Formative 2

Question 1

asystole mx

Answer 1

epinephrine

Question 2

after a house fire, ox sats 100% but dull headache, what other parameter should you measure + why

Answer 2

Carboxyhaemoglobin

• CO inhalation is likely
• will not show on pulse oximeter as it is read as oxyhaemoglobin

Question 3

60Y M, 2d hx swollen painful r leg, hx HTN + ramipril

• venous duplex USS: thrombus in superficial femoral vein
• what other Ix is required and why

Answer 3

CT Abdo Pelvis

• pt has unprovoked DVT
• pts should be offered CT scan abdo + pelvis to help identify possible malignancy

Question 4

what meds do pts with mechanical heart valves require

Answer 4

aspirin + warfarin

• LMWH is used as bridging anti-coagulation but not long term
• no place for NOACs yet

Question 5

scale formation at sites of minor skin injuries, eg scratches or insect bites as they heal is typical of what condition

Answer 5

= koebnerisation

• typical of psoriasis
• can occur in vitiligo too

Question 6

After 8 hours of a water deprivation test, the serum osmolality is 308 mOsmol/kg (NR 285-295) and the urinary osmolality is 152 mOsmol/kg. (NR 100-1000)

• Following the administration of desmopressin, the serum osmolality is 286 mOsmol/kg and the urinary osmolality is 660 mOsmol/kg
• what is the next best Ix

Answer 6

CRANIAL DI

• after giving ADH –> urine osmolality INCREASES
• SO next best Ix looks for potential causes = MRI scan of pituitary

Question 7

A 30 year old woman has irregular periods, decreased libido and galactorrhoea.
Visual field examination is normal.
Ix: Prolactin: 5000 mU/L (100–500)
Pregnancy test: negative
MR scan of pituitary shows a 4-mm mass in the sella turcica.
what is the appropriate mx?

Answer 7

Cabergoline (dopamine agonist) = first line tx for micro and macro prolactinomas

Question 8

A 23 year old man is admitted to the acute surgical ward with appendicitis and
is prepared for theatre. Although he has not eaten for 24 hours, he has been
vomiting on and off all day.
what is the airway to protect him against aspiration?

Answer 8

ETT

-seals the trachea off + protects against aspiration

Question 9

32Y man hepatomegaly with 3cm liver edge - non smoker + drinks 16U / week

• hx of T2DM
• ALT high, Ferritin HIGH, CRP slightly raised

Answer 9

DM + hepatomegaly = HAEMACHROMATOSIS

-screening test = TRANSFERRIN SATURATION

Question 10

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
-Most appropriate next ix?

Answer 10

CXR to rule out other pathology then Wells score then CTPA (or V/Q scan) if PE likely or D-dimer if PE unlikely
-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 CXR to exclude other causes

Question 11

A healthy 23 year old man is scheduled to undergo an elective arthroscopy of his knee. He is to have a general anaesthetic for the operation and asks the pre-operative assessment nurse how long he needs to fast beforehand.
- Which are the most appropriate fasting times for clear liquids and solids respectively?

Answer 11

2H for CLEAR liquids, 6h for SOLIDS

• standard guidelines for elective pts with no problems affecting gastric emptying
• too long a period of fasting is unnecessary whilst residual solid food in stomach poses big risk of aspiration/asphyxiation

Question 12

A 28 year old woman presents to her GP with a neck lump that she noticed
incidentally when rubbing her neck.
There is a smooth, non-tender 1.5 cm mobile lump within the thyroid gland.
Investigations:
TSH 2.3 mU/L (0.3–4.2)
Free T4 17 pmol/L (9–25)
-what is next Ix?

Answer 12

US of neck

= for non-functional thyroid nodule you need US to clarify - FNA then may be indicated

Question 13

what is discrimination

Answer 13

Discrimination is the unjust or prejudicial

treatment of different categories of people.

Question 14

what is the mechanism of cocaine induced ACS

Answer 14

coronary artery spasm

Question 15

malaria mx

Answer 15

Artemisin based combination therapy (ACT) or chloroquine

Question 16

An 18 year old man, who was born in the UK, develops DROWSINESS and CONFUSION 2 days after returning from visiting his grandparents in Malawi. Over
the past week he has had recurrent episodes of high F.
Investigations:
Haemoglobin 92 g/L (130–175)
White cell count 3.2 × 109
/L (3.8–10.0)
Platelets 184 × 109
/L (150–400)
Blood film parasites visible
what is the most likely causative organism?

Answer 16

Malaria - specifically Plasmodium falciparum = most common and most severe
-plus most common with cerebral involvement

Question 17

A 31 year old man visits his GP with a painless lump in his scrotum. There is a well-defined, non-tender spherical 1 cm mass on the right side of the scrotum. It is SUPERIOR to the TESTIS and TRANSILLUMINATES.
Which is the most likely diagnosis?

Answer 17

EPIDIDYMAL CYST (spermatocele)- separate and can get above mass which is cystic

• benign + usu asymptomatic + mx conservatively
• NB. although a hydrocele transilluminates it would surround the testis

Question 18

A 78 year old patient is admitted with chronic oropharyngeal dysphagia. He
has left ventricular systolic dysfunction from ischaemic heart disease. He is breathless on exertion, particularly when climbing stairs. He is being prepared for a percutaneous endoscopic gastrostomy feeding tube. The passage of a
nasogastric tube has been unsuccessful, and he is having nil by mouth. He weighs 70 kg. His pulse rate is 72 bpm and BP 132/80 mmHg.
-Which is the correct volume of maintenance fluids (in mL) to prescribe for the next 24
hours?

Answer 18

Maintenance fluid requirements for someone
with underlying cardiac disease is recommended as 20-25 mL/kg.
-This gives an upper volume of 25 x 70= 1750. This conforms to current NICE guideline CG
174

Question 19

mx of delirium

Answer 19

low dose haloperidol

Question 20

72Y W - pain at base of right thumb - difficulty opening jars and sewing - first CMC joint SWOLLEN + TENDER - with reduced opposition of THUMB
-what is dx

Answer 20

Osteoarthritis - common site for it

-pain of De quiervan tenosynovitis would be felt over RADIAL ASPECT of WRIST

Question 21

A 62 year old man has acute breathlessness with a weak cough, following a recent viral URTI. Over the past 4 mths, he has had double vision, limb weakness and slurred speech when tired.. His RRnis 18 breaths per minute and 02 sats 96% breathing air. He is sweating and using his accessory muscles of inspiration.
-Appropriate test to monitor resp ftn??

Answer 21

Myasthenic crisis is an acute respiratory failure
characterised by FVC< 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. -ABG analysis commonly shows hypercapnia before hypoxia
-There should be a low threshold for ET intubation due to rapid deterioration of bulbar and
respiratory muscles

Question 22

A 40 year old man has 4 days of left flank pain associated with fever, nausea
and vomiting.
His temperature is 39.6°C, pulse rate 118 bpm and BP 90/40 mmHg. Imaging
shows an obstructing proximal left ureteric stone with severe hydronephrosis.
He is treated with intravenous antibiotics and intravenous fluids.
what is the next most appropriate step in mx

Answer 22

NEPHROSTOMY

-renal pelvis should be decompressed with nephrostomy

Question 23

acute gout initial mx

Answer 23

start NSAID

before stopping allopurinol

Question 24

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.
what type of hearing loss + what ear?

Answer 24

R. CONDUCTIVE DEAFNESS

a= Webers + in R ear = conductive in R ear or SNHL in L ear
b = Rinne’s - in R ear = conductive in R ear
(as in SNHL it is globally reduced)

Question 25

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?

Answer 25

STREP PYOGENES = most common pathogen in leg cellulitis (incl in diabetic patients)

Question 26

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. Mx ?

Answer 26

NSAIDs - naproxen 1st line

Question 27

A 64 year old woman is due to undergo an arthroscopy of her knee. She has T2DM + takes METFORMIN (500 mg twice daily) and GLICLAZIDE (80 mg each morning). Her glycated haemoglobin is 54 mmol/mol (20–42). She is scheduled first on the morning day case list and is asked to fast from midnight the previous night. -what is the most appropriate plan for mx diabetic meds?

Answer 27

OMIT gliclazide and CONT metformin - Principles are to minimise fasting times (hence first on list) and disruption to usual medication. In this setting where the procedure is fairly minor, patient should be eating again at lunchtime and hence there is no call for insulin in any form.

Question 28

A 70 year old man has a brief episode of twitching that starts in his left hand and spreads up the arm over 2 minutes, then stops. His arm feels weak for an hour afterwards. -He had an ischaemic stroke affecting his left side 6 months ago with good functional recovery. He has a history of type 2 diabetes mellitus and is taking clopidogrel, metformin, ramipril and simvastatin. He is anxious about a further stroke. There is no weakness on neurological examination.

Answer 28

The description fits with PARTIAL SEIZURE | affecting his R HEMISPHERE as a result of a previous stroke.

Question 29

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) USS abdomen: single 2-cm gallstone in gallbladder, common bile duct normal, evidence of fatty liver. - what is the most appropriate mx

Answer 29

LAP CHOLE - for symptomatic gallstone disease - Percutaneous cholecystectomy is for pts not fit for surgery

Question 30

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. -what is the most likely dx

Answer 30

CEREBELLAR STROKE - triad of headache, nausea/vomiting + ataxia - profound imbalance, sudden onset + prominent headache suggest cerebellar stroke

Question 31

A 26 year old woman sustains a head injury in a motorcycle accident. Her eyes are closed, but she opens them when asked to. 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?

Answer 31

Opens eyes in response to voice = 3 Confused & disoriented = 4 Localizes painful stimuli = 5.

Question 32

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.

Answer 32

ACUTE GLAUCOMA NB. Uveitis whilst causing red eye, headache and visual disturbance is associated with a small pupil.

Question 33

A 68 year old man collapses when rising from a chair and is seen in the ED 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. -what is the most appropriate initial radiological ix?

Answer 33

CT head | -this is likely stroke (CVA) - so need to exclude ICH with CT head to allow for thrombolysis

Question 34

A 65 year old woman with newly diagnosed advanced lung cancer has 1 day of breathlessness and 1 week of progressive headache. Her pulse rate is 88 bpm, respiratory rate 20 breaths per minute and oxygen saturation 95% breathing 4 L/min oxygen via nasal prongs. She has a swollen face and neck and distended veins on her chest. Her chest is clear. CT scan of chest shows mediastinal lymphadenopathy compressing the superior vena cava. -what is the most appropriate initial tx?

Answer 34

SVC obstruction - std initial tx is DEXAMETHASONE to reduce tumour swelling - no evid of thrombus to justify systemic anticoagulation + systemic thrombolysis has no place

Question 35

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 -what ix is diagnostic?

Answer 35

RENAL BIOPSY | -nephrotic syndrome in adults requires renal biopsy to identify cause, prior to definitive tx