Formative 1

Question 1

urge inconctinence initial mx

Answer 1

PO oxybutynin

Question 2

elderly W - mild constipation for 6m - calcium high - phosphate low - PTH high

Answer 2

Primary hyperparathyroidism

-common in older F pts - sx mild or absent

Question 3

icidental finding of asympt AF in young fit 52y man, HR 72, Mx

Answer 3

NONE

• rate controlled
• no need for rhythm control
• no need for anticoagulation as CHADSVASC is 0

Question 4

epistaxis 2hours, 80Y man, bleeding site visible in anterior nasal cavity, not stopped despite compression, hx HTN

Answer 4

mx with silver nitrate cautery

NB.anterior packing is for profuse bleeding from sites tha are difficult to visualise

Question 5

48h post-sigmoid colectomy + anastomosis - abdo distension, no flatus, tenderness over wound but no RT or guarding, obs stable, what is the initial mx (+ dx)

Answer 5

post-op PARALYTIC ILEUS (due to handling of bowel, it goes to sleep)
-Mx = NBM + NGT

Question 6

23Y MSM - painful swelling in groin and pain when opening bowels + inguinal lymphadenopathy + perianal ulcer

Answer 6

LGV - endemic in MSM population

Question 7

25Y man vomits large am of blood - OGD: deep ulcer in posterior wall at the junction of the 1st + 2nd parts of the duodenum - bleeding vessel at the base, what vessel?

Answer 7

GASTRODUODENAL ARTERY

-runs posterior to the 1st and 2nd parts of the duodenum and may be a source of major haemorrhage in PUD

Question 8

PCOS bloods

Answer 8

increased ratio of LH:FSH with oligomenorrhoea and overweight BMI of 29

• PCOS most likely
• mild elevation in prolactin is sometimes seen in PCOS

Question 9

A 75 year old man is admitted with WEAKNESS in his legs. He has a squamous cell lung C tx by radiotherapy 18 months previously.
He is cachetic. He has 4/5 power in hip flexion and knee flexion bilaterally.
Sensation and reflexes are normal, and sphincter function is preserved. His BMI
is 17 kg/m2. MRI spine shows destructive bony lesions of T12 and L2–L4 vertebral body
what tx is most likely to preserve neurological FTN?

Answer 9

Hx + exam - suggest SPINAL CORD COMPRESSION
He has multiple lesions + is too frail for surgery
Mx - RADIOTHERAPY is the best tx option

Question 10

34Y W headaches for 3m - BP 180/92 - FHx HTN at yg age - Fundoscopy normal

• sodium normal - potassium HIGH
• Plasma aldosterone: renin ration RAISED
• DX?

Answer 10

Primary hyperaldosteronism = Conn’s syndrome

Question 11

2d visible hameaturia - urine + for blood + protein - 2d ago had tonsillitis - cause?

Answer 11

IgA nephropathy - few days after URTI causes haematuria
vs
post-inf GN lag of 2 weeks before haematuria

Question 12

duodenal ulcer vs gastric

Answer 12

DUODENAL - more common -epigastric pain WHEN HUNGRY, RELIEVED BY EATING

GASTRIC - epigastric p WORSENED BY EATING

Question 13

What clinical feature is SPECIFIC for inflammatory back pain

Answer 13

-Inflammatory back pain (IBP) is typically IMPROVED WITH ACTIVITY + NOT RELIEVED BY REST, as opposed to mechanical pain which is worse with activity and is relieved by rest
-IBP can wake the pt in the early
hrs of the AM + sacroiliitis 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.

Question 14

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
- what is best initial tx of these options:
A. Arthroscopic joint washout
B. Intravenous flucloxacillin
C. Oral allopurinol
D. Oral naproxen
E. Oral prednisolone

Answer 14

E = oral prednisolone

• FOR ACUTE GOUT - NSAIDs (CI due to CKD stage 4) , Colchicine (not an option) , IA or Oral steroids
• allopurinol doesn’t help acute attacks

Question 15

34Y M - pain in right shoulder + upper arm - 6wks - worsens when elevating arm above head, pain on abduction of R shoulder, worse with arm in int rotation + when abduction is resisted
-dx + next step in mx

Answer 15

Painful arc of ABDUCTION between 60-120 degreees = Dx = Supraspinatus tendinopathy = Rotator Cuff Injury

• no ix required
• mx in primary care with home exercises + physio

Question 16

Adhesive Capsulitis (Frozen shoulder)

Answer 16

common in middle age + diabetics

• painful stiff mvmnts
• limited mvmnts in ALL directions, with loss of EXT ROTATION + ABDUCTION in 50% pts

Question 17

pt confused and agitated - recognised to be dying

dx = terminal restlessness

Answer 17

Midazolam PRN SC injections or continuous SC infusions

Question 18

early AD on MRI brain changes most likely found where

Answer 18

TEMPORAL LOBE

Question 19

TCA OD - 4H ago - HR 105, BP 95/40, Drowsy, dilated pupils, QRS prolongation

Answer 19

SODIUM BICARB is the tx of choice in pts with prolonged QRS complexes after a TCA overdose

Question 20

76Y M had an AP resection for a low rectal carcinoma

• hx of severe COPD + HTN
• what is the best form of post op analgesia initially

Answer 20

EPIDURAL ANALGESIA

• can be topped up and titrated where spinal cannot (catheter is removed)
• for major abdo surgery with resp disease AVOID OPIODS

Question 21

A researcher is seeking to examine whether long-term mobile phone use is
linked to acoustic neuroma risk. The information on mobile phone usage is
collected from participants with acoustic neuroma and a comparable group of
participants without acoustic neuroma, selected from the general practice
register
-what type of study design is this

Answer 21

CASE-CONTROL STUDY

Question 22

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.
Ix:
Urinary albumin: creatinine ratio 42 mg/mmol (<3.5)
eGFR 43 mL/min/1.73 m2
(>60)
what Mx?

Answer 22

DIabetes trumps everything - so get them on an ACEi
-also there is good evidence for RENAL FTN
PROTECTION in diabetic nephropathy with ACE-1 in addition to its hypertensive
properties.

Question 23

A 70 year old man has dry cough and breathlessness on exertion for the past 3
months. He has lost 4 kg in 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.
-what is the dx + what is the best Ix

Answer 23

PULMONARY FIBROSIS as a Cx of Amiodarone therapy

• high resolution CT
• pt has cough + dyspnoea
• FEVER + REACTIVE BLOOD CHANGES (WCC + ESR incr) not uncommon
• HRCT confirms interstitial lung disease

Question 24

delirium tremens features

Answer 24

confusion, visual hallucinations, tachycardia + pyrexia on bg of heavy alcohol use
-normally occurs on reduction or abstinence

Question 25

A 61 year old woman is admitted with 2 days of confusion. She has a history of
hypertension and takes nifedipine. She smokes 20 cigarettes per day. She is
confused but has no focal neurological deficit. Her pulse rate is 75 bpm, BP
139/87 mmHg and JVP 2 cm above the sternal angle.
Investigations:
Sodium 117 mmol/L (135–146)
Potassium 4.2 mmol/L (3.5–5.3)
Urea 1.9 mmol/L (2.5–7.8)
Creatinine 57 μmol/L (60–120)
Serum osmolality 252 mOsmol/kg (285–295)
Urine osmolality 585 mOsmol/kg (100–1000)
-what meechanism best explains hyponatraemia development

Answer 25

INCR WATER ABSORPTION IN CD
= SIADH
-hyponatraemia and inappropriately concentrated urine. ADH
-stimulates synthesis of AQP-2 in the apical membrane of the CD which promotes water absorption
-This leads to a DILUTIONAL HYPONATRAEMIA.

Question 26

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 CKD stage 3 and HTN. She is taking lisinopril and simvastatin. She has weakness of hip flexion bilaterally. There is no muscle or bony tenderness.
Ix:Calcium 2.1 mmol/L (2.2–2.6) LOW
eGFR 41 mL/min/1.73 m2
(>60)
ALP 230 IU/L (25–115) HIGH
PTH 14.5 pmol/L (1.6–8.5) HIGH
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

Answer 26

C - Serum 25-OH cholecalciferol
The clinical features suggest OM. She
has hypocalcaemia and proximal muscle weakness. The low serum calcium is not adeq explained by CKD
-SERUM Vit D would est the dx. 24 hr urinary calcium is sometimes performed in 1’ hyperparathyroidism but
not in a 2’ case such as this.
-The pres is not one of myositis + CK 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 dx features (unlike in children)