Extras Flashcards
1
Q
Partial agonists exhibit a low efficacy
what is the defining property of a partial agonist?
A) it has a high binding affinity
B) it has a low binding affinity
C) Has a maximum response the same as a full agonist
D) must occupy all receptors to elicit maximum response
E)it will always be less potent than a full agonist
A
D) must occupy all receptors to elicit maximum response
2
Q
For mild to moderate pain , the drug paracetamol can be administered orally
What is the reason for the oral administration of paracetamol as opposed to other
routes of administration?
A) its absorbed from the mouth
B) it is a prodrug requiring hepatic metabolism to be activated
C) easy to administer orally
D) less toxic if administered orally
E) poorly absorbed from the intestine
A
C) easy to administer orally
3
Q
The GP practice pharmacist is conducting a review of an 80 year old woman’s
medications.
What is the most common type of prescribing error they are likely to encounter?
A) contraindication to medicine use
B) potential severe drug-drug reaction
C) duplication of therapy
D) Incomplete medication or personal details
E) wrong frequency of medication use
A
D) incomplete medication or personal details
4
Q
Which disorder of haemostasis is best detected with the prothrombin time laboratory test? A) acquired fibrinogen deficiency B) coagulation factor VII deficiency C) DIC D) hyperfibronlysis E) Immune thrombocytopenia
A
b) coagulation factor VII deficiency
They are used to determine the clotting tendency of blood, in such things as the measure of warfarin dosage, liver damage, and vitamin K status. PT measures the following coagulation factors: I (fibrinogen), II (prothrombin), V (proaccelerin), VII (proconvertin), and X (Stuart–Prower factor).
5
Q
what does APTT test for
A
intrinsic blood clotting factors
factors 8, 9, 11
6
Q
An unknown patient is brought into A&E with massive bleeding after a road
traffic accident. They need immediate transfusion but there is insufficient time
to determine their blood group.
What ABO group red cells and platelets and plasma should be administered while
the laboratory is processing their blood group sample?
A) Group A Red cells, Group A platelets, Group AB plasma
B) Group A Red cells, Group O platelets, Group O plasma
C)Group O Red cells, Group A platelets, Group AB plasma
D) Group O Red cells, Group O platelets, Group AB plasma
E) Group O Red Cells, Group O platelets, Group O plasma
A
C) Group O red cells, group A platelets, group AB plasma
7
Q
You are discussing the risks and benefits of transfusion with a 25 year old
patient with newly diagnosed leukaemia, who is likely to need multiple
transfusions for their care.
Which complication of transfusion currently causes the largest number of
transfusion-related deaths in the UK?
A) ABO incompatible transfusion
B) Anaphylaxis
C) TACO
D)transfusion transmitted infection
E) wrong blood given to wrong patient
A
C) taco - transfusion associated circulatory overload
8
Q
A 45 year old woman presents with fatigue. Her past medical history includes
hypothyroidism and vitiligo. A full blood count shows a macrocytic anaemia,
and severe vitamin B12 deficiency is confirmed with an appropriate laboratory
test.
Based on the information available, what is the most likely underlying cause of her
anaemia?
A) coeliac disease
B) Chron’s disease
C) dietary inadequance
D) fish tape worm
E) pernicious anaemia
A
E) pernicious anaemia
Pernicious anaemia is an autoimmune condition that affects your stomach. An autoimmune condition means your immune system, the body’s natural defence system that protects against illness and infection, attacks your body’s healthy cells. Vitamin B12 is combined with a protein called intrinsic factor in your stomach.
9
Q
An 80 year old asymptomatic woman is found to have a persistent stable
lymphocytosis with an otherwise normal full blood count. She has no
lymphadenopathy or splenomegaly. On the blood film there are small mature
lymphocytes and smear cells. Flow cytometry detects a clone of B cells.
What is the likely diagnosis?
A) acute lymphoblastic leukaemia
B) chronic lymphocytic leukaemia
C) Lymphoma
D) myeloproliferative neoplasm
E) reactive lymphocytosis (due to viral infection)
A
B) chronic lymphocytic anaemia
10
Q
blood test results for acute lymphoblastic leukemia
A
Tests and procedures used to diagnose acute lymphocytic leukemia include: Blood tests. Blood tests may reveal too many or too few white blood cells, not enough red blood cells, and not enough platelets. A blood test may also show the presence of blast cells — immature cells normally found in the bone marrow.
11
Q
how would you diagnose lymphoma
A
Testing for lymphatic cancer generally begins with a physical examination, during which your physician will review your medical history and discuss your symptoms. Lymphoma can be confirmed with a biopsy, in which a tissue sample is taken from an affected area of the body for analysis.
12
Q
how to confirm myeloproliferative neoplasm
A
The diagnosis of myeloproliferative neoplasms (MPNs) requires a combination of CBC and peripheral smear examination, bone marrow histology, chromosome analysis, and molecular testing. The combination of these studies allows clinicians to determine whether results meet corresponding diagnostic criteria.
13
Q
A patient is admitted to hospital suffering from chest pain. Following a series
of tests, it is revealed that they are suffering from a heart attack. Prior to a
percutaneous intervention by a cardiologist, the patient is administered
ticagrelor.
How does the antiplatelet drug ticagrelor reduce platelet function?
A) By acting as a reversible antagonist at the P2Y12 receptor
B) By acting as an agonist at the TP thromboxane receptor
C) By acting as an antagonist at the Glycoprotein IIb/IIIa receptor
D) By acting as an antagonist at the TP thromboxane receptor
E) By acting as an irreversible antagonist at the P2Y12 receptor
A
A) By acting as a reversible antagonist at the P2Y12 receptor
14
Q
what are P2Y12 receptor blocks
give some examples
A
P2Y12 receptor blockers are another group of antiplatelet drugs. This group of drugs includes: clopidogrel, ticlopidine, ticagrelor, prasugrel, and cangrelor.
15
Q
function of thromboxane
A
Thromboxane is a potent vasoconstrictor and stimulus for platelet aggregation and the reduced vasoconstriction and platelet aggregation that occur may be significant in patients with bleeding tendencies or may complicate surgical procedures.
16
Q
A 65 year old man with suspected ST elevation myocardial infarction was
taken to the cardiac catheter laboratory for primary percutaneous coronary
intervention. Angiography revealed occlusion of the right coronary artery.
Which of the following leads of his 12 electrocardiogram would most likely have
revealed ST elevation prior to the procedure?
A) I,II and aVL
B) II,III, and aVR
C) II,III and aVL
D) II,III and aVF
E)V1 and V2
A
D) II, III and aVF
17
Q
How to remember leads for ECG
A
acronym LISA L = lateral -> I, aVL, V5 and V6 = LAD I = inferior -> II,III, aVF = RCA S = septal -> V1, V2 = LAD circumflex A = anterior -> V3, V4 = LAD Bundle branch
18
Q
A GP requests a U&E profile on a patient, and the sample is taken at 9am.
Unfortunately, it is not delivered to the lab until the next morning.
Which of the analytes in the sample is likely to be inaccurate?
A) all of them
B) creatinine
C)potassium
D) sodium
E) urea
A
c) potassium
19
Q
A 35 year old man is diagnosed with Familial hypercholesterolaemia (FH). Which clinical sign, along with a raised cholesterol and a family history, indicates a diagnosis of FH? A) corneal arcus B) eruptive xanthomata C) palmar xanthomata D) tendon xanthomata E) xanthelesmata
A
D) tendon xanthomata
20
Q
You have a 50 year old male patient with a blood pressure of 125/85, BMI 29
and a history of smoking. He complains of being tired, frequently out of breath
with no major chest pains and his shoes get very tight when standing (but the
swelling goes down when he puts his legs up). You carry out a medical
examination.
What is the most likely prescription after this examination?
A) atenonolol
B) chorthalidone
C) enalapril
D) isosorbide dinitrite patch
E) lose weight and exercise more
A
C) enalapril
21
Q
A 65 year old woman is on warfarin for an aortic mechanical valve, she is
involved in a road traffic accident and has multiple injuries with shock due to
major haemorrhage. Her recent INR is 3.
What is the correct course of action?
A) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, protamine, and vitamin K
B) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, idarucizumab
C) Resuscitation (including blood products according to major haemorrhage
protocol), local measures and aprotinin
D) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, prothrombin complex concentrate
and vitamin K
E) Resuscitation (including blood products according to major haemorrhage
protocol), local measures and tranexamic acid
A
D) Resuscitation (including blood products according to major haemorrhage
protocol), local measures, tranexamic acid, prothrombin complex concentrate
and vitamin K
22
Q
when to give tranexamic acid
A
Tranexamic acid (sometimes shortened to txa) is a medicine that controls bleeding. It helps your blood to clot and is used for nosebleeds and heavy periods. If you're having a tooth taken out, using tranexamic acid mouthwash can help stop bleeding. also major haemorrhage
23
Q
when to give vitamin K in bleeding
A
xVitamin K is needed for blood to clot. Not having enough vitamin K is the main cause of vitamin deficiency bleeding. If your baby’s blood doesn’t clot, they may have severe bleeding or a hemorrhage. This can be life-threatening.
Or if they are on warfarin
24
Q
when is prothrombin complex concentrate given in bleeding
A
Prothrombin complex concentrate (PCC), also known as factor IX complex, is a medication made up of blood clotting factors II, IX, and X. Some versions also contain factor VII. It is used to treat and prevent bleeding in hemophilia B if pure factor IX is not available.
25
when is aprotinin used in bleeding
is indicated for prophylactic use to reduce perioperative blood loss and the need for blood transfusion in patients undergoing cardiopulmonary bypass in the course of coronary artery bypass graft surgery who are at an increased risk for blood loss and blood transfusion.
26
when to give idaruxicumab
Idarucizumab is used during a medical emergency to treat severe or uncontrolled bleeding that has been caused by taking dabigatran. Idarucizumab is also used when an emergency surgery or other invasive medical procedure is needed in a person who takes dabigatran.
27
when to give protamine
Protamine is a medication used to reverse and neutralize the anticoagulant effects of heparin. Protamine is the specific antagonist that neutralizes heparin-induced anticoagulation
28
A 72 year old woman presents with sudden severe tearing chest pain
radiating to her back. She has a history of poorly controlled hypertension. Her
chest X-ray shows a widened mediastinum. ECG is normal.
What would be the next diagnostic test that should be immediately arranged?
A) coronary angiogram
B) CT aorta
C) trans thoracic echocardiogram
D). D dimer
E) troponin
B) CT aorta
29
A 60 year old woman with a chronic respiratory condition is found to have a
blue/purplish discolouration of her nailbeds, lips and tongue.
Which pathophysiological process best describes the disturbance in her oxygen
cascade?
A) anaemic hypoxia
B) decreased barometric pressure
C) histotoxic hypoxia
D) hypoxaemia (hypoxic hypoxia)
E) stagnant hypoxia
D) hypoxaemia (low oxygen)
not A not anemia
Not B
Not C because not poisoning ( like cyanide)
Not stagnant (not reduced cardiac pressure)
30
causes of stagnant hypoxia
Stagnant hypoxia, in which blood flow through the capillaries is insufficient to supply the tissues, may be general or local. If general, it may result from heart disease that impairs the circulation, impairment of veinous return of blood, or trauma that induces shock.
(occurs in raynauds, shock states, cardiac arrest, severe congestive heart failure)
31
what causes histotoxic hypoxia
Histotoxic hypoxia results from tissue poisoning, such as that caused by cyanide (which acts by inhibiting cytochrome oxidase) and certain other poisons like hydrogen sulfide (byproduct of sewage and used in leather tanning).
32
what causes hypoxaemia (hypoxic hypoxia)
Hypoxia can also result from lung damage due to trauma. Other things can cause hypoxia include: Lung diseases such as chronic obstructive pulmonary disease (COPD), emphysema, bronchitis, pneumonia, and pulmonary edema (fluid in the lungs) Strong pain medicines and other drugs that hold back breathing.
33
A 24 year old woman is training to run a marathon.
During moderate aerobic exercise how will her PaCO2, alveolar ventilation and rate
of carbon dioxide production compare with resting levels?
A. PaCO2 ↑ CO2 production ↑ Alveolar ventilation ↑
B. PaCO2 ↔ CO2 production ↑ Alveolar ventilation ↑
C. PaCO2 ↓ CO2 production ↑ Alveolar ventilation ↑
D. PaCO2 ↓ CO2 production ↓ Alveolar ventilation ↓
E. PaCO2 ↔ CO2 production ↑ Alveolar ventilation ↔
B PaCO2 ↔ CO2 production ↑ Alveolar ventilation ↑
34
A 63 year old man presents with acute shortness of breath and tightness in
his chest. He has a mild non-productive cough. He has no fever but appears
to be working hard to breathe, with low oxygen saturations. Respiratory
examination is normal, but he has significant oral thrush. He rapidly
deteriorates and is admitted to the intensive care unit. Following transfer onto
ICU, he is found to have reduced air entry on the right, and a chest X-ray
shows a right sided pneumothorax. The gentleman is diagnosed
withPneumocystis jiroveci.
What is the most appropriate next investigation?
A) blood film
B) HIV test
C) Mycobacterium culture
D) Pneumococcal urinary antigen
E) Sputum culture
B) HIV test
Pneumocystis jirovecii is a yeast-like fungus of the genus Pneumocystis. The causative organism of Pneumocystis pneumonia, it is an important human pathogen, particularly among immunocompromised hosts. Prior to its discovery as a human-specific pathogen, P. jirovecii was known as P. carinii.
35
```
A patient has persistent breathlessness. His GP arranges spirometry which
shows:
FEV160%, FVC 95%, FEV1/FVC 58%
What is the pattern seen?
A) Mixed obstructive and restrictive
B) Normal
C) obstructive
D) reduced gas transfer
E) restrictive
```
C) obstructive
36
Spirometry criteria for obstructive lung disease
A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction. Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
37
Spirometry criteria for restrictive lung disease
the classic definition of a restrictive pattern on spirometry is low FVC in the presence of a normal FEV1/FVC ratio. However, restrictive lung disease is characterized by a decrease in total lung capacity (TLC).
38
what is interstitial lung disease
Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream. Lung damage from ILDs is often irreversible and gets worse over time.
39
A 76 year old man reports 6 months of breathlessness. He has minimal past
medical history and is not taking any medications. His chest X-ray shows
signs of interstitial lung disease.
What type of interstitial lung disease is most likely?
A) connective tissue interstitial lung disease
B) hypersensitivity pneumonitis
C) Non - specific interstitial lung disease
D) idiopathic pulmonary fibrosis
E) sarcoidosis
D) idiopathic pulmonary fibrosis
40
what is sarcoidosis of lung
Sarcoidosis is a rare disease caused by inflammation. It usually occurs in the lungs and lymph nodes, but it can occur in almost any organ. Sarcoidosis in the lungs is called pulmonary sarcoidosis. It causes small lumps of inflammatory cells in the lungs.
41
```
What is the most appropriate method of qualitative data collection to explore an
individual's views in detail?
A) diaries
B) focus groups
C) in depth interview
D) meta - analysis
E) non - participant observations
```
C) in depth interview
42
```
A 67 year old man presents to his GP with chronic obstructive pulmonary
disease.
What is the most likely clinical examination finding?
A) asterixis (flapping tremor)
B) cyanosis
C) finger clubbing
D) hyper-inflated chest
E) peripheral oedema
```
D) hyper inflated chest
43
what does the right coronary artery supply
right atrium
right ventricle
inferior aspect of left ventricle
posterior septal area
44
what does the circumflex artery supply
left atrium
| posterior aspect of the left ventricle
45
what does the left anterior descending artery supply
anterior aspect of left ventricle
| anterior aspect of septum
46
. A 78 year old man develops increasing confusion on the ward at night. He is
wandering around naked asking for his wife, shouting, and threatening staff
and patients. He was admitted this morning with 1 week of productive cough
and temperature. He has a history of idiopathic Parkinson's disease.
His temperature is 37.6°C, pulse rate 100 bpm, BP 132/71 mmHg and oxygen
saturation 95% breathing air. His capillary blood glucose is 5 mmol/L.
Attempts to calm him with nursing measures do not improve the situation, and
he begins hitting staff.
Which is the most appropriate treatment?
A. Amitriptyline
B. Haloperidol
C. Immediate release carbidopa-levodopa
D. Lorazepam
E. Risperidone
Correct Answer: D Lorazepam
Justification for correct answer
Whilst anti-psychotics are first-line to manage delirium where medication required, they
are contra-indicated in Parkinson’s disease. (NICE CG103 Delirium: prevention,
diagnosis and management).
47
A 28 year old man is investigated for polyuria and polydipsia. He has bipolar
disorder for which he has taken lithium for 2 years.
Initial investigations:
Sodium 145 mmol/L (135–146)
Potassium 3.9 mmol/L (3.5–5.3)
Serum osmolality 296 mOsmol/kg (285–295)
Urinary osmolality 356 mOsmol/kg (350–1000)
Fasting glucose 5.8 mmol/L (3.0–6.0)
Serum lithium 0.75 mmol/L (0.5–1.2)
Which is the most useful diagnostic investigation?
A. 24-h urinary cortisol test
B. Glucose tolerance test
C. Serum corrected calcium
D. Short Synacthen test
E. Water deprivation test
Correct Answer: C serum corrected calcium
Justification for correct answer
It is essential to exclude hypercalcaemia due to hyperparathyroidism before progressing
to a water deprivation test.
48
A 65 year old woman had a stroke 2 weeks ago causing right arm weakness
and dysphasia. CT scan of head showed a left parietal lobe infarct. Her
medication since the stroke includes aspirin and simvastatin.
Her pulse rate is 82 bpm and irregular.
Investigations:
ECG: atrial fibrillation, rate 68 bpm.
Which is the most appropriate long-term plan for secondary stroke prevention?
A. Apixaban
B. Aspirin
C. Aspirin and dipyridamole
D. Clopidogrel
E. Ticagrelor
Correct Answer: A
Justification for correct answer
For patients with a stroke and AF should start anticoagulation as secondary prevention.
This can be with either warfarin or with a factor Xa inhibitor such as apixaban. This is
covered in both NICE AF guidelines (https://pathways.nice.org.uk/pathways/atrialfibrillation#path=view%3A/pathways/atrial-fibrillation/preventing-stroke-in-people-withatrial-fibrillation.xml&content=view-node%3Anodes-anticoagulation-treatment ) and the
most recently updated stroke guidance (2016) (https://www.rcplondon.ac.uk/guidelinespolicy/stroke-guidelines ). This version reflects increasing use of the novel oral
anticoagulants, which FY doctors need to be aware of.
49
What is Kayser-Fleischer rings
Kayser–Fleischer rings are dark rings that appear to encircle the iris of the eye. They are due to copper deposition in part of the Descemet's membrane as a result of liver diseases.
(including Wilsons disease)
50
Difference between type 1 and type 2 respiratory failure
Respiratory failure is divided into type I and type II. Type I respiratory failure involves low oxygen, and normal or low carbon dioxide levels. Type II respiratory failure involves low oxygen, with high carbon dioxide.
51
examples of type 1 respiratory failure
Causes of type 1 respiratory failure include: pulmonary oedema, pneumonia, COPD, asthma, acute respiratory distress syndrome, chronic pulmonary fibrosis, pneumothorax, pulmonary embolism, pulmonary hypertension.
52
causes of type 2 respiratory failure
Type 2 respiratory failure is commonly caused by COPD but may also be caused by chest-wall deformities, respiratory muscle weakness and Central nervous system depression (CNS depression.) CNS depression is associated with reduced respiratory drive and is often a side effect of sedatives and strong opioids.
53
example of factor xa inhibitor
mechanism
and use
examples: apixaban, rivaroxaban, edoxaban
mechanism: inhibit fibrin formation in the final common pathway of the coagulation cascade
use: Treat and prevent venous thromboembolism
54
A 67 year old man is due to have a CT scan of chest, abdomen and pelvis
with intravenous contrast as assessment for possible lymphoma. He had a
renal transplant 5 years ago. His medication includes prednisolone, tacrolimus
and lisninopril.
His BP is 131/86 mmHg.
Investigations:
Urea 12.9 mmol/L (2.5–7.8)
Creatinine 165 µmol/L (60–120)
eGFR 39 mL/min/1.73 m2
(>60)
Which is the most appropriate treatment to give before the scan?
A. Intravenous 0.9% sodium chloride infusion
B. Intravenous acetylcysteine
C. Intravenous furosemide infusion
D. Intravenous hydrocortisone
E. Intravenous mannitol
Correct Answer: A
Justification for correct answer
The patient is due to receive IV contrast and has existing CKD. He is an increased risk of
contrast nephropathy. Volume expansion with 0.9% sodium chloride infusion (1 mL/kg) is
recommended and shown to reduce the incidence of contrast nephropathy. Some units
still recommend oral acetylcysteine (although trial data is lacking), but IV acetylcysteine is
no longer used due to risk of anaphylactoid reaction. There is no indication for additional
steroids. IV furosemide may increase risk of contrast nephropathy. IV mannitol is no
longer used as no evidence of benefit.
55
A 78 year old woman is admitted after been found collapsed at home. She
has been lying on the floor overnight. She has a history of hypertension and
takes amlodipine.
Her temperature is 35.8°C, pulse rate 88 bpm and irregular, and BP 102/60
mmHg.
Investigations:
Sodium 136 mmol/L (135–146)
Potassium 5.8 mmol/L (3.5–5.3)
Urea 20.9 mmol/L (2.5–7.8)
Creatinine 180 μmol/L (60–120)
Creatine kinase 870 U/L (25–175)
Urinalysis: glucose negative, ketones negative, blood 2+, protein 1+,
leucocytes positive (catheter sample).
She has passed 60 mL of urine over the past 2 hours.
Which is the most likely cause for her acute kidney injury?
A. Glomerulonephritis
B. Hypovolaemia
C. Renal arterial emboli
D. Rhabdomyolysis
E. Ureteric obstruction
Correct Answer: B
Justification for correct answer
This patient is hypovolaemic due to long lie without hydration and the probably sepsis.
The level of CK is compatible with minor soft tissue injury. Rhabdomyolysis would give a
CK of >10,000. There is no indicators of glomerulonephritis and the urinalysis
abnormalities are compatible with a catheter sample +/- urosepsis. Renal emboli are
rare and would give loin pain. Ureteric obstruction is unlikely as the patient is still
passing some urine.
56
9. A 76 year old woman has become increasingly confused over the past 2
weeks. She has a history of hypertension and cardiac failure. She is taking
bendroflumethiazide, doxazosin, amlodipine, ramipril and atenolol.
Her BP is 108/71 mmHg.
Investigations:
Sodium 121 mmol/L (135–146)
Potassium 3.5 mmol/L (3.5–5.3)
Urea 10.0 mmol/L (2.5–7.8)
Creatinine 105 µmol/L (60–120)
Which medication is most likely to be responsible for her presentation?
A. Amlodipine
B. Atenolol
C. Bendroflumethiazide
D. Doxazosin
E. Ramipril
Correct Answer: C
Justification for correct answer
Of the medications listed, bendroflumethiazide is most likely to cause hyponatraemia.
57
A 92 year old woman has severe neck, chest and back pain and tingling in her
left hand following a mechanical fall. She has bruising around her right eye.
Investigations:
CT scan of head no intracranial injury or bleed, mild small vessel disease;
right orbital fracture
Chest X-ray lung fields clear; left sided 4th rib fracture
Full blood count and clotting screen are normal.
Which is the most appropriate next investigation?
A. Cervical spine X-ray
B. CT angiography
C. CT scan of chest
D. CT scan of neck
E. MR scan of brain
Correct Answer: D
Justification for correct answer
The history and examination suggest a cervical spine fracture. This is best detected by a
CT scan of the neck.
58
A 24 year old woman attends her GP with 2 months of intermittent
palpitations. She describes the episodes as feeling as if the heart stops for a
second followed by a pounding sensation. She reports episodes two to three
times per week lasting 5–10 minutes, most commonly when she is going to
sleep. She is otherwise well. She has been taking the combined oral
contraceptive pill for 2 years.
Her pulse rate is 68 bpm and BP 108/71 mmHg. Her heart sounds are normal.
Investigations:
ECG: sinus rhythm, rate 70 bpm.
Which is the most likely diagnosis?
A. Paroxysmal atrial fibrillation
B. Sinus arrhythmia
C. Sinus tachycardia
D. Supraventricular premature beats
E. Supraventricular tachycardia
Correct Answer: D
Justification for correct answer
The description of the arrhythmias best fits with ectopics (either supraventricular or
ventricular). Supraventricular are probably more common in this age group. There are no
worrying features and the cause is most likely benign.
59
what type of drug is mesalazine/what does it treat
Mesalazine is used to treat ulcerative colitis and Crohn's disease and other types of inflammatory bowel disease. It belongs to a group of medicines called aminosalicylates. These help to reduce redness and swelling (inflammation) and can help with healing.
60
A 52 year old man has 3 months of fatigue. He has a history of ulcerative
colitis and takes mesalazine. He drinks 20 units of alcohol per week.
His temperature is 36.8°C and pulse rate 80 bpm. He has 3 cm
hepatomegaly.
Investigations:
Albumin 36 g/L (35–50)
ALT 65 IU/L (10–50)
ALP 580 IU/L (25–115)
Bilirubin 18 µmol/L (<17)
γGT 230 IU/L (9–40)
Ultrasound scan of abdomen: bile duct wall thickening and dilatation
Which is the most appropriate next diagnostic investigation?
A. CT scan of abdomen
B. Endoscopic retrograde cholangiopancreatography
C. Liver biopsy
D. MR cholangiopancreatography
E. Percutaneous transhepatic cholangiography
Correct Answer: D
Justification for correct answer
The patient has a classic cholestatic pattern of blood test abnormalities. PSC often has
limited symptoms at presentation and bilirubin and albumin are often normal. There is a
strong association with UC. Ultrasound shows evidence of abnormal bile ducts. MRCP
is the typical initial diagnostic investigation as it is non-invasive. This usually shows
typical beaded appearance of the bile duct.
61
A 60 year old woman has 6 weeks of a cough productive of blood streaked
sputum.
Investigations:
CT scan of chest: mass in left lower lobe
Needle biopsy: nuclei that are enlarged, hyperchromatic and pleomorphic
Which is the most likely diagnosis?
A. Adenoma
B. Carcinoma
C. Hamartoma
D. Sarcoidosis
E. Tuberculosis
Correct Answer: B
Justification for correct answer
This is because nuclear enlargement, hyperchromasia and pleomorphism are features
that suggest carcinoma in all sites of the body.
62
features that suggest sarcoidosis
| think histology
Sarcoidosis is a multisystem disorder that can affect practically any organ of the body. The hallmark of sarcoidosis is the presence of noncaseating granuloma, a cluster of macrophages, epithelioid cells, mononuclear cells, and CD4+ T cells with a few CD8+ T cells in the peripheral zone
63
A 65 year old woman has an infective exacerbation of COPD.
Her temperature is 37.8°C, pulse rate 108 bpm, BP 100/75mmHg, respiratory
rate 26 breaths per minute and oxygen saturation 88% breathing 15 L/minute
oxygen via a non-rebreather mask. She is alert.
Investigations:
Arterial blood gas on 15 L/min oxygen
pH 7.28 (7.35–7.45)
PO2 7.2 kPa (11–15)
PCO2 8.9 kPa (4.6–6.4)
Bicarbonate 31.3 mmol/L (22–30)
Lactate 1.2 mmol/L (1–2)
Which is the most appropriate next management option?
A. Continuous positive airway pressure
B. Invasive ventilation
C. Nasal high flow oxygen
D. Nasopharyngeal airway
E. Non-invasive ventilation
Correct Answer: E
Justification for correct answer
Respiratory acidosis needs to be corrected with ventilation in an alert patient.
CPAP for type 1 (just low O2)
because she is high CO2 and Low O2 she is type 2 and so she needs BiPAP (non invasive ventilation)
64
A 50 year old woman has acute onset of shortness of breath. She underwent
a laparoscopic cholecystectomy 10 days ago.
Her temperature is 37.4°C, pulse rate 104 bpm, BP 122/80 mmHg, respiratory
rate 24 breaths per minute and oxygen saturation 94% breathing air. Her
chest is clear. She has minimal tenderness over the right hypochondrium.
Which is the most likely diagnosis?
A. Myocardial infarction
B. Pancreatitis
C. Pneumonia
D. Pulmonary embolus
E. Subphrenic abscess
Correct Answer: D
Justification for correct answer
This is because she is most likely to have suffered pulmonary embolus after period of
surgery.
65
A 39 year old man has had fever, chills and generalised weakness for
1 month. He has a history of systolic heart murmur. He is an intravenous drug
user.
Investigations:
White cell count 15 × 109
/L (3.0–10.0)
Erythrocyte sedimentation rate 55 mm/hr (<20)
Blood cultures are awaited.
Which further investigation will help to establish the diagnosis?
A. Chest X-ray
B. ECG
C. Nasal swabs
D. Transoesophageal echocardiogram
E. Urine dipstick analysis
Correct Answer: D
Justification for correct answer
The patient has a likely diagnosis of endocarditis and requires a TOE and blood cultures
66
A 16 year old girl presents to the Emergency Department after an episode of
loss of consciousness following a fall. She had consumed an excessive
amount of alcohol at a party before the fall.
She has a dirty scalp wound and cannot remember recent events. Her pulse
rate is 68 bpm, BP 110/80 mmHg and oxygen saturation 98% breathing
air. She opens her eyes to command and is confused. Her capillary blood
glucose is 6.0 mmol/L.
Her wound is cleaned and sutured.
Which is the most appropriate immediate management plan?
A. Admit and observe for 24 h
B. CT scan of head
C. Discharge with head injury instructions
D. Refer to neurosurgeon
E. X-ray of skull
Correct Answer: B
Justification for correct answer
Current guidelines. Safety issue. A child of 16 doesn't need a tetanus booster.
67
```
A 72 year old woman has 6 months of mild constipation.
Investigations:
Haemoglobin 110 g/L (115–165)
Creatinine 70 µmol/L (60–120)
Calcium 2.90 mmol/L (2.2–2.6)
Phosphate 0.65 mmol/L (0.8–1.5)
24 h urinary calcium 7 mmol (2–6)
Parathyroid hormone 11.2 pmol/L (1.6–8.5)
Vitamin D 65 nmol/L (>60)
Which is the most likely diagnosis?
A. Familial hypocalciuric hypercalcaemia
B. Multiple myeloma
C. Primary hyperparathyroidism
D. Tertiary hyperparathyroidism
E. Vitamin D intoxication
```
Correct Answer: C
Justification for correct answer
This is because primary Hyperparathyroidism is commoner in older female patients. In
most cases symptoms are either mild, as in this case or absent. Biochemistry
hypercalcaemia, elevated PTH and hypercalciuria point towards primary
hyperparathyroidism. Tertiary hyperparathyroidism is possible but less likely as renal
function is normal. There is no evidence for anaemia (malabsorption) and the patient is
well.
68
```
A 52 year old man visits his GP for health screening. He is well.
His pulse rate is 80 bpm and irregular, and BP 128/84 mmHg.
Investigations:
Sodium 136 mmol/L (135–146)
Potassium 3.9 mmol/L (3.5–5.3)
Urea 4.9 mmol/L (2.5–7.8)
Creatinine 80 μmol/L (60–120)
HbA1c 40 mmol/mol (20–42)
Thyroid function tests are normal.
ECG shows atrial fibrillation, 76 bpm.
Which is the most appropriate treatment?
A. Apixaban
B. Aspirin
C. Diltiazem hydrochloride
D. No treatment
E. Warfarin sodium
```
Correct Answer: D
Justification for correct answer
The patient has incidental non-symptomatic AF. This is a common way to pick up AF. The
rate is controlled. He has no other risk factors and his CHA2DS2-VASc score is 0 and
anticoagulation is not recommended (Atrial fibrillation: management (2014) NICE
guideline CG180)
69
what is epistaxis
nose bleed
70
An 80 year old man presents to the Emergency Department with 2 hours of
epistaxis that has not stopped despite compression. He has a history of
hypertension.
A bleeding site is visible in the anterior nasal cavity. His BP is 160/95 mmHg.
Which is the most appropriate initial management option?
A. Anterior pack
B. Antihypertensive medication
C. Cautery
D. Cryotherapy
E. Ice pack
Correct Answer: C
Justification for correct answer
Minor bleeding from an accessible site can be treated with cautery using a silver nitrate
stick or electrocautery. Anterior pack is for profuse bleeding with site difficult to localise.
Anti hypertensives will only prevent further attacks of epistaxis. Cryotherapy and ice pack
of little advantage and secondary.
71
what is a paralytic ileus
A condition in which the muscles of the intestines do not allow food to pass through, resulting in a blocked intestine. Paralytic ileus may be caused by surgery, inflammation, and certain drugs.
72
A 65 year old man has abdominal distension and vomiting 48 hours after a
sigmoid colectomy with primary anastomosis for bowel cancer. He has not
passed any flatus for 24 hours. He is taking regular paracetamol and as
required intravenous morphine.
His abdomen is distended with tenderness over the wound but no rebound or
guarding. There are no bowel sounds.
His temperature is 37.6°C, pulse rate 96 bpm and BP 122/85 mmHg.
Which is the most appropriate initial management?
A. Give intravenous piperacillin with tazobactam
B. Give Microlax ® enema
C. Insert a nasogastric tube
D. Start regular intravenous morphine
E. Take to theatre for laparotomy
Correct Answer: C
Justification for correct answer
The patient has evidence of a paralytic ileus. The initial treatment would involve making
patient nil by mouth and inserting a nasogastric tube. Morphine would make the condition
worse. There is no indication for antibiotics. An enema would not be appropriate and
unlikely to be of benefit. There is no indication for immediate surgery as further
investigations will be required to identify treatable causes
73
A 23 year old man attends the sexual health clinic with a painful swelling in his
groin and pain when opening his bowels. He had unprotected anal sex with a
new male partner 4 weeks ago.
He has a perianal ulcer and tender inguinal lymphadenopathy.
Which is the most likely diagnosis?
A. Genital herpes
B. Gonorrhoea
C. HIV seroconversion
D. Lymphogranuloma venereum
E. Secondary syphilis
Correct Answer: D
Justification for correct answer
Proctitis and lymp
74
A 30 year old woman attends 3 months after a diagnosis of iron deficiency
anaemia. She was advised to take oral iron supplements and has been taking
these regularly. She has some looseness of her stools, and her periods are
scanty on a combined oral contraceptive.
Investigations:
Haemoglobin 92 g/L (115–165)
MCV 70 fL (80–96)
Ferritin 8 µg/L (12–200)
Which antibody test is most likely to diagnose the underlying cause?
A. Anti-gastric parietal cell
B. Antimitochondrial
C. Antinuclear
D. Anti-smooth muscle
E. Anti-tissue transglutaminase
Correct Answer: E
Justification for correct answer
Coeliac disease is the most likely diagnosis.
75
A 20 year old man has 2 days of visible haematuria. Three days before the
haematuria started, he developed tonsillitis and was treated with
phenoxymethylpenicillin. He has no significant medical history.
His BP is 112/54 mmHg.
Investigations:
Urea 3.2 mmol/L (2.5–7.8)
Creatinine 61 µmol/L (60–120)
Urinalysis: glucose negative, ketones negative, blood 3+, protein 3+, nitrites
negative, leucocytes negative.
Which is the most likely cause of his haematuria?
A. Alport's nephropathy
B. Drug reaction
C. Granulomatosis with polyangiitis
D. IgA nephropathy
E. Postinfectious glomerulonephritis
Correct Answer: D
Justification for correct answer
IgA characteristically causes visible haematuria a few days after URTI (post-infectious
GN has lag time of around 2 weeks before haematuria occurs and would be a less benign
presentation if associated with visible haematuria).
76
A 38 year old man has 2 months of epigastric pain that radiates into his back.
It is worse at night and sometimes wakes him up. It is better after eating. He
has been very busy at work. He occasionally misses lunch, which worsens the
pain. He has not lost weight. He smokes 10 cigarettes per day and drinks two
bottles of wine per week.
Examination is normal.
Which is the most likely diagnosis?
A. Cholecystitis
B. Chronic pancreatitis
C. Duodenal ulcer
D. Gastric ulcer
E. Gastric carcinoma
Correct Answer: C
Justification for correct answer
Duodenal ulcers tend to be made worse with stress and the pain is often worse at night
radiating into the back - it is relieved by eating and patients tend to put weight on - in
contrast to a gastric ulcer which is made worse with eating and people often lose weight.
77
A 26 year old woman has 12 months of back pain, located in the low
lumbosacral region. She has intermittent bilateral thigh pain. The back pain
disturbs her sleep. The pain is improved by activity but not relieved by resting.
She finds it difficult to bend down during the day to pick things up from the
floor.
Which clinical feature is most specific for inflammatory back pain?
A. Improvement with activity
B. Nocturnal pain
C. Radiation to leg
D. Stiffness during the day
E. Young age
Correct Answer: A
Justification for correct answer
Inflammatory back pain (IBP) is typically improved with activity and not relieved by rest,
as opposed to mechanical pain which is worse with activity and is relieved by rest. IBP
can wake the patient in the early hours of the morning and sacroilieitis can radiate to the
thigh, but these features are much less specific. Morning stiffness is specific for
inflammatory back pain but not persistent daytime stiffness. IBP can occur at any age
although mechanical pain is less common in young people.
78
A 68 year old man has a swollen tender knee for 3 days and cannot weight
bear. He has had previous episodes of big toe swelling. He has a history of
chronic kidney disease stage 4.
Investigations:
Fluid analysis of knee aspirate:
White cell count 55 000/mL, 95% neutrophils
Gram stain negative
Copious 10 μm intracellular needle shaped crystals
Which is the best initial treatment for his acute knee pain and swelling?
A. Arthroscopic joint washout
B. Intravenous flucloxacillin
C. Oral allopurinol
D. Oral naproxen
E. Oral prednisolone
Correct Answer: E
Justification for correct answer
The presentation is likely due to an acute attack of gout. Although infection is not
completely excluded at this stage it is less likely as G stain is negative and there are
several positive features of gout in the history. IA or oral steroids, colchicine or NSAIDs
are all effective treatments for acute gout. NSAIDs are contraindicated in CKD of this
stage. Allopurinol will not help the acute attack
79
An 18 year old man is in the intensive care unit with septic shock as a result of
a compound fracture of his leg. His urine output has been <30 mL for the past
2 hours.
His pulse rate is 125 bpm, BP 85/40 mmHg and JVP 4 cm above the sternal
angle. There are basal crackles on auscultation of the chest.
Investigations:
ECG shows sinus rhythm, 125 bpm.
He is being treated with intravenous 0.9% sodium chloride at 125 mL/h and
antibiotics.
Which is the most appropriate additional intravenous treatment?
A. 500 mL 0.9% sodium chloride over 15 min
B. 500 mL Hartmann's solution over 15 min
C. Dopamine hydrochloride
D. Furosemide
E. Noradrenaline/norepinephrine
Correct Answer: E
Justification for correct answer
Description of adequate (if not over) hydration. Needs vasoconstriction.
80
A 34 year old man has pain in his right shoulder and upper arm for 6 weeks
that worsens when elevating his arm above his head. He does not recall any
injury.
There is no deformity, tenderness or reduced range of movement. There is
pain on abduction of the right shoulder that is worse with the arm in internal
rotation and when abduction is resisted. He is treated with ibuprofen.
Which is the most appropriate next step in management?
A. MR scan of shoulder
B. Refer for orthopaedic opinion
C. Refer for physiotherapy
D. Ultrasound scan of shoulder
E. X-ray of shoulder
Correct Answer: C
Justification for correct answer
Clinically the diagnosis is right supraspinatus tendinopathy and no further investigation is
required to confirm the diagnosis. Most cases can be managed in primary care and a
referral to orthopaedics is not required. The most appropriate management is either
general advise and home exercises or referral to a physiotherapist.
81
A 65 year old woman with advanced carcinoma of the breast with cerebral
and liver metastases is rapidly deteriorating and is recognised to be dying.
She becomes confused and agitated.
Which is the most suitable initial treatment?
A. Diamorphine hydrochloride
B. Glycopyrronium
C. Hyoscine hydrobromide
D. Midazolam
E. Mirtazapine
Correct Answer: D
Justification for correct answer
Terminal restlessness is a common and distressing condition that requires active
management: important knowledge for FY doctors. The diagnosis of dying has already
been made and reversible causes of her deterioration will thus have been considered and
excluded: NICE guidelines indicate that terminal restlessness should be managed with
Midazolam by prn subcutaneous injections / continuous subcutaneous infusion via a
syringe driver.
82
what is amitriptyline
| hydrochloride
This medication is used to treat mental/mood problems such as depression. It may help improve mood and feelings of well-being, relieve anxiety and tension, help you sleep better, and increase your energy level. This medication belongs to a class of medications called tricyclic antidepressants.
83
A 43 year old woman is admitted to hospital with an overdose of amitriptyline
hydrochloride taken 4 hours previously. She has a history of chronic
headache.
Her pulse rate is 105 bpm and BP 95/40 mmHg. She is drowsy and her pupils
are dilated. ECG shows significant QRS prolongation.
Which is the most appropriate immediate management option?
A. Activated charcoal
B. Intravenous amiodarone hydrochloride
C. Intravenous atropine sulfate
D. Intravenous magnesium
E. Intravenous sodium bicarbonate
Correct Answer: E
Justification for correct answer
Bicarbonate is the treatment of the choice in patients with prolonged QRS complexes
following a tricyclic antidepressant overdose
84
A 56 year old woman has home blood pressure readings averaging 160/90
mmHg.
Hypertension is confirmed on 24 hour ambulatory monitoring. She has type 1
diabetes mellitus.
Investigations:
Urinary albumin: creatinine ratio 42 mg/mmol (<3.5)
eGFR 43 mL/min/1.73 m2
(>60)
Which type of antihypertensive is most appropriate?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Calcium channel blocker
E. Thiazide-like diuretic
Correct Answer: A
Justification for correct answer
There is good evidence for renal function protection in diabetic nephropathy with ACE-1
in addition to its hypertensive properties.
85
A 70 year old man has dry cough and breathlessness on exertion for the past
3 months. He has lost 4 kg is weight. He has a history of ischaemic heart
disease and atrial fibrillation. He takes warfarin sodium, ramipril and
amiodarone hydrochloride. He is a never smoker.
His temperature is 37.5°C, pulse rate 70 bpm, respiratory rate 18 breaths per
minute and oxygen saturation 91% breathing air. He has fine bibasal
inspiratory crackles. There is no finger clubbing.
Investigations:
Haemoglobin 141 g/L (130–175)
White cell count 14.0 × 109
/L (3.0–10.0)
Erythrocyte sedimentation rate 65 mm/hr (<20)
Chest X-ray shows bilateral reticular opacities in both bases.
Which investigation is most likely to confirm the diagnosis?
A. Blood cultures
B. Bronchoscopy
C. Echocardiography
D. High resolution CT scan of chest
E. Induced sputum for microscopy and culture
Correct Answer: D
Justification for correct answer
This is because the patient has pulmonary fibrosis as a complication from amiodarone
therapy. This classically does not cause clubbing. Patients present with cough and
dyspnoea. Fever and reactive blood changes (raised WCC, ESR) are not uncommon. An
HRCT would confirm changes of interstitial lung disease. Blood cultures are indicated but
this is unlikely to be an infective cause. Bronchoscopy is not indicated. The features are
not those of heart failure so an echo will not confirm the diagnosis. An induced sputum is
not indicated at this stage.
86
what does a high erythrocyte sedimentation rate mean
an erythrocyte sedimentation rate (ESR) is a type of blood test that measures how quickly erythrocytes (red blood cells) settle at the bottom of a test tube that contains a blood sample. Normally, red blood cells settle relatively slowly. A faster-than-normal rate may indicate inflammation in the body
87
A 43 year old woman has a sudden severe headache that started 24 hours
ago. She has a history of autosomal dominant polycystic kidney disease.
Her temperature is 36.8°C, pulse rate 92 bpm and BP 140/100 mmHg.
Neurological examination is normal. CT scan of head is normal.
Which is the most appropriate next step in management?
A. Erythrocyte sedimentation rate
B. Lumbar puncture
C. MR scan of brain
D. Refer to outpatient headache clinic
E. Start amlodipine
Correct Answer: B
Justification for correct answer
This is because APKD is associated with subarachnoid haemorrage. A lumbar puncture
should be performed. MRA would be reasonable, but not MRI.
88
what does prednisolone do
Prednisolone is a medicine used to treat a wide range of health problems including allergies, blood disorders, skin diseases, inflammation, infections and certain cancers and to prevent organ rejection after a transplant. It helps by reducing swelling (inflammation) and can also calm down your immune system.
89
A 74 year old man has progressively worsening muscle aches that are now
causing him to struggle to get up from a chair or raise his arms above his
head. He has a history of oesophageal cancer treated surgically and
ischaemic heart disease. He is taking bisoprolol, clopidogrel, ramipril and
simvastatin.
Investigations:
Haemoglobin 125 g/L (130–175)
White cell count 7.8 × 109
/L (3.0–10.0)
Platelets 391 × 109
/L (150–400)
Erythrocyte sedimentation rate 105 mm/hr (<20)
Which is the most appropriate therapeutic change?
A. Start co-codamol
B. Start ibuprofen
C. Start prednisolone
D. Stop bisoprolol
E. Stop simvastatin
Correct Answer: C
Justification for correct answer
Classical PMR history, presentation and raised inflammatory markers.
PMR - polymyalgia rhuematica
90
A 59 year old woman has 6 months of pain affecting her hips and lower back.
She is Libyan and has lived in the UK for 10 years. She has chronic kidney
disease stage 3 and hypertension. She is taking lisinopril and
simvastatin. She has weakness of hip flexion bilaterally. There is no muscle or
bony tenderness.
Investigations:
Urea 7.8 mmol/L (2.5–7.8)
Creatinine 122 μmol/L (60–120)
Calcium 2.1 mmol/L (2.2–2.6)
eGFR 41 mL/min/1.73 m2
(>60)
Alkaline phosphatase 230 IU/L (25–115)
Parathyroid hormone 14.5 pmol/L (1.6–8.5)
Which additional investigation is most likely to confirm the diagnosis?
A. Creatine kinase
B. Erythrocyte sedimentation rate
C. Serum 25-OH cholecalciferol
D. Ultrasound scan of neck
E. X-ray of thoracic and lumbar spine
Correct Answer: C
Justification for correct answer
The clinical features suggest osteomalacia. She has hypocalcaemia and proximal
muscle weakness. The low serum calcium is not adequately explained by CKD. Serum
vitamin D would establish the diagnosis. 24 hour urinary calcium is sometimes
performed in primary hyperparathyroidism but not in a secondary case such as this. The
presentation is not one of myositis and this is unlikely to be significantly elevated.
Ultrasound of neck is another primary hyperparathyroidism test. The lumbar spine X-ray
is most likely to show osteopenia but does not give diagnostic features (unlike in
children)
91
How high does creatine kinase have to be to suggest rhabdomyolysis
>10,000
92
what is polymyalgia rheumatica
Polymyalgia rheumatica is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.
which responds well to prednisolone and poorly to analgesics such as Naproxen or cocodamol
93
```
A 60 year old man has 2 days of a swollen, painful right leg. He has a history
of hypertension and takes ramipril. He is otherwise well.
He has a swollen right leg. The remainder of the examination is normal.
Investigations:
Haemoglobin 140 g/L (130–175)
White cell count 8.0 × 109/L (3.8–10.0)
Platelets 340 × 109/L (150–400)
Creatinine 94 µmol/L (60–120)
Calcium 2.5 mmol/L (2.2–2.6)
ALT 30 IU/L (10–50)
ALP 99 IU/L (25–115)
APTT 30 seconds (22–41)
PT 12 seconds (10–12)
Urinalysis: normal
Chest X-ray: normal
Venous duplex ultrasound scan: thrombus in superficial femoral vein
Which is the most appropriate additional investigation?
A. CT of abdomen and pelvis
B. Serum carcinoembryonic antigen
C. Serum prostate specific antigen
D. Serum protein electrophoresis
E. Ultrasonography of abdomen
```
Correct Answer(s): A
Justification for correct answer
The patient has an unprovoked DVT. Patients should be offered CT scan abdomen and
pelvis to help identify possible malignancy
94
A 65 year old woman had a mechanical aortic valve replacement and
coronary revascularisation 3 days ago. She is being treated with dalteparin
sodium. She is also taking aspirin long term.
Which is the most appropriate long-term patient management?
A. Apixaban
B. Clopidogrel
C. Continue dalteparin sodium
D. Rivaroxaban
E. Warfarin sodium
Correct Answer(s): E
Justification for correct answer
All patients with mechanical valves require treatment with aspirin and warfarin. Low
molecular weight heparin is used as bridging anti-coagulation but not long-term. There is
no place for novel oral anticoagulants (yet).
low molecular weight heparin (dalteparin sodium)
Clopidogrel (P2Y12 receptor ) - anti platelet drug and irreversible
95
An 18 year old woman has had a chronic skin condition for several years. She
has noticed that she gets well-defined areas of scale formation at the sites of
minor skin injuries, such as scratches or insect bites, typically when the
injuries are healing. The scaling can persist for several weeks or months.
What is the most likely underlying skin condition?
A. Acne vulgaris
B. Eczema
C. Psoriasis
D. Seborrhoeic dermatitis
E. Vitiligo
Correct Answer(s): C psoriasis
Justification for correct answer
This is typical of Koebnerisation. Psoriasis is by far the commonest underlying cause,
though it can also occur in vitiligo
96
What is Koebner phenomenon?
is the appearance of new skin lesions on previously unaffected skin secondary to trauma.
It happens most often in people with psoriasis, but it happens in other skin conditions, too, including warts and vitiligo. If you have active flares, you are more likely to have a Koebner response.
97
A 64 year old man has vomiting and severe chest pain after eating a large
meal.
His temperature is 37.6°C, pulse rate 130 bpm, BP 95/50 mmHg and
respiratory rate 30 breaths per minute. There is palpable subcutaneous
emphysema on the left side of his neck.
Which is the most likely diagnosis?
A. Diaphragmatic rupture
B. Mallory–Weiss tear
C. Necrotising fasciitis
D. Oesophageal rupture
E. Spontaneous pneumohaemothorax
Correct Answer(s): D
Justification for correct answer
The scenario describes Boerhaave's syndrome (oesophageal rupture).
98
A 54 year old woman has polyuria and the feeling that she needs to drink
continuously. She drinks at least 1 litre of water before bedtime and gets up
three to four times during the night to pass urine. She has another glass of
water each time that she gets up.
Investigations:
Sodium 140 mmol/L (135–146)
Potassium 4.1 mmol/L (3.5–5.3)
Urea 4.5 mmol/L (2.5–7.8)
Creatinine 86 µmol/L (60–120)
Calcium 2.56 mmol/L (2.2–2.6)
Fasting glucose 4.8 mmol/L (3.0–6.0)
Serum osmolality 295 mOsmol/kg (285–295)
Urinary osmolality 86 mOsmol/kg (100–1000)
After 8 hours of a water deprivation test, the serum osmolality is 308
mOsmol/kg and the urinary osmolality is 152 mOsmol/kg.
Following the administration of desmopressin, the serum osmolality is 286
mOsmol/kg and the urinary osmolality is 660 mOsmol/kg.
Which is the most appropriate next investigation?
A. CT scan of thorax, abdomen and pelvis
B. MR scan of pituitary
C. Oral glucose tolerance test
D. Technetium-99 Sestamibi parathyroid scan
E. Supervised fluid restriction and daily weights
Correct Answer(s): B
Justification for correct answer
The test results are consistent with cranial diabetes insipidus
99
A 32 year old man is referred to a gastroenterology clinic with hepatomegaly.
He has a history of type 2 diabetes that is diet controlled. He is taking no
regular medication. He is a non-smoker and drinks approximately 16 units of
alcohol per week. He is married with no children.
Cardiovascular and respiratory examinations are normal. His abdomen is soft,
with a 3 cm palpable liver edge. His BMI is 23 kg/m2(18–25).
Investigations:
Albumin 38 g/L (35–50)
ALT 90 IU/L (10–50)
ALP 112 IU/L (25–115)
Bilirubin 15 µmol/L (<17)
Ferritin 710 µg/L (12–200)
CRP 6 mg/L (<5)
Which is the most appropriate next investigation?
A. Hepatitis C serology
B. Liver biopsy
C. Reticulocyte count
D. Serum γGT
E. Transferrin saturation
Correct Answer(s): E
Justification for correct answer
Transferrin saturation is the screening test for haemochromatosis.
100
A 27 year old man is brought to the Emergency Department with left-sided
chest pain of sudden onset that is worse on taking a deep breath.
His temperature is 36.8°C, pulse rate 126 bpm, BP 108/60 mmHg, respiratory
rate 28 breaths per minute and oxygen saturation 94% breathing air.
Investigations:
ECG: sinus tachycardia
Which is the most appropriate next investigation?
A. Chest X-ray
B. CT pulmonary angiography
C. D dimers
D. Echocardiography
E. Ventilation/perfusion isotope lung scan
Correct Answer(s): A
Justification for correct answer
CXR to rule out other pathology before Well’s score and then CTPA (or V/Q) if PE likely
or D-dimer if PE unlikely. (NICE CG144) Diagnostic investigations for pulmonary
embolism 1.1.7 If a patient presents with signs or symptoms of pulmonary embolism
(PE), carry out an assessment of their general medical history, a physical examination
and a chest X ray to exclude other causes. [2012]
101
A 33 year old woman has 4 months of joint pain and stiffness, predominantly
affecting her feet. This is worst in the morning and gradually improves through
the day. She feels tired all the time but reports no other health problems.
Which investigation would confirm the most likely diagnosis?
A. Anti-cyclic citrillinated peptide antibody
B. Anti-double-stranded DNA antibodies
C. Antinuclear antibody
D. CRP
E. Rheumatoid factor
Correct Answer(s): A
Justification for correct answer
The correct answer is A (Anti CCP) antibody. This is the test that has the highest
specificity for rheumatoid arthritis, which is what the question is asking. CCP antibodies
are found in 80% of people with rheumatoid arthritis, but fewer than 0.5% of healthy
individuals. Rheumatoid factor is present in up to 10% of the healthy population, and
whilst of similar sensitivity to CCP, is much less specific. CRP is a non-specific marker of
inflammation, and can often be normal in early rheumatoid. ANA testing is high
sensitivity (but low specificity) test for connective tissue disorders such as SLE and
Sjorgren’s.
102
```
Which test is used to diagnose bronchiectasis?
A. CT scan
B. exercise test
C. spirometry
D. sputum samples
E. tests for allergies
```
A. CT scan
103
```
A patient presents to his GP with shortness of breath. The GP suspects that the patient may have heart failure, and wants to investigate this.
What investigation should he request?
a) CRP
b) D-dimer
c) ESR
d) NT-pro-BNP
e) Troponin I
```
d) NT-pro-BNP
104
Treatment of anticholinergic toxidrome
is physostigmine salicylate. Most patients can be safely treated without it, but it is recommended for those who have tachydysrhythmia with subsequent hemodynamic compromise, intractable seizure, severe agitation or psychosis, or some combination thereof.
105
4 types of infective endocarditis
1. native valve
2. prosthetic valve
3. PWID (people who take drugs/IV )
4. Nosocomial (related to a hospital procedure)
106
What does CHA2DS2-VASc score stand for
```
congestive heart failure
hypertension
age >75 (+2 points)
diabetes
stroke (+2 points)
vascular disease
sex (Female)
```
107
Test that's raised in coeliac disease
Anti-tissue transglutaminase
108
A 54-year-old woman presents with a long history of fatigue and joint pain. She complains particularly of joint stiffness in her knees that is worst in the morning and lasts for an hour before settling. Her knees are swollen on examination, with generalised tenderness. Her blood tests reveal a mildly elevated CRP, with a positive rheumatoid factor. Her doctor requests a knee x-ray, to attempt to narrow the differential diagnosis, which induces rheumatoid arthritis and osteoarthritis.Which radiographic feature would best support a diagnosis of rheumatoid arthritis in this patient?
a) Loss of joint space
b) Marginal erosions
c) Osteophyte formation
d) Subchondral cyst formation
e) Subchondral sclerosis
B) marginal erosions
Classic feature of RA
LOSS is an acronym for OA
109
Auto-inflammatory conditions are increasingly recognised as a cause of recurrent fever. Which of the following applies to this disease spectrum?
a) Auto-antibodies are typically present
b) Cytokines are important in disease pathogenesis
c) Family history is not relevant
d) Infection is confirmed in 50% of cases
e) Inflammatory markers are generally not raised
b) Cytokines are important in disease pathogenesis
110
Normal skin structure allows for cells to be regularly shed from the surface of the epidermis without damage to the underlying tissue.
What is this impermeable shedding layer of the epidermis of the skin known as?
a) Stratum basale
b) Stratum corneum
c) Stratum granulosum
d) Stratum lucidum
e) Stratum spinosum
b)stratum corneum
111
A 37-year-old female, day 3 post transsphenoidal surgery for pituitary macroadenoma, is passing 7-8 litres of urine a day. Her thirst sensation is intact, and she is able to match urinary loss with adequate fluid intake.
What is the cause of her polyuria, and what do you expect her urine osmolality to be?
a) Central diabetes insipidus, urine osmolality will be high
b) Central diabetes insipidus, urine osmolality will be low
c) Nephrogenic diabetes insipidus, urine osmolality will be high
d) Nephrogenic diabetes insipidus, urine osmolality will be low
e) This is the normal condition in all postoperative patients, urine osmolality will be
normal
b) Central diabetes insipidus, urine osmolality will be low
112
A 71-year-old male had surgery 4 days ago to resect a bowel cancer. He becomes breathless and lightheaded. On examination, he is apyrexial, pulse is 115 bpm, respiratory rate is 26/min.
What clinical scoring system is there to assess the pre-test probability of a pulmonary embolism?
a) AVPU scale
b) MRC (Medical Research Council) dyspnoea score
c) NEWS (National Early Warning Score)
d) PHQ-9 (Patient Health Questionnaire-9)
e) Wells’ criteria
E) wells criteria
113
A 56-year-old man is admitted to the emergency department with an adverse drug reaction.
Which of the following is an example of a Type B adverse drug reaction?
a) Anaphylactic reaction to penicillin
b) Dry mouth with tricyclic antidepressant
c) Gastrointestinal haemorrhage following warfarin use
d) Hypokalaemia with furosemide
e) Syncope with beta-blocker
a) anaphylactic reaction to penicillin
Type B Reactions Type B (bizarre) reactions are novel responses that are not expected from the known pharmacological actions of the drug. These are less common, and so may only be discovered for the first time after a drug has already been made available for general use.
114
high lactate dehydrogenase and Non Hodgkins lymphoma
Serum LDH is commonly elevated in lympho-proliferative disorders. In patients with non-Hodgkin's lymphoma (NHL), LDH levels are of prognostic importance and thus can be used to monitor treatment response and recurrence, if any
115
A 68 year old man has 3 days of worsening vomiting and abdominal pain. He
has not passed any stool for 3 days. He has a history of a right
hemicolectomy for Dukes' A (T1, N0) bowel cancer 6 months ago.
He is dehydrated and his abdomen is distended.
Which is the most likely diagnosis?
A. Adhesional small bowel obstruction
B. Anastomotic leak
C. Cholecystitis
D. Pancreatitis
E. Tumour recurrence
Correct Answer(s): A adhesion small bowel obstruction
Justification for correct answer
Adhesional bowel obstruction is most likely as he has had a hemicolectomy. Recurrence
is less likely because this is Dukes A (early stage). Too late after surgery for anastamotic
leak. Pancreatitis and cholecystitis are less likely because they don't cause constipation
116
A 75 year old woman is reviewed 4 days after a fractured neck of femur
repair. She has been agitated and upset, particularly at night. She has
punched nurses and keeps trying to leave the ward. She has seen strange
men in black capes entering the ward and believes that they are controlling
the hospital. When she was seen in the memory clinic 6 months ago, she was
found to have mild cognitive impairment.
What is the most appropriate treatment?
A. Chlordiazepoxide hydrochloride
B. Chlorpromazine hydrochloride
C. Donepezil hydrochloride
D. Haloperidol
E. Memantine hydrochloride
```
Correct Answer(s): D Haloperidol
Justification for correct answer
This woman has delirium. Therefore, low dose haloperidol would be the best option,
according to NICE guidelines.
```
117
A 72 year old woman has 6 months of increasing pain at the base of her right
thumb. She is having difficulty opening jars and sewing. She is otherwise well.
No other joints are painful. She is taking regular analgesia.
The first carpometacarpal joint is swollen and tender, with reduced opposition
of the thumb.
Which is the most likely diagnosis?
A. De Quervain's tenosynovitis
B. Gout
C. Osteoarthritis
D. Rheumatoid arthritis
E. Septic arthritis
Correct Answer(s): C
Justification for correct answer
This is a classic description of osteoarthritis and a common site
Gout and septic arthritis
would have a much more acute history. Rheumatoid arthritis would affect multiple joints. The
pain of de Quervains tenosynovitis would be felt over the radial aspect of the wrist.
Rheumatoid arthritis usually affects multiple joints.
118
A 62 year old man has acute breathlessness with a weak cough, following a
recent viral upper respiratory infection. Over the past 4 months, he has
had double vision, limb weakness and slurred speech when tired.
His respiratory rate is 18 breaths per minute and oxygen saturation 96%
breathing air. He is sweating and using his accessory muscles of inspiration.
Which is the most appropriate test to monitor his respiratory function?
A. Arterial blood gas
B. FEV 1
C. FVC
D. Peak expiratory flow rate
E. Ratio of FEV 1 to FVC
Correct Answer(s): C
Justification for correct answer
Myasthenic crisis is an acute respiratory failure characterised by forced vital capacity
(FVC) below 1 L, negative inspiratory force (NIF) of 20 cm H2O or less, and the need for
ventilatory support. The use of accessory muscles indicates significant inspiratory
weakness. Weak cough indicates weakness of expiratory muscles. Arterial blood gas
analysis commonly shows hypercapnia before hypoxia. There should be a low threshold
for endotracheal intubation due to rapid deterioration of bulbar and respiratory muscles.
119
A 19 year old man has 2 days of right-sided chest pain and breathlessness on
exertion. He smokes cannabis and takes cocaine.
His temperature is 36.4°C, pulse rate 108 bpm, BP 112/80 mmHg, respiratory
rate 24 breaths per minute and oxygen saturation 94% breathing air. His
trachea is central. He has reduced breath sounds at the right apex.
What is the most likely diagnosis?
A. Acute coronary syndrome
B. Coronary artery spasm
C. Pneumonia
D. Pneumothorax
E. Pulmonary embolism
Correct Answer(s): D
Justification for correct answer
Pneumothoraces are more commonly encountered in young, tall men who smoke. There
is no past medical history provided in the vignette confirming the presence of existing
lung disease - this excludes secondary pneumothorax as a diagnosis
120
An 80 year old woman is admitted to the Emergency Department after being
found collapsed at home. She has central chest pain.
Her pulse rate is 30 bpm, BP 70/40 mmHg and respiratory rate 26 breaths per
minute. Her 12-lead ECG shows sinus bradycardia with no evidence of
myocardial ischaemia.
Which is the most appropriate initial treatment?
A. Adrenaline/epinephrine
B. Atropine sulfate
C. Dobutamine
D. Normal saline
E. Permanent cardiac pacemaker
Correct Answer(s): B atropine sulphate
Justification for correct answer
Atropine is the first line initial treatment for sinus bradycardia.
Atropine is a tropane alkaloid and anticholinergic medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate, and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle
121
what is allopurinol
Allopurinol is a medication used to decrease high blood uric acid levels. It is specifically used to prevent gout, prevent specific types of kidney stones and for the high uric acid levels that can occur with chemotherapy. It is taken by mouth or injected into a vein.
122
A 62 year old man develops acute pain, redness, swelling and warmth of his
right first metatarsophalangeal joint. He has a history of gout and
hypertension. His medications are allopurinol, amlodipine and ramipril.
His eGFR is >60 mL/min/1.73 m2(>60).
Which is the most appropriate next step in his management?
A. Change allopurinol to febuxostat
B. Start naproxen
C. Stop allopurinol
D. Stop amlodipine
E. Stop ramipril
Correct Answer(s): B start naproxen
Justification for correct answer
The patient has acute gout. The immediate management would be to commence an
NSAID.
123
A previously healthy 10 year old boy has deafness of new onset. He has a
history of a recent respiratory tract infection.
Tuning fork tests show:
a) when the tuning fork is placed in the middle of his forehead he hears the
tone loudest in his right ear;
b) when the tuning fork is held in front of his right external auditory meatus it is
quieter than when it is placed on the bone behind the same ear;
c) when the tuning fork is held in front of the left external auditory meatus the
sound is louder than when it is placed on the bone behind the same ear.
Which ear(s) is/are affected and which type of hearing loss is this?
A. Bilateral mixed deafness
B. Left conductive deafness
C. Left sensorineural deafness
D. Right conductive deafness
E. Right sensorineural deafness
Correct Answer(s): D
Justification for correct answer
The combination of lateralisation of Weber’s test to the right and a negative Rinne’s test on
the right (i.e. bone conduction louder than air conduction) occurs with right conductive
deafness. This also fits with the clinical history of a recent respiratory tract infection.
124
A 55 year old man has 2 days of painful red swelling of his left lower leg. He
has a history of type 2 diabetes mellitus and takes metformin.
His temperature is 37.6°C. He has a tender erythematous area extending
from the ankle to the proximal calf.
What is the most likely causative organism?
A. Bacteroides species
B. Proteus mirabilis
C. Pseudomonas aeruginosa
D. Staphylococcus epidermidis
E. Streptococcus pyogenes
Correct Answer(s): E Streptococcus pyogenes
Justification for correct answer
Streptococcus is the most common pathogen in leg cellulitis (including in patients with
diabetes).
125
A 55 year old woman has a tender, erythematous, swollen hard cord in the
long saphenous vein distribution in her calf. She has a longstanding history of
bilateral varicose veins.
An ultrasound scan shows superficial thrombophlebitis without deep vein
thrombosis.
Which is the most appropriate treatment?
A. Dipyridamole
B. Flucloxacillin
C. Naproxen
D. Paracetamol
E. Rivaroxaban
Correct Answer(s): C Naproxen
Justification for correct answer
NSAIDs are the first-line treatment for superficial thrombophlebitis (NICE CKS
thrombophlebitis – superficial, May 2017)
126
what does metformin do to body
metformin works by helping to restore your body's proper response to the insulin you naturally produce. It also decreases the amount of sugar that your liver makes and that your stomach/intestines absorb.
127
A 67 year old man has difficulty walking. He states that he has to raise his left
leg higher in the air than normal to avoid scraping his toes on the ground
when he walks.
When he raises the left foot from the floor, the ankle assumes a plantar-flexed
position with the toes directed towards the floor.
Which nerve is most likely to be affected?
A. Common peroneal
B. Medial plantar
C. Saphenous
D. Superficial peroneal
E. Tibial
Correct Answer(s): A common perineal
Justification for correct answer
The patient has foot drop due to loss of active dorsiflexion. The muscles affected are
supplied by the common peroneal nerve.
128
A 63 year old woman has 4 months of abdominal bloating, fatigue and
nausea.
She is found to have with ovarian cancer. Staging CT is performed to look for
lymphatic spread and metastatic disease.
To what regional lymph nodes is her tumour most likely to spread initially?
A. Deep inguinal nodes
B. External iliac nodes
C. Internal iliac nodes
D. Para-aortic nodes
E. Superficial inguinal nodes
Correct Answer(s): D para aortic node
Justification for correct answer
The main lymphatic drainage of the ovary is to the para-aortic nodes. The iliac nodes are
less frequently involved.
129
A 52 year old woman has had three episodes of severe epigastric pain
associated with vomiting over the past 3 months. The episodes occurred
following eating and lasted for about 1 hour. She has type 2 diabetes mellitus
and takes metformin.
Abdominal examination is normal. Her BMI is 35 kg/m2(18–25).
Investigations:
ALT 15 IU/L (10–50)
ALP 71 IU/L (25–115)
Bilirubin 9 µmol/L (<17)
Ultrasound scan of abdomen: single 2-cm gallstone in gallbladder, common
bile duct normal, evidence of fatty liver.
Which is the most appropriate management?
A. Endoscopic retrograde cholangiopancreatography
B. Laparoscopic cholecystectomy
C. MR cholangiopancreatography
D. Open cholecystectomy
E. Ursodeoxycholic acid
Correct Answer(s): B laparoscopic cholecystectomy
Justification for correct answer
The patient has symptomatic gallstone disease and laparoscopic cholecystectomy is
indicated. Percutaneous cholecystostomy may be used in patients who are not fit for
surgery. urosdeoxycholic acid may be used for gallstone dissolution, but is not part of
common UK practice.
130
A 56 year old woman develops vertigo, nausea, vomiting and intense occipital
headache of sudden onset. She is unable to walk without falling. She has a
history of hypertension treated with ramipril.
Her temperature is 37.4°C, pulse rate 94 bpm, BP 146/92 mmHg, respiratory
rate 12 breaths per minute and oxygen saturation 96% breathing air. She has
multidirectional nystagmus and some clumsiness of her right arm.
Which is the most likely diagnosis?
A. Acute labyrinthitis
B. Benign paroxysmal positional vertigo
C. Cerebellar stroke
D. Ménière's disease
E. Multiple sclerosis
Correct Answer(s): C cerebellar stroke
Justification for correct answer
Triad of headache, nausea/vomitting and ataxia. Profound imbalance, sudden onset and
prominent headache suggest cerebellar stroke.
131
A 26 year old woman sustains a head injury in a motorcycle accident. Her
eyes are closed, but she opens them when asked to do. She is confused
about what happened and about where she is, but attempts to talk about it.
She is repeatedly attempting to remove the cannula from her right wrist.
What is her GCS?
A. 3
B. 7
C. 9
D. 12
E. 14
Correct Answer(s): D 12
Justification for correct answer
Opens eyes in response to voice = 3 Confused, disoriented = 4 Localizes painful stimuli
= 5.
132
```
A 65 year old man has sudden pain and redness in his right eye. He also has
a headache and nausea.
Visual acuity is 6/60 in the right eye. The eye is congested, with a hazy
cornea and mid-dilated pupil.
Which is the most likely diagnosis?
A. Acute glaucoma
B. Conjunctivitis
C. Corneal ulcer
D. Scleritis
E. Uveitis
```
Correct Answer(s): A acute glaucoma
Justification for correct answer
All the symptoms and signs described can occur with acute glaucoma. Uveitis whilst causing
red eye, headache and visual disturbance is associated with a small pupil. Scleritis, corneal
ulcer and conjunctivitis are not generally associated with headache and nausea or a
significant drop in visual acuity.
133
A 45 year old woman attends her GP surgery with symptoms of vaginal
soreness, itching and discharge. She has had recurrent episodes of vaginal
candidiasis over the past 4 months.
The labia minora are red and swollen. A diagnosis of vaginal candidiasis is
made.
What is the most appropriate investigation at this stage?
A. Glycated haemoglobin
B. HIV test
C. Sexually transmitted infection screen
D. Test her partner for candidiasis
E. Vaginal pH testing
Correct Answer(s): A glycated haemoglobin
Justification for correct answer
Recurrent candidiasis indicates the need to test for diabetes mellitus
134
A 68 year old man collapses when rising from a chair and is seen in the
emergency department 45 minutes later. He is conscious but has reduced
power in his left arm and leg (3/5 and 4/5 respectively) and is slurring his
speech. He has a past medical history of COPD and hypertension. He
smokes 10 cigarettes per day.
He has bilateral scattered wheeze and carotid bruits on auscultation.
Which is the most appropriate initial radiological investigation?
A. Carotid ultrasonography
B. Cerebral angiography
C. CT cerebral venography
D. CT of head
E. MR imaging of brain
Correct Answer(s): D CT of head
Justification for correct answer
This is a probable CVA (presentation and risk factors). Due to rapid presentation he is a
candidate for systemic thrombolysis. Non-contrast CT head is the most rapid
investigation to exclude intracranial haemorrhage and allow thrombolysis
135
A 25 year old man sustains 40% full-thickness burns in a house fire. Despite
intensive treatment, he becomes breathless and hypotensive. He develops a
petechial rash.
His temperature is 38°C, pulse rate 110 bpm, BP 80/50 mmHg and oxygen
saturation 96% breathing 40% oxygen.
Investigations:
Haemoglobin 110 g/L (130–175)
White cell count 4.2 × 109/L (3.8–10.0)
Platelets 15 × 109/L (150–400)
APTT 75 seconds (22–41)
PT 25 seconds (10–12)
Fibrinogen 0.7 g/dL (1.5–4.0)
Fibrinogen degradation products 137 mg/mL (<8)
Which is the most likely diagnosis?
A. Anaphylactic reaction to antibiotics
B. Disseminated intravascular coagulation
C. Fat embolism
D. Immune thrombocytopenic purpura
E. Pulmonary embolism
Correct Answer(s): B
Justification for correct answer
The history, signs and investigations are all most indicative of DIC.
136
An 80 year old man presents to the Emergency Department with dizziness
and melaena of recent onset. He has a metallic mitral valve and is taking
aspirin and warfarin sodium. His pulse rate is 80 bpm and BP 122/70 mmHg.
Investigations:
Haemoglobin 105 g/L (130–175)
White cell count 7.0 × 109/L (3.8–10.0)
Platelets 676 × 109/L (150–400)
INR 9.6 (1.0)
He is treated with intravenous vitamin K and is blood cross-matched.
What is the most appropriate additional treatment?
A. Fresh frozen plasma
B. Pantoprazole
C. Protamine sulfate
D. Prothrombin complex concentrate
E. Tranexamic acid
Correct Answer(s): D Prothrombin complex concentrate
Justification for correct answer
Prothrombin complex concentrate is used to reverse warfarin in medical emergencies. It is
quicker to administer than FFP and can reverse anti-coagulation within minutes. FFP also
carries the risk of allergic reactions, transfusion-related lung injury and volume overload.
PCC is therefore considered first-line to reverse warfarin. The other drugs do not reverse
warfarin.
137
A 65 year old man has 3 weeks of progressive ankle oedema. He is a lifelong
heavy smoker and drinks 12 units of alcohol per week.
His BP is 125/85 mmHg and oxygen saturation 98% breathing air. He has
marked bilateral pitting ankle oedema.
Investigations:
Creatinine 85 µmol/L (60–120)
Urinary protein: creatinine ratio 400 mg/mmol (<30)
Fasting glucose 5.7 mmol/L (3.0–6.0)
Total cholesterol 9 mmol/L (<5.0)
Albumin 20 g/L (35–50)
He is treated with furosemide.
Which investigation is most likely to be diagnostic?
A. Chest X-ray
B. Renal arteriography
C. Renal auto-antibody screen
D. Renal biopsy
E. Serum protein electrophoresis
Correct Answer(s): D renal biopsy
Justification for correct answer
Nephrotic syndrome in adults requires renal biopsy to identify the cause, prior to
definitive treatment
138
```
A 42 year old man has 1 day of severe epigastric pain. He has vomited five
times. He smokes 12 cigarettes per day and drinks 27 units of alcohol per
week.
His temperature is 37.9°C, pulse rate 88 bpm and BP 140/86 mmHg. He is
tender in the epigastrium and right upper quadrant, and there is voluntary
guarding.
Investigations:
White cell count 15.6 × 109/L (3.8–10.0)
ALT 41 IU/L (10–50)
Alkaline phosphatase 135 IU/L (25–115)
Bilirubin 14µmol/L (<17)
Amylase 249U/L (<220)
CRP 42 mg/L (<5)
Which is the most likely diagnosis?
A. Acute cholangitis
B. Acute cholecystitis
C. Acute hepatitis
D. Acute pancreatitis
E. Biliary colic
```
Correct Answer(s): B acute cholecystitis
Justification for correct answer(s): History and investigations fit with acute
cholecystitis. Amylase not high enough for acute pancreatitis and would
expect higher bilirubin with cholangitis. Biliary colic would not have
inflammatory response. LFTs do not fit with hepatitis.
139
A 74 year old man has two weeks of memory problems and confusion. He
also has headaches that are worse when bending over and associated with
vomiting. He had bowel cancer treated with sigmoidectomy and adjuvant
chemotherapy two years ago.
His BP is 181/105 mmHg. He has no focal neurological signs.
Which is the most likely diagnosis?
A. Cerebral metastases
B. Hypercalcaemia
C. Hyponatraemia
D. Paraneoplastic encephalitis
E. Severe hypertension
```
Correct Answer(s): A cerebral metastases
Justification for correct answer(s): Typical Observations due to intracranial
hypertension secondary to cerebral metastases
```
140
A 24 year old woman develops low back pain the day after falling while
playing hockey. She is usually well and takes no regular medication. She is a
chef.
Which is the most appropriate advice?
A. Avoid work until the pain has completely settled
B. Back strengthening exercises
C. Bed rest until pain improves, then gradual mobilisation
D. Continue usual activity
E. Self referral for physiotherapy
Correct Answer(s): D continue usual activity
Justification for correct answer(s): Short duration acute low back pain in fit
person. Therefore most appropriate response would be to continue usual
activity and to provide appropriate safety netting advice. NICE Clinical
Knowledge Summaries - back pain
141
A 66 year old woman presents to the Emergency Department feeling
generally unwell with no specific symptoms. She is being treated with
neoadjuvant chemotherapy for oesophageal cancer. She underwent the
second cycle 8 days ago.
Her temperature is 38.8°C, pulse rate 91 bpm, BP 132/68 mmHg, respiratory
rate 16 breaths per minute and oxygen saturation 95% breathing air.
Examination is otherwise unremarkable. Blood tests have been taken, but
results are not yet available.
Which is the most appropriate next step in management?
A. Admit to medical receiving unit
B. Await blood results before taking further action
C. Discuss with local oncology team for advice
D. Give intravenous broad-spectrum antibiotics
E. Give intravenous fluid therapy
Correct Answer(s): D IV antibiotics
Justification for correct answer(s): The student should be able to identify the
potential for neutropenic sepsis in a patient who is 8 days post-chemotherapy,
(even though agent is unknown) and must know the importance of prompt
antibiotic administration prior to any other action.
142
```
A 66 year old woman has 48 hours of severe abdominal pain. She was
discharged from hospital 6 weeks ago following an aortobifemoral bypass
graft.
She has diffuse tenderness of the abdomen with absent bowel sounds. Plain
X-ray of the abdomen is unremarkable.
Investigations:
Haemoglobin 119 g/L (115-160)
White cell count 15 × 109/L (3.8–10.0)
Urea 16.4 mmol/L (2.5–7.8)
Creatinine 158 µmol/L (60–120)
CRP 110 mg/L (<5)
Arterial blood gas breathing air
pH 7.28 (7.35–7.45)
PO2 13 kPa (11–15)
PCO2 4.6 kPa (4.6–6.4)
Bicarbonate 16 mmol/L (22–30)
Lactate 4.5 mmol/L (1–2)
Which is the most likely diagnosis?
A. Acute diverticulitis
B. Acute pancreatitis
C. Incarcerated paraumbilical hernia
D. Mesenteric ischaemia
E. Ruptured aortic aneurysm
```
```
Correct Answer(s): D mesenteric ischaemia
Justification for correct answer(s): History of vascular disease and lactic
acidosis make mesenteric ischaemia most likely diagnosis.
```
143
A 59 year old woman has haemoptysis and breathlessness of sudden onset.
She had a bleeding peptic ulcer secondary to NSAID use 4 weeks ago
requiring a 2-unit blood transfusion. She has a history of osteoarthritis. She is
taking lansoprazole and co-codamol.
Her pulse rate is 112 bpm, BP 114/74 mmHg, respiratory rate 26 breaths per
minute and oxygen saturation 93% breathing 40% oxygen. Her chest is clear.
Investigations:
Haemoglobin 85 g/L (115–150)
Creatinine 81 µmol/L (60–120)
CT pulmonary angiogram: thrombus in the right pulmonary artery
Which is the most appropriate initial treatment?
A. Insertion of vena cava filter
B. Intravenous alteplase
C. Intravenous heparin
D. Oral apixaban
E. Subcutaneous dalteparin sodium
Correct Answer(s): C IV heparin
Justification for correct answer(s): The patient has a sub-massive pulmonary
embolus but is also at risk of haemorrhage. In this setting IV unfractionated
heparin is best option as it can be stopped and reversed in event of recurrent
bleeding.
144
why would someone presenting with pericarditis have a positive d dimer
In patients with pericarditis, D-dimer elevation is associated with elevated CRP indicating pericardial inflammation. A positive D-dimer in the setting of otherwise unexplained chest pain should lead to consideration of pericarditis as a possible etiology.
145
A 49 year old man has 24 hours of severe, paroxysms of pain of sudden
onset in the left flank. He has a past medical history of irritable bowel
syndrome.
Urinalysis shows blood 2+, protein trace and leucocytes 2+.
Which is the most appropriate initial investigation?
A. Contrast CT of abdomen and pelvis
B. Intravenous urography
C. Non-contrast CT of renal tract
D. Plain X-ray of renal tract
E. Ultrasonography of renal tract
```
Correct Answer(s): C non contrast CT of renal tract
Justification for correct answer(s): An unenhanced CTKUB is the
recommended first investigation of renal stones. NICE guideline NG118- 8/1/19
```
146
A 54 year old woman has 1 day of a painful, swollen left wrist and fever. She
has a history of rheumatoid arthritis and takes methotrexate and etanercept.
Her temperature is 38.2°C, pulse rate 100 bpm and BP 119/83 mmHg. The
left wrist is swollen and erythematous.
Investigations:
White cell count 15.2 × 109/L (3.8–10.0)
Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 µmol/L (60–120)
CRP 171 mg/L (<5)
Joint aspiration: no organisms on Gram stain, white cell count 2263/µL
(<200), mostly neutrophils, no crystals.
She is advised to take oral paracetamol.
Which is the most appropriate additional management?
A. Inject methylprednisolone into the joint
B. No further treatment pending culture results
C. Start intravenous flucloxacillin
D. Start oral colchicine
E. Start oral prednisolone
Correct Answer(s): C start IV flucloxacillin
Justification for correct answer(s): The patient should be considered to have
septic arthritis. The patient is septic and is immunocompromised. The gram
stain is positive in about 50% of cases, so a negative gram stain does not
mean there is no infection. Intravenous antibiotics should be started pending
culture results.
147
A 57 year old woman is found collapsed on the medical ward. She was
admitted 24 hours ago with pneumonia and is being treated with intravenous
antibiotics. She has a history of type 1 diabetes and has been taking her usual
doses of subcutaneous insulin.
She is unrousable and is clammy. Her capillary blood glucose is 1.5 mmol/L.
Which is the most appropriate immediate treatment?
A. 20 mL of 50% glucose by slow intravenous injection
B. 75 mL of 20% glucose by intravenous infusion
C. 150 mL of 5% glucose by intravenous infusion
D. Glucagon 1 mg by intramuscular injection
E. Glucose gel 25 g (contains 10 g glucose) applied to buccal mucosa
Correct Answer(s): B 75 mL of 20% glucose by IV infusion
Justification for correct answer(s): 20% glucose is first choice treatment. 50%
glucose too hyperosmolar with risk of local tissue necrosis. Glucagon has
unpleasant effects (nausea and flushing) but is reasonable second choice if no
venous access available. 5% glucose will not reverse hypo effectively. Risk of
aspiration with glucose gel in unconscious patient. Joint British Diabetes
Society Guidelines: Hospital management of hypoglycaemia in adults with
diabetes mellitus (3rd edition Feb 2018)
148
A 45 year old woman has 2 days of worsening abdominal pain. She has also
had recent constipation. There is no rectal bleeding.
Her temperature is 38.1°C, pulse rate 105 bpm and BP 140/85 mmHg. She
has tenderness in the left iliac fossa with a palpable mass. Bowel sounds are
normal. Rectal examination shows hard stools only.
Which is the most likely diagnosis?
A. Ischaemic colitis
B. Meckel's diverticulitis
C. Proctocolitis
D. Rectal carcinoma
E. Sigmoid diverticulitis
```
Correct Answer(s): E sigmoid diverticulitis
Justification for correct answer(s): The classical presentation of diverticulitis
includes change in bowel habit, left iliac fosa pain and features of infection (ie
pyrexia).
```
149
A 50 year old woman has nausea, fever and rigors. She has foul smelling
urine. She was discharged 4 days ago after being treated for a PE. She has
been having low molecular weight heparin injections twice daily since the
diagnosis. She had a cholecystectomy 12 years ago.
Her temperature is 39.7°C, pulse rate 108 bpm and BP 85/52 mmHg.
Investigations:
APTT 43 seconds (22–41)
PT 18 seconds (10–12)
Which is the most likely cause of the prolonged prothrombin time?
A. Disseminated intravascular coagulation
B. Liver disease
C. Low molecular weight heparin
D. Lupus anticoagulant
E. Vitamin K deficiency
Correct Answer(s): A DIC
Justification for correct answer(s): Diagnosis of DIC is based on presence of
≥1 known underlying condition causing DIC plus abnormal global coagulation
tests: decreased platelet count, increased prothrombin time, elevated fibrinrelated marker (D-dimer/fibrin degradation products) and decreased fibrinogen
level. In this patient the underlying condition triggering DIC is sepsis and it is
likely that further blood tests would show abnormalities in the above markers.
150
A 41 year old man has a left-sided hearing loss. There has been slow
deterioration over the previous year, and he is now also troubled by
numbness over the left side of the face.
A pure-tone audiogram shows a left-sided high-frequency hearing loss. He
has normal tympanometry bilaterally.
Which is the most appropriate diagnostic investigation?
A. Cerebral angiography
B. CT of head
C. CT of petrous temporal bones
D. MR imaging of internal acoustic meatus
E. PET–CT of brain
Correct Answer(s): D MR of internal acoustic meatus
Justification for correct answer(s): Where there is a unilateral sensorineural
hearing loss, it is vital to exclude the presence of a vestibular schwannoma or
other neoplasm of VIII nerve or brainstem. This is done via an MRI scan.
151
A 63 year old woman has had bloody diarrhoea six times each day for the
past 3 weeks and is feeling unwell. She has lost weight and has noticed
urgency to pass stool. Her left eye has been itchy, but not painful.
Her temperature is 38.2°C, pulse rate 118 bpm, BP 110/70 mmHg and
respiratory rate 19 breaths per minute.
Investigations:
Stool culture: negative
Which is the most likely diagnosis?
A. Adenocarcinoma of the colon
B. Crohn's disease
C. Irritable bowel syndrome
D. Microscopic colitis
E. Ulcerative colitis
Correct Answer(s): E UC
Justification for correct answer(s): Typical IBD history, including bloody
diarrhoea and eye symptoms. These symptoms are far more common in UC
than Crohn's.
(UC - only affects large intestine)
(Chrons - can affect any part of the GI tract)
152
what pathology does Anti-tissue transglutaminase antibodies test for
coeliac disease
153
A 31 year old man presents to his GP with 6 weeks of right iliac fossa
discomfort, weight loss of 5 kg and diarrhoea six times a day. He previously
opened his bowels once daily. He has not travelled abroad. He lives with his
partner, who is well.
Rectal examination is normal.
Investigations:
Haemoglobin 129 g/L (Men: 135-180 g/l Women: 115-160 g/l)
Albumin 32 g/L (35–50)
White cell count 10.8 × 109/L (3.8–10.0)
Platelets 450 × 109/L (150–400)
Erythrocyte sedimentation rate 60 mm/hr (<20)
ALT 10 IU/L (10–50)
ALP 110 IU/L (25–115)
Bilirubin 15 µmol/L (<17)
Which is the most appropriate next investigation?
A. Antimitochondrial antibodies
B. Anti-tissue transglutaminase antibodies
C. Faecal calprotectin
D. Faecal occult blood testing
E. Stool cultures
Correct Answer(s): E stool cultures
Justification for correct answer(s): NICE CKS suggest stool cultures as part of
work up in primary care before referral. Most likely diagnosis is IBD
154
A 36 year old man is undergoing investigation for hypogonadism. He has no
visual symptoms.
His visual acuity is 6/5 bilaterally. There is a visual field defect.
Investigations:
MR scan of brain: craniopharyngioma indenting the optic chiasm
Which is the most likely visual field defect?
A. Bilateral concentric visual loss
B. Bilaterally enlarged blind spots
C. Bitemporal hemianopia
D. Left-sided homonymous hemianopia
E. Right-sided homonymous hemianopia
Correct Answer(s): C bitemporal hemianopia
Justification for correct answer(s): In a patient with an intracranial tumour
(pressing the chiasm) who has no visual symptoms and normal visual acuity,
the earliest visual field deficit will be red desaturation in the bitemporal lower
visual fields and subsequent bitemporal hemianopia. The blind spots are
normal in chiasmal compression unless there is associated papilloedema from
raised intracranial pressure (Foster Kennedy syndrome).
155
A 23 year old woman has recurrent episodes of collapse over 3 months.
When laughing, her muscles feel limp and she falls to the floor, but she
remains alert. She has a history of anxiety and depression and takes
citalopram. Her mother died from sudden cardiac death aged 59 years.
Which is the most likely diagnosis?
A. Cardiogenic syncope
B. Cataplexy
C. Cough syncope
D. Dissociative (non-epileptic) seizures
E. Epilepsy
```
Correct Answer(s): B cataplexy
Justification for correct answer(s): Cataplexy classically presents with loss of
skeletal muscle tone with strong (usually postive) emotions
```
156
what is cataplexy
Cataplexy is the term given to sudden muscular weakness triggered by strong emotions such as laughter, anger and surprise. The loss of muscle tone that occurs may range from a just-perceptible weakening of the facial muscles through weakness at the knees, to total collapse on the floor.
157
A 45 year old man has 8 months of a painful, stiff right shoulder. The pain is
nagging and worse particularly when reaching for the seatbelt in a car. There
is no history of trauma. He has type 1 diabetes mellitus.
He has reduced passive and active range of movement in the right shoulder
with pain at extremes of range of motion. Neck movements are normal. Power
and sensation are normal.
Investigations:
Erythrocyte sedimentation rate 12 mm/hr (<20)
Which is the most likely diagnosis?
A. Adhesive capsulitis
B. Glenohumeral osteoarthritis
C. Polymyalgia rheumatica
D. Rotator cuff tear
E. Subacromial bursitis
Correct Answer(s): A adhesive capsulitis
Justification for correct answer(s): Adhesive capsulitis (frozen shoulder)
presents with dull shoulder pain, that often disturbs sleep, followed by
stiffness and loss of shoulder mobility. Adhesive capsulitis is unlikely in
patients younger than 40 years of age, and patients older than 70 are more
likely to have rotator cuff tears or glenohumeral osteoarthritis. Patients with
subacromial pathology often give an occupational or athletic history of heavy
lifting or repetitive movements, especially above shoulder level. Patients with
rotator cuff tendinopathy and subacromial bursitis often complain of activityrelated pain and problems performing usual activities. Adhesive capsulitis is
more common is diabetics.
158
what does high amylase suggest
acute pancreatitis
159
physiological livedo reticularis
is a harmless condition that causes mottled skin to develop when a person experiences cold temperatures
common in young females and newborns
160
pathological livedo reticularis
anitphospholipid syndrome
SLE
systemic sclerosis
161
two main types of acquired thrombophilia
(blood clots more than it should)
APS - antiphospholipid syndrome
HIV
162
A 54 year old woman is reviewed following a bone densitometry scan (DXA).
She was recently found to have temporal arteritis, and treatment with oral
prednisolone was started. The T-score for the bone mineral density in her
femoral neck is –3.9.
She is advised to take colecalciferol with calcium carbonate.
Which is the most appropriate additional treatment?
A. Alendronic acid
B. Denosumab
C. No additional treatment
D. Raloxifene hydrochloride
E. Teriparatide
Correct Answer(s): A Alendronic acid
Justification for correct answer(s): Alendronic acid first line; The other options
are all used to treat osteoporosis but are not used first line. National
Osteoporosis Guideline (NOG) group 2017 (updated 2018): Clinical guideline
for the prevention and treatment of osteoporosis
Alendronic acid, sold under the brand name Fosamax among others, is a bisphosphonate medication used to treat osteoporosis and Paget's disease of bone. It is taken by mouth. Use is often recommended together with vitamin D, calcium supplementation, and lifestyle changes
163
A 70 year old man presents to the GP with 3 weeks of intermittent dizziness
that he describes as 'the room spinning'. The episodes start suddenly, are
usually triggered by rolling over in bed, and last less than a minute before
resolving completely. He reports nausea during these episodes. He is
otherwise well.
Otoscopic and neurological examinations are normal.
Which is the most likely diagnosis?
A. Acoustic neuroma
B. Benign paroxysmal positional vertigo
C. Cerebellar lesion
D. Ménière's disease
E. Vestibular neuritis
Correct Answer(s): B BBPV
Justification for correct answer(s): The signs and symptoms are typical of
benign paroxysmal positional vertigo (BPPV). All of the answer options can
cause “dizziness”, but the description of the dizziness, along with the absence
of other accompanying signs/symptoms, the timing (recurrence with periods of
being asymptomatic), trigger (of turning head quickly) and normal neurological
exam indicate BPPV rather than any of the other options.
164
A 64 year old woman becomes increasingly short of breath 2 hours after the
removal of a chest drain. This was inserted to drain a right-sided pleural
effusion secondary to breast cancer. Three litres of bloodstained fluid were
drained before removal.
Which is the most likely diagnosis?
A. Aspiration pneumonia
B. Pneumothorax
C. Pulmonary embolism
D. Pulmonary oedema
E. Recurrence of effusion
Correct Answer(s): B Pneumothorax
Justification for correct answer(s): This patient has suffered an iatrogenic
pneumothorax secondary to insertion of a chest drain.
165
A 73 year old man has abdominal pain 4 days after a laparoscopic sigmoid
colectomy with primary anastomosis for diverticular disease.
His temperature is 37.3°C, pulse rate 100 bpm, BP 120/72 mmHg and oxygen
saturation 96% breathing oxygen 4 L/min via nasal prongs. He has reduced
breath sounds in both bases. He has abdominal tenderness with guarding and
reduced bowel sounds.
Which is the most appropriate diagnostic investigation?
A. Abdominal X-ray
B. Barium enema
C. CT of abdomen
D. Erect chest X-ray
E. Point-of-care FAST scan
Correct Answer(s): C CT of abdomen
Justification for correct answer(s): The question aims to assess investigation
of an acute abdomen following abdominal surgery. A CT scan (usually with
intravenous contrast) is most likely to provide diagnostic information to plan
further management. None of the other investigations are likely to be useful in
this setting.
166
A 70 year old woman reports feeling dizzy 2 hours after a chest drain insertion
for a haemothorax. She has large amount of blood exiting from the drain. Her
pulse rate is 130 bpm, BP 96/58 mmHg, respiratory rate 24 breaths per
minute and oxygen saturation 96% breathing oxygen 4 L/minute via nasal
cannulae.
She is treated with an IV fluid bolus, and the medical registrar is informed.
Which is the most appropriate next management step?
A. Activate major haemorrhage protocol
B. Give IV noradrenaline/norepinephrine
C. Give IV tranexamic acid
D. Give prothrombin complex concentrate
E. Increase oxygen to 15 L/min via a non-rebreather mask
Correct Answer(s): A activate major haemorrhage protocol
Justification for correct answer(s): The question checks that candidates
recognise the seriousness of this condition and that blood and blood products
will be required quickly. This is achieved by activation of major haemorrhage
protocol, that FY doctors should be aware of.
167
A 59 year old man is reviewed in clinic. He has type 1 diabetes mellitus,
hypertension, ischaemic heart disease and CKD stage 4 [recent eGFR 25
mL/min/1.73 m2(> 60)]. He is taking insulin, lisinopril, metoprolol tartrate and
aspirin.
His BP is 152/100 mmHg. He has pitting oedema to the mid calves.
Investigations:
Sodium 136 mmol/L (135–146)
Potassium 5.8 mmol/L (3.5–5.3)
Urea 15.6 mmol/L (2.5–7.8)
Creatinine 237 µmol/L (60–120)
eGFR 26 mL/min/1.73 m2 (>60)
Urinalysis: protein 2+
Which is the most appropriate therapeutic change?
A. Add indapamide
B. Add furosemide
C. Add spironolactone
D. Stop lisinopril
E. Switch lisinopril to losartan
Correct Answer(s): B add furosemide
Justification for correct answer(s): The patient has hypertension outside of
target (130/80 mmHg), with evidence of peripheral oedema. Furosemide will
reduce peripheral oedema, lower BP and help with hyperkalaemia.
Bendroflumethiazide is less effective when compared to furosemide when the
creatinine clearance is below 30. Although the potassium is elevated this is not
an indication to stop lisinopril. Spironolactone is relatively contraindicated by
hyperkalaemia and not as effective as furosemide. There is no benefit in
switching to an angiotensin receptor blocker.
168
An 18 year old woman is brought to the resuscitation room of the Emergency
Department after being involved in a road traffic collision. She is 25 weeks
pregnant. Her cervical spine is immobilised.
She is conscious and asks about her baby. Her temperature is 37°C, pulse
rate 100 bpm, BP 83/56 mmHg and oxygen saturation 99% breathing room
air. Fluid resuscitation has been started and bloods have been sent.
Which is the most appropriate next step?
A. Image the long bones and pelvis, and orthopaedic review
B. Perform a full primary survey
C. Scan the baby and arrange fetal monitoring
D. Transfer to theatre for immediate delivery of baby
E. X-ray cervical spine
Correct Answer(s): B perform a full primary survey
Justification for correct answer(s): The patient is tachycardic and hypotensive.
It is likely that they are bleeding. They need a full primary survey to identify any
potential life threatening injuries and commence treatment. The resuscitation
efforts are mainly focused on the mother not the fetus. Delivery of the fetus at
this point would only be indicated to aid resuscitation of the mother.
169
A 61 year old man is brought to the Emergency Department with 2 hours of
central chest heaviness A pre-hospital ECG shows 2 mm of ST elevation in
leads V1-V4, for which paramedics gave aspirin and glyceryl trinitrate spray.
On arrival at hospital, he is sweating and distressed. His pulse rate is 64 bpm,
BP 130/80 mmHg, respiratory rate 20 breaths per minute and oxygen
saturation 98% breathing air. His GCS score is 15/15.
Which is the most appropriate management?
A. Continue breathing air
B. Start 28% oxygen via a Venturi mask
C. Start 40% oxygen via a Venturi mask
D. Start oxygen 2 L/min via nasal cannulae
E. Start oxygen 15 L/min via a non-rebreathe mask
```
Correct Answer(s): A continue breathing air
Justification for correct answer(s): Airway is patent and does not require
intervention. Oxygen will increase mortality for STEMI with sats of >94%. (BMJ
Nov 2018)
```
170
A 38 year old woman has intentionally self harmed by cutting both wrists. She
became very sad earlier that day after forgetting to bring a plastic bag when
going to the supermarket. Her mood changes between being happy and sad
several times per week. She struggles with concentration and has never been
able to settle well into school, college or work. She has been disqualified from
driving for driving recklessly. She has never experienced psychotic symptoms.
Which is the most likely diagnosis?
A. Adjustment disorder
B. Bipolar disorder
C. Borderline personality disorder
D. Dissocial personality disorder
E. Unipolar depressive episode
```
Correct Answer(s): C BPD
Justification for correct answer(s): Frequent changes in mood suggests
borderline PD, not pervasive depression. Mood changes too rapid for bipolar
disorder. Also impulsive self-destructive behaviours and unstable
relationships are classical symptoms.
```
171
A 20 year old woman has a brief episode of feeling faint. She has had 2 days
of dysuria, loin pain and fever. She has been feeling tired for 6 months and
has lost 3 kg in weight.
Her temperature is 37.4°C, pulse rate 100 bpm, BP 100/55 mmHg lying and
90/50 mmHg sitting, respiratory rate 18 breaths per minute and oxygen
saturation 95% breathing air. Her JVP is not visible.
Investigations:
Haemoglobin 106 g/L (115–150)
White cell count 14 × 109/L (3.8–10.0)
Platelets 201 × 109/L (150–400)
Sodium 132 mmol/L (135–146)
Potassium 5.6 mmol/L (3.5–5.3)
Urea 9.5 mmol/L (2.5–7.8)
Creatinine 98 µmol/L (60–120)
Random plasma glucose 3.6 mmol/L
12-lead ECG sinus rhythm
Which is the most appropriate additional investigation?
A. CT of head
B. CT pulmonary angiography
C. Echocardiography
D. Plasma cortisol and adrenocorticotropic hormone
E. Urinary and serum osmolality
Correct Answer(s): D plasma cortisol and adrenocorticotropic hormone
Justification for correct answer(s): Classic presentation of adrenal crisis.
Nearly all patients have a history of lethargy and weight loss. Plasma cortisol
and ACTH should be sent immediately so that definitive treatment can be
initiated. You would not wait for results before starting IV steroids. -
Justification for Unselected: Presentation does not fit with either a PE or
cerebral disease. Hypotension more likely to be due to adrenal insufficiency
than cardiac disease. Urine and plasma osmolality is not required as there is
more likely cause for hyponatraemia.
172
A 66 year old man with stage 4 renal cell carcinoma has 48 hours of back
pain at the T12 level. He has also developed difficulty walking and urinary
retention.
Which is the most appropriate investigation?
A. CT of spine
B. Isotope bone scan
C. MR imaging of spine
D. PET–CT
E. X-ray of thoracic and lumbar spine
Correct Answer(s): C MR of spine
Justification for correct answer(s): Clinical cord compression needs MR.
Malignant cord compression is often multifocal so whole spine required
173
A 70 year old man attends his GP surgery with reducing exercise tolerance
and a cough productive of white sputum on most mornings. He has never had
haemoptysis and has lost 2kg in weight. He describes two chest infections in
the past year treated with a short course of steroids and antibiotics. He has a
20 pack-year smoking history.
His heart rate is 82. Chest X-ray is normal.
Which is the most appropriate investigation to establish the diagnosis?
A. Cardiopulmonary exercise test
B. Echocardiography
C. High resolution CT scan of thorax
D. Spirometry
E. Sputum cytology
```
Correct Answer(s): D Spirometry
Justification for correct answer(s): COPD is the most likely diagnosis and
basic spirometry most appropriate
```
174
difference between supra ventricular tachycardia and ventricular tachycardia
ventricular tachycardia is tachycardia arising from the ventricles whereas supra ventricular tachycardia is tachycardia arising from above the ventricles
SVT is more common in women than men
175
A 67 year old woman is oliguric 20 hours after an emergency sigmoid
colectomy for a perforated diverticulum. She has a history of chronic kidney
disease stage 2, obesity and type 2 diabetes mellitus. She takes metformin
and ramipril.
Her pulse rate is 110 bpm, BP 100/50 mmHg and JVP not visible. Her urine
output has been 10 mL per hour for the past 4 hours. She has been given 2 L
of 0.9% sodium chloride since returning from theatre.
Investigations:
Urea 15.8 mmol/L (2.5–7.8)
Creatinine 164 µmol/L (60–120)
Which is the most likely cause of her oliguria?
A. Acute tubular necrosis
B. Catheter obstruction
C. Intraoperative ureteric injury
D. Prerenal hypovolaemia
E. Renal artery occlusion
Correct Answer(s): D prerenal hypovolaemia
Justification for correct answer(s): The patient continues to show signs of
hypovolaemia so a pre-renal cause for the oliguria is most likely. ATN usually
takes longer to develop and would need to ensure adequate fluid resuscitation.
Ureteric injury is unlikely and would need to be bilateral to cause AKI. Catheter
blockage would cause anuria. Renal artery occlusion is rare and would cause
loin pain and more severe clinical picture.
176
A 40 year old man is brought to the Emergency Department having been
struck on the side of the head with a baseball bat.
He has a minor scalp abrasion. His GCS is 15/15 and there are no focal
neurological signs.
Seven hours later he collapses, at which point his GCS is 6/15. A CT scan of
brain reveals a biconvex haemorrhage in the left parietal region.
Which is the most likely vessel to be injured?
A. Anterior communicating artery
B. Basilar artery
C. Bridging veins
D. Middle meningeal artery
E. Vertebral artery
Correct Answer(s): D middle meningeal arerty
Justification for correct answer(s): The middle meningeal sits beneath
temporal bone and is fragile
177
A 41 year old man has 16 hours of a severe headache of sudden onset.
When the headache started, he lost consciousness briefly and vomited; he
also has neck pain. He has no significant past medical history.
Neurological examination is normal. A non-contrast CT scan of brain is
normal.
What is the most appropriate next step in management?
A. Carotid Doppler studies
B. Lumbar puncture
C. MR scan of brain
D. MR imaging of brain with MR venography
E. No future investigations required
```
Correct Answer(s): B Lumbar puncture
Justification for correct answer(s): This is a case of a possible subarachnoid
haemorrhage. A normal CT brain scan does not rule out haemorrhage although
the earlier it is done the more likely it is that haemorrhage will be detected on
the scan. When the CT is unhelpful a lumbar puncture should be performed to
look for presence of xanthochromia (haem breakdown products)
```
178
A 50 year old man has recurrent left-sided constant headaches lasting up to
36 hours associated with photophobia. The headache is usually preceded by
the appearance of zig-zagging lines in the vision. These headaches have
caused him to lose touch with friends as he regularly misses social occasions.
Which is the most appropriate treatment to reduce the frequency of these episodes?
A. Acupuncture
B. Gabapentin
C. Propranolol
D. Sumatriptan
E. Venlafaxine
Correct Answer(s): C propranolol
Justification for correct answer(s): Migraine prophylaxis NICE guidance CG150
(2015)
179
typical migraine prophylaxis drugs
propranolol
timolol
amitriptyline
sodium valproate
180
An 80 year old woman reports increasing fatigue. She has noticed intermittent
difficulty swallowing, usually in the evening. She is a smoker. Her only regular
medication is levothyroxine.
There is bilateral mild ptosis. The rest of the neurological examination is
normal.
Which is the most likely diagnosis?
A. Guillain–Barré syndrome
B. Migraine
C. Multiple sclerosis
D. Myasthenia gravis
E. Stroke
Correct Answer(s): D myasthenia gravis
Justification for correct answer(s): Myasthenia Gravis is an autoimmune
disorder characterised by muscle weakness that worsens with exercise
(fatigability) and improves with rest. Double vision, ptosis, difficulty chewing
and swallowing, and slurring of speech that worsen throughout the day are
characteristic symptoms
181
Six students living in the same hall of residence have developed diarrhoea
and vomiting within 24 hours of each other. There is no blood in the stool,
they have not eaten similar foods and have no history of foreign travel.
A doctor requests stool samples from each to confirm the likely diagnosis.
Which test is most likely to confirm the diagnosis?
A. Clostridium difficile enzyme assay and toxin detection
B. Faecal elastase test
C. Stool for culture and sensitivity
D. Stool for viral PCR
E. Stool microscopy for ova, cysts and parasites
Correct Answer(s): D stool for viral PCR
Justification for correct answer(s): PCR is the current method for confirming
norovirus
182
A 55 year old woman has three weeks of memory problems and confusion.
She also has headaches that are worse when coughing or sneezing and
associated with vomiting. She had a melanoma that was resected and treated
with adjuvant immunotherapy two years ago. BP is 169/100 mmHg. She has
no focal neurological signs.
Which is the most likely diagnosis?
A. Cerebral metastases
B. Hypercalcaemia
C. Hyponatraemia
D. Paraneoplastic encephalitis
E. Severe hypertension
```
Correct Answer(s): A brain metasases
Justification for correct answer(s): Typical Observations due to intracranial
hypertension secondary to cerebral metastases.
```
183
saddle shape changes on an ECG indicate what pathology
pericarditis
184
```
A middle aged man presents with a history suspicious of subarachnoid haemorrhage. You assist your registrar in performing a lumbar puncture. You are asked to label the bottles in the order that they are collected and to send them off. Other than normal cell microscopy, what else would it be important for you to send the samples for?
A. India ink staining
B. Xanthochromia
C. Culture and sensitivity
D. Erythrocyte sedimentation rate (ESR)
E. Oligoclonal bands
```
B. xanthochromia
When trying to exclude a subarachnoid haemorrhage, it is essential to have a red blood cell count and xanthochromia. The red blood cells should be constant throughout the samples. If the red blood cells decrease in the order the bottles are collected, this could indicate a “bloody tap”, or traumatic lumbar puncture where there was some initial bleeding during the needle insertion, which then decreases as CSF is collected.
Xanthochromia is the yellow discolouration of the CSF caused by bilirubin released from the breakdown of red blood cells. It is measured quantitatively by spectrophotometry.
Culture and sensitivity are important is the differential diagnosis of meningitis is being considered (headache, photophobia, neck stiffness), although the question specifically states that a SAH is the main differential.
185
A 67 year old presents with unilateral headache focussed over her left temporal area. It started this morning and she noticed it was particularly painful and tender on brushing her hair on that side.
Give the most likely diagnosis, select the most helpful investigation from the list below for confirming the diagnosis.
A. LFT
B. Serum electrophoresis for immunoglobulines
C. ESR
D. Creatine Kinase
E. CRP
C. ESR
Classically ESR is raised in temporal arteritis. The gold standard for confirming the diagnosis is the obtain a temporal artery biopsy. Duplex ultrasound gives a characteristic picture in temporal arteritis, and can be useful in diagnosis.
Treatment should not be delayed as it can progress quickly to irreversible loss of vision.
Management
40-60mg prednisolone per day (depending on if claudication or visual symptoms present)
Aspirin 75mg daily decreases visual loss and strokes
Co-prescribe a proton pump inhibitor (e.g. omeprazole) for gastric prevention (while on steroids)
Co-prescribe calcium and vitamin D (e.g. Adcal-D3) for osteoporosis prevention (while on steroids)
Consider also bisphosphonates for osteoporosis prevention (if at high risk)
Continue steroids until laboratory abnormalities gone and clinically symptom free, then start weaning
186
A 54 year old lady presents with a sudden onset occipital headache that started 4 hours ago whilst shopping. She said it felt like she had been hit suddenly over the back of her head. The severe pain has remained at the back of her head since, although she has developed other symptoms of neck stiffness and photophobia. She has had no fever, weakness or rash. She is otherwise fit and well, and has had no unwell contacts.
Examination is unremarkable except for observational pain and photophobia.
Blood tests and a CT head are normal.
What is the most appropriate next step in management?
A. MRI head
B. Admission for monitoring
C. CT angiogram
D. Immediate craniotomy
E. Discharge with reassurance and analgesia
F. Lumbar puncture
F. Lumbar puncture
This lady has a history highly suspicious of a subarachnoid haemorrhage. This condition is potentially fatal if missed. Although a CT head scan is >90% sensitive and >90% negative predictive value for subarachnoid haemorrhage, even a tiny risk of missing a subarachnoid haemorrhage is not worth taking. She should have a lumbar puncture to look for xanthochromia and red cell count.
Investigations
CT head first line
Lumbar puncture
If CT negative for SAH but suspicious history. To exclude the diagnosis.
Send samples for:
RBC will be raised (if decreasing in number over the samples, this could be due to a traumatic LP)
Xanthochromia (the yellow colour of CSF caused by bilirubin)
Angiography once SAH is confirmed to locate the cause
187
A 45 year old man, who is known to have cluster headaches, presents to the A&E department with severe pain behind his left eye associated with left eye watering and erythema.
He has already self administered a sumatriptan 6mg subcutaneous injection, with little relief.
```
What would be an appropriate initial management?
A. IV morphine
B. IM sumatriptan
C. 100% oxygen via facemask
D. Oral diclofenac
E. Oral prednisolone
```
C. 100% oxygen via facemask
Treatment options
Rescue medications (taken as soon as headache starts)
Triptans – sumatriptan 6mg subcutaneously
High flow pure (100%) oxygen (can be given at home)
Prophylaxis options:
Verapamil
Lithium
Prednisolone
188
A 47 year old lady is referred to migraine clinic with shooting pains across the left side of her face.
The shooting pains occur randomly, and only last a few seconds. They occur across her left cheek and jaw, and do not affect her forehead or eye. They occur three or four times per day.
```
What would be the most appropriate first line medication to start to help prevent her symptoms?
A. Propranolol
B. Verapamil
C. Sumatriptan
D. Gabapentin
E. Carbamazepine
```
E. Carbamezapine
NICE guidelines recommend starting carbamazepine 100mg twice daily for trigeminal neuralgia and titrating up as required to prevent symptoms.
189
A 19 year old man presents with polyuria, polydipsia, vomiting and exhaustion.
On examination he has reduced skin turgor, dry mouth and sunken eyes, and a sweet acetone smell to his breath.
His blood pressure is 94/67, heart rate 106, respiratory rate 19, temperature 36.7C and oxygen saturation of 99% on room air.
While waiting for laboratory blood tests and an ABG to come back, the emergency department nurse checks his capillary blood glucose on a bedside device. The result simply says “high”, and is unrecordable.
```
What is the most appropriate initial management whilst awaiting further results?
A. IV antibiotics
B. IV sodium bicarbonate
C. IV fluids
D. IV hydrocortisone
E. IV insulin
```
C. IV fluids
This patient is most likely in DKA. The local DKA protocol should be followed in this patient.
The most important initial management for patients with DKA is rehydration by IV fluids. They are more likely to die of dehydration rather than hyperglycaemia. Rehydration with IV fluids will help bring down the blood glucose even before insulin is started, and will help correct the acidosis. It is important to closely monitor potassium as this can drop very quickly in patients with DKA.
DKA Treatment
Follow local treatment protocols:
IV fluid resuscitation with normal saline (e.g. 1 litre stat, then 4 litres with added potassium over the next 12 hours)
Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour)
Closely monitor serum potassium and correct as required
Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)
Monitor blood ketones (or bicarbonate is ketones unavailable)
Monitor fluid balance
Treat underlying triggers (e.g. sepsis)
Establish the patient on their normal subcut insulin regime prior to stopping the insulin and fluid infusion!
190
```
Which of the following would you expect to find in a patient with Conn’s syndrome?
A. Hypocalcaemia
B. Hypomagnesaemia
C. Hyperkalaemia
D. Hyponatraemia
E. Hypermagnesaemia
F. Hypokalaemia
```
F. Hypokalaemia
Aldosterone causes sodium reabsorption and potassium and hydrogen excretion at the kidneys. Therefore, you expect to find hypokalaemia, hypertension (due to excessive sodium – serum sodium is usually the higher end of normal) and alkalosis.
191
A 45 year old, normally fit and well lady presents with polyuria and polydipsia. On examination she appears dehydrated. Her blood sugar and other blood tests are normal.
What is the most appropriate next step in investigating this patient?
A. Oral glucose tolerance test
B. Dexamethasone suppression test
C. Long synacthen test
D. Short synacthen test
E. Fluid deprivation and ADH stimulation test
E. Fluid deprivation and ADH stimulation test
This patient may have diabetes incipidus. A fluid deprivation and ADH stimulation test would be the most appropriate investigation to confirm the diagnosis and distinguish between a central or a nephrogenic cause.
Fluid deprivation test (desmopressin (ADH) stimulation test).
Method:
Fluid deprivation (no fluids) for 8 hours
Urine osmolality is measured and synthetic ADH is given,
8 hours later urine osmolality is measured again
If urine osmolality is low after deprivation and then high after ADH, this indicates cranial diabetes insipidus.
If urine osmolality is low after deprivation then low after ADH, this indicates nephrogenic diabetes insipidus
If urine osmolality is high after deprivation, this suggests primary polydipsia (the patient is drinking too much water for any reason other than DI)
192
TPA - what does it do? what are some examples
tissue plasminogen activator
Its primary function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.
alteplase
reteplase
193
43 year old black diabetic women would be on what antihypertensive
candesartan - angiotensin receptor blocker
194
74 year old woman with uncontrolled diabetes already on amlodipine and ramipril would be on what antihypertensive
indapamide
195
76 year old diabetic man would be on what antihypertensive
ramipril
| ace inhibitor
196
84 year old women would be on what antihypertensive
amlodipine
| calcium channel blocker
197
<55 or non black patient would be put on what antihypertensives initially
```
A (ACE inhibitors, i.e. ramipril)
or B (beta blockers i.e. bisoprolol)
```
198
>55 or black would be put on what antihypertensives initially
C (calcium channel blocker, i.e. amlodipine)
199
What blood test is most important in a patient who is starting and ACE inhibitor?
a. G6PD
b. FBC
c. U&E
d. antiphospholipid antibodies
e. LFT
c. U&E
A kidney profile using U+Es blood test is most important prior to ACE inhibitors. U+E should be monitored prior to starting and regularly whilst titrating the dose upwards. One established on ACE inhibitors patients should have a minimum of yearly U+Es.
It is normal to see a small
200
first degree heart block
delayed AV conduction
| PR interval greater than 0.2 seconds
201
2:1 heart block
P waves remain normal
| QRS complex occurs after alternate P waves
202
Wencebackes phenomenon
(Mobitz Type 1)
Increasing PR interval until the P wave no longer conducts to ventricles.
Culminates in absent QRS complex after a P wave.
203
Other than atrial fibrillation, what can cause an irregularly irregular pulse?
a. Wolff-Parkinson-White Syndrome
b. Mobitz Type 1
c. Ventricular ectopics
d. Supraventricular tachycardia
e. Mobitz Type 2
c. ventricular ectopics
204
Select the pathology from the list below that would be best heard by auscultation using the stethoscope bell rather than the diaphragm?
a. Aortic stenosis
b. Mitral regurgitation
c. Mitral stenosis
d. Third heart sound
e. Atrial fibrillation
c. mitral stenosis
Auscultate with the bell to better hear low pitched sounds (think of a kid screaming with their diaphragm vs a church bell giving a deep “bong”).
Mitral stenosis causes a low pitched rumbling murmur.
205
thrombin is regulated by?
anti thrombin and activated protein C system
206
what is vWF regulated by?
ADAMTS13
207
levosimendan drug?
```
positive inotrope ( increase contractility)
calcium sensitiser (mechanism)
```
208
A 60-year-old man who has no other medical problems presents with a one-week history of intermittent, colicky pain in his right groin. In the past 24 hours, he has started to feel feverish and has noticed blood in his urine.
Which organism is associated with this clinical syndrome?
a) Enterococcus faecalis
b) Escherichia coli
c) Proteus mirabills
d) Pseudomonas aeruginosa
e) Staphyloccus aureus
c) Proteus mirabills
Gram-negative bacterium which is well-known for its ability to robustly swarm across surfaces in a striking bulls'-eye pattern. Clinically, this organism is most frequently a pathogen of the urinary tract, particularly in patients undergoing long-term catheterization
209
Amitriptyline belongs to a class of drug called tricyclic antidepressants (TCAs) and is commonly used for migraine prevention.
What is the main mechanism of action of Amitriptyline?
a) Inhibits carbonic anhydrase activity
b) Inhibits glutamate pathway
c) Inhibits sodium and calcium channels
d) Inhibits the GABA pathway
e) Inhibits the reuptake of noradrenaline and serotonin
e) Inhibits the reuptake of noradrenaline and serotonin
210
A 45-year-old male patient is admitted to hospital suffering with a severe headache. He is currently being treated for major depressive disorder and has received electroconvulsive shock therapy, and is currently on antidepressant medication. Prior to feeling ill, the patient had been out for a meal at a restaurant, and the doctor suspects he may be experiencing an interaction because of his medication and something he has eaten. On taking his blood pressure, the doctor diagnoses a hypertensive crisis.
Which class of antidepressant is the most likely to have been prescribed?
a) Monoamine oxidase inhibitor
b) Receptor-blocking antidepressant
c) Selective noradrenaline re-uptake inhibitor
d) Selective serotonin re-uptake inhibitor
e) Tricyclic antidepressant
```
d) Selective serotonin re-uptake inhibitor
or MAOI (A) because that's worse
```
Tyramine-Rich Food Products:Interaction between sertraline and tyramine-rich foods like cheese, milk, beef, chicken liver, meat extract, avocados, bananas, canned figs, soy beans and excess chocolate can result in a sudden and dangerous increase in blood pressure.
211
A 75-year-old male patient has been admitted with Chronic Obstructive Airways Disease (COPD). He gives consent for you to perform a respiratory examination.
Which of the following clinical signs best indicated COPD?
a) Ankle oedema
b) Coarse crepitations at the left base
c) Dullness to percussion at the right base
d) Fine bi-basal crepitations
e) Hyperinflated chest
e)hyperinflated chest
212
A 60-year-old male smoker with hypertension presented with chest pain. This occurred at rest and was associated with sweating and nausea. He had an ECG in the emergency department.
Which of the following statements is true regarding the 12 lead ECG?
a) Acute myocardial infarction results in ST-segment depression in leads II, III and aVF
b) An anterior myocardial infarction will cause ST-segment depression in leads V1-V4
c) Anterior (V1-V4) ST-segment changes are caused by ischaemia in the circumflex artery territory
d) A right coronary artery occlusion will cause ST-segment elevation in leads II, III and aVF
e) In the setting of acute myocardial infarction, the ECG is immediately abnormal at the onset of chest pain
d) A right coronary artery occlusion will cause ST-segment elevation in leads II, III and aVF
213
The formation of memory immune responses is the objective of vaccination. Immunological memory is predominantly the function of which type of immune cells?
a) Cells bearing pattern-recognition receptor molecules
b) Cells of the adaptive immune system
c) Macrophages
d) Natural Killer (NK) cells
e) Neutrophils
b) Cells of the adaptive immune system
214
```
A 6-month-old eastern Asian boy is taken to the baby clinic for a routine check. While the mother changes his nappy, the paediatric nurse notices a large dark blue-grey spot on his left buttock. The boy’s growth is regular, and he is happily interactive with his mother. The woman mentions that her elder child also presented with a similar spot which disappeared a few years after birth.
What is the most likely diagnosis?
a) Cafe au lait spot
b) Congenital nevus
c) Mongolian spot
d) Superficial bruise
e) Vascular birthmark
```
c) Mongolian spot
215
A 55-year-old man presents to his general practitioner (GP) with lower chest pain for six weeks, which is unrelated to exertion and worsened at mealtimes. He smokes heavily and regularly consumes >30 units of alcohol per week. Over-the-counter antacid treatment had eased his discomfort initially but is no longer effective. His GP thinks that cardiac chest pain is unlikely and suspects a diagnosis of peptic ulcer disease. Regarding this suspected diagnosis, which of the statements below is correct?
a) Abdominal pain in peptic ulcer disease is typically constant, unremitting, and generalised
b) Abdominal pathology is a rare cause of chest pain
c) Common complications of peptic ulcer disease include bowel obstruction
d) Non-steroidal anti-inflammatory drugs may induce peptic ulceration
e) Smoking and alcohol consumption are the commonest causes of peptic
ulceration
d) Non-steroidal anti-inflammatory drugs may induce peptic ulceration
216
A 55-year-old man presents to A&E with sudden onset severe pain, swelling and redness in his left knee. He does not feel unwell and is apyrexial. He does not have any past medical history apart from being overweight and hypertensive. His left knee is aspirated, and the fluid is examined at the bedside for colour and clarity - see below: (yellow aspiration and cloudy)
What is the most likely cause for his swollen joint?
a) Gout
b) Haemarthrosis
c) Osteoarthritis
d) Psoriatic arthritis
e) Septic arthritis
d) psoriatic arthritis
- because it is inflammatory
non inflammatory = clear, slightly yellow
inflammatory = not clear, very yellow/orange
septic = orange/red
haemorrhage = red
gout = yellow to milky
OA = yellow and clear
SLE = straw and clear
RA = yellow to green and cloudy
septic arthritis = grey or bloody and turbid (cloudy/thick)
217
a 21-year-old student participates in a clinical trial. What is the main purpose of a Phase 3 clinical trial?
a) Assessing effectiveness
b) Assessing efficacy
c) Assessing pharmacodynamics
d) Assessing pharmacokinetics
e) Assessing safety
e) Assessing safety
however ..Phase III clinical trials compare the safety and effectiveness of the new treatment against the current standard treatment. Because doctors do not yet know which treatment is better, study participants are often picked at random (called randomized) to get either the standard treatment or the new treatment.
so could be effectiveness but my best guess would be safety cuz duh
218
A 65-year-old man with a chronic pain syndrome has taken an overdose of amitriptyline. His 12 lead electrocardiogram shows a sinus tachycardia with pathological widening of his QRS complexes.
In addition to supportive measures, which one of the following antidotes should be administered?
a) Atropine
b) Intralipid
c) N-acetylcysteine
d) Naloxone
e) Sodium bicarbonate
e) Sodium bicarbonate
219
A drug is orally administered and is eliminated solely by hepatic metabolism to an inactive metabolite. Which one of the following would be likely to lead to a significant decrease in plasma half-life (t0.5) of the drug in a patient?
a) Co-administration of a drug that inhibits hepatic enzymes
b) Congestive heart failure
c) Decreased renal function
d) Increased thyroid function
e) Liver cirrhosis
d) increased thyroid function
feeling behind this is because the others would inhibit the metabolism and so the half life would increase because it is not getting metabolised whereas in the increased thyroid then the metabolism would increase and so the drug would be metabolised much quicker
220
A 65-year-old male attends the Bristol Heart Institute complaining of acute onset chest pain with evidence of anterior ST-elevation myocardial infarction. He is transferred directly to the cath lab, and the left anterior descending artery is recanalised with inflation of a balloon. An intravascular imaging probe is placed down the coronary to guide stent selection.
Which underlying plaque defect is most likely to be observed?
a) Coronary spasm
b) Endothelial cell plaque erosion
c) Eruptive calcific nodule
d) Fibrous cap plaque rupture
e) Intima-medial dissection/separation
D) fibrous cap plaque rupture
Results. Among 1241 patients, 607 patients (48.9%) were classified as plaque rupture, 477 patients (38.4%) as plaque erosion, and 157 patients (12.7%) as calcified plaque. In 648 STEMI patients, 385 (59.4%) patients had plaque rupture and 193 (29.8%) patients had plaque erosion
221
Coombs test
The Coombs test checks your blood for antibodies that attack red blood cells. You might also hear it called an antiglobulin test or red blood cell antibody screening. Not everyone's red blood cells are alike. Your immune system will make antibodies if it finds ones that don't match yours
conditions that may lead to a positive direct Coombs test include: autoimmune hemolytic anemia, when your immune system reacts to your red blood cells. chronic lymphocytic leukemia and some other leukemias. systemic lupus erythematosus, the most common type of lupus.
222
```
A 30-year-old woman has recent tiredness and jaundice. She is found to have a normocytic anaemia with a high reticulocyte count, high LDH and raised bilirubin (other liver function tests are normal). A blood film shows spherocytes, polychromasia, and the coombs test is positive. She has never had a transfusion.
What is the likely diagnosis?
a) Autoimmune haemolytic anaemia
b) G6PD deficiency
c) Liver disease
d) Microangiopathic haemolytic anaemia
e) Thalassemia
```
a) Autoimmune haemolytic anaemia
223
A 19-year-old female presents to her GP with excessive anxiety and worry that impairs her social life and impacts her studies.
Which of the following are required for a diagnosis of generalised anxiety disorder according to DSM-5?
a) Irritability
b) Sleep disturbance
c) Symptoms are present in at least one setting, e.g. work
d) Symptoms have lasted for 6 months or more
e) The person can control the worry
d) symptoms have lasted for 6 months or more
The DSM-V diagnostic criteria for GAD include: At least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk, and causes distress, or impairment.`
224
```
A 26-year-old lady sees her GP with lethargy. She has no significant past medical history. A full blood count is performed, and ferritin is low:
Hb 78g/L (normal range 115-165g/L) MCV 77fl (normal range 80-100fl)
What treatment would you recommend?
a) Intravenous iron replacement
b) Oral iron replacement
c) Transfuse 1 units of red blood cells
d) Transfuse 2 units of red blood cells
e) Vitamin B12 replacement
```
b) oral iron replacement
low ferritin suggests iron deficient
microcytic anaemia = ITA with the I being iron deficient
oral is usually given over IV
(Iv given when patient cannot tolerate oral)
225
How is the spread of a virus from a localised epithelial cell infection to a systemic
infection determined?
A. By the presence or absence of a mucus layer
B. By the presence of macrophages at the site of infection
C. By the site of viral exit from the cell
D. By the site of viral replication in the cell
E. By whether the virus causes an acute or persistent infection
C. By the site of viral exit from the cell`
226
What factor is most likely to affect serum creatinine measurement?
a) Bone mass
b) Calcium uptake
c) Fat
d) Muscle mass
e) Vitamin D
d) muscle mass
227
What is the half-life (t0.5) of a drug in a patient where the Clearance is 5 litres/hour, and the Apparent Volume of Distribution in the patient is 60 litres?
a) 3.4 minutes
b) 8.3 minutes
c) 12 minutes
d) 498 minutes
e) 720 minutes
b) 8.3 mins
t½ = 0.693 × Vd /CL
228
a 25-year-old female with a BMI of 32kg/m2 presented with gradually increasing headaches and blurred vision. Fundoscopy revealed bilateral papilloedema. Intracranial imaging is normal, and she undergoes a lumbar puncture which demonstrates an elevated opening pressure of 35 cm H2O (normal <25 cm H2O) and otherwise normal constituents.
What is the best long-term management option for this condition?
a) Commence Acetazolamide 250 mg BD and titrate the dose
b) Commence Topiramate 25 mg OD and titrate the dose
c) Referral to neurosurgery for ventriculoperitoneal shunt surgery
d) Regular lumbar punctures to reduce intracranial pressure
e) Sustained weight loss of 5-10%
e) sustained weight loss of 5-10%
229
A 30-year-old woman is brought to the emergency department with a productive cough, breathlessness and fever. She is mildly confused. On examination, she has central cyanosis, and bronchial breathing is auscultated over her left lower lung lobe. Analysis of a sample of arterial blood gas reveals a partial pressure of oxygen of 8 kPa (Reference range 11-13 kPa) and a partial pressure of carbon dioxide of 4 kPa (Reference range 4.7-6.7 kPa). Treatment is commenced for a community-acquired pneumonia (CAP). Which one of the following most accurately describes her physiological state?
a) Histotoxic hypoxia
b) Hypoxaemia
c) Hypoventilation
d) Stagnant hypoxia
e) Type II respiratory failure
b) hypoxaemia
not histotoxic because not poisoned
could be hyperventilating because she has reduced o2 and co2
not stagnant because not HF
type 1 resp failure not type 2
230
```
A 5-year-old child presents with a 4-day history of a 2 cm yellow golden-crusted lesion on the cheek.
What is the most likely diagnosis?
a) Atopic dermatitis
b) Cold sore
c) Erythema Infectiosum
d) Impetigo
e) Infantile acne
```
d) impetigo
231
side effects of LMWH
uncontrolled bleeding
loss of bone strength
elevated liver enzymes
heparin induced thrombocytopenia
232
How to differentiate between a ruptured bakers cyst and a DVT
The only clinical sign differentiating ruptured Baker's cyst from DVT is bruising below the malleolus. This results from drainage of inflamed synovial fluid dissecting the calf structures to the foot. Discoloration of the malleolus area should therefore alert the physician to the diagnosis of ruptured Baker's cyst
233
antidote for benzodiazepine overdose
flumazenil
234
antidote for carbon monoxide poisoning
oxygen
235
antidote for warfarin
vitamin K
236
antidote for morphine overdose
naloxone
237
antidote for methanol overdose
fomepizole
238
how long after the ingestion of an overdose of paracetamol should the paracetamol levels in the blood be checked
4 hours
239
how do you calculate the anion gap
| and the reference range
anion gap = (sodium + potassium) - (bicarbonate + chloride)
| reference range of 12-16
240
antidote for ethylene glycol
ethanol and fomepizole
241
equation for osmolality
osmolality = 2(sodium+potassium) +urea + glucose
242
describe a paracetamol overdose (how they might present)
may be no symptoms despite large overdose
otherwise, nausea and vomiting, abdominal pain, drowsiness
may see metabolic acidosis
later: hepatocellular necrosis
243
describe an aspirin overdose (how they might present)
| and management
nausea and vomiting, tinnitus, flushing, hyperventilation
respiratory alkalosis or metabolic acidosis (high anion gap)
management: no antidote - just supportive measures
244
describe SSRI overdose (how they might present)
| and management
neuromuscular - tremor, hyperreflexia, clonus, myoclonus, rigidity
autonomic dysfunction - tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea,
altered mental state - agitation, confusion, mania
management - no antidote, supportive measures, stop serotenergic drugs
245
describe TCA overdose (how they might present) and management
serotonin syndrome
anticholinergic symptoms: dry mouth, tachycardia, dilated pupils, cerebral toxicity and cardiac arrhythmias
management - monitor ECG and check electrolyte levels, general supportive measures
246
describe opiate overdose (how they might present) and management
respiratory depression, pinpoint pupils, coma
management - naloxone: short acting, so several doses/infusions may be required
247
describe benzodiazepine overdose (how they might present) and management
confusion, slurred speech, ataxia, drowsiness, hyporeflexia
management - flumazenil on expert advice (unlicensed)
248
describe what is meant by positive and negative symptoms in schizophrenia
While positive symptoms reflect an excess or distortion of normal function (eg, delusions, hallucinations, disorganized behavior), negative symptoms refer to a diminution or absence of normal behaviors related to motivation and interest (eg, avolition, anhedonia, asociality) or expression (eg, blunted affect, alogia).
249
what is the mechanism of action of the drug apixaban?
a) Antiplatelet
b) Factor Xa inhibitor
c) Fibrinolytic
d) Thrombin inhibitor
e) Vitamin K antagonist
b) direct factor xa inhibitor
250
Hypercholesterolaemia is frequently managed with statins, e.g. Simvastatin or Atorvastatin. What is the mechanism of action of a statin?
a) Binds cholesterol and enables it to be excreted
b) Increases HDL production
c) Inhibits HMG CoA reductase
d) Inhibits lipoprotein lipase
e) Prevents the dietary absorption of cholesterol
c) inhibits HMG CoA reductase
251
What test is performed in clinical medicine to check how well the kidneys are working?
a) Erythropoietin synthesis
b) Glomerular filtration rate (GFR)
c) Sodium balance
d) Vitamin D synthesis
e) Water balance
b) glomerular filtration rate (GFR)
252
A 24-year-old male presents to his GP with thirst and polyuria. Which one of the following is the most important information to find out next?
a) Ask about his past medical history
b) Ask if he has dysuria (pain on passing urine)
c) Ask if he has lost any weight
d) Assess his alcohol intake
e) Assess his ideas, concerns and expectations
c) ask if he has lost any weight
| thinking cancer as a red flag??
253
A 42-year-old man presents with sudden onset sharp chest pain, which is worse when lying flat and improves sitting forwards. His resting ECG shows ST-segment elevation. What is the most likely diagnosis?
a) Acute coronary syndrome
b) Aortic dissection
c) Peptic ulcer
d) Pericarditis
e) Pulmonary embolism
d) pericarditis
worse on lying flat better on sitting
254
What cell type plays an important role in the immune barrier function of skin by detecting pathogen invasion via activation of pattern recognition receptors?
a) Endothelial cells
b) Fibroblasts
c) Keratinocytes
d) Melanocytes
e) Neutrophils
c) keratinocytes
255
What is the most common cause of chronic renal failure in the UK?
a) Diabetes
b) Glomerulonephritis
c) Hypertension
d) Polycystic kidney
e) Pyelonephritis
a) diabetes
256
When following are correct?
measuring blood pressure using a manual sphygmomanometer, which of the
a) If the cuff size is too large, the blood pressure reading will be falsely raised
b) If the pulse is irregular, you should use an automatic blood pressure monitor
c) Place your stethoscope over the radial artery to listen for sounds
d) The first sound heard equates to the systolic blood pressure
e) The patient’s arm should be relaxed, hanging by their side
d) the first sound heard equates to the systolic blood pressure
257
Following intravenous bolus administration of a lipid-soluble drug such as thiopentone or fentanyl, the brain concentration of a drug increases very rapidly and then decreases quite rapidly.
What is the main reason for this decrease?
a) The drug is actively transported into the brain
b) The drug is rapidly metabolised in the brain
c) The drug redistributes from brain to blood and then into fat and muscle
d) The drug redistributes from brain to blood and is then rapidly eliminated from the
body
e) These drugs have short half-lives
c) the drug redistributes from brain to blood and then into fat and muscle
lthough thiopental has a relatively long half-life of ∼ 9 hours, it is a short-acting, highly lipid-soluble compound. Its short duration of action is due to redistribution into muscle and eventually fat Marshall and Longnecker (1996).
258
A 45-year-old woman presents to her GP with a change in a mole, it has become darker over the past few months. She is concerned it could be a skin cancer. Which of the following points from the history and examination is of most concern for a malignant melanoma?
a) The diameter of the lesion is 3mm
b) The lesion has a regular border
c) The lesion has been present for more than 2 years
d) The lesion is raised
e) The lesion is unevenly pigmented
e) the lesion is unevenly pigmented
259
A 63-year-old male is due to be discharged following admission for acute coronary syndrome 4 days ago. He gives consent for you to practise a cardiovascular examination.
When auscultating the heart sounds, which of the following is true?
a) Aortic regurgitation produces an ejection systolic murmur
b) Aortic stenosis produces a diastolic murmur
c) Mitral stenosis is best heard with the bell of the stethoscope at the apex
d) The first heart sound (S1) is produced by the closure of the pulmonary and aortic valves
e) The mitral valve is best listened to in the 2nd left intercostal space
c) mitral stenosis is best heard with the bell of the stethoscope at the apex
260
In peripheral neuropathy, which of the following statements is true?
a) Burning pain is often perceived in denervated territories
b) Joint position sense is preserved
c) The loss of the stretch reflex is a useful marker of severity
d) The sensory loss starts centrally and progresses to involve the peripheries
e) There is sparing of autonomic nerve fibres
c) the loss of the stretch reflex is a useful marker of severity
261
an 83-year-old man was admitted with a 3-week history of increasing breathlessness, night sweats and weight loss. He had a history of urinary tract infections and intermittent self-catheterisation. A vegetation was seen on his mitral valve on a transthoracic echocardiogram.
What is the most likely cause of his infective endocarditis?
a) Candida albicans
b) Coxiella burnetii
c) Enterococcus faecalis
d) Escherichia coli
e) Staphylococcus aureus
c) Enterococcus faecalis
Enterococci, most often Enterococcus faecalis, cause 5%-20% of cases of infective endocarditis (IE). Enterococcal IE is usually a disease of older men, and the most frequent source of infection is the genitourinary tract.
262
A 52-year-old man presents with sudden onset of his worst-ever headache in the occipital region with neck stiffness whilst mowing the lawn. What would be the most helpful first-line investigation you could request?
a) ABG
b) CT head scan
c) Lumbar puncture
d) MRI brain scan
e) Urinalysis
b) CT head scan
263
Enthesitisis is a hallmark feature of which rheumatic disease?
a) Gout
b) Rheumatoid arthritis
c) Polymyalgia rheumatica
d) Psoriatic arthritis
e) Systemic lupus erythematosus
d) psoriatic arthritis
264
Which of the following is not caused by asbestos exposure?
a) Chronic obstructive lung disease
b) Mesothelioma
c) Pleural thickening
d) Pleural effusion
e) Pulmonary fibrosis
a)COPD
Asbestos exposure does not directly cause Chronic Obstructive Pulmonary Disease (COPD), but it can increase a person's risk of developing the condition. COPD may weaken the lungs, making a person more susceptible to additional asbestos-related diseases.
265
A 26-year-old woman taking the combined oral contraceptive pill experiences new headaches, which gradually build up over the course of 2 days and then her first seizure. What would be the most likely diagnosis for this woman?
a) Brain tumour
b) Central venous sinus thrombosis
c) Meningitis
d) Pre-eclampsia
e) Subarachnoid haemorrhage
b) Central venous sinus thrombosis
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A 5-year-old child falls and scratches herself and within a few days has an enlarged lymph node in the area draining the abrasion due to the reaction of the cells in the lymph node to the foreign antigen that entered the skin.
How is the antigen transported to the lymph node?
a)Via B cells
b)Via complement receptors
c)Via dendritic cells
d)Via T cells
e)Via toll-like receptors
c) via dendritic cells
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103) A 28-year-old woman presents to her GP with freckles on her back. Her aunt lived in Australia and had a history of skin cancer.
What is the best sun protection advice for her?
a) If she doesn’t want to cover up, she should apply sunscreen
b) It is safe to use sunbeds unless you have skin type 1 (always burns, never tans)
c) She should apply sun cream when the sun is at its most intense, around midday
d) She should select sun cream with SPF of 30 or above and UVA protection of 4 or
5 stars
e) The factor on a sun cream indicates the UVA protection
d) She should select sun cream with the SPF of 30 or above and UVA protection of 4 or 5 stars
268
Jane is a 24-year-old woman in the emergency department. Her partner reports that she has not slept in 3 nights and is behaving oddly. This is a transcript of your conversation.
You: How are you?
Jane: “fantastic, fantastic, over the moon, like a cow with a hot air balloon, lots of balloons and cake too, it’s a party, happy birthday to you. My birthday’s in March, that’s why I like to walk, left, right, left, right, left, right, attention!, are you paying attention?”
How would you best describe this form of thought in the mental state exam?
a) Euthymia
b) Disorientated
c) Flight of ideas
d) Increased rate
e) Mania
e) mania
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106) A 20-year-old woman presents to her GP with 3 days of stinging when she is passing urine and urinary frequency. She is systemically well, with no fever, abdominal pain or loin pain.
What is the most likely diagnosis?
a) Diabetes mellitus
b) Ectopic pregnancy
c) Lower urinary tract infection
d) Ovarian cyst
e) Pyelonephritis
```
c) lower urinary tract infection
270
For drug-induction of hepatic drug metabolism, what is most likely to happen to the half-life, Volume of Distribution and clearance whose metabolism is induced?
a) Half-life decreased, Volume of Distribution unchanged, Clearance increased
b) Half-life decreased, Volume of Distribution unchanged, Clearance decreased
c) Half-life increased, Volume of Distribution decreased, Clearance increased
d) Half-life increased, Volume of Distribution increased, Clearance increased
e) Half-life unchanged, Volume of Distribution increased, Clearance decreased
a) half life decreased, volume of distribution unchanged, clearance increased
271
A 65-year-old man presents to his GP with lower abdominal pain for 4 weeks. He reports a trend towards looser stool for the last 8 weeks and has been noticing blood mixed with his stool for the last 4 weeks. He reports no weight loss and no foreign travel. Abdominal and rectal examination are carried out. He has normal observations.
What is the most appropriate investigation for this man?
a) Colonoscopy
b) CT abdomen
c) Gastroscopy
d) Stool sample for microscopy, culture and sensitivity
e) Ultrasound abdomen
a) colonoscopy
272
A 70-year-old man is known to have chronic congestive cardiac failure (CCF). His main symptom is fatigue. On examination, he has a raised JVP and pitting oedema of both legs. One of the compensatory responses to the decreased cardiac output is increased activity of the renin-angiotensin-aldosterone system (RAAS).
Which one of the following best describes the effects of the RAAS upon cardiac preload and afterload?
a) Preload ↑ Afterload ↔
b) Preload ↓ Afterload ↑
c) Preload ↑ Afterload ↓
d) Preload ↓ Afterload ↓
e) Preload ↑ Afterload ↑
e) Preload ↑ Afterload ↑
273
A 24-year-old comes to her GP with abdominal pain and constipation. Her bowel frequency has dropped to once a week. When she does pass stool, it is hard and difficult to pass. Once she passes, stool her abdominal pain briefly improves.
What would be an appropriate first-line therapy?
a) Acetylcholine
b) Prednisolone
c) Psyllium
d) Reduce fibre intake
e) Reduce fruit intake
c) psyllium
The soluble fiber found in psyllium husks can help lower cholesterol. Psyllium can help relieve both constipation and diarrhea, and is used to treat irritable bowel syndrome, hemorrhoids, and other intestinal problems. Psyllium has also been used to help regulate blood sugar levels in people with diabetes.
274
Someone has angular stomatitis and koilonychia
| what do we think they have
iron deficient anaemia
275
what is staphylococcal aureus eczema
staphylococcus aureus (Staph. aureus) is the bacterium that is most commonly responsible for secondary infection of eczema. It is often associated with hair follicle infections (folliculitis), boils and abscesses. 'Impetiginized eczema' is another label or name given to eczema infected with Staph.
276
describe what guttate psoriasis looks like
a type of psoriasis that shows up on your skin as red, scaly, small, teardrop-shaped spots. It doesn't normally leave a scar. You usually get it as a child or young adult. Less than a third of people with psoriasis have this type. It's not as common as plaque psoriasis.
277
what is seborrheic dermatitis
is a common, chronic, or relapsing form of eczema/dermatitis that mainly affects the sebaceous gland-rich regions of the scalp, face, and trunk.
dandruff is the uninflamed form of it
278
what is cellulitis caused by
The most common bacteria causing cellulitis are Streptococcus pyogenes (two-thirds of cases) and Staphylococcus aureus (one third).
279
what is lupus vulgaris
progressive and persistent form of cutaneous TB
Small sharply defined reddish-brown papules merge into plaques with a gelatinous consistency (called apple-jelly nodules)
Lesions persist for years, leading to disfigurement and sometimes skin cancer
280
What does HPV (human papilloma virus) cause?
herpes/warts
281
How is shingles different to chickenpox?
It will have a dermatomal distribution and does not cross the midline
282
at what layer of the skin are fungal infections
stratum corneum
| most on surface of the skin so do not cause systemic upset
283
What is pityriasis versicolor?
Overgrowth of commensal yeast
Common cause of dandruff and seborrhoeic dermatitis
Versicolour as with a tan it appears white
No tan = brown
