synthesis at the 30s ribosome
Inhibits protein synthesis at the 50s ribosome
Inhibits cell wall synthesis
Inhibits folate synthesis
Inhibits the replication of DNA inside the nucleus by stopping topoisomerase attach to the DNA strand

Answer 50

vancomycin is a glycopeptide that inhibits cell wall synthesis - Inhibits cell wall synthesis

Question 51

83. What type of immunoglobulin is able to cross the placental barrier

IgA
IgG
IgM
IgE
IgD

Answer 51

IgM

Question 52

85. ‘The proportion of all positive results that actually have the disease’ is the definition of what concept

Sensitivity
Specificity
Positive predictive value
Negative predictive value
Non of the above

Answer 52

c

Question 53

86. A 45 year old patient presents to you as they have discomfort due to a mass in their flank region. Their blood pressure is 165/105. They tell you that one of their parents also had this all through their life, but he cant remember what condition it is called. The consultant suspects a diagnosis and refers the patient for testing. The patient is found to be positive for genetic mutation found on chromosome 16.

Given the likely diagnosis, which of the following is linked to the patients condition.

Rheumatoid arthritis
Development of diabetes later in life
subarachnoid haemorrhage
DVT
Non ST elevation myocardial infarction

Answer 53

subarachnoid haemorrhage

C - this is polycystic kidney disease. It is an autosomal dominant condition caused by a mutation in the PKD1 gene on chromosome 16. Sub arrachnoid haemorrhage is more common in these patients

Question 54

90. A patient is started on a new mediation for their hypertension. A few weeks later he tells you he cant get his shoes on cause his ankles are very swollen now. Which of the following was most likely prescribed.

Ramipril
Atenolol
Verapamil
Bendroflumethiazide
Indapamide

Answer 54

Verapamil
- verapamil is a calcium channel blocker, these can cause ankle swelling (this is sometimes a DDX for right sided heart failure)

Question 55

91. A 55-year-old female presents to you in your GP practice with pain and swelling in her distal and proximal interphalangeal joints in her left hand. She says the pain is worsened with movement. A subsequent X-Ray of these joints shows loss of the joint space as well as subchondral sclerosis. What is the most likely diagnosis?

A) Rheumatoid Arthritis
B) Gout
C) Osteoarthritis
D) Psoriatic Arthritis
E) Pseudogout

Answer 55

C) Osteoarthritis

Question 56

92. A 21-year-old male presents in A&E with a hot and swollen right knee. He has just recently returned from a holiday abroad with his friends. You take his temperature, and it measures at 39.1 °C. You suspect septic arthritis in his right knee joint. What possible causative organism should be suspected initially?

A) Staphylococcus aureus
B) Streptococcus pyogenes
C) E. coli
D) Haemophilus influenza
E) Neisseria gonorrhoea

Answer 56

E) Neisseria gonorrhoea
· This patient is young, possibly sexually active and has just come back from a foreign country
· Though staphylococcus aureus is the most common causative organism of septic arthritis, Neisseria gonorrhoea is more common in younger patients and can be caused by STI infection
· Therefore, this must be ruled out initially with gram staining
· If present, the stain would show a gram negative diplococcus

Question 57

97. A 63-year-old female presents to you in hospital with pain and swelling in her hands and feet on both sides. This pain is worse when she is sat still, however improves once she starts moving around the house. She also says they feel stiff in the morning and this can last for up to two hours. On examination, you notice that her distal interphalangeal joints are hyperextended and her proximal interphalangeal joints are flexed. What is this hand sign called?

A) Boutonnieres deformity
B) Z-shaped deformity
C) Swan neck deformity
D) Heberden’s nodes
E) Bouchard’s nodes

Answer 57

A) Boutonnieres deformity

Boutonnieres deformity – hyperextended DIP with flexed PIP ·  	Swan neck deformity – hyperextended PIP with flexed DIP ·  	Z shaped deformity generally occurs in the thumb ·  	Heberden’s nodes (DIP joints) and Bouchard’s node (PIP joints) are associated with osteoarthritis

Question 58

99. A 30-year-old male has been referred to you with bilateral muscle pain and weakness around his shoulders and pelvis. You notice scaly erythematous patches on his knuckles and a rash on his back and shoulders. His wife informs you that the rash particularly worsens when exposed to light. What is the gold standard investigation for this condition?

A) Muscle biopsy
B) Creatine kinase levels
C) MRI
D) Electromyography
E) Autoantibody levels

Answer 58

B) Creatine kinase levels

Question 59

100. A 70-year-old female is diagnosed with rheumatoid arthritis and started on leflunomide. What is leflunomide’s mechanism of action?

A) It interferes with toll-like receptors, disrupts antigen presentation and increases the pH in the lysosomes of immune cells. This causes an overall immunosuppressive effect.

B) It blocks tumour necrosis factor, which reduces inflammation.

C) It disrupts folate metabolism and therefore requires folic acid to be taken with it.

D) It targets the CD20 protein on the surface of B cells, which initiates B cell destruction. This causes an overall immunosuppressive effect.

E) It interferes the production of pyrimidine, which is an important component of RNA and DNA.

Answer 59

E) It interferes the production of pyrimidine, which is an important component of RNA and DNA.