2018 (Paper 1) Flashcards
1
Q
RTA. Conscious at the event. Brought into the A&E with reducing consciousness. Had to work out GCS from the info. Calculated as 6/7:
- Neurosurgical review
- Intubated and ventilate
- Rapid CT
- Burr hole
A
Intubated and ventilate
2
Q
Anterior neck lump biopsied as a squamous cell carcinoma of a tonsillar primary. Which infection causes this cancer:
- EBV
- HPV
- Cytomegalovirus
- HTLV-1
- HIV
A
EBV
3
Q
Man with rheumatoid arthritis has painless ulcer on the medial malleolus what’s the diagnosis, had evidence of lipodermatosclerosis and hemosiderosis (thickened brown pigmentation surrounding it):
- venous ulcer
- pyoderma gangrenosum
- Granuloma annulare
- Necrobiosis lipoidica
A
venous ulcer
4
Q
Small lump, Mammograohy shows calcication, DCIS diagnosed on histology what is the treatment
- wide local excision
- Mastectomy
- Radiotherapy
- Review in 6 months
- Tamoxifen
A
wide local excision
5
Q
55 year old Woman smokes 10 per day with a 6 month history of white sputum and a cough what should be done first
- CXR
- PEF diary
- Spirometry
- Culture
A
CXR
6
Q
5 days post AP resection and now peritonitic, temp 38 abdo distension and lower abdo pain. (rpt Q)
- Pelvic abcess
- Anastomotic leak
- Subphrenic abscess
- Subpelvic abscess
A
Anastamotic leak
7
Q
Private healthcare screening 21 y/o asymptomatic. Fasting bm was 7.2. What should you do with him?
- HbA1c
- Diet
- Gliclazide
- Dietary advice
A
HbA1c
8
Q
Breast cancer with lung and bone mets. On low-dose haloperidol. Confused, constipated, (hypercalcaemia). What is causing these symptoms:
- Hypercalcaemia
- Brain mets
- Haloperidol
- Diabete Mellitus
A
Hypercalcaemia
9
Q
22 year old soldier Comes out of cramped military aircraft after a long flight and collapses and hits her head some limb twitching for 15 seconds, regains consciousness after 5 mins. looks pale
- Vasovagal
- PE
- Tachyarrhythmia
- Epilepsy
A
Vasovagal
10
Q
Young woman, no lump, bloody discharge from boob:
- Intraductal papilloma
- DCIS
- Duct ectasia
A
Intraductal papilloma
11
Q
Woman who had been in bangladesh for 6 months found to have decreased chest expansion, dull percussion on R side
- Pneumothorax
- Pleural effusion
- Emphysema
A
Pleural effusion
12
Q
Patient with symptoms of UC, which investigation is diagnostic
- Colonoscopy
- Faecal calprotectin
- Flexi sig
- CT
- USS
A
Faecal calprotectin
BMJ:
Faecal calprotectin is recommended. It is elevated when there is bowel inflammation and correlates with endoscopic and histological gradings of disease severity. It is useful in supporting clinicians in the differential diagnosis of irritable bowel syndrome (IBS)/inflammatory bowel disease (IBD) and can prevent unnecessary referrals for colonoscopy. In those with an established diagnosis of IBD this test can be useful to assess for ongoing bowel inflammation
Colonoscopy is expensive, requires full bowel preparation and sedation, and should be performed in a special setting (endoscopy suite).
Indicated in patients with UC who are not responding well to treatment, in order to rule out infections (particularly cytomegalovirus and Clostridium difficile ) and assess the need for surgery.
13
Q
Patient with UC, what features indicate for colectomy
- Epithelial dysplasia
- Paneth cell metaplasia
- Crypt abscess
- Crypt architecture disruption
- Numerous granulomas
A
Epithelial dysplasia
Epithelial dysplasia a term becoming increasingly referred to as intraepithelial neoplasia, is the sum of various disturbances of epithelial proliferation and differentiation as seen microscopically. Individual cellular features of dysplasia are called epithelialatypia.
Paneth cell metaplasia occurs in chronic inflammatory conditions of the colon, most notably ulcerative colitis and colonic Crohn’s disease
14
Q
Greek guy takes antimalarials and becomes jaundice
- G6PD deficiency
- SCD
- Autoimminue heamolytic anaemia
- Adverse drug side effect
A
G6PD deficiency
15
Q
Asthma in a 40yr old lady with unable to finish sentences, hypoxic, high PCO2, pH on ABG 7.30. Already treated with IV nebulisers and pred.
- CPAP
- IV aminophylline
- Intubate ventilate
- Reduce her O2
A
Intubate
CO2 high->intubate
British Thoracic Society guidelines
- magnesium sulphate recommended as next step for patients who are not responding (e.g. 1.2 - 2g IV over 20 mins)
- little evidence to support use of IV aminophylline (although still mentioned in management plans)
- if no response consider IV salbutamol
16
Q
Old guy with COPD with CO poisoning, normal O2 sats
- 15L non rebreather mask
- 2L nasal cannula
- Different concentrations with venturi mask
A
15L non rebreather mask
17
Q
PEFR 65%, Sats 95%, Pulse 130 bpm. What clinical feature is most useful in determining whether someone with asthma needs admission
- Peak flow
- O2 sats
- Heart rate
- Wheeze
- Respiratory rate
A
Peak flow
18
Q
Hypotensive patient post op, has been given 500ml bolus, no signs of HF, 10 ml urine, no pain
- Remove epidural
- Give fluids
- Give vasoconstrictor
- Give diuretics
- Put them head down
A
Give fluids
19
Q
Sickle cell disease with back pain, what analgesia do you give first
- paracetamol/ibuprofen
- Epidural
- Fluids
- Exchange transfusion
A
Fluids
20
Q
Person on morphine epidural after THR and confused, shouting in middle of night about things in his kitchen. How to manage
- Stop morphine
- IM Haloperidol
- Diazepam
- Well lit side room
- Midazolam
A
Well lit side room
21
Q
Epilepsy not responsive to two xLorazepam
- Phenytoin
- Propofol
- Diazepam
- Thiopentone
- Thiamine
A
Phenytoin
22
Q
Full-thickness ulcer on medial malleolus, person with rheumatoid, hardended dark brown skin around it
- Venous ulcer
- Pyoderma gangrenosum
- Granuloma annulare
- Erythema Multiforme
A
Venous ulcer
23
Q
Peripheral oedema, scrotal oedema, proteinuria. Which diagnostic investigation do you do?
- Renal biopsy
- Protein creatinine ratio
- Ureteroscopy
A
Renal biopsy
24
Q
Post tonsillitis guy who got proteinuria, haematuria, swollen face, red cell casts, self resolved over the next 3 months
- Iga nephropathy
- Acute glomerulonephritis
- Nephrotic syndrome
A
Iga nephropathy
25
**Tonsillar exudates, jaundice (change in skin colour), upper abdo pain. What was the cause**
1. EBV
2. Tonsillitis
3. Staph sepsis
4. Influenza
5. Malaria
EBV
26
**Guy with seizure and no focal neurology. LP results normal protein, normal glucose, raised cell count (20). CT head clear.**
1. Viral encephalitis
2. Pneumococcal meningitis
3. Viral meningitis
4. TB meningitis.
Viral encephalitis
27
**80 year old guy with increased confusion, type 2 diabetes AF with warfarin. Complains of headaches and had 2 falls, increased confusion**
1. UTI
2. Chronic subdural
3. Extradural
4. Thrombotic emboli
Chronic subdural
28
**Old lady falls in nursing home, GCS 14 dropped next day to 9, had headache**
1. Extradural
2. Subdural
3. SAH
4. Intracerebral haematoma
????extradural
29
**Someone has watery vomiting and diarrhoea. What precautions will you take**
1. None
2. Don’t let kids see her
3. Ask staff and visitors to wash hands
4. Side room + enteric precautions
Side room + enteric precautions
30
**Woman calls GP about husband with terminal prostate cancer and is breathless. What do you do?**
1. Call 999
2. Ask GP to go next week
3. Visit them in that morning + palliative care discussion
4. Ask district nurse to see them urgently
Visit them in that morning + palliative care discussion
31
**Man diagnosed with hypothyrodism 2 years, and history of ischaemic heart disease (and AF?) on bisoprolol, ramipril, amlodipine, warfarin, and has DM and develops erectile dysfunction. Standing and lying BP are normal - what’s the cause?** **no vasc symptoms, palpable peripheral pulses, normal sensation peripherally.**
1. Autonomic neuropathy
2. Side effect meds
3. Vascular insufficiency
4. Cauda equina
5. BPH
Side effect meds
32
**Facial swelling, distended chest veins, weight loss, JVP raised but non pulsating, clubbing**
1. Bronchial carcinoma
2. CLD
Bronchial carcinoma
33
**Which test should you do next? Standard pneumonia - started on antibiotics and IV fluids.**
1. Urinary legionella and pneumococcal antigen
2. PCP sputum
3. Spirometry
4. CT abdomen
Urinary legionella and pneumococcal antigen
34
Blood gas showing chronic resp acidosis that had full metabolic compensation
35
Woman with rheumatoid arthritis previous knee replacement, having cystoscopy for urinary symptoms. Now knee is hot swollen and tender.
1. Pseudogout
2. Septic arthritis
Septic arthritis
36
**36 year old guy, pain in lumbar back and swollen DIP**
1. Psoriatic arthritis
2. Anky spond
3. Reactive
4. Osteo
Psoriatic
37
**30 year old guy with morning stiffness reduced lumbar flexion**
1. Ank spond
Ank spond
38
**Bell palsy treatment:**
1. Prednisone
2. No treatment
3. Cinnarizine
4. Aciclovir
5. Aspirin
Prednisone
BMJ: Evidence supports the use of oral corticosteroids within 72 hours of symptom onset in all patients with Bell's palsy to shorten the time to complete recovery and to improve long-term outcomes, regardless of the baseline severity of facial palsy.
39
**Faecal incontinence, long standing back pain, anal sphincter loose, heavy lifter**
1. MR lumbar
2. CT lumbar
3. X-Ray lumbar
MR lumbar
*This is the imaging study of choice for suspected cord compression of any aetiology. Conventional T2 and T2-weighted fast spin-echo images are used in the diagnosis of degenerative disc disease*
40
**Bilateral knee pain, stiffness 20 min in morning, swollen at night**
1. Osteoarthritis
2. Psoriatic
3. Septic arthritis
4. Rheumatoid
Osteoarthritis
41
**Pain in small joints and wrists, pleuritic pain, protein ++ and blood ++, what abs do you expect?**
1. ANA
2. Rheumatoid factor
3. Anti Centromere
4. Anti Glomerular Basement Membrane
5. ANCA
ANA
42
**Sudden onset chest pain, post PCI with stent for STEMI, ECG shows ST elevation widespread in anterior leads and T-wave inversion, pleuritic chest pain, worse pain on movement, quiet heart sounds and auscultation, chest clear**
1. Coronary artery dissection
2. Pericarditis
3. Another anterior MI
4. PE
Pericarditis
43
**Arrhythmia after MI**
1. VF
2. SVT
3. AF
VF
44
**Anti-jo with signs of polymyositis. Which ix would confirm dx?**
1. CK
2. Muscle bx
3. Electromyography
4. Serum myoglobin
5. MR of thighs
Muscle biopsy
_Muscle biopsy_: *Mandatory for definitive diagnosis. For accurate results there are 3 essential prerequisites: proper choice of muscle; appropriate staining; and interpretation of results by an expert in myopathology. A very weak muscle should be avoided because of the high risk of loss of the distinguished characteristics of idiopathic inflammatory myopathies, yielding non-specific end-stage myopathic changes. A moderately weak muscle offers the best chance of a positive biopsy.*
_CK_: *The most sensitive and specific muscle-derived serum enzyme of disease activity. Can be elevated as much as 50 times above normal, especially in polymyositis. Can be normal in active dermatomyositis and rarely in active polymyositis. Normal o*r only mildly elevated in inclusion body myositis. When elevated, serial evaluation represents the most effective laboratory guide for monitoring disease progression in polymyositis and dermatomyositis, as well as treatment response
_EMG:_ *May show myopathic motor units on voluntary activity.*
45
CREST sx on a patient. Pleuritic CP/sob with crackles? Which ix?
1. HRCT
2. Spirometry
3. Echo
4. VQ scan
5. CXR
HRCT
46
**First ix for someone with exertional breathless.**
1. 12 lead ECG
2. Echo
12 lead ECG
47
Myelodysplasia which has got worse in the last few weeks. Abundant primitive cells on slide:
1. AML
2. CML
3. Myelofibrosis
AML
*Myelodysplastic syndrome (MDS) is a group of clonal stem cell disorders, characterised by ineffective and dysplastic haematopoiesis resulting in 1 or more cytopenias, and a varying predilection to develop acute myeloid leukaemia*
48
**Features of SLE. Jaundiced, raised reticulocytes. Spherocytes and polychromasia:**
1. AIHA
2. Spherocytosis
3. SCD
AIHA
49
**Traveler back from Thailand with anaemia, jaundice and back pain. Intermittent fever:**
1. Malaria
2. Hep A
3. Chronic liver disease
4. Weil’s disease
Malaria
_Weil's disease_ aka: leptospirosis is commonly seen in questions referring to sewage workers, farmers, vets or people who work in abattoir. It is caused by the spirochaete Leptospira interrogans (serogroup L icterohaemorrhagiae), classically being spread by contact with infected rat urine. Weil's disease should always be considered in high-risk patients with hepatorenal failure
* Features
* fever
* flu-like symptoms
* renal failure (seen in 50% of patients)
* jaundice
* subconjunctival haemorrhage
* headache, may herald the onset of meningitis
* Management
* high-dose benzylpenicillin or doxycycline
50
**Most likely diagnosis. 36 yo black man who had multiple episodes of limb pain in the past. Previously had a big spleen but now it’s small.**
1. Sickle cell anaemia
2. G6PD
3. Thalassemia
SCD
51
**11 & 14 miscarriage. DVTs. Livedo reticularis:**
1. SLE
2. Antiphospholipid
Antiphospholipid
52
Calculate GCS, opened eyes to pain and withdrew hand to cannulation. No sounds.
1. 7
2. 9
9
53
**Hyponatraemia and dehydrated. Dry mucous membrane. How do you decide on fluid status:**
1. Serum urea
2. Serum creatine
3. Urine sodium
4. Urine osmolarity
5. Serum calcium
Serum urea
_Urea_
* Produced from ammonia by liver in ornithine cycle
* ↑ c¯ protein meal (e.g. upper GI bleed, supplements)
* ↓ c¯ hepatic impairment
* 10-70% is reabsorbed: depends on urine flow.
* ↓ flow → ↑ urea reabsorption *(e.g. in dehydration)*
*Nb, for in Interpretation
Isolated ↑ urea = ↓ flow (i.e. hypoperfusion / dehydration)
↑ U and ↑ Cr = ↓ filtration (i.e. renal failure)*
54
**Old lady on second blood transfusion develops sudden breathlessness, normotensive, history of IHD, bilateral crackles and wheeze. Nurse has stopped the transfusion. What do you give?**
1. IV furosemide
2. IV Chlorphenamine
3. IM Adrenaline
4. Nebulised salbutamol
5. IV Hydrocortisone
IV furosemide
55
Bowel screening question. What is FOB for:
1. Monitoring people with existing disease
2. Screening for people with asymptomatic disease
3. Screening for symptomatic disease
4. Screening for people at risk of developing colonic disease
Screening for people with asymptomatic disease
56
**Elderly guy on 2nd transfusion bag after heavy blood loss in theatre, starts feeling breathless, haeemoglobinuria present.**
1. Immediate transfusion reaction
2. Re-bleed
3. Infection
Immediate transfusion reaction
57
**Women on long term lithium. Peeing loads even at night. Blood results showing hyponatremia, normal blood glucose:**
1. DM
2. DI
3. SIADH
4. Psychogenic Polydipsia
Diabetes insipidus
58
**Classic pneumonia signs (Gram +ve in pairs) what antibiotic to give**:
1. Amoxicillin
2. Clarithromycin
3. Gentamicin
Amoxicillin
## Footnote
*(staph)*
59
**Clarithromycin and atorvastatin, metformin:**
1. No change
2. Stop statin
3. Stop metformin
4. Stop Lisinopril
5. Reduce metformin
?Continue
60
**Vocal cord surgery, struggling to speak, tachypnoeic 28, grip weakens when asked to grip nurses fingers What is the antidote:**
1. Neostigmine
2. Glycopyronium
3. Rocuronium
4. Doxapram
5. Edrophonium
*Neostigmine is used to reverse the effects of non-depolarizing muscle relaxants such as rocuronium and vecuronium at the end of an operation, usually in a dose of 25 to 50 μg per kilogram.*
61
21 year old female has acne, tried topical antibiotics and topical retinoids no success. DVT in past after plane. What to try next?
1. Lymecycline
2. Isotretinoin
3. Flucloxacillin
4. Desogestrel
5. Co-cyprindiol
Lymecycline
Antibiotic options: *tetracycline, minocycline*, *doxycycline*
* Mild acne: no inflammation:
* topical retinoid or salicyclic acid
* Mild acne: with inflammation
* topical retinoid + topical antibiotic
* +topical benzoyld peroxide
* +topical azelaic acid
* Moderate acne: No inflammation
* topical retinoid
* Moderate acne with inflammation:
* topical retinoid + Oral antibiotic
* +topical benzoul peroxide
* +topical azaleic acid
* Severe/resistant acne:
* Oral retinoid
* Oral corticosteroid
62
**Guy has dyspepsia, wakes up in night and drinks milk to make it better**
1. Gastric ulcer
2. Duodenal ulcer
3. Pancreatitis
4. GORD
Duodenal ulcer
63
**Old woman forgetting over 18 months - remembers the past well**
1. Alzheimer's disease
2. Frontotemporal
3. Parkinsons
4. Huntington's
5. Vascular Dementia
Alzheimer’s Disease
* Epi: 50%
* Path: neurofibrillary tangles and β amyloid plaques
* PC: progressive, global cognitive decline
* RFs: ApoE4 allele, presenillin 1/2 mutations, Down’s
* Ix: MRI – medial temporal lobe atrophy
* Rx: cholinesterase inhibitors (donepezil, rivastigmine) if
* MMSE is 10-20
64
**Old lady has a hemicolectomy. Post op her morphine epidural in situ comes out and she is in significant pain for the interim, before it is eventually replaced. She now has a pyrexia. What is the cause?**
1. Atelectasis
2. PE
3. Wound infection
4. UTI
5. Chest infection
Atelectasis
65
**Guy with swollen face, jaundice, distended abdomen, drinks 90 units a week.**
1. Chronic liver disease
2. Acute pancreatitis
3. Hepatic vein obstruction
Chronic liver disease
66
**5 days post AP resection and now peritonitic, temp 38 abdo distension and lower abdo pain. (rpt Q)**
1. Pelvic abcess
2. Anastomotic leak
3. Subphrenic abscess
4. Subpelvic abscess
Anastomotic leak
67
**Guy with faecal incontinence and tenesmus**
1. Rectal cancer
2. Diverticulitis
3. Haemorroids
4. UC
Rectal cancer
68
* Guy with terminal dribbling etc*
1. *BPH*
* Urinary incontinence once. BPH?*
* ^poor question recall*
69
**Person with nephrectomy and had stone in the good kidney at PUJ and swelling of upper urinary tract on imaging. Had fever. ?Septic obs. How to manage?**
1. Lithotripsy
2. Percutaneous nephrostomy
3. Conservative
4. Antibiotics
5. Cystoscopy and Stent
?Lithotripsy
70
**Black man with high ACE, high Calcium and CXR showed hilar lymphadenopathy**
1. Sarcoidosis
2. TB
3. Lumphadenopathy
Sarcoidosis
71
Guy who’d undergone a renal transplant. On tacrolimus, mycophenolate mofetil. Resp signs, clear chest, fuzzy hilar shadowing on CXR, which organism?
1. PCP
2. Tuberculosis
3. Pneumococcus
4. Hemophilis B
5. Klebsiella
?
72
Palpitations, weight loss and altered bowel habit in old lady, what nail changes are seen? What was the answer here someone please? Here - skin changes in hyperthyroid include -
1. Onycholysis
2. Pitting
3. Staining
4. Leukonychia
5. Koilonychia
Onycholysis
An overactive thyroid gland can cause onycholysis.
73
Young guy in A+E breathless, 4cm pneumothorax, trachea non-deviated, how to manage?
1. Chest Drain
2. Aspirate
3. Send home and OP review
4. Emergency Venflon
5. Administer O2
Aspirate
74
D+V after eating chicken at barbecue initial Culture at 37C Negative, Culture at 42C - curved gram negative rods
1. Campylobacter Jejuni
2. Shigella
3. E. Coli
4. Salmonella
5. C. diff
Campylobacter Jejuni
* Campylobacter means "curved rod", deriving from the Greek campylos (curved) and baktron (rod)*
* Results in a flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody*
* Complications include Guillain-Barre syndrome*
Incubation period
* 1-6 hrs: Staphylococcus aureus, Bacillus cereus\*
* 12-48 hrs: Salmonella, Escherichia coli
* 48-72 hrs: Shigella, Campylobacter
* \> 7 days: Giardiasis, Amoebiasis
75
**Guy falls off roof, gets chest pain for one day, painful on breathing deeply or coughing, in R Axilla, O2 sats - 99%**
1. Costochondritis
2. Fractured ribs
3. Pneumothorax
4. MI
Fractured ribs
76
**Another man falls 10m, wide pulse pressure, enlarged mediastinum**
1. Cardiac Tamponade
2. Pneumothorax
3. Traumatic aortic Dissection
Traumatic aortic Dissection
77
**Guy with ECG - P wave 70, QRS wave 45 (repeat from prev. paper)**
1. Complete heart block
2. Type 2 heart block
3. AF
Complete heart block
78
**Young guy, collapses frequently during sport? with ECG - Sinus rhythm. PR or QRS 120ms, cQT 510ms**
1. Ventricular arrhythmia
2. Sick sinus syndrome
3. AF
4. VT
5. Asystole
VT
79
**Man on motorbike crashes into a car, he now has an internally rotated and shortened leg, adducted and flexed**
1. Neck of femur fracture
2. Posterior dislocation of femur
3. Shaft of femur fracture
4. Anterior hip dislocation
5. Pubic Ramus fracture
Posterior dislocation of femur
80
**Patient with sputum culture of Pneumocystis jirovecii. Antibiotic treatment**
1. Co-trimoxazole
2. Ciprofloxacin
3. Metronidazole
Co-trimoxazole
81
**Woman with new headaches and sweaty. Her blood results showed raised IGF1 and raised prolactin (roughly 1200)**
1. Acromegaly
2. Pituitary macroadenoma
3. Hyperthyroidism
Acromegaly
82
Morphine question - woman with metastatic cancer, taking 60 mg BD oral - can’t tolerate oral anymore, what to replace with?
1. Morphine subcut 240mg/24h
2. Morphine subcut 60mg/24h
3. Gabapentin
4. Morphine oral solution
Morphine subcut 60mg/24h
83
**Mc Murray’s positive, had twisted knee and heard a pop - which Ix**
1. MR knee
2. X-ray knee
3. Arthrography
4. ultrasound
MR knee
84
**Fatigue, diabetic with photocoagulation, urine had protein etc**
1. CKD
2. Urinary tract infection
CKD
85
**Patient with COPD had several previous courses of steroids and now has postural hypo and cushingoid facies. Sounded like secondary adrenal insufficiency. What test?**
1. Short synacthen
2. Plasma glucose
3. Dexamethasone suppression test
Short Synacthen
*The disorder may be associated with Addison's disease, atherosclerosis (build-up of fatty deposits in the arteries), diabetes, pheochromocytoma, porphyria,and certain neurological disorders, including multiple system atrophyand other forms of dysautonomia.*
86
Treatment for Meningitis
IV ceftriaxone
87
**Young lady with massive HTN. High Na, low K - which hormone?**
1. Aldosterone
2. Cortisol
3. Catecholamine
Aldosterone
88
**Lifting heavy and now has back pain radiating down leg and some neuro signs (weakness of ankle dorsiflexion/loss of ankle reflex):**
1. Transverse myelitis
2. Lumbar disc prolapse
3. Spondylolithesis
Lumbar disc prolapse
89
Young Woman breast-feeding- fever, breast pain, lump:
1. Abscess
2. Galactocele
3. Mastitis
4. Cancer
5. Fat necrosis
Abscess
90
**How to investigate aortic dissection- different imaging options**
1. CT (contrast)
2. Trans-thoracic echo
3. Trans oesophageal echo
CT (contrast)
91
**Anal abscess - erythema and swelling - Treatment:**
1. incision and drainage
2. Fucloxacillin
incision and drainage
92
**History of constipation, severe pain on DRE so unable to perform it.**
1. Anal fissure
2. Haemorrhoids
Anal fissure
93
**Severe abdo pain radiating to the back. Suddenly goes unresponsive and pale, pulse 120, BP unrecordable - likely diagnosis?**
1. Ruptured AAA
2. Mesenteric ischaemia
Ruptured AAA
94
**59 yr old female with pruritus and got IgM anti-mitochondrial antibodies. What makes PBC likely?**
1. Xanthelasma
2. Tendon xanthomata
3. Hepatomegaly 8cm
4. Macroglossia
5. Facial rash
Xanthelasma
Primary Biliary cholangitis: Clinical features
* early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
* cholestatic jaundice
* hyperpigmentation, especially over pressure points
* around 10% of patients have right upper quadrant pain
* _xanthelasmas_, xanthomata
* also: clubbing, hepatosplenomegaly
* late: may progress to liver failure
95
**BCC - most likely progression:**
1. Mets to liver
2. Mets to local lymph nodes
3. Local invasion
4. Spontaneous regression
Local Invasion
Basal cell carcinoma (BCC) is one of the three main types of skin cancer. Lesions are also known as rodent ulcers and are characterised by slow-growth and local invasion. Metastases are extremely rare. BCC is the most common type of cancer in the Western world.
Features
* many types of BCC are described. The most common type is nodular BCC, which is described here
* sun-exposed sites, especially the head and neck account for the majority of lesions
* initially a pearly, flesh-coloured papule with telangiectasia
* may later ulcerate leaving a central 'crater'
Management options:
* surgical removal
* curettage
* cryotherapy
* topical cream: imiquimod, fluorouracil
* radiotherapy
96
**Pt recently had dosage of atorvastatin increased, presents with myalgia etc. CK 2000**
1. Stop atorvastatin
2. Stop and switch to rosuvastatin
3. Stop and switch to simvastatin
4. Half dose of atorvastatin
Stop atorvastatin
Muscle effects
* When a statin is suspected to be the cause of myopathy, and creatine kinase concentration is markedly elevated (more than 5 times upper limit of normal), or if muscular symptoms are severe, treatment should be discontinued. If symptoms resolve and creatine kinase concentrations return to normal, the statin should be reintroduced at a lower dose and the patient monitored closely; an alternative statin should be prescribed if unacceptable side-effects are experienced with a particular statin. Statins should not be discontinued in the event of small, asymptomatic elevations of creatine kinase. Routine monitoring of creatine kinase is unnecessary in asymptomatic patients.*
* Statins should not be discontinued if there is an increase in the blood-glucose concentration or HbA1C as the benefits continue to outweigh the risks.*
97
**Old lady with THR. Hip internally rotated.**
1. Hip fracture
2. Hip dislocation
3. Shaft fracture
4. Neck of femur fracture
Hip dislocation
98
**Guy with AF who had a pale leg. Weak movement and loss of sensation.**
1. Urgent embolectomy
2. Prostacyclin infusion
3. Amputate
4. Venogram
Urgent embolectomy
99
**Guy with renal failure. Vomitting etc. Which of his regular medications is contributing to abnormal blood tests?**
1. Diclofenac (OA)
2. Simvastatin
3. Aspirin
4. Metformin (DM)
Metformin
100
**APTT and PT raised, low platelets. What to measure?**
1. D-dimer and fibrinogen
2. vWF
3. Bone marrow biopsy
D-dimer and fibrinogen
101
**Retrosternal chest pains, partially relieved by antacids. Now dry cough. Worse at night. Diagnosis**:
1. GORD
2. Achalasia
3. Angina
GORD
102
**Dysphagia to both liquid and solids, Birds beak appearance**
1. Achalasia
2. Oesophageal webs
3. Oesophageal cancer
4. Barett’s
Achalasia
103
**Bordetella pertussis found. What’s the diagnosis?**
1. Whooping cough
2. Cystic Fibrosis
3. Asthma
Whooping cough
104
**Acute diverticulitis. What is the diagnostic investigation:**
1. Flexi sig
2. CT abdomen
3. MRI
4. US Abdomen
CT abdomen
The imaging modality of choice to confirm suspicion of acute diverticulitis or other causes of acute abdomen, if not confirmed by physical examination and abdominal x-ray. Helpful to select patients for medical rather than surgical treatment, and to determine if hospitalisation is required. Also helps rule out complications of acute diverticulitis.
_Colonoscopy_: Used when diagnosis of diverticular disease is unclear and cancer or bowel ischaemia is suspected. Can be used for accurate diagnosis in acute bleeding.
_Sigmoidoscopy_: used when diagnosis of diverticular disease is unclear and cancer or bowel ischaemia is suspected. Can be used for accurate diagnosis in acute bleeding.
105
**Surfer’s ear:**
1. Otitis externa
2. Otitis media
3. Cholesteatoma
4. Perf tymp membrane
Otitis externa
Causes include:
* infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
* seborrhoeic dermatitis
* contact dermatitis (allergic and irritant)
Features
* ear pain, itch, discharge
* otoscopy: red, swollen, or eczematous canal
The recommend initial management of otitis externa is:
* topical antibiotic or a combined topical antibiotic with steroid
* if the tympanic membrane is perforated aminoglycosides are traditionally not used\*
* if there is canal debris then consider removal
* if the canal is extensively swollen then an ear wick is sometimes inserted
106
**Floaters in her eye, and then now has a patch of blindness in the superotemporal area.**
1. Retinal detachment
2. Inferonasal retinal vein occlusion
3. Superotemporal vein occlusion
4. Amaurosis fugax
Retinal detachment
107
**Blurred vision, painful right eye, right eye congested and bigger.**
1. Angle closure glaucoma
2. Temporal arteritis
Angle closure glaucoma
108
**Graves disease picture - eyes bulging forward, mechanism?**
1. Rectus muscle thickening
2. Rtrobulbar tumour
3. Cavernous sinus
4. Retinal vein thrombosis
Rectus muscle thickening
109
**60 year old gentlemen with recurrent lower GI bleeding. Rigid sigmoidoscopy was normal up to 15 cm. What is the next appropriate investigation?**
1. CT pneumocolon
2. Colonoscopy
3. Red cell scan
4. Mesenteric angiogram
5. MR scan of the abdomen
Colonoscopy
110
Guy recently got a parrot and now has pneumonia -
1. chlamydia psittaci
2. H5N1 pneumonia
3. EAA
4. Mycoplasma infection
chlamydia psittaci
111
**Management of Person with N&V with metastatic cancer and has brain lesions and raised ICP -**
1. Dexamethasone
2. Mannitol
Dexamethasone
112
**Young guy with 4 cm pneumothorax and breathless**
Aspiration
chest drain
discharge
emergency venflon
administer O2
113
**Obese lady with bilateral papilloedema. Visual changes when straining on toilet. Extensive alcohol, coffee and smoking history. LP opening pressure high. What is the best management?**
1. Lose weight
2. Stop smoking
3. Stop drinking
4. Stop caffeine
Lose weight
114
**Slow rising pulse - what murmur?**
Ejection Systolic
115
**Man with leg claudication and ABPI of 0.84 - what do you do?**
1. Structured exercise programmes
2. fempop bypass
3. another type of bypass
4. vasodilator medications
Structured exercise programmes
116
**30 y/o male. Only sexual partner is his wife. Has symptoms of epididymo-orchitis. What is the cause?**
1. Chlamydia
2. Gonorrhoea
3. E.Coli
E.Coli
117
**Lady with chronic renal failure for 9 years on dialysis. PTH massively increased (148), Ca high (2.9), Phosphate high.**
1. Primary hyperparathyroidism
2. Secondary hyperparathyroidism
3. Tertiary hyperparathyroidism,
Tertiary hyperparathyroidism,
118
**Hyperkalaemia (6.5) and symptoms of pneumonia. ECG changes - tented T waves and broad QRS. What is the most important initial treatment?**
1. Calcium gluconate
2. Glucose/insulin
3. Co-amoxiclav
4. Amiodarone
Calcium gluconate
119
**Man has ultrasound to look for gallstones, incidental finding of 4cm solid renal mass:**
1. angiomyolipoma
2. renal cyst
3. renal cell carcinoma
4. renal metastases
??Renal cell cyst
120
**CXR: Bronchial wall thickening. Coarse creps on the right side. Change with coughing.**
1. Bronchiectasis
2. Idiopathic pulmonary fibrosis
Bronchiectasis
121
**Patient had a stroke. SALT assessment showed he can’t feed himself. What is the most appropriate way to give nutrition?**
1. NGT
2. PEG
3. Parenteral nutrition
NGT
122
**Acute onset pain ‘under her breast’. Has just come back from a holiday in India. ECG shows sinus tachy.**
1. PE
2. Myocardial infarction
PE
123
What markers are high in this patient with obstructive picture?
High bilirubin, high ALP, normal ALT
Low bilirubin, high ALP, normal ALT
High bilirubin, Low ALP, High ALT
High bilirubin, high ALP, normal ALT
124
**Man presents with dysphagia/weight loss:**
1. Squamous cell carcinoma
2. Adenocarcinoma
Squamous cell carcinoma
125
Variable ventricular rate and absent P waves.
AF
126
Guy with AF and multiple TIAs. What do you give him?
1. Warfarin
2. Aspirin
3. Amlodipine
Warfarin
127
**60 year old man with 2 cm smooth non tender swelling fixed to underlying structures?**
Ganglion
Lipoma
Ganglion
128
**Lady with asthma. On various inhalers + LTRA + Theophylline tablet. Which one has caused his painful swallow?**
Beclomethasone
Beclomethasone
129
**Patient with fine end inspiratory crackles, clubbing. Spirometry showing a restictive pattern**
1. Pulmonary fibrosis
2. Heart failure
Pulmonary fibrosis
130
**Alcoholic with diplopia on looking laterally both sides, nystagmus, what vitamin to give him. Also hypotensive and tachycardic?**
1. Thiamine
2. IV fluids
IV fluids
131
**Zig zag lines and painful eyes+ N&V for 30 min episodes?**
1. Migraine
2. Glaucoma
Migraine
132
**Pain on exercise, troponin is normal.**
1. Angina pectoris
2. MI
Angina pectoris
