Assessment MCQs Flashcards
A 94 year old man presents with recurrent anaemia. He lives in a nursing home and requires a hoist to transfer out of bed. He was admitted to the medical ward 6 months previously with fatigue and was found to have a Hb of 86 g/L with iron deficiency. He was transfused 2 units of packed red cells and had upper and lower GI endoscopy which was normal. He was discharged with a Hb of 112 g/L. Now he feels lethargic again and his Hb is 72 g/L. MCV 74 fl. Urinalysis normal.
What is the most appropriate step in investigation/management?
A) Prescribe twice daily oral iron and check FBP monthly
B) Transfuse a further unit of packed red cells
C) Arrange a capsule endoscopy
D) IV Iron infusion
E) Urinalysis
A) Prescribe twice daily oral iron and check FBP monthly
All possible:
- if wish for aggressive management then capsule endoscopy to look for small bowel bleeding lesions appropriate
- urinalysis should always be performed in iron deficiency anaemia to look for a renal source for blood loss
- Treatment depends on current symptoms: dramatic fatigue, SOB, chest pain, or signs of heart failure = indications for blood transfusion
- High dose oral iron with repeat FBP is less invasive option
- If already been on oral iron or have had difficulty tolerating higher doses of iron then IV iron infusion may be beneficial
A 75 year old anxious lady complains of urinary frequency and urgency causing disruption of her social life. She has occasional urinary incontinence particularly on laughter. She had a previous TAH and no other PMHx of note. Her blood glucose, U&E, and FBC are normal. Urine dipstick was negative.
Her voiding diary in the last 3 days shows an average of 3,800 mL fluid intake. She has increased urinary urgency and frequency during the daytime only. There was increased 24 hourly urinary output. There were 2 occasions where she leaked a small amount of urine laughing.
Which of the following best explains this lady’s symptoms?
A) Mixed urge and stress incontinence B) Psychogenic polydipsia C) Stress incontinence D) Stress incontinence and psychogenic polydipsia E) Urge incontinence
D) Stress incontinence and psychogenic polydipsia
- symptoms of urgency and frequency during the day only
- reduce fluid intake (and caffeine) will likely improve her urgency and stress incontinence
A 68 year old woman had a sudden episode of slurring of speech with left face and arm weakness lasting 30 minutes. She is diabetic. Neurological examination is normal. Blood pressure is 162/89. Carotid dopplers show bilateral carotid stenosis. ECG shows AF. CT brain is normal.
What is the most appropriate next step in management?
A) An oral anticoagulant B) Aspirin 300 mg C) Carotid endarectomy D) Insulin infusion E) Labetalol infusion
A) An oral anticoagulant
Probably TIA with full resolution
However, given her AF she should be started immediately on an anticoagulant
An 80 year old man has been treated with Parkinson’s disease for the past 15 years. He is currently on Sinemet Plus four time a day and Selegelline 10 mg once a day. His carer reports worsening confusion and intermittent hallucinations over the past 12 months. He scores 20/30 on the Montreal Cognitive Assessment (MoCA)
A) Alzheimer's dementia B) Delirium C) Lewy body dementia D) Medication overuse E) Parkinson's disease dementia
E) Parkinson’s disease dementia
- Cognitive impairment usually presents a lot earlier in Lewy body dementia
A 74 year old woman sustained a fractured neck of femur after a fall. She has a previous history of PE after a Colle’s fracture 3 years ago. Her eGFR is 51 and her calcium and vitamin D levels are normal. DEXA scan reveals a bone mineral density of -3.2 SD at the lumbar spine.
Which of the following treatments would be contraindicated?
A) Alendronic acid B) Calcium and vitamin D C) Risedronate sodium D) Strontium ranelate E) Zolendronic acid
D) Strontium ranelate
Small but significant increased risk of VTE associated with strontium renelate for post-menopausal osteoporosis. Therefore, previous PE is a contraindication.
Any of the bisphosphonates are probably appropriate treatment for this patient.
NB/it would be appropriate to treat this woman without a DEXA scan in view of her Colle’s and NoF fractures.
NB/do NOT treat patients with hypocalcaemia with bisphosphonates
An 80 year old man presents with 16 hours of painless visual loss in his right eye. His medical history includes hypertension and COPD. There is complete visual loss in the right eye. Ocular pressures were normal in both eyes. Fundoscopy is normal.
BP 170/90, pulse 88 beats per minute, saturations 95% on room air, respiratory rate 16, temperature 36.3, blood glucose 6.8.
What investigation should be performed next?
A) Carotid doppler B) Direct ocular massage C) Echocardiogram D) Formal visual field testing E) MRI head
A) Carotid doppler
Isolated retinal artery occlusion: common source of embolism to retinal arteries is a clot or atheromatous material from a stenosis of the internal carotid artery. Excluding high grade stenosis here is the most urgent consideration - prompt carotid endarterectomy in the setting of a significant ICA stenosis reduces risk of subsequent stroke dramatically.
NB/always important to rule out temporal arteritis in isolated retinal artery occlusion BUT in this case, low inflammatory markers make this less likely.
A 69 year old man with a 3 year history of MND has a right mid zone pneumonia. He has had recurrent infections over the past 6 months. his wife says that he can eat normal food, but can get chesty after drinking. He passes a water swallow test performed by a nurse and appears to be able to swallow food satisfactorily on the ward.
What should be done next?
A) Arrange oesophageal pH monitoring
B) Make the patient NBM and discuss the need for a PEG tube
C) Refer to SLT
D) Start a long-acting, combined beta agonist/steroid inhaler
E) Treat the pneumonia and discharge when medically stable
C) Refer to SLT
Neurological dysphagia with aspiration likely - causing recurrent chestiness/chest infections in last 6 months. Despite passing simple water swallow test and managing solid foods fine on the ward - it is likely he is having both symptomatic and silent aspiration. Formal SLT assessment for thickened fluids is needed. He may even need invasive testing such as videofluoroscopy or ‘FEES’.
A 78 year old man was admitted with a fall and fractured neck of femur, treated with hemiarthroplasty. He has been successfully treated for a post-operative pneumonia with associated delirium. He remains a little confused. At day 10 post-op he is requiring assistance of 2 people and a Stedy for transfers and needs assistance of 2 physios to help stand. He scores 24/30 on MMSE. CT-brain showed moderate cerebral atrophy. He now wishes to go home but his daughter feels he will need to spend 4-6 weeks in a NH prior to coming home.
Which of the following is most appropriate?
A) Arrange a NH placement for 6 weeks and inform the patient that he will be discharged home from there once he has improved physically.
B) Continue with rehabilitation in hospital, in the orthogeriatric rehabilitation unit, until his confusion has fully resolved and he needs assistance of 1 to transfer and mobilise.
C) Inform the patient of the perceived risks of going home at this stage. If he understands these risks and can demonstrate an ability to weigh them up to make an informed decision then arrange his discharge with social services and community rehabilitation input.
D) Inform him and his daughter of the likely diagnosis of dementia, and therefore suggest that given the expected deterioration over time that a long term nursing home placement may be best.
E) Perform an Addenbrooke’s Cognitive Assessment (ACE-R) if he scores less than 50/100 he does not have capacity and a decision in his best interests, in conjunction with his family, should be made regarding his discharge plan.
C) Inform the patient of the perceived risks of going home at this stage. If he understands these risks and can demonstrate an ability to weigh them up to make an informed decision then arrange his discharge with social services and community rehabilitation input.
Despite recent confusion, and in fact regardless of any cognitive test score, if he can display evidence that he understands any risks, weighs information about benefits and risks of the decision in the balance and can communicate his informed decision, then it is incumbent on us doctors to comply with and facilitate the patient’s wishes.
Public health has improved significantly over the past 100 years, driven by improvements in housing, sanitation, nutrition, and medicine. With respect to ageing this has led to which of the following?
A) Compression of life expectancy and triangularisation of the morbidity curve
B) Compression of morbidity and rectangularisation of the survival curve
C) Compression of mortality and triangularisation of the morbidity curve
D) Compression of physiological ageing and elongation of the survival curve
E) Compression of survival and rectangularisation of the morbidity curve
B) Compression of morbidity and rectangularisation of the survival curve
People live longer, healthier lives. Illness is increasingly a feature of older age, with the majority of severe illness being experienced in the last few years of life. However, there has been little increase in the maximum life expectancy of humans. This is called compression of morbidity. This leads to rectangularisation of the human survival curve.
Regarding the Barthel index, which of the following is correct?
A) A score of 20/20 means that the patient is fully dependent
B) Each sub-section is score between 0 and 2
C) It assesses both functional and cognitive function
D) It includes an assessment of the patient’s ability to transfer
E) It was designed to be used in patients with stroke only
D) It includes an assessment of the patient’s ability to transfer
Barthel index = ordinal scale used to measure performance of ADLs. It measures 10 variables: faecal continence, urinary continence, grooming, toilet use, feeding, transfers, walking, dressing, climbing stairs and bathing. Each sub-section varies between a top score of 1 to 3. A score of 20 means fully independent, whereas a score of 0 means fully dependent. It does not include an assessment of cognitive function directly.
