A. Sam 1-4

Question 1

List 3 investigations in order for cardiac chest pain.

Answer 1

1. ECG
2. Troponin:
   - +ve: coronary angiography
   - -ve: Exercise tolerance
3. Echocardiography

Question 2

What is long QT syndrome?
What family history is associated?
What are causes?

Answer 2

• Abnormal ventricular repolarisation
• FH of sudden death.
• Congenital mutations in K+ channel or acquired low K+.

Question 3

Give 3 differential diagnoses of raised JVP

Answer 3

• R heart failure: secondary to LHF or pulmonary HTN.
• Tricuspid regurgitation, R ventricle dilatation.
• Constrictive pericarditis: infection (TB), inflammation (CTD), malignancy.

Question 4

• Give 3 causes of sinus tachycardia.
• What cardiac abnormality is present in supraventricular tachycardia?
• Give two types of SVT.

Answer 4

• Sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaeochromocytoma)
• Re-entry circuit
• AVNRT and AVRT

Question 5

Give 2 ECG signs of AVRT

Give 3 causes of Ventricular tachycardia.

Answer 5

• Short PR interval
• Delta wave.
• Ischaemia, electrolyte imbalance, long QT.

Question 6

Give 3 management steps of SVT.

Give 2 steps in management of AF.

Answer 6

• Vagal manoeuvres
• Adenosine (cardiac monitor)
• DC cardio version
• Rhythm control: if onset >48 hours anticoagulant for 3-4 weeks before cardio version
• Rate control: beta blocker, digoxin.

Question 7

Describe LVH by voltage criteria.

Answer 7

• S in V1 + R in V5/6 > 7 squares.

i. e. deep S in V1/2 and tall R in V5/6

Question 8

Give 3 steps in management of acute heart failure.

Answer 8

• Sit up
• Oxygen
• Furosemide IV

Question 9

What is the Advanced Life Support algorithm for VF/ pulseless VT?

What is the algorithm for asystole/ pulseless electrical activity?

Answer 9

• Shock
• CPR 2 min
• Assess rhythm
• Adrenaline every 3-5 min
• Amiodarone after 3 shocks.
• CPR 2 min
• Adrenaline every 3-5 min
• Correct reversible causes.

Question 10

Give management of primary and secondary pneumothorax dependent on size.

What may be complication causing SOB after chest drain?

Answer 10

Primary:

• <2cm, discharge, repeat CXR
• > 2cm: aspiration, if unsuccessful: chest drain

Secondary

• <2cm: aspiration
• > 2cm: chest drain
• Re-expansion pulmonary oedema: can be pus, fluid or blood.

Question 11

How is axis deviation determined using Leads I, II and aVL?

Answer 11

• Lead 1 or 2 negative- axis deviation.

- aVL positive: left axis deviation. aVL negative, right axis deviation.

Question 12

Which organs are supplied by the following mesenteric arteries?

• Celiac
• Superior mesenteric artery
• Inferior mesenteric artery

Answer 12

Celiac:
- Stomach, spleen, liver, gall bladder, duodenum
SMA:
- Small intestine, right colon
IMA:
- Left colon, rectum.

Question 13

What abdominal condition is complicated by abdominal aortic aneurysm?

Answer 13

• Acute pancreatitis. You will see raised serum amylase.

Question 14

Differentiate causes of transudate and exudate ascites.

Answer 14

Transudate: due to increased portal vein pressure

• Cirrhosis
• cardiac failure
• nephrotic syndrome.

Exudate:

• Malignancy
• Infection
• Budd-Chiari syndrome: hepatic portal vein thrombosis

Question 15

In spontaneous bacterial peritonitis with ascites, what is neutrophil level?

Answer 15

• Ascites neutrophils >50 cells per mm3

Question 16

• What causes pale stool in jaundice?
• Which enzyme conjugates bilirubin?
• What is Gilbert’s syndrome?

Answer 16

• Low stercobilinogen
• Glucuronyltransferase
• Low glucuronidation.

Question 17

Give 2 blood markers of obstructive jaundice.

What is next investigation if LFTs are raised?

Answer 17

• Raised ALP, raised CA19-9

- Raised LFTs, do Ultrasound

Question 18

What is management of variceal bleed?

Answer 18

• Antibiotics

- Terlipressin: splanchnic vasoconstriction: restrict movement of bacteria.

Question 19

What is appropriate investigation of the following GI presentations:

• Dysphagia, weight loss
• PR bleed, weight loss

Answer 19

• OGD and biopsy

- Colonoscopy.

Question 20

Give 5 steps to manage ascites

Answer 20

• Diuretics: spironolactone/ furosemide
• Dietary sodium restriction
• Fluid restriction in hyponatraemic patients
• Monitor weight daily
• therapeutic paracentesis with IV human albumin.

Question 21

What are the steps in neurological examination of upper and lower limbs?

Answer 21

ITPCRSGB

• Inspection
• Tone
• Power
• Coordination
• reflexes
• Sensation
• Gait
• Back.

Question 22

What is the sensory loss distribution in lesions in the following:

• Cerebral cortex
• Spinal cord
• Nerve roots (radiculopathy)
• Mononeuropathy
• Polyneuropathy

Answer 22

• Hemisensory loss
• Level e.g. umbilicus
• dermatome
• specific area
• glove and stocking.

Question 23

Give investigation/ clues for following toxic/ metabolic causes of peripheral neuropathy:

• Drugs
• Alcohol
• B12 deficiency
• Diabetes
• Hypothyroidism
• Uraemia
• Amyloidosis.

Answer 23

• Drugs: history
• Alcohol: history, raised GGT and MCV
• B12: anaemia, raised MCV
• Diabetes: glucose, HbA1C
• Hypothryoidism: TFTs
• Uraemia: U&Es
• Amyloidosis: history of myeloma or chronic infection/ inflammation.