2021 paper Flashcards

We think are answers??

1
Q

A 19 year old man has pain in the ulnar aspect of his right hand since he threw a punch with his right fist. Which structure is most likely to have been injured?
* Distal humerus
* Distal radius
* Fifth metacarpal
* Lunate
* Scaphoid

A

fifth Metacarpel -> This is a boxer’s fracture The pain is in the ulnar aspect of the hand. There is another fracture involving boxers that is called the Bennett’s fracture and is on the first metacarpal joint.

Scaphoid fracture is the most common but is associated with pain in and around the snuff box and there is pain on wrist movement.

Distal Radius fracture is the colles fracture or Smith’s -> Colles is when you fall forward on to extended hands and wrist whereas Smith’s is when you fall backwards on you your hand and wrist

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2
Q

A 44 year old man is admitted for a day-case knee arthroscopy. He is first on the list and is scheduled for 09.00. He drank a cup of black coffee at 06.00. He has a history of oesophagitis and has suffered severe nausea and vomiting after general anaesthesia for a hernia repair. He is recovering from a cold but still has a hoarse voice. His temperature is 37.2°C and BP 160/95 mmHg. His throat is inflamed. Which clinical feature is most likely to indicate postponing the operation?
* History of oesophagitis
* Hypertension
* Laryngitis
* Previous postoperative nausea and vomiting
* Recent consumption of black coffee

A

Laryngitis

The consumption of black coffee is fine if there was milk then this would be more concerning, but clear liquids uptill 2 hours before surgery is fine.

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3
Q

A 28 year old man has had a painful red eye for five days.
He has a redness around the border of the sclera and cornea and the eye is watery. Fluorescein staining is normal. The pupil is irregular.
Which is the most likely diagnosis?
* Acute closed angle glaucoma
* Acute conjunctivitis
* Anterior uveitis
* Corneal abrasion
* Dendritic ulcer

A

Anterior Uveitis -> The irregular pupils and the painful red eye is suggestive of Anterior uveitis. The pupils can also present as small. there is eye pain and there is reduced acuity. This also presents with Anterior uveitis

Acute closed angle Glaucoma -> Will have a painful red eye but will likely present with a fixed and dilated pupil rather than an irregular one. Acuity can be reduced in both Anterior Uveitis and Acute Glaucoma. May present with HALOS.

Corneal Abrasian -> will have a Fluorescein staining defect green on slit lamp

Acute Conjunctivitis -> This can present as painful, there should be no drop in acuity and there pupil and the cornea should be normal and unaffected. There may be photophobia.

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4
Q

A 67 year old woman has an ulcer with a raised white margin on her left ear; it has been present for 3 years, growing slowly and never completely healing. She spent 20 years living in Australia before returning to the UK recently.
On examination, she has a small ulcerated area, 4mm x 6mm, on her left pinna.
Which is the most likely diagnosis?
* Actinic keratosis
* Basal cell carcinoma
* Malignant melanoma
* Seborrhoeic keratosis
* Squamous cell carcinoma

A

Basal Cell Carcinoma -> This is slow growing and is found in sun exposed areas commonly. This is more likely than SCC as it is very small but has a long history whereas SCC is normally larger… Additionally SCC is not likely to be pale as described but more pink or red.

BCC this would start of as a raised nodule that slowly starts growing and becomes a ulcerated in the middle with dilated vessels in the middle. telegiectasia

Actinic keratosis -> This is small crusty scaly lesions and can progress to become a SCC but I dont think it causes ulcerations.

Seborrhoeic keratosis -> This is a wart. this does not normally ulcerate.

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5
Q

A 35 year old woman has an ill-defined lumpy area in the upper outer quadrant of her right breast which becomes larger and tender during the second half of her menstrual cycle.
Which is the most likely diagnosis?
* Breast cancer
* Duct ectasia
* Fat necrosis
* Fibroadenoma
* Fibrocystic disease

A

Fibrocystic Disease -> The changes with relation to the Menstrual cycle I think is more suggestive of fibrocystic disease.

Fibroadeonams are in the same sort of age group, infact it is the case that if less than 30 and presenting with a lump like a fibroadenoma they may not need to be referred urgently. {NEED TO ASK MRS HOGBEN ABOUT URGENT AND NOT URGENT REFERRALS,}

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6
Q

A 43 year old man is rescued from a house fire. There are no signs of burns to the face or neck, but he has soot deposits in his nose and mouth.
His temperature is 37.5°C, pulse rate 120 bpm, BP 135/86 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 97% breathing air. He has widespread wheeze.
Which is the most appropriate management?
* Hyperbaric oxygen
* Intravenous dexamethasone
* Intubation and ventilation
* Nebulised salbutamol
* Non-rebreather mask and 100% oxygen

A

Intubation and ventilation - early I&V indicated in smoke inhalation when suspected oropharynx oedema

In patients with suspected Carbon monoxide poisoning there is a need to give 100% 15 L oxygen to the patient, The gold standard treatment however is a
hyperbaric O2 Chamber (This is a relative contraindication in COPD patients.)

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7
Q

A 71 year old man is brought to the Emergency Department with increasing drowsiness and confusion for the past 12 hours. He is taking clozapine for schizophrenia and has a history of intravenous drug abuse.
He has a temperature of 39.8°C, pulse rate 110 bpm and BP of 110/70 mmHg, and his oxygen saturation is 91% on air. Heart sounds are normal. His GCS is 12/15 (eyes 3/4, motor 6/6, verbal 3/5). He has neck stiffness. He moves all four limbs equally. There is no rash.
Which is the most likely diagnosis?
* Bacterial meningitis
* Cerebral abscess
* Neuroleptic malignant syndrome
* Serotonin syndrome
* Viral encephalitis

A

Viral Encephalitis -> This stem clearly indicates a meningitic picture. Viral is more likely to present with confusion, seizures and drowsiness and this patient presents with 2 of these symtoms -> the prescence of a rash makes the Bacterial more likely.

Neuroleptic Malignant syndrome or Serotonin syndrome -> Needs evidence that he is actually taking those medications.

NMS -> high fever, confusion, tachy - would have stiff muscles, stem says can move arms equally

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8
Q

A 56 year old woman with breast cancer has a mastectomy followed by adjuvant chemotherapy. Molecular profiling of the tumour is performed and further treatment with trastuzumab is considered.
When might this further treatment be indicated?
* BRCA1 is mutated
* Tumour is oestrogen receptor positive
* Tumour is progesterone receptor positive
* Tumour is triple negative
* Tumour overexpresses HER2 protein

A

Tumour overexpresses HER2 protein -> Trastuzumab is another word for Herceptin. This means that it the patient is HER 2 positive and so an antagonist is used to stop the activation of this receptor to stop cancer cells replicating.

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9
Q

A 24 year old man with long-standing atopic eczema develops a rash that is different from his usual eczema.
There are multiple eroded papules on the head and neck, in addition to excoriated eczema on the trunk and limbs.
Which is the most appropriate treatment for the acute eruption?
* High-potency topical corticosteroid ointment
* Oral acyclovir
* Oral flucloxacillin
* Oral prednisolone
* Topical fusidic acid

A

Oral Acyclovir -> this is under the assumption that they are describing Eczema herpeticum On an eczema rash. I which the treatment is with Oral Acyclovir.

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10
Q

A 64 year old man with a two year history of intermittent claudication presents with worsening lumbar back pain, not related to movement. He has type 2 diabetes mellitus.
Examination of his abdomen and spine is normal, but he has an absent right popliteal pulse and absent pulses in his left foot.
Which is the most appropriate initial investigation?
* Dual energy x-ray absorptiometry (DEXA) scan
* MR scan of spine
* Ultrasound scan of abdomen
* X-ray of abdomen
* X-ray of lumbosacral spine

A

US of the Abdomen -> this is to rule out a possible diagnosis of Abdominal Aortic Aneurysm

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11
Q

An 80 year old woman has recurrent abdominal pain approximately 20 minutes after she has a meal. She has noticed weight loss of 14 kg over the past six months.
She is thin and has tarstained fingers. Her temperature is 36.5°C and pulse rate 85 bpm. She has an abdominal bruit.
Which is the most likely diagnosis?
* Duodenal ulcer
* Gallstones
* Gastric carcinoma
* Mesenteric angina
* Pancreatic carcinoma

A

Mesenteric Angina -> The risk factors of smoking and the abdominal bruit suggests a vascular cause. Additionally the loss in weight is likely due to the bowels not working properly and so nutrients not being absorbed as well.

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12
Q

A 59 year old man has a prolonged postoperative ileus after a sigmoid colectomy for diverticulitis.
Which is the most appropriate method of nutrition for this patient?
* Fortified oral supplements
* Intravenous 10% glucose
* Intravenous total parenteral nutrition
* Nasogastric feeding tube
* Percutaneous endoscopic gastrostomy feeding tube

A

Intravenous Total parentral nutrition
In the case of a post operative ileus -> Initially pt should be NBM + with IV fluids–> be placed with an NGT if they are vomiting . This is then progressed into total paraentral nutrition if the Post operative Ileus is PROLONGED.

Add BMJ SCREENSHOT

Prolonged > 4days

Total parade trail nutrition should be started after 7 days

If not prolonged if fluids is 1st and you consider an NGT

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13
Q

A 69 year old woman has constant dribbling of urine and has had to wear pads continuously for the last 12 month. She had radiotherapy for carcinoma of the cervix when she was 48 years old.
Her temperature is normal. Her bladder is not palpable or tender and neurological examination is normal.
Which is the most likely cause of her symptoms?
* Detrusor overactivity
* Neurogenic bladder
* Stress incontinence
* Urinary infection
* Vesicovaginal fistula

A

Vesicovaginal fistula -> Would explain the constant dribbling. Neurogenic bladder and detrusor activity will have more of an urge incontinance history. Additionally the Radiotherapy is a risk factor for vesicovaginal fistula.

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14
Q

A 65 year old woman has a hoarse voice for 4 weeks. She has lost 2 kg in weight over the past 2 months. She had a right hemithyroidectomy 10 years ago for a solitary nodule. She has an 80 pack-year smoking history.
There are no lymph nodes palpable in the neck. Chest X-ray is normal.
Which is the most important next investigation?
* CT scan of chest
* Flexible nasendoscopy
* Isotope scan of thyroid
* Thyroid function tests
* Ultrasound scan of neck

A

Nasoendoscopy -> The hoarse voice is persistent and is a red flag sign. This needs to be further investigated with after a 2week referral to ent with a nasoendoscopy followed by a contrast CT

Paste email from reg

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15
Q

A 23 year old woman has 8 weeks of intensely itchy transient circular weals on her trunk and limbs. Individual lesions last for less than 24 hours and resolve without any discolouration of the skin. She is otherwise fit and well.
Which is the best management advice?
* Frequent application of emollient
* Oral loratadine
* Oral prednisolone
* Topical hydrocortisone
* Trial of dairy-free diet

A

Oral Loratadine -> Describing Uritcaria -> this needs to be treated intially with Oral Antihistamines of which Loratadine is one. In Severe cases thoug I dont know what that would be it would be treated with corticosteroids.

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16
Q

A 67 year old man has back pain that is not controlled by paracetamol (1 g four times daily). He is receiving palliative care for pancreatic cancer.
Which is the most appropriate next analgesic?
* Fentanyl patch
* Lidocaine patch
* Regular codeine phosphate
* Regular controlled release morphine
* Short acting morphine as required

A

Regular Codeine phosphate -> The pain ladder starts with paracetamol-> this then progresses to NSAIDS or another non opiod management of pain. This can then be progressed onto a opioids but first weak opiods such as codeine phsophate. Morphine is a stronger and so would not be used. Short acting would be used initially if there is evidence that this is used a lot then a regular controlled release morphine may be used.

Apparent patches can only be started if analgesia has been established

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17
Q

A 20 year old man has a painless lump arising from the lower pole of his right testis. His left testis is normal. An ultrasound scan shows a solid mass in his right testis and a radical orchidectomy is planned.
In addition to β-human chorionic gonadotropin (HCG), which tumour marker should be measured before the procedure?
Cancer antigen 19-9 (CA 19-9)
Cancer antigen 27.29 (CA 27.29)
Cancer antigen 125 (CA 125)
Carcinoembryonic antigen (CEA)
A-Fetoprotein (AFP)

A

Alpha Fetoprotein -> is one of the tumour markers for testicular cancer. This makes it an approapriate marker to test for. Teratoma linked.
Beta HCG -> Also linked with testicular cancer

Ca 19-9 -> Pancreatic cancer
CA125 -> Ovarian cancer
CEA -> Colorectal cancer
Ca 27.29 -> Another tumour marker for breast cancer Ca15-3 is the other breast cancer one

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18
Q

A 62 year old woman has blurred vision and extreme pain in her right eye of sudden onset. She is nauseated, has a headache and is seeing haloes around bright lights. The ocular pressure is reduced with drugs. The ophthalmologist explains to the patient that medical management alone is likely to be insufficient to reverse the problem.
Which I the most appropriate surgical treatment? (Mentiont the medical management for Acute close angle glaucoma)
* Laser capsulotomy
* Laser peripheral iridectomy
* Macular grid laser
* Optic nerve sheath fenestration
* Panretinal photocoagulation

A

Laser Peripheral iridectomy ->
This patient has Acute closed angle glaucoma. -> The definitive management for this patient would be to have the above surgery.
The initial medical managment for this would however be -> a combination of eye drops -> Pilocarpine, beta blocker and an* alpha 2 agonist*
Acetazalomide + Topical steroids are also sometimes used

Pan retinal Photocoagulation -> is the treatment for Diabetic retinopathy, It is also sometimes used in the treatment of Age related macular degeneration

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19
Q

A 55 year old man undergoes endoscopy for haematemesis. A duodenal ulcer is seen with a clot visible in its base.
Which substance is the primary factor facilitating platelet adhesion?
* Factor IX
* Factor VIII
* Fibronectin
* Tissue factor
* Von Willebrand factor

A

Von Willebrand factor

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20
Q

A 78 year old man has a serum creatinine of 148µmol/L (60-120). Three months ago, his serum creatinine was normal. He has prostate cancer with multiple bone metastases and recently had a pathological facture of the L4 vertebral body. He also has heart failure and diabetes mellitus. He takes amlodipine, bisoprolol, gliclazide, ibuprofen and morphine.
Which drug is the most likely cause of his deteriorating renal function?
* Amlodipine
* Bisoprolol
* Gliclazide
* Ibuprofen
* Morphine

A

Ibuprofen Nephrotoxic drug because it causes reduced renal plasma flow.

Drugs like morphine and Metformin need to be carefully used in renal failure as they are likely to accumulate as they are renally excreted. However these drugs are not nephrotoxic.

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21
Q

A 40 year old man has an extensive rash that started 2 days ago and is worsening. He is shivering and feeling generally unwell. He has no past medical history, but has recently been treated for a chest infection.
His skin is now red over most of the body, with some large blisters and some areas of erosion. There is extensive ulceration in the mouth, and the conjunctivae are injected.
Which is the most likely diagnosis?
* Bullous pemphigoid
* Eczema herpeticum
* Pemphigous vulgaris
* Staphylococcal scalded skin syndrome
* Toxic epidermal necrolysis

A

Toxic Epidermal Necrolysis -> The fact that mucousal lesions are present means that staphylococcal scalded skin syndrome is unlikely. This leaves Toxic epidermal necrolysis or Steven Johnson syndrome. If there is mention of rupture of the bullae with mild lateral pressure makes the above SSS and TEN more likely
The systemic features points more towards the diagnosis of Toxic Epidermal Necrolysis and SSS

Bullous pemphigoid also does not useually have mucousal involvment and often the blisters heal. -> PEMPHIGUS Vulgaris Will have mucousal involvement, And will have less systemic features.. Apparently it is also less itchy…

Additionally Pemphigus Vulgaris will have blisters that rupture easily like SSS and TEN but this is different to bullous pemphigoid.

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22
Q

A 50 year old woman has suddenly become short of breath. She has found it painful to swallow for two months, and she has coughed up a small amount of blood. She is distressed and cannot lie flat.
Her temperature is 37.5°C. Her respiratory rate is 40 breaths per minute and her oxygen saturation is 78% using 15L pe minute via a re-breather mask. She has inspiratory stridor.
What is the most appropriate action to take?
* Continuous positive airways pressure ventilation
* Endotracheal intubation
* Nebulised bronchodilators
* Oral airway
* Tracheostomy

A

Endotracheal Intubation
This seems to be the start of airway obstruction and a secure airway needs to be placed.

The crico would be the other possible emergency airway that is patent and garunteed. Tracheostomy is a planned emergency procedure…

If there was stridor on its own with no painfuls swallow I would be inclined to try the bronchodilators or nebulaised adrenaline.

CPAP if there is tType 1 respiratory failure eg with HF.

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23
Q

A 29 year old man presents after a fall on to his outstretched left arm.
The left shoulder is deformed and there is sensory loss over the deltoid muscle. The radial pulse is palpable and the patient is able to extend his wrist.
What nerve is most likely to have been damaged?
* Axillary
* Median
* Musculocutaneous
* Radial
* Ulnar
*

A

Axillary -> This is the innervation of the Deltoid. hence the sensort loss there. This is often damaged in a* shoulder dislocation*

Radial Nerve is responsible for the extenstion movments of the arm. This is damaged in humoral shaft injuries

Ulnar and median nerve is often caused by fractures and disloncations of the elbows. They can both present with a claw deformity however the resting position would be claw shaped for an ulnar deformity and when trying to make a fist there will be the claw deformity in median nerve palsy.

Add info on musculocutaneous nerve injury

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24
Q

An 88 year old woman has had a major stroke and has developed bilateral bronchopneumonia and acute kidney injury. Her breathing becomes noisy, with a water rattling noise with each inspiration. Her family become distressed by this noise and ask what is causing it.
Which is the most likely mechanism for this noisy breathing?
* Bacterial infection of the larynx
* Compensatory hyperventilation in acidosis
* Increased parasympathetic tone leading to increased salivary secretion
* Pooling of saliva because of poor swallowing
* Unidentified pharyngeal foreign body

A

Pooling of saliva because of poor swallowing -> the stroke increases the likeliness of this being the cause.

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25
Q

A 45 year old window cleaner falls off a ladder and sustains a comminuted closed facture of his right calcaneum.
There is gross swelling and tenderness over all aspects of his heel.
Which is the most appropriate imaging to help to plan for surgery?
* Bone scan
* CT
* MR imaging
* Ultrasonography
* X-ray

A

CT scan -> This is needed to know about the soft tissue injuries before planning for surgery

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26
Q

A 45 year old woman develops an intensely painful eruption around her right eye. The illness started with pain 5 days previously, followed by the appearance of a few vesicles, which has now developed into the rash. (see image). She has no significant medical history. Treatment is started.
Which is the most likely long-term outcome?
* Complete resolution with no sequelae
* Corneal ulceration
* Extensive scarring of the right temple
* Partial ptosis
* Reduced visual acuity

A

Complete resolution with no sequelae

Reduced Visual Acuity -> This is Chicken pox eruption on the ocular devision of the trigeminal nerve
These patients need to be treated with oral acyclovir. -> they often have kertitis and corneal ulceration(this is one of the acute features that eventually can lead to reduced visiual acuity) and iritis

There is also Ramsay hunt syndrome which is when there is Herpes zoster activation in the ear.

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27
Q

A 65 year old man receives a renal transplant. He is transferred back to the ward after four hours in recovery.
He has a pulse rate 96 bpm and regular, BP of 115/70 mmHg, CVP +4 cmH2O and respiratory rate 18 breaths per minute. His chest is clear or auscultation. His urine output has been 15-20 mL per hour while in recovery. Drain output has been 120 mL since surgery.
Investigations:
Haemoglobin
90 g/L

(130-175) (preoperative level 103 g/L)
Sodium

142 mmol/L
(135-146)
Potassium
5.8 mmol/L
(3.5-5.3)
Urea

31.9 mmol/L
(2.5-7.8)
Creatinine
590 µmol/L
(60-120)
Which is the next most appropriate management step?
* Blood transfusion
* Fluid challenge
* Furosemide
* Haemofiltration
* Insulin and dextrose infusion

A

fluid Challenge ->

Often 0.5-1.5 ml/kg/hour is the normal post operative urine output… For a normal person this means around 70ml/hr

GIULIA if it’s less than half its bad

The above shows that the patient is producing less urine.

Hyperuraemia is only treated if it is symptomatic.

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28
Q

A 70 year old woman is admitted with a one week history of worsening breathlessness.
She looks pale. She has a temperature of 36.2°C, pulse rate 100 bpm, BP of 132/68 mmHg, JVP +8 cm above the sternal angle and oxygen saturation 94% on 40% oxygen via a face mask. She has bilateral inspiratory crepitations to the midzones. She has a pansystolic murmur at the apex.
Investigations:
Haemoglobin 52 g/L (115-150)
MCV 120 fL (80-96)
White cell count 3.0 x 109/L (3.8-10.0)
Platelets 87 x 109/L (150-400)
Which is the most likely diagnosis?
* Acute myeloid leukaemia
* Alcoholic cardiomyopathy
* Hypothyroidism
* Pernicious anaemia
* Viral myocarditis

A

Alcoholic Cardiomyopathy -> This is a cause of macrocytic anaemia.

HONESTLY not to sure about this… I also thought that this could be something like Parvovirus causing aplapstic anaemia and viral myocarditis.

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29
Q

A 35 year old man has pain in his left foot for three months; it is worse after playing football but improves when he keeps his foot still. Recently, the pain has become more persistent. He is unable to recall any specific injury that may have brough on the pain. He plays sport several times a week. He is otherwise fit and well. There is tenderness over the mid-foot.
What is the most likely diagnosis?
* Fractured calcaneum
* Metatarsal stress fracture
* Morton’s neuroma
* Plantar fasciitis
* Sesamoid injury

A

Metatarasl stress fracture Otherwise known as marathon fracture.. This is the most common site of stress fractures

PLantar Fascitis is normally localised pain on the attachements of the ligaments on the foot, It is associated with pain due to incorrect footwear

A clear fracture will not be weight bearable. The fact that he is able to weight bear makes a fractured calcaneum unlikely.

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30
Q

A 77 year old woman has 2 years of increasing urinary frequency, associated with urgency and occasional incontinence and nocturia. She has vague discomfort in her lower abdomen most of the time. She has attempted bladder training with only minor improvement.
Which class of drug is most likely to be beneficial?
* Analogue of anti-diuretic hormone
* Anti-muscarinic agent
* Inhibitor of serotonin and noradrenaline reuptake
* Monoamine oxidase inhibitor
* Phosphodiesterase type 5 inhibitor

A

Anti-Mscarinic receptor -> Oxybutynin 1st line medical management 1st is still conservative
Mirabegron -> is a beta 3 agonist and is the 2nd line management option.

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31
Q

A 60 year old man has been unable to hear with his left ear for 6 months.
Examination of both ear canals is normal. Tuning fork tests suggest sensorineural hearing loss in the left ear.
Which is the most likely diagnosis?
* Acoustic neuroma
* Cholesteatoma
* Ménière’s disease
* Otitis media
* Presbycusis

A

Acoustic Neuroma -> This is a cause of sensoneural hearing loss

Presbycisis is bilateral and is often slow onset and associated with age.

Menire’s disease will have symptoms of tinnitus and nystagmus

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32
Q

A 19 year old woman has 5 days of headache and fevers. She returned last week from a 2 month elective in Kenya.
Her temperature is 38.2°C. She does not have neck stiffness. Urine dipstick analysis shows a trace of blood only.
Which is the most important initial investigation?
* Blood cultures
* Blood film
* Cerebrospinal fluid microscopy
* CT scan of head
* Urinary microscopy and culture

A

Blood film -> Travelling fever is likely to be malaria and so this is the most important intial investigation

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33
Q

A 39 year old woman has worsening tiredness for two weeks. She was previously well.
She appears mildly jaundiced. She has a pulse rate 96 bpm and BP of 112/76 mmHg.
Investigations:
Haemoglobin 48 g/L (115-150)
MCV 98 fL (80-96)
White cell count 6.2 x 109/L (3.8-10.0)
Bilirubin 41 µmol/L (<17)
Aspartate aminotransferase 27 IU/L (10-40)
Alkaline phosphatase 100 IU/L (25-115)
Lactate dehydrogenase 560 IU/L (70-250)
Blood film: red cell polychromasia, occasional spherocytes, no red cell fragments
Which is the most appropriate diagnostic investigation?
* Bone marrow aspiration
* Direct antiglobulin test
* Serum antinuclear antibody
* Serum folate
* Serum vitamin B12

A

Direct Antiglobulin test => Tests for haemolytic anaemia.
Spherocytosis can suggest AIHA or Spherocytosis. In this case the late presentation makes AIHA more likely

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34
Q

A 47 year old man has nausea and epigastric pain. He undergoes endoscopy and biopsy, and he is found to have a carcinoma of the lesser curve of the gastric body. His case is discussed at the multidisciplinary team meeting.
Which lymph node group is most likely to be the site of metastasis?
* Coeliac
* Pyloric
* Retrocaval
* Right gastroepiploic
* Superior mesenteric

A

Coeliac -> Blood vessels match with the lymphatic drainage… The blood comes from the coeliac artery that becomes the splenic hepatic and the gastric. It is the gastric artery that supplies the Lesser curvature of the stomach

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35
Q

A 24 year old man has had a high speed motorcycle crash. A cervical spine fracture is suspected and a series of cervical spine X-rays is requested.
Which X-ray view is most likely to reveal a vertebral body crush facture?
* Anteroposterior
* Closed mouth odontoid peg
* Lateral
* Open mouth odontoid peg
* Swimmer’s view of cervicothoracic junction

A

Lateral view yh probabs lateral…

The Swimmer’s view is used when the patient is soooooo fkn dench that the LAteral View isnt good enough cause their muscles are built different.

To look at atlanto spine fractures -> open mouth odontoid peg view fractures are used to visualise the C1 and C2 bone

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36
Q

A 78 year old man has 1 month of painless haematuria.
Physical examination is unremarkable. Cystoscopy shows a tumour in the bladder. A biopsy is taken.
Which is the most likely histological diagnosis?
* Adenocarcinoma
* Anaplastic carcinoma
* Papillary carcinoma
* Squamous cell carcinoma
* Transitional cell carcinoma

A

Transitional Cell Carcinoma -> most common cause of bladder cancer

Adenocarcinoma is often associated with secretery location like stomacks or lower third of the oesophagus

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37
Q

A 75 year old man develops difficulty speaking and swallowing two days after a right carotid endarterectomy.
On examination of his cranial nerves, his tongue deviates to the right on protrusion.
Which is the most likely cause of this problem?
* Damage to the glossopharyngeal nerve
* Damage to the hypoglossal nerve
* Damage to the vagus nerve
* Occlusion of the external carotid artery
* Postoperative embolus to the motor cortex

A

Hypoglossal nerve damage
A lesion causes the tongue to deviate towards the lesion…

The Vagus nerve innervates the Uvula and points away from the lesion.

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38
Q

A 75 year old man has increased urinary frequency, nocturia (four times per night), poor urine flow and reduced urinary volumes over the past six months. Urinalysis shows glucose trace, blood and protein negative.
Investigations: electrolytes: normal
serum creatinine 387 µmol/L (60-120)
random blood glucose 5.6 mmol/L
Which is the most likely cause of his renal impairment?
* Chronic pyelonephritis
* Diabetic nephropathy
* Obstructive uropathy
* Polycystic kidney disease
* Renovascular disease

A

Obstructive uropathy -> the presentation is that off a patient that is presenting with obstructive problems from things like BPH (poor flow and invcreased freq)

Renovascular disease would be associated with HTN

Pyelonephritis should have other signs on urine dip

Diabetic nephropathy would demonstrate poor glucose controls or other evidence of poor glucose control.

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39
Q

An 18 year old man attends the Emergency Department after cutting the volar radial border of his left index finger with a knife while cutting up an apple. There was immediate arterial bleeding.
Other than the digital artery, which is the most likely structure to have been damaged?
* Digital nerve
* Extensor tendon
* Flexor digitorum profundus tendon
* Flexor digitorum superficialis tendon
* Proximal phalanx

A

Digital Nerve
The digital nerve is found right next to the digital artery as seen in the picture.

40
Q

An 82 year old man is confused and agitated in the recovery room following a transurethral resection for benign prostatic hyperplasia. He had a spinal anaesthetic containing bupivacaine and diamorphine hydrochloride. Hypotonic glycine was used for irrigation for the procedure, and he absorbed 1200 mL of glycine fluid. He was given prophylactic gentamicin at the start of the procedure.
His temperature is 36.2°C, pulse rate 82 bpm, BP 178/92 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 96% breathing 28% oxygen.
Which is the most likely cause of his confusion?
* Atelectasis
* Bupivacaine toxicity
* Hyponatraemia
* Opiate toxicity
* Urosepsis

A

Hyponatraemia -> The Glyycine water is essentially water as it gets converted to water as it is used and so has a high chance of causeing hyponatraemia

41
Q

A 20 year old woman presents to the Emergency Department complaining of muscle pain, malaise and headache. She visited her father’s family in India 2 weeks ago where she suffered a bout of diarrhoea. She took appropriate malarial prophylaxis medication.
Her temperature is 39.5°C and pulse rate 62 bpm.
Which I the most likely diagnosis?
* Campylobacter food poisoning
* Enteric fever
* Epstein-Barr virus infection
* Malaria
* Tuberculosis

A

Enteric fever -> This is associated with relative Bradycardia. Additionally there is signs of systemic upset.

EBV will present with more general symtpoms not typical to have gastro symptoms more likely to have a sore throat etc

Anti Malarials make malaria less likely

Campylocbacter jejuni is likely to present with bloody diarrhoes.

42
Q

While playing squash, a 30 year old man was hit by a racquet just below his left knee. Since then he can neither evert nor dorsiflex his left foot. There is a loss of sensation over the front and outer half of his left leg and the dorsum of his left foot. The knee and ankle reflexes are normal.
Which nerve is most likely to be injured?
* Common peroneal
* Obturator
* Sciatic
* Sural
* Tibial

A

Common Peroneal -> This will have foot drop and loss of the front and outer part of the foot. This is innervated by L4 which is also part of the Knee reflex.

43
Q

A 71 year old man dies in hospital 36 hours after admission with a chest infection. He was an inpatient briefly 2 weeks ago, when he had an inconclusive bronchoscopy and pleural biopsy. He had been receiving an occupational pension for pneumoconiosis and was living alone, refusing help from social services.
Which is the most important reason for referring to the coroner/procurator fiscal?
* Death due to hospital-acquired pneumonia
* Death due to industrial disease
* Death due to neglect by statutory authorities
* Death within 6 months of an invasive procedure
* Death within 48 h of hospital admission

A

Death by industrial disease

Other reasons for refferring to the coroners inc:
* Unexpected or sudden deaths
* Not seen within 28 days before death
* Death occurs within 24 hours of hospital admission
* Accidents, injuries and suicide
* Industrial injury or disease (e.g. asbestosis)
* Deaths occurring as a result of ill treatment, starvation or neglect
* Death occurred during an operation or before recovery from the effect of an anaesthetic
* Poisoning, including taking illicit drugs
* Stillbirths - if there is doubt as to whether the child was born alive
* Prisoner or people in police custody
* Service disability pensioners

The above can be split into:
* Death due to benign substance
* Death due to exposure to or contact with Toxic substance
* Death due to medicinal substance
* Death due to violence trauma or injury
* Death due to self-harm
* Death due to self neglect
* Death due to medical procedure
* Death due to employment
* COD unknown
* Death during custody
* Death cannot be signed by doctor, because been too long since they have seen the patient/ not available to sign the certificate
* Death of John/Jane Doe

44
Q

A 67 year old woman has weakness in her left arm and shoulder. She has recently undergone a left mastectomy and lymph node dissection for breast carcinoma.
She has reduced abduction in her left shoulder and winging of the scapula.
Which nerve is most likely to have been damaged?
* Axillary nerve
* Intercostal nerve
* Long thoracic nerve
* Median nerve
* Radial nerve

A

Long thoracic nerve -> Leads to the winging of the scapula

Axillary nerve -> Causes deltoid muscle wasting

45
Q

A 67 year old man with lung cancer requires 60 mL of 10 mg/5 mL oral morphine solution per day to control his pain. His GP would like to convert this to regular controlled release morphine.
Which is the correct dose of controlled release morphine required to manage his pain?
* 15 mg twice daily
* 30 mg twice daily
* 60 mg twice daily
* 120 mg twice daily
* 150 mg twice daily

A

60mg twice daily These are both morphine the dosage for this conversion should be the same.

Dose increases for opiods shouls be 30-50% increases

Conversions from oral codeine and tramadol to oral morphine is divide by 10 aka 100mg of Cod -> 10mg morphine

Oral morphine to subcut morphine -> divide by 2

Oral Morphine to subuct diamorphine -> divide by 3

Oral immediate release morphine should be given as a SIXTH of the daily dose…

If there is renal impairement then there is a preference to use Buprenorphine or fentanyl

46
Q

A 21 year old man presents to his GP with an erythematous rash on his glans penis. He also reports tiredness and increased thirst over the past 1 month. He has been waking up to pass urine three or four times per night and also has daytime urinary frequency but no other urinary symptoms.
Which is the most likely diagnosis?
* Diabetes mellitus
* Herpes simplex type 2
* HIV infection
* Non-specific urethritis
* Urinary tract infection

A

Diabetes MEllitus -> We think the red rash is penile thrush…

47
Q

A 72 year old woman has severe lower gastrointestinal haemorrhage. Colonoscopy shows active bleeding from a caecal carcinoma that cannot be controlled endoscopically. A decision is made to proceed to embolisation.
Which artery must be accessed for embolisation?
* Coeliac axis
* External iliac
* Inferior epigastric
* Inferior mesenteric
* Superior mesenteric

A

Superior mesenteric artery The question is asking for the blood supply of the ceacum. The Superior mesenteric artery is a large artery and provides the blood supply to the pancreas, duodenum, jejunum, ilieum and the caecum and the ascending and part of the transverse colon.

The inferior Mesenteric artery provides blood to the other half of the transverse the descenfing colon, sigmoid and rectum.

Essentially the Coeliac axis splits off first and forms 3 vessels that perfuse the spleen liver and part of the stomach

The external iliac is the major blood supply to the lower limbs and becomes the femoral artery at the inguinal ligament.

The inferior epigastric supplys blood to yout abs.

48
Q

A 65 year old woman attend for routine breast screening. She has no symptoms of breast disease, no relevant family history and is not on any medication. She has a normal breast examination. The mammogram shows and area of focal microcalcification.
Which is the most common pathological cause?
* Ductal carcinoma in situ (DCIS)
* Fibroadenoma
* Fibrocystic change
* Invasive carcinoma of breast
* Simple cyst

A

ductal carcinoma -> this is the most common breast cancer. It could be DCIS as it shows as microcalcifications on mammogram but so does ICS and ICS is more common… If there is mention of pleiomorphic cells then it is IDC.

Fibrocystic disease is more common in middle aged women…

49
Q

A 70 year old man attends his general practitioner with pain in his left foot. He has pain in his left calf when walking that has been progressively worsening over the past three months. Now he has pain at night. He has a past medical history of ischaemic heart disease and stopped smoking six years ago after a myocardial infarction.
He has a pulse rate 88 bpm and BP of 160/88 mmHg. His left foot is cold and there are no palpable pulses below the femoral artery.
Which is the most likely diagnosis?
* Acute limb ischaemia
* Critical limb ischaemia
* Deep vein thrombosis
* Raynaud’s syndrome
* Spinal stenosis

A

Acute limb Ischaemia
This patient is presenting with a few of the 6 ps and only one needs to be present for it to be ALL

Critical limb ischaemia needs to be rest pain for more than 2 weeks, evidence of tissue damage/loss or and ABPI less than 0.5, which this qs just doesnt mention.

50
Q

A 62 year old man becomes progressively hypotensive six hours after a right hemicolectomy. He has a past history of type 2 diabetes and hypertension. He received prophylactic antibiotics per-operatively. His observation charts show a rising heart rate before his BP started to fall.
He now has a pulse rate of 120 bpm and BP of 80/54 mmHg. He looks pale and his peripheries are cool. A fluid bolus of 500 mL of 0.9% sodium chloride results in a rise in systolic blood pressure to 100 mmHg and a reduction of his heart rate to 96bpm. His urine output in his catheter bag is <30mL/h.
Which type of shock is most likely in this case?
* Anaphylactic
* Cardiogenic
* Hypovolaemic
* Neurogenic
* Septic

A

Hypovolaemic -> The improvement in the BP and HR suggests that the problem was the lack of fluids making hypovolaemia the cause

51
Q

A 72 year old woman is admitted with three days of cough and fever. She has been unwell for the past two to three months with lethargy, arthralgia and anorexia. She has hypertension. Her creatinine concentration two months previously was 71 µmol/L (60-120).
She has a temperature of 38°C, pulse rate 87 bpm and BP of 132/70 mmHg, and her oxygen saturation is 98% on 40% oxygen via a face mask. She has coarse inspiratory crackles at the right base. Urinalysis shows protein 4+, blood 1+.
Investigations:
sodium 132 mmol/L (135-146)
potassium 5.3 mmol/L (3.5-5.3)
urea 14.7 mmol/L (2.5-7.8)
creatinine 275 µmol/L (60-120)
eGFR 25/mL/min/1.73 m2 (>60)
albumin 28 g/L (35-50)
urinary protein:creatinine ratio 340 mg/mmol (<20)
urinary sodium 18 mmol/L
Ultrasound scan shows that both kidneys are 11 cm in diameter and not obstructed.
Which feature favours an intrarenal, as opposed to a prerenal, cause for her acute kidney injury?
* Normal renal ultrasound
* Serum albumin <30 g/L
* Systolic BP >130 mmHg
* Urinary protein:creatinine ratio >300 mg/mmol
* Urinary sodium <20 mmol/L

A

Systolic BP >130 -> Most common prerenal cause is because of hypoperfusion soooo assuming that if thats not a problems its a prerenal problem… If anyone knows otherwise let me know
Unlikely to be the right answer as RAS -> Hypertension and so this would have high BP…

Urinary protein:creatinine ratio >300 mg/mmol I think the answer is this…

<20 urinary sodium is suggestive of Pre renal
I think Serum albumin less than 30 is possible for both renal and pre renal, a normal renal US helps exclude post renal causes of AKI leaving only Urinary protein : Creatinine ratio > 300 which is also suggestive of nephrotic syndrome which is often caused by renal damage…

52
Q

A 75 year old woman has a 1.5cm left breast lump. She has a history of hypertension and COPD.
Investigations:
Core biopsy: grade 3 invasive ductal carcinoma that is oestrogen receptor negative
Ultrasound scan of axillary: negative

Which is the most appropriate initial treatment?

  • Anastrozole
  • Chemotherapy
  • Radiotherapy
  • Tamoxifen
  • Wide local excision and sentinel node biopsy
A

Wide local excision and sentinal node biopsy -> MIGHT BE TOO ILL THEREFORE RADIO

Anastrazole and tamoxifen would be useful for Er+ve but also would not be the most approapriate as the most approapriate is to remove the tumour.

Chemo would be approapriate if the tumour had spread

Most likely there is a need to excise the tumour, chemo and radiotherapy may be used as sasjuvants.

53
Q

A 19 year old man is admitted to hospital following a motor bike collision where he sustained a severe head injury.
He is on a ventilator and his brain scan shows extensive damage. His pupils are fixed, dilated and non responsive. He is not sedated.

Which investigation needs to be performed before he becomes a heart beating organ donor?

  • Brain stem death tests
  • Cerebral angiogram
  • Cerebrospinal fluid analysis
  • Electroencephalogram
  • Intracranial pressure measurement
A

brain stem death tests

54
Q

An 84 year old woman has cut her leg following a fall in the garden. She cannot provide any immunisation history.
There is a deep laceration. The laceration is cleaned and sutured, and she is given analgesia and antibiotics.

Which is the most appropriate additional treatment?

  • Diphtheria, tetanus and pertussis vaccine
  • Equine antitetanus globulin
  • No additional treatment
  • Pooled human immunoglobulin
  • Tetanus toxoid
A

Pooled Human IG

So this is split based on the vaccination status of the patient.

If you are** unsure about their vaccination history (ASSUME NO VACCINATION)** then there is a need to give the patient IG and also give them a reinforcing or intial dose of Tetanus vaccinations, if this a tetanus prone wound or high risk wound. If it is a clean wound then there is a need only for the vaccine.

If the patient** was vaccinated more than 10 years ago **a clean wound does not require treatment but a an at risk wound would require a tetanus vaccine with a high risk wound requirinig both IG and a tetnus vaccine.

If they have been vaccinated within 10 years then there is no need to do anything…

55
Q

A 35 year old man has a gradual onset of hesitancy and poor urinary flow. He has a past history of urinary tract infection, which he developed while on holiday. Urinalysis is normal. Digital rectal examination reveals a small, firm, non-tender prostate.

Which is the most likely underlying cause for his symptoms?

  • Acute prostatitis
  • Benign prostatic hyperplasia
  • Chronic prostatitis
  • Urethral calculus
  • Urethral stricture
A

Urethral stricture -> The holiday and age I think is suggessting a STI Hx and a complication of that can be a stricture. Additonally I think the description of the prostate gland is normal and so that essentially rules out BPH and chronic prostatitis (prostatitis I think is also tender but not sure)

hesistancy and poor flow are all signs of obstructive uropathy.

56
Q

A 68 year old man is receiving palliative care for bone metastases. He complains of pain in his right arm which paracetamol and ibuprofen fail to relieve. Morphine sulphate is suggested to him, but he is concerned about the side effects of morphine.

Which is the most frequent side effect?

  • Confusion
  • Constipation
  • Drowsiness
  • Pruritis
  • Respiratory depression
A

Constipation

57
Q

A 21 year old man has 4 days of a widespread rash and malaise. He has had several male sexual partners over the past few months.
There is a macular rash over his body, including his palms, soles and scalp, a few palpable lymph nodes in his groin and a small popular lesion on the glans of his penis.

Which is the most likely diagnosis? + What is the treatment of these as well?

  • Disseminated herpes simplex
  • Gonorrhoea
  • HIV seroconversion illness
  • Infectious mononucleosis
  • Syphilis
A

Syphylis

Initially presents with a painless ulcer. and it heals itself within 3-6 weeks. There is non-tender lymphadenopathy.
Secondary features include (What we think this patient has):
Fevers and lymphadenopathy
Rash on the trunk palms and soles
snail track ulcers
Painless and warty lesions on the genitalia

  • Disseminated herpes simplex -> Acyclovir
  • Gonorrhoea -> IM Ceftriaxone or Oral Cefixime + oral azithromycin
  • HIV seroconversion illness
    -> Presents with sore throat, lymphadenopathy, diarrhoea a maculopapular rash mouth ulcers and malaise/myalgia
  • Infectious mononucleosis
  • Syphilis -> Benzathine penecillin + Doxycylcine
58
Q

A 66 year old man has had left sided abdominal discomfort for the pat 1 month.
He has widespread purpura and a palpable spleen measuring 17 cm from the left costal margin. There is no hepatomegaly or lymphadenopathy.

Investigations:

Haemoglobin 85 g/L (130-175)
White cell count 0.5 x 109/L (3.0-10.0)
Platelet count 38 x 109/L (150-400)
INR 1.0 (1.0)
Activated partial thromboplastin time 31 s (22-41)

Which is the most likely diagnosis?

  • Aplastic anaemia
  • Chronic myeloid leukaemia
  • Cirrhosis with portal hypertension
  • Hypovitaminosis C
  • Myelofibrosis
A

Myelofibrosis ->

The following are the three main causes of massive splenomegaly and 17 cm is fkn massive thats like 7 inches ;)
CML
Myelofibrosis
Leishmania

Myelofibrosis is also associated with pancytopenia where as with CML you would expenct a increase in the amount of WCC. I think

59
Q

An 18 year old man is worried about his cancer risk. His paternal grandfather died of colorectal cancer at 42 years of age and his 36 year old father has just been diagnosed with colorectal cancer. The son’s colonoscopy shows hundreds of colonic polyps, and biopsies from several of the polyps show adenomatous change with low grade dysplasia.

Which is the most appropriate strategy to prevent colon cancer in this situation?

  • Daily low dose aspirin
  • Diet rich in fruit and vegetables
  • Panproctocolectomy
  • Regular faecal occult blood tests
  • Yearly colonoscopy and biopsy
A

Panprococolectomy

60
Q

A 70 year old man has bright red rectal bleeding. Rigid sigmoidoscopy reveals a smooth and pedunculated polyp, 1 cm in diameter and 3 cm from the anal margin.
Which type of tumour is this polyp most likely to be?
* Adenocarcinoma
* Adenoma
* Fibroadenoma
* Squamous cell carcinoma
* Squamous cell papilloma

A

Adenoma -> Most polyps are benign??

Fibroadeonoma is the breast?

smooth and pedunculated suggests being polyl therefore suggestive of an adenoma.

61
Q

A 55 year old woman ha two months of increasing ankle oedema. She has felt tied and lethargic and has also noticed occasional blood and mucus in her stools.

Her BP is 168/90 mmHg and JVP +2 cm above the sternal angle. She has oedema to mid-calf bilaterally.

Investigations:

Urea 8.0 mmol/L (2.5-7.8)
Creatinine 124 µmol/L (60-120)
Albumin 22 g/L (35-50)
Urinary protein: creatinine ratio 754 mg/mmol (<30)

Which is the most likely diagnosis?

  • Amyloidosis
  • Chronic pyelonephritis
  • Membranous nephropathy
  • Systemic lupus erythematosus
  • Ulcerative colitis
A

Membranous nephropathy ->

HASSAN THis legennnddd of a mannn,

Basically the current theory is that this lady has membranous nephropathy as well as a malignancy. Apparently Membranous nephropathy is associated with Cancers and so this would explain the findings.
Linked to Hep B
SLE

UC’s Extraintestinal features do not include kidneys

SLE can cause membranous nephropathy CLASS V further down in the lupus nephritis

Fever Malaise and flank pain is the common presentaiton of Chronic pyelonephritis,

62
Q

A 25 year old man has urinary hesitancy and a sensation of incomplete voiding, just after recovering from a severe urinary infection. He has primary progressive multiple sclerosis but lives independently.
An ultrasound scan of his bladder indicates 400 mL of urine after voiding. Urinalysis reveals heavy growth of Proteus species.

Which is the most appropriate long term management?

  • Continuous low dose oral trimethoprim
  • Intermittent self catheterisation
  • Intravesical botulinum toxin injection
  • Oral oxybutynin tablets daily
  • Suprapubic catheterisation
A

Intermittent cathertisation

I have explained this in one of the other decks…

63
Q

A 60 year old man presents with weight loss and a cough productive of mucus mixed with blood. He is a smoker and has a history of chronic cough. His voice has recently become very weak. On examination, his left vocal cord is paralysed but the rest of the larynx is normal.

What is the most likely cause of the vocal cord paralysis?

  • Bronchiectasis
  • Carcinoma of the larynx
  • Carcinoma of the left main bronchus
  • Chronic laryngitis
  • Mesothelioma
A

Carcinoma of the left main bronchus

laryn is normal so not the carcinoma of the larynx

Chronic laryngitis cause weight loss

Bronchiectasis wont cause paralysed vocal chords

64
Q

A 64 year old man had a mitral valve replacement two years ago. He attends the Anticoagulant Clinic three days after his son’s wedding where he consumed 30 units of alcohol. He has a previous history of excess alcohol consumption.
His international normalised ratio (INR) is 8.5 (1.0) and he has a few old bruises on his legs. There is no haematuria and no epistaxis or other evidence of bleeding. Abdominal examination shows mild tenderness with sparse bowel sounds.
His warfarin has been temporarily discontinued.

Which is the most appropriate treatment?

  • Cryoprecipitate intravenously
  • Fresh frozen plasma intravenously
  • No treatment required, repeat INR in 48 hours
  • Prothrombin complex concentrate intravenously
  • Vitamin K orally
A

Prothrombin complex concentrate

If there was any signs of major bleed then the answer is the IV PCC.

If there was no bleeding or minor bleeding then this would be Oral Vit K…

The alcohol the warfarin the epigastric tenderness is ssuggestive of an ulcer and it is suggestive of bleeding.

GIULIAS DAD IS THE SOURCE FOR ABOVE… if he hat to chose he would pick PCC…

65
Q

A 22 year old woman has a painless swelling in the left side of her neck. She first discovered the lump several months ago and noticed that it became slightly more prominent after a recent cold.
She looks well. Her temperature is 37.2°C. There is a 3 cm x 4 cm oval, non-tender, fluctuant mass along the lower third of the anteromedial border of the sternocleidomastoid muscle.

Which is the most likely diagnosis?

  • Branchial cyst
  • Cystic hygroma
  • Lymphoma
  • Thyroglossal cyst
  • Tuberculous lymph node
A

Branchial cyst
This is a mobile cystic lesion that develops between the sternocleidomastoid and the pharynx.

Carotid anurysm would be pulsatile

Phyngeal pouch -> generally not seen, but if it is then often in the midline and it gurgles on palapation. Associated with with dysphagia, regurgitation and aspiration

Thyroglossal cyst is the only midline lump that moves with tingue protrussion. It moves with swallowing as well

Thyroid lumps will also move with swallowing and are found on the midline

Lymphadenopathy is the most common cause of a neck lump and is often seen when there is a localised infectionm

Cystic hygroma is congenital and so seen in newborns.

66
Q

A 23 year old woman has 2 days of localised right-sided loin pain, and visible haematuria but no dysuria.
Her temperature is 36.5°C and BP 158/86 mmHg. There is a mass that is just palpable in the right loin. Urinalysis shows blood 4+, protein 1+, leucocytes 1+ and nitrites negative.
Investigations:
Haemoglobin 135 g/L (115-150)
Urea 6.2 mmol/L (2.5-7.8)
Serum creatinine 98 µmol/L (60-120)

Which is the most likely diagnosis?

  • Acute pyelonephritis
  • Adult polycystic kidney disease
  • Hydronephrosis
  • Nephrolithiasis
  • Renal cell carcinoma
A
67
Q

A 28 year old man has a headache, intermittent fever, sore throat and diarrhoea.
He has a temperature of 37.7°C. His facies are red and there are two small aphthous ulcers on his left buccal mucosa. He also has a maculopapular erythematous rash on his upper trunk, red hands and folliculitis on his chest. His liver and spleen are just palpable and he has mild neck stiffness.
Investigations:

haemoglobin 135 g/L (130-175)
white cell count 3.3 x 109/L (3.0-10.0)
platelets 84 x 109/L (150-400)

Which next investigation is most likely to lead to a diagnosis?

  • First catch urine microscopy
  • Glandular fever screening test
  • HIV serology
  • Serum antinuclear antibodies
  • Serum toxoplasma gondii IgM antibody titre
A

HIV serology -> searched HIV seroconversion on passmed and so the features shown in the image…

68
Q

A 23 year old woman has 2 days of localised right-sided loin pain, and visible haematuria but no dysuria.
Her temperature is 36.5°C and BP 158/86 mmHg. There is a mass that is just palpable in the right loin. Urinalysis shows blood 4+, protein 1+, leucocytes 1+ and nitrites negative.

Investigations:

Haemoglobin 135 g/L (115-150)
Urea 6.2 mmol/L (2.5-7.8)
Serum creatinine 98 µmol/L (60-120)
Which is the most likely diagnosis?

  • Acute pyelonephritis
  • Adult polycystic kidney disease
  • Hydronephrosis
  • Nephrolithiasis
  • Renal cell carcinoma
A

Adult polycystic kidney disase
RCC would be loin pain, haemturia abdo mass

69
Q

A 27 year old man is brought to the Emergency Department having fallen from a ladder. He has a compound fracture of his right femur.
He is maintaining his airway and has cold peripheries with a capillary refill time of 4 seconds. His pulse rate is 135 bpm, BP 89/55 mmHg, respiratory rate 32 breaths per minute and oxygen saturation 98% breathing 15 L/min oxygen via a non-rebreathing mask.

Fluid resuscitation is started with Hartmann’s solution.

Which is the most appropriate initial treatment for his pain?

  • Intramuscular diclofenac
  • Intravenous morphine me paracetamol?
  • Intravenous paracetamol
  • Oral codeine phosphate
  • Subcutaneous morphine
A

**IV paracetamol ** pain ladder

70
Q

A 90 year old woman is admitted with a urinary tract infection and acute kidney injury. She has a history of peripheral vascular disease, hypertension, CKD stage and osteoarthritis. She takes amlodipine (5 mg once daily), clopidogrel (75 mg once daily), docusate sodium (100 mg three times daily), morphine sulfate (20 mg twice daily), and paracetamol (1 g four times daily).

Her temperature is 37.5°C, pulse rate 90 bpm and BP 130/85 mmHg.

Investigations:
Creatinine 201 µmol/L (60-120)
eGFR 18 mL/min/1.73m2 (>60)

Which of her medications is most likely to accumulate?

  • Amlodipine
  • Clopidogrel
  • Docusate sodium
  • Morphine sulfate
  • Paracetamol
A

Morphine

Metformin is another drug that does the same thing,

71
Q

A 34 year old man has fevers, rigors and collapse.
His temperature is 39.1°C, pulse rate 105 bpm, BP 92/56 mmHg and respiratory rate 25 breaths per minute. He has widespread purpura and evidence of papilloedema.
He is treated with fluids and broad-spectrum antibiotics.
Investigations:
Haemoglobin 85 g/L (130-175)
White cell count 75.2 x 109/L (3.0-10.0)
Platelets 38 x 109/L (150-400)
Neutrophils 73.2 x 109/L (2.0-7.5)
Blood culture Escherichia coli isolated

Which is the most likely cause of his high white cell count?

  • Acute leukaemia
  • Aplastic anaemia
  • Hodgkin’s lymphoma
  • Myelofibrosis
  • Reactive neutrophilia
A

Acute leukaemia

72
Q

A 40 year old woman with a malignant brain tumour is invited to consider participation in a phase 3 clinical trial of a new agent. She asks the purpose of phase 3 clinical trials.
Which is the key purpose of a phase 3 clinical trial?
* To allow access to the new agent before NICE approval
* To establish the likely cost of the new agent
* To establish the safe dosing level of the new agent
* To establish the side-effect profile of the new agent
* To test efficacy of the new agent compared with standard care

A

To test efficacy of the new agent compared with standard care

73
Q

A 38 year old woman is scheduled to have an elective hysterectomy for menorrhagia. She smokes 20 cigarettes a day and is not taking any medications.
Her haemoglobin concentration is 98 g/L (115-150).
Which preoperative test is it essential to undertake?

  • Blood group and save serum
  • Chest X-ray
  • Coagulation screen
  • ECG
  • Spirometry
A

Blood group and save serum

74
Q

A 65 year old man has 3 weeks of progressive ankle oedema.
His BP is 125/85 mmHg and oxygen saturation 98% breathing air. He has marked bilateral pitting ankle oedema and reduced chest expansion.

Investigations:
Creatinine 85 µmol/L (60-120)
Urinary protein: creatinine ratio 300 mg/mmol (<30)
Fasting glucose 5.7 mmol/L (3.0-6.0)
Albumin 22 g/L (35-50)
Total cholesterol 9 mmol/L (<5.0)

Which treatment is most likely to reduce the amount of urinary protein?

  • Furosemide
  • Low-protein diet (0.8 g/kg/day)
  • Metoprolol tartrate
  • Oral fluid restriction (<1 L/day)
  • Ramipril
    *
A

Ramipril

Nephrotic Syndrome is treated with steroids and ACE i

75
Q

A 42 year old man is found unconscious at home. He has Huntington’s disease, which has deteriorated recently. En route to the hospital he has a generalised seizure.
In the Emergency Department, he has a temperature of 35.8°C and GCS is . Examination shows no focal neurology.
CT scan of the head shows no acute structural change. A lumbar puncture is performed.
Cerebrospinal fluid results:
Appearance clear
Total protein 0.3 g/L (0.15-0.45 g/L)
Glucose 4.5 mmol/L (paired serum glucose 5.0 mmol/L) (reference range 2.2-4.4)
Cell count 2/µL (<5/µL)
Which is the most likely diagnosis?
* Brainstem stroke
* Drug overdose
* Psychogenic non epileptic seizure
* Subarachnoid haemorrhage
* Viral encephalitis

A

Psychogenic non-epileptic seizure

NO CLUE WTF IS GOING ON BUT THATS WHAT THE OLDER YEAR PUT

In this condition, there will normally be raised prolactin.

76
Q

A 33 year old woman has had pruritus for 1 year. Her weight and appetite are normal. She is a previous intravenous drug user.
Investigations:
Albumin 39 g/L (35-50)
ALT 105 IU/L (10-50)
AST 29 IU/L (10-40)
ALP 95 IU/L (25-115)
Bilirubin 34 µmol/L (<17)
Which virus is the most likely cause of her abnormal liver chemistry?
* Epstein-Barr
* Hepatitis A
* Hepatitis B
* Hepatitis C
* Human immunodeficiency

A

Hepatitis C This is more likly to be onne that becomes chronic hepatitis infection. We think the pruritis for a year suggests taht tthis is a chronic infcetion

77
Q

An 84 year old woman falls and sustains a fractured neck of femur. She has a history of stable angina, COPD, osteoporosis and idiopathic thrombocytopenic purpura.
The orthopaedic surgeons plan to perform an urgent fixation of her fracture with a dynamic hip screw.
Which is the contra-indication to spinal anaesthesia?
* COPD
* Idiopathic thrombocytopenic purpura
* Ischaemic heart disease
* Length of surgery
* Osteoporosis

A

ITP

Absolute contraindications:
* patient refuses,
* clinically in shock,
* presence of infection at injection site.

Relative contraindications:
* coagulation disorders,
* spine disorders,
* increased intracranial pressure,
* uncooperative patient.

78
Q

A 23 year old woman commenced her chemotherapy for Burkitt’s lymphoma yesterday. Since then she has been feeling increasingly nauseated. Urine output has been 40 mL in the last 12 hours.
Her temperature is 36.8°C, pulse rate 96 bpm and BP 112/80 mmHg.
Investigations on admission were normal. Investigations today:
Potassium
6.2 mmol/L
(3.5-5.3)
Urea

9 mmol/L
(2.5-7.8)
Creatinine
410 µmol/L
(60-120)
Which investigation is most likely to identify the cause of her acute deterioration?

  • Blood cultures
  • C reactive protein
  • Creatine kinase
  • Phosphate
  • Urate
A

URATE -> Confirmed answer from one of the MSCAA papers

79
Q

A 19 year old man has 3 weeks of diarrhoea. He is a student and has just returned from a gap year in Thailand.

Investigations:
Haemoglobin 96 g/L (130-175)
MCV 76 fL (80-96)
White cell count 10.2 x 109/L (3.0-10.0)
Platelets 240 x 109/L (150-400)
Eosinophils 3.1 x 109/L (0-0.4)

Which is the most likely diagnosis?

  • Amoebiasis
  • Campylobacter
  • Hookworm
  • Shigellosis
  • Typhoid fever
A

Hookworm -> the low Hb and the low MCV as well as the high eisonophil count is characteristic ogf hookworm and this is also a very common condition in Thailand

The eisonophils are not typically seen in amoebiasis or in campylobacter jejuni or in shigella or in typhoid.

Additionally typhoid diarrhoea does not last this long,

Amoebiasis stems -> Will often present with a long incubation period and then dysentry and then later on will get ameobic liver massess… fever hepatomegaly… etc Management of amoedbiases is metrondiazole

Shigella and E.coli -> within a day gastroentritic symptoms

Amoebiasis and giardia -> longer incubation period… As mentioned above amoebiasis is bloody diarrhoea but giardiasis will nnot be bloody and will not have liver pathology.

80
Q

A 45 year old woman is returned to the ward following laparoscopic cholecystectomy. She is lying flat on one pillow. She is making respiratory effort, but her chest and abdomen appear to be making ‘see-saw’ movements and there is no misting of her oxygen mask. Her BMI is 6 kg/m2.

Which manoeuvre is most likely to improve her airway patency?

  • Apply cricoid pressure
  • Head-down tilt (Trendelenberg position)
  • Insert nasal airway
  • Jaw thrust
  • Neck flexion
A

Jaw thrust

The seesaw chest is a sign of complete or almost complete airway obstruction. This means that the bet way to improve hwe airway patency is to do a jaw thrust as it makes the airway more open.

Head down tilt is not the same as head tilt chin lift. The head down tilt apparently makes it easier to get pelvic access in a patient.
Nasal airway is pointless if there is an obstruction

Applying cricoid pressure just blocks the oesophagus and so reduces the risk of aspiration…. This is why pressure is felt during intubation because of this pressure.

81
Q

A 75 year old man has been diagnosed with pneumonia, and treatment started with clarithromycin and amoxicillin. He has ischaemic heart disease and a previous stent. His medications include aspirin, bisoprolol, clopidogrel, ramipril and simvastatin.

Which medication should be stopped during treatment for his pneumonia?

  • Aspirin
  • Bisoprolol
  • Clopidogrel
  • Ramipril
  • Simvastatin
A

Simvastatin
Erythromycin and Statin dont go together so statisn should be stopped.

82
Q

A 60 year old man has pain in his right calf on walking 400 yards that forces him to stop walking. The pain disappears within 2 or 3 minutes when he stops walking but returns again when he walks another 400 yards. He smokes 15 cigarettes daily. His BP is 156/88 mmHg. His ankle:brachial pressure index is 0.6 on the right, and 0.9 on the left.

Which is the most likely site of pathology?

  • Right anterior tibial artery
  • Right common iliac artery
  • Right posterior tibial artery
  • Right profunda femoral artery
  • Right superficial femoral artery
A

Right superficial femoral artery

This becomes the right posterior tibial and the anterior tibial artery which is where the ischaemia is taking place… The profunda does not provide blood that low down the leg.

83
Q

A 32 year old woman has 2 weeks of low back pain, with no radiation and no other associated symptoms. There is no history of trauma and no significant past medical history.
There is lower back tenderness but no neurological abnormalities. She is advised to take analgesia.

Which is the most appropriate next step in management?

  • Bed rest
  • Lumbar spine X-ray
  • Mobilisation
  • MR scan of lumbar spine
  • Physiotherapy
A

Mobilisation

84
Q

A 68 year old woman has noticed a lump in her neck for 2 months, but otherwise feels well.
There are small lymph nodes palpable in both anterior cervical regions, supraclavicular fosse, both axillae and both inguinal areas.

Investigations:
Haemoglobin 124 g/L (115-150)
White cell count 27.2 x 109/L (3.8-10.0)
Neutrophils 4.0 x 109/L (2.0-7.5)
Lymphocytes 21.6 x 109/L (1.1-3.3)
Monocytes 0.9 x 109/L (0.2-1.0)
Eosinophils 0.1 x 109/L (0-0.4)
Basophils 0.1 x 109/L (0-0.1)
Platelets 157 x 109/L (150-400)
Blood film increased lymphocytes with smear cells

Which is the most likely diagnosis?

  • Acute lymphoblastic leukaemia
  • Chronic lymphocytic leukaemia
  • Hodgkin’s lymphoma
  • Myeloma
  • Non Hodgkin’s lymphoma
A

CLL -> Smear cells
Auer rods -> AML
Massive spleen -> CML
2,3,4,5 kid -> ALL

85
Q

A 40 year old man is referred to the General Surgery Clinic after two episodes of painlessly passing blood per rectum. On each occasion there was a small volume of bright red blood, with no obvious mucus. His general health is good and he has not lost any weight. He has not had any other change in bowel habit.

Which is the most appropriate initial investigation?

  • Barium enema
  • Coagulation screen
  • Colonoscopy
  • Faecal occult blood testing - silly
  • Proctosigmoidoscopy
A

Proctosigmoidoscopy

This is haemorrhoids, after DRE this can be done if the previous in inconclusive… This investigation is often done to rule out other causes of the fresh rectal bleeding,

86
Q

A 65 year old man is reviewed on the surgical ward following an abdominoperineal resection earlier that day for rectal cancer. He has an indwelling urinary catheter. His urinary output in the past 2 hours has been zero. In the preceding 3 hours, urine output was 56 mL, 61 mL and 73 mL per hour.
His temperature is 36.7°C, pulse rate 102/min, BP 126/73 mmHg and oxygen saturation 95% on 40% oxygen.

Which is the most likely explanation for this finding?

  • Acute kidney injury
  • Blocked catheter
  • Dehydration
  • Intraoperative bladder injury
  • Intraoperative ureteric injury
A

Blocked Catheter

If someone knows what the significance of the increaseing urine output per hour is… Or knows the thought process of this question please tell me….

Big Up artistic Natalie ->
Also his BP is normal which doesn’t really give a dehydration picture or even AKI. AKI - I’d expect there might be more signs to point to a pre/intra/post renal cause and maybe some U&Es. Bladder or ureteric injury might either cause an intrabdominal leak/inflammation and blockage - either way his UO would be decreasing not improving.

Improving UO and then a sudden stop suggests more a block as if it was an intraoperative injury then this would not present so much later than the surgery

87
Q

A 38 year old man wakes with severely reduced vision in his right eye. He noticed a few floaters the previous evening. He has no pain and no flashing lights. He has had type 1 diabetes for 25 years and is hypertensive. At retinal screening 18 months previously, he had pre-proliferative retinopathy, but failed to attend follow up.
Visual acuity in his right eye is reduced to light perception only.

Which is the most likely diagnosis?

  • Anterior ischaemic optic neuropathy
  • Central retinal artery occlusion
  • Central retinal vein occlusion
  • Retinal detachment
  • Vitreous haemorrhage
A

Vitreous Haemorrhage

The optic neuropathy and the retinal detachement are both causes if flashing lights and vision loss.

The diabetic retinopathy is a riskfactor of vitreous hemorrhage. This ialong with the reduced vision and the prescence of lfoaters makes Vitreous Haemorrhage more likley

ChatGPT notes

AION -> painless vision loss in one eye/ Floaters are NOT common in this condition

CRAO -> Again sudden and painless loss of vision but described as curtain coming down over the vision

CRVO -> another cause of sudden vision loss but the floaters are not a typical symptoms/ Additionally the fact that acuity is reduced to light only is also more rare that what is expected of CRVO

Retinal detachement -> this will be associated with a sudden loss of vision and only light preception this is an extreme presentation and it is often also associated with a curten or veil over the visual fielsd and flashes of light.

88
Q

A 76 year old man undergoes an abdominoperineal resection for a low rectal carcinoma. He is an ex-smoker and has exertional dyspnoea.
All blood tests are normal. Preoperative spirometry shows FVC 1.8 L (predicted 3.5) and FEV1 0.9 L (predicted 2.8).

Which is the most appropriate treatment for controlling his pain during the early postoperative period?

  • Epidural analgesia
  • Intramuscular injection
  • Intrathecal analgesia
  • Patient controlled intravenous analgesia
  • Transcutaneous electrical nerve stimulation
A

epidural

Post op epidural is good

89
Q

A 75 year old woman has 6 weeks of an intensely itchy rash. She lives in a nursing home. Several other residents have recently reported itching. She has excoriated papules on both hands, breasts and abdomen.

Which is the most appropriate topical treatment?

1% hydrocortisone
5% permethrin
Fluorouracil
Fusidic acid
Ketoconazole

A

Permethrin -> Scabies treatment

Hydrocortison -> reduce inflammation, itching, and redness associated with various skin conditions, such as eczema, dermatitis, and insect bites

Fluorouracil -> used to treat actinic keratosis (a precancerous skin growth) and superficial basal cell carcinoma (a type of skin cancer)

Fusidic acid -> used to treat bacterial skin infections, such as impetigo and certain types of dermatitis

Fluconazole -> used to treat fungal infections, including skin conditions such as ringworm, athlete’s foot, and yeast infections

90
Q

A 23 year old woman has had generalised itching for 8 weeks. There are many excoriation marks on her arms and chest. There is linear scaling at finger webs, which she attributes to hand washing required in her job; she works in an old people’s home and as a result, she often washes her hands. Her symptoms have not responded to topical eczema treatments. She has been taking the oral contraceptive pill for the past 3 years.

Which is the most likely diagnosis?

  • Atopic eczema
  • Drug reaction
  • Fungal infection
  • Irritant contact dermatitis
  • Scabies
A

Scabies

irritant dermatitis wouldnt affect the chest . the generalised itching including the chest suggests scabies instead of- dermatologist jiwon

linear burrowing of the finger webs is seen in scabies sbas - Still G1

I think it might be irritant contact dermatitis due to the repeated washing that she is doing…

91
Q

A 78 year old man has slowly increasing right leg pain, radiating from the buttocks to just below his knee. He has intermittent low back. He is otherwise and is a non-smoker.
The leg pain is precipitated by walking. Foot pulses are present.

Which is the most likely cause of his symptoms?

  • Disc herniation
  • Lumbar spondylosis
  • Osteoarthritis of the hip
  • Peripheral vascular disease
  • Spinal canal stenosis
    **
A

Spinal canal stenosis

Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. -> this is a key feature possibly in future qs

92
Q

A 60 year old man has reduced urine output 24 hours after gastrectomy and splenectomy for a gastric tumour. He is receiving 0.18% sodium chloride/4% glucose at 80 mL/h.
His temperature is 37.0°C, pulse rate 88 bpm, BP 121/67 mmHg and CVP 4 cmH20. His urine output has been 10-20 mL/h for the past 4 hours. Clinical examination is normal.
Which is the most appropriate immediate management?

a) Continue with current fluid regimen
b) Intravenous diuretic bolus
c) Intravenous fluid challenge
d) Replace urinary catheter
e) Ultrasound scan of kidney, ureter and bladder

A

Intravenous fluid challenge

This patients urine output is low and he has a low CVP therefore an intravenous fluid challenge would be appropriate

93
Q

A 75 year old woman has a 1.5cm left breast lump. She has a history of hypertension and COPD.
Investigations:
Core biopsy: grade 3 invasive ductal carcinoma that is oestrogen receptor negative
Ultrasound scan of axillary: negative
Which is the most appropriate initial treatment?

a) Anastrozole
b) Chemotherapy
c) Radiotherapy
d) Tamoxifen
e) Wide local excision and sentinel node biopsy

A

Wide local excision and sentinel node biopsy

This would be first line treatment

–> Is she fit enough for surgery though?

94
Q

A 64 year old man has weight loss of 10kg over the last three months. He drinks six units of alcohol and smokes 20 cigarettes per day. He is jaundiced and has 2 cm hepatomegaly.
What is the most likely primary site of malignancy?

a) Colon
b) Liver
c) Oesophagus
d) Pancreas
e) Stomach

A

Pancreatic cancer
Painless jaundice and the hepatomegaly is probably due to metastasis

95
Q

A 72 year old man attends the Emergency Department with a 2 hour history of severe interscapular pain. He has a past history of hypertension.
His pulse is 104 bpm and his BP is 145/60 mmHg. He has an early diastolic murmur on expiration at the left sternal edge. The ECG is normal. A chest x-ray shows mediastinal widening.
Which is the single most appropriate next investigation?

  • Contrast enhanced CT scan of thorax
  • Serum D-dimer
  • Serum troponin
  • Trans-oesophageal echocardiogram
  • Transthoracic echocardiogram
A

Contrast CT scan of thorax

The answer depends on stability, a stable patient will have a CT an unstable person requires a transoesophageal echo in the surgical room, if a AD is seen a surgery will be done there and then.

96
Q

A 78 year old woman is due to be admitted to hospital for an elective laparoscopic cholecystectomy. She has a chronic lower leg ulcer with no signs of cellulitis. This is swabbed by her community nurse, and culture from the ulcer grows MRSA.
Which is the most appropriate next step?

a) Admit for intravenous antibiotic therapy
b) Continue with planned surgery
c) Oral antibiotic therapy
d) Surgical debridement
e) Topical bacterial decolonisation

A

Topical bacterial decolonisation