Formative Flashcards
A 70 year old man has pain on chewing his food. He has tenderness in the temporal region and proximal muscle weakness in his arms. Which is the single most appropriate treatment for him? Select one: A. aspirin B. ibuprofen C. hydrocortisone D. methyl prednisolone E. prednisolone
The diagnosis is giant cell arteritis and the treatment for this is oral prednisolone.
A 93 year old man has a series of falls. He has been progressively forgetful and has had episodic hallucinations over the past year. Which is the single most likely diagnosis? Select one: A. Alzheimer’s disease Incorrect B. diffuse Lewy body disease C. multi-infarct dementia D. multisystem atrophy E. Parkinson’s disease
This is a classical description of Diffuse Lewy Body disease – drop attacks and neuropsychiatric symptoms occur early in the disease.
A 56 year old obese man has recurrent abdominal pain radiating to his back and made worse by eating spicy foods and bending over. Antacids relieve his pain. Which is the single most appropriate next investigation?
Select one:
A. abdominal x-ray
B. abdominal CT scan
C. double contrast barium meal
D. Helicobacter pylori breath test Incorrect
E. oesophagogastroduodenoscopy (OGD)
He should have an OGD – his age makes pathology other than GORD morecommon, this is the recommended course of action for all those over 45 years of age
A 79 year old woman has urinary frequency, urgency and urgency incontinence. Which single investigation is most appropriate to arrange next?
Select one:
A. dipstick urinalysis
B. frequency volume chart (bladder diary)
C. multi-channel cystometry
D. renal tract ultrasound
E. video urodynamics
A dipstick urinalysis is the next simplest examination to perform; all others either will add nothing to the diagnosis or are unnecessarily invasive.
A 65 year old man has a persistent high temperature, profuse diarrhoea and abdominal pain two weeks after finishing antibiotics following an elective hip replacement. There are reddened ulcers and yellowish plaques on his colonic mucosa at sigmoidoscopy. Which is the single most likely diagnosis? Select one: A. Clostridium perfringens enterocolitis B. Crohn’s disease C. pseudomembranous colitis D. ulcerative colitis E. viral gastroenteritis
Severe inflammatory changes in the mucosa and antibiotic use suggest pseudoembranous colitis due to clostridium difficile infection.
A 87 year old man has a longstanding, non healing ulcer on the side of his nose. It has an opalescent sheen and multiple telangectases running over the surface. The centre is depressed and necrotic. Which is the single most likely diagnosis? Select one: A. basal cell carcinoma B. keratoacanthoma C. melanoma D. solar keratosis E. squamous cell carcinoma
The basal cell carcinoma typically has the features as described and may also have a depressed centre.
Features:
- non healing ulcer (often on side of nose)
- opalescent sheen
- multiple telangectases
- centre depressed / necrotic
An 80 year old woman inpatient with schizophrenia has a temperature of 38.6oC and increasing rigidity. Which is the single most likely cause of her symptoms? Select one: A. haloperidol and amitriptyline B. haloperidol and diazepam C. haloperidol and flupenthixol D. haloperidol and sertraline E. haloperidol and zopiclone
The diagnosis here is neuroleptic malignant syndrome which can be precipitated by either high doses of a single anti-psychotic medication, but more commonly by the use of combinations of anti-psychotic medication (haloperidol and flupenthixol)
A 50 year old man with epigastric burning pain has an OGD which shows gastro-oesophageal reflux. Which single oral medication is the most effective for his condition? Select one: A. bismuth B. gaviscon C. magnesium trisilicate D. omeprazole E. ranitidine
A PPI is more effective than the H2 antagonist.
Omeprazole
A 47 year old man had a history of chronic alcohol misuse. Which single enzyme would most likely be found to be raised in his serum? Select one: A. alcohol dehydrogenase B. alkaline phosphatise C. amylase. D. gamma glutamyl transferase E. pancreatic lipase
Gamma GT is commonly raised in patients who consume large amounts of alcohol.
A 75 year old man who smokes 20 cigarettes a day has had a worsening productive cough, high temperature, fatigue and shortness of breath for four days. His oxygen saturations is 91% on room air and he has focal coarse crepitations at the left base. Which single organism is the most likely cause of his symptoms? Select one: A. Haemophilus influenza B. Legionella pneumonia C. Mycoplasma pneumonia D. Staphylococcus aureus E. Streptococcus pneumonia
the commonest cause of community acquired pneumonia is streptococcus pneumonia
A 67 year old woman has had shortness of breath and a productive cough for two days. Her temperature is of 38˚C, pulse rate 100bpm, respiratory rate 26, oxygen saturations 93%, and BP 110/50 mmHg. Her abbreviated mental test score is 6/10. Blood tests show:
Haemoglobin 13.0g/dL
White cell count 15 x 109/L
Urea 9 mmol/L
Creatinine 105µmol/L
Which is the single most appropriate action to take?
Select one:
A. admit to hospital and consider ITU referral
B. admit to hospital for immediate NIV
C. admit to hospital to the medical assessment unit
D. discharge home on oral antibiotics
E. discharge home with home iv antibiotic service
she is hypoxic, with altered mentation and evidence of sepsis; she could deteriorate rapidly and so needs urgent high dependency care
The correct answer is: admit to hospital and consider ITU referral
A 49 year old woman is waiting for a liver transplant. Which single condition is the most likely indication in this woman? Select one: A. alcoholic liver disease B. chronic active hepatitis C. Hepatitis A liver disease D. Hepatitis E liver disease E. hepatocellular carcinoma
hepatitis c, alcoholic liver disease and primary biliary cirrhosis are the commonest indications for liver transplantation in the uk
The correct answer is: alcoholic liver disease
A 20 year old woman has repeated episodes of self harm, feelings of emptiness and intense and unstable relationships. Which is her single most likely diagnosis? Select one: A. antisocial personality disorder B. avoidant personality disorder C. borderline personality disorder D. histrionic personality disorder E. narcissistic personality disorder
Feedback: typical features of emotional instability, impulse to self harm and inability to form stable relationships
The correct answer is: borderline personality disorder
A 50 year old man with schizophrenia takes olanzapine. Which single condition is he more at risk of developing? Select one: A. COPD B. diabetes mellitus C. hypothyroidism D. nephrogenic diabetes insipidus E. pancreatitis
olanzapine most of all atypical anti-psychotics cane lead to diabetes, as well as weight gain and metabolic syndrome
The correct answer is: diabetes mellitus
A year 4 medical student is shadowing an FY2 on ITU. The FY2 asks the medical student to take blood from an unconscious patient. The patients close family are at the bedside. The medical student has completed her venepuncture training. Which is the single most appropriate action for the medical student to take?
Select one:
A. ask the consultant’s permission before taking blood
B. ask the relatives’ permission before taking blood Correct
C. explain to the FY2 she cannot take the blood as the patient cannot give consent
D. get written consent from the next of kin before taking blood
E. offer to assist the FY2 but not take the blood herself
Feedback: getting oral consent from the next of kin is most appropriate
The correct answer is: ask the relatives’ permission before taking blood
You are a year 4 student on a clinical attachment. You have been asked to take a history from a 21 year old woman who may have a sexually transmitted infection. Which is the single most appropriate way to introduce the sexual history?
Select one:
A. ask whether she is currently in a relationship.
B. explain that any information she gives is completely confidential.
C. explain that you need to ask about her sexual history, as she may have a sexually transmitted infection.
D. say that you have some routine questions you ask all patients.
E. say you would like to ask some more personal questions.
Feedback: this is an open ended approach introducing the subject of more intimate questioning which will include sexual history
The correct answer is: say you would like to ask some more personal questions.
A 23 year old university student wakes up in the middle of the night with vomiting, malaise and a high temperature. He is admitted to hospital for observation. Within two hours, he has a stiff neck and convulses. Which is the single most likely diagnosis?
Select one:
A. Haemophilus influenzae type B meningitis
B. Listeria meningitis
C. Meningococcal meningitis
D. Pneumococcal meningitis
E. Tuberculous meningitis
meningism in a young patient should alert you to the possibility of meningococcal infection and promt immediate antibiotic treatment before LP
The correct answer is: Meningococcal meningitis
A 42 year old obese man is noted by his GP to have glucose in his urine. Two fasting blood glucose levels were 7.3 and 7.4mmol/L. Which is the single most appropriate management option for this man? Select one: A. admit to hospital for insulin therapy B. advice on diet and exercise C. start insulin therapy D. metformin treatment E. sulphonylurea treatment
He has impaired glucose tolerance (fasting blood glucose > 7 or random glucose > 11.1) and should be given advice on diet and exercise – he is at risk of developing Type 2 diabetes
The correct answer is: advice on diet and exercise
A 34 year old man has fatigue and shortness of breath. His ECG recording is below. He has a cardiac biopsy, and the image is also below. ECG - ST elevation Cardiac biopsy - inflammatory infiltrate What is the single most likely diagnosis? Select one: A. cardiac amyloidosis B. infective endocarditis C. myocardial infarction D. myocarditis E. pericarditis
The S-T elevation and neutrophilic infiltration of the myocardium are consistent. ST changes and T wave inversion can occur in myocarditis.
The correct answer is: myocarditis
A 64 year old man has central chest pain. Which single set of findings is most likely in the diagnosis of myocardial infarction?
Select one:
A. high troponin T and high creatine kinase (muscle-brain) (CK-MB)
B. high troponin T and high lactate dehydrogenase (LDH)
C. high troponin T and low CK-MB
D. normal troponin T and high LDH
E. normal troponin T and normal CK-MB
A. Both Trop and CK-MB indicate myocardial damage in the context of myocardial infarction.
The correct answer is: high troponin T and high creatine kinase (muscle-brain) (CK-MB)
A 25 year old woman has a high temperature, haematuria, splenomegaly and splinter haemorrhages. Which is the single most likely diagnosis? Select one: A. Burkitt’s lymphoma B. carcinoid syndrome C. endocarditis Correct D. enteric fever E. pneumococcal pneumonia
The combination of features is characteristic of endocarditis
The correct answer is: endocarditis
A 68 year old woman had a post mortem. The lungs were heavy and macroscopically had scattered firm grey areas. Histologically, the alveolar spaces were filled with neutrophils. Which is the single most likely diagnosis? Select one: A. adult respiratory distress syndrome B. bronchopneumonia Correct C. chronic obstructive pulmonary disease D. CMV pneumonitis E. tuberculosis
The features of neutrophil infiltration are consistent with bronchopneumonia. For those who put ARDS as an answer, the pathologic features of the lung in ARDS derive from severe injury to the alveolo-capillary unit. This leads to a pulmonary oedema due to leakage of protein rich fluid and also cellular necrosis, epithelial hyperplasia, inflammation, and fibrosis.
The correct answer is: bronchopneumonia
A 68 year old woman has acute shortness of breath. Which single clinical finding would indicate pulmonary oedema? Select one: A. dry cough B. fine inspiratory crackles Correct C. inspiratory wheeze D. polyphonic wheeze E. prolonged expiration
fine, late inspiratory crackles are consistent with pulmonary oedema
The correct answer is: fine inspiratory crackles
A 76 year old man has a persistent discharge from his right ear. The image is that seen through the otoscope. Which is the single most likely diagnosis? See mass in ear on otoscope Select one: A. cholesteatoma B. foreign body C. otitis externa D. otitis media E. perforation of ear drum
Cholesteatoma occurs if skin from the inner side of the tympanic membrane sloughs off and mixes with ear wax that penetrates to the middle ear and fails to drain through the Eustachian tube. The accumulation of dead skin and wax causes a cyst-like mass, the cholesteatoma. If left untreated the mass can cause serious damage to the eardrum and ossicles. In serious cases, cholesteatomas can erode into the mastoid and can cause cerebral infection.
The correct answer is: cholesteatoma
A 70 year old man has shortness of breath secondary to a pleural effusion. The protein content of the pleural fluid is 45 g/L. Which is the single most likely cause of his effusion? Select one: A. congestive cardiac failure B. chronic liver failure C. malabsorption D. nephrotic syndrome E. non small cell lung cancer
The protein content of the effusion fluid which is high (> 30 g/L)suggests an exudate. The causes of this are chronic inflammation and malignancy. All the other causes are transudates (generally protein content
A 26 year old mother of a son with haemophilia A has a third acute haemarthrosis following a relatively minor fall. Which single factor best describes the most likely reason for this?
Select one:
A. a low level of Factor VIII is associated with carrier status in females
B. a high level of Factor VIIIc is associated with carrier status in females
C. a spontaneous mutation of the responsible gene has occured
D. factor VIII resistance is a characteristic feature in mothers of haemophiliacs
E. the mother has a haemophiliac mother
Haemophilia A is due to Factor VIII deficiency and Haemophilia B is due to factor IX deficiency. Both are X linked disorders. This means that an affected X chromosome is commonly paired with an unaffected X chromosome, thus conferring carrier status in females which may lead to low Factor VIII levels.
The correct answer is: a low level of Factor VIII is associated with carrier status in females
A 38 year old woman has had a cough and malaise for two days. Her chest radiograph is below. CXR - wedge shape in R middle zone Which is the single most likely diagnosis? Select one: A. atypical pneumonia B. broncho-alveolar cell carcinoma C. lobar pneumonia D. pleural effusion E. right lower lobe collapse
There is consolidation of the right lower lobe along anatomical boundaries – hence lobar pneumonia
The correct answer is: lobar pneumonia
A 62 year old woman has facial redness and swelling following a superficial wound. Which is the single most appropriate treatment for this condition? Select one: A. intravenous amikacin B. intravenous benzylpenicillin C. intravenous ciprofloxacin D. intravenous erythromycin E. intravenous flucloxacillin
This is erysipelas. It is typically a streptococcal disease – best treated with Benzylpenicillin
The correct answer is: intravenous benzylpenicillin
Erysipelas also known as “Ignis sacer”, “holy fire”, and “St. Anthony’s fire” is an acute infection of the upper dermis and superficial lymphatics, usually caused by streptococcus bacteria. Erysipelas is more superficial than cellulitis, and is typically more raised and demarcated.
Symptoms: high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis. Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen.
Which is the single major criterion in the diagnosis of rheumatic fever? Select one: A. athralgia B. erythema marginatum Correct C. fever D. previous history of rheumatic fever E. prolonged PR interval
Major criteria of rheumatic fever are: Migratory polyarthritis, Carditis, Subcutaneous nodules, Erythema marginatum and Sydenham’s chorea.
The correct answer is: erythema marginatum
CASES: Carditis Arthritis Sydenham's chorea Erythema marginatum Subnutaneous nodules
A 50 year old Caucasian man has a blood pressure of 158/90mmHg. He is a not a smoker or diabetic, with no other significant history other than being overweight. Which is the best initial management? Select one: A. advise lifestyle measures. B. ACE inhibitor C. beta blocker D. calcium channel antagonist E. no treatment required
The BP is borderline high, and target for treatment is over 160/100 in patients with no risk factors. The correct thing to do is offer lifestyle advice and repeat the BP measurement
The correct answer is: advise lifestyle measures.
A 73 year old man with COPD has an infective exacerbation. His respiratory rate is 12 breaths per minute and arterial oxygen saturation on air 97%. He has no other significant medical history. Which is the single most appropriate antibiotic regime to prescribe him?
Select one:
A. amoxicillin 500mg three times daily by mouth
B. ciprofloxacin 500mg twice daily by mouth
C. co-amoxiclav 625mg thrice daily with clarithromycin 500mg twice daily by mouth
D. flucloxacillin 500mg four times daily by mouth
E. penicillin V 500mg four times daily and trimethoprim 200mg twice daily by mouth
He has mild COPD exacerbation. Amoxicillin is the most appropriate therapy
The correct answer is: amoxicillin 500mg three times daily by mouth
A 19 year old woman has an appendicectomy and the surgeon takes care to ensure a good cosmetic appearance of the skin wound when it heals. Which is the single best description of the healed skin incision?
Select one:
A. fibrous repair of both the dermis and epidermis
B. fibrous repair of the dermis, and regeneration of the epidermis
C. granulation tissue in the dermis, and regeneration of the epidermis
D. hyperplasia of both the dermis and epidermis
E. regeneration of both the dermis and epidermis
Mechanisms of wound healing – this is the process where keratinocytes migrate and help regeneration.
The correct answer is: fibrous repair of the dermis, and regeneration of the epidermis
A 48 year old man has had an inferior myocardial infarction. He has a monitored arrhythmia. His 12 lead ECG is below. Which is the single most likely diagnosis? Prolongation of PR interval Select one: A. atrial fibrillation B. Mobitz Type 1 atrioventricular block C. Mobitz Type 2 atrioventriciular block D. premature ventricular contractions (ventricular extrasystole) E. Type 1 atrioventricular block
Mobitz Type 1 atrioventricular block - prolongation of PR interval
Rather than Mobitz type 2 where there is a dissociation of P waves and QRS complexes. p waves are not conducted
A 22 year old woman has tiredness and weight loss. She has a tachycardia, a palpable goitre and a thyroid bruit. Investigations show:
TSH
This woman is hyperthyroid. The TSH is typically suppressed by free T3.
The correct answer is: suppression by free T3
A 56 year old woman has chest pain lasting for an hour. Her ECG is below. Which is the single most appropriate treatment?
ECG shows ST elevation in II, III and aVF
Select one: A. aspirin B. aspirin and streptokinase C. clopidogrel D. clopidogrel and aspirin E. primary percutaneous coronary intervention
PCI is now the treatment of choice in myocardial infarction.
The correct answer is: primary percutaneous coronary intervention
A 22 year old obese woman has a temperature of 37.8ºC 24 hours after appendicectomy. Which is the single most likely cause? Select one: A. pulmonary atelectasis B. pulmonary embolism C. pelvic abscess D. thrombophlebitis E. urinary tract infection
Pulmonary atelectasis (enlargement of small airways) may contribute to the development of postoperative pyrexia. The correct answer is: pulmonary atelectasis
A 30 year old woman has a blood stained nipple discharge associated with a small palpable retro-areolar mass. Which is the single most likely diagnosis? Select one: A. cyst B. fat necrosis C. fibroadenoma D. mammary fistula E. papilloma
This is a characteristic description for a papilloma
The correct answer is: papilloma
A 35 year old African woman has a haemoglobin level of 6g/dL. A blood film shows microcytic, hypochromic red blood cells with target cells. Which is the single most likely diagnosis? Select one: A. anaemia of chronic disease B. iron deficiency anaemia C. sickle cell disease D. sideroblastic anaemia E. thalassaemia trait
The blood film shows iron deficiency, thalassaemia causes microcytosis, but the anaemia is unusual with thalassemia trait.
The correct answer is: iron deficiency anaemia
A 49 year old woman has had breathlessness for one day. Her chest x-ray is below: Which is the single most likely diagnosis? CXR - opacity in LLL with meniscus sign Select one: A. collapse of the left lower lobe B. consolidation of the left lower lobe C. fibrosis of the left lower lobe D. left sided pleural effusion Correct E. left sided pulmonary infarction
The chest x-ray shows a left sided pleural effusion. There is a meniscus at the fluid- lung interface
The correct answer is: left sided pleural effusion
Which single risk scoring system places patients in one of five categories based on general medical history and examination without requiring any specific investigations, and is effective in predicting mortality?
Select one:
A. APACHE Score (Acute physiological chronic health evaluation)
B. American Society of Anaesthesiology (ASA) Score
C. Glasgow Coma Scale
D. Ranson’s score
E. revised trauma score
This is a validated measure of morbidity scoring. ASA stands for American Society of Anesthesiologists. The ASA adopted a five category physical status classification system for assessing a patient before surgery. These are:
A normal healthy patient.
A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a constant threat to life.
A moribund patient who is not expected to survive without the operation.
The correct answer is: American Society of Anaesthesiology (ASA) Score
A 72 year old man collapses and dies suddenly on the ward, four days after a confirmed anterior myocardial infarction. Which is the single most likely cause of death? Select one: A. cardiac rupture B. mural thrombus C. pericarditis D. sub acute bacterial endocarditis E. ventricular aneurysm
A cardiac rupture (due to infracted cardiac muscle) is the most likely cause of sudden death
The correct answer is: cardiac rupture
A 45 year old hypertensive man has sudden onset of central chest pain, radiating to his left arm, associated with tingling and numbness. The pain radiates to his back and he has nausea, vomiting and sweating. A chest x-ray shows mediastinal widening. Which is the single most likely diagnosis? Select one: A. acute myocardial infarction B. aortic dissection C. aortic regurgitation D. pulmonary embolism E. tension pneumothorax
Chest pain radiating to the back is consistent with an aortic dissection, widening of the mediastinum is due to an aortic aneurysm which is a predisposing risk factor
The correct answer is: aortic dissection
A 67 year old man had a myocardial infarction three days ago. He is now confused with a systolic blood pressure of 70mmHg and an irregular narrow complex tachycardia that has a ventricular rate of 160 beats/minute. Which is the single most appropriate management of his arrhythmia? Select one: A. amiodarone intravenously B. DC cardioversion C. digoxin intravenously D. sotolol intravenously E. verapamil intravenously
This man has fast atrial fibrillation with haemodynamic compromise and needs cardioversion
The correct answer is: DC cardioversion
A 72 year old man with COPD has reduced lung transfer factor for carbon monoxide (TLCO). Which single factor is measured by the TLCO?
Select one:
A. plasma carbon monoxide concentration
B. pulmonary gas transfer
C. pulmonary transluminal oxygen gradient
D. total lung compliance
E. total lung oxygenation capacity
The TLCO (transfer factor) measures the integrity of the alveolar-capillary surface area for gas transfer. It may be reduced in disorders that damage the alveolar walls (septa) such as emphysema, which leads to a loss of effective surface area and in disorders that thicken or damage the walls eg: pulmonary fibrosis. The correct answer is: pulmonary gas transfer
A 52 year old man with treated epilepsy is confused and has difficulty in walking. He has some speech difficulty and is drowsy. He recently bought cimetidine for indigestion. His blood results are shown:
haemoglobin 9.8g/dL
MCV 105fL
white cell count 5.5x109/L
platelets 190x 109/L
Which is the single most likely explanation for his phenytoin toxicity?
Select one:
A. impaired absorption caused by achlorhydria
B. impaired elimination caused by folate deficiency
C. impaired metabolism caused by vitamin D deficiency
D. inhibition of metabolism caused by cimetidine
E. non-adherence to medication
cimetidine (a H2 receptor antagonist used to reduce acid production from the stomach), available over the counter, is an inhibitor of hepatic CYP enzymes. This inhibition of enzymes leads to reduced metabolism of other drugs e.g. phenytoin in this case
The correct answer is: inhibition of metabolism caused by cimetidine
A 36 year old man has unilateral hearing loss and a recurrent discharge from this ear. An image from otoscopy is below. Which is the single most likely diagnosis? See erythema and discharge in front of ear drum Select one: A. acute perforation of the eardrum B. cholesteatoma C. otitis interna D. otitis media Correct E. otosclerosis
This is suppurative otitis media – there is erythema around the middle ear and also discharge.
The correct answer is: otitis media
An 81 year old man with COPD has an increase in cough, sputum viscosity, wheeze and breathlessness. He is able to complete short sentences with a respiratory rate of 18 breaths per minute. Which is the single best initial treatment?
Select one:
A. antibiotics, nebulised Beta 2 agonist, nebulised anti-cholinergic, intravenous steroids
B. antibiotics, nebulised Beta 2 agonist, nebulised anti-cholinergic, oral steroid Correct
C. antibiotics, nebulised Beta 2 agonist, oral steroid, montelukast
D. nebulised Beta 2 agonist, montelukast, intravenous steroid, nebulised anti-cholinergic
E. nebulised Beta 2 agonist, nebulised anti-cholinergic, intravenous steroids
The combination should be anbitiotics (amoxicillin), B2 agonist (salbutamol), anticholinergic (atrovent) and oral steroids (prednisolone).
The correct answer is: antibiotics, nebulised Beta 2 agonist, nebulised anti-cholinergic, oral steroid
A 65 year old woman has palpitations (trace below) and has a pulse rate of 185bpm. By the time she reaches medical help she is better and her pulse is 80bpm and regular. Which is the single most likely cause for her palpitations? Select one: A. atrial fibrillation B. atrial flutter Incorrect C. sinus tachycardia D. ventricular fibrillation E. ventricular tachycardia
Paroxysmal AF is the most common arrhythmia of the older person.
The correct answer is: atrial fibrillation
A 70 year old man with known ischaemic heart disease and diabetes has permanent atrial fibrillation with a ventricular rate of 70bpm. He is asymptomatic. Which is the single best management option?
Select one:
A. anticoagulate with 300mg aspirin a day
B. anticoagulate with warfarin
C. direct current cardioversion
D. regular cardiology review
E. rhythm control with amiodarone
He will need anticoagulation with warfarin if in AF as age and diabetes gives him a CHADS-2 score of 2.
The correct answer is: anticoagulate with warfarin
CHADS-2 score
The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF).
CCF -1 point
Hypertension >140/90 - 1 point
Age over 75 - 1 point
DM - 1 point
Stroke / TIA / thromboembolism - 2 points
CHA2DS2-VASc score has been proposed. These additional non-major stroke risk factors include age 65-74, female gender and vascular disease. In the CHA2DS2-VASc score score, ‘age 75 and above’ also has extra weight, with 2 points.
The European Society of Cardiology (ESC) guidelines recommend that if the patient has a CHADS2 score of 2 and above, oral anticoagulation therapy (OAC) such as warfarin (target INR of 2-3) or one of the new OAC drugs (such as dabigatran) should be prescribed.
A 27 year old woman has a painless breast lump. It is mobile, with no overlying skin changes. A core biopsy shows an encapsulated lesion containing both epithelial and stromal elements. Which is the single most likely diagnosis? Select one: A. benign breast disease B. ductal carcinoma-in-situ (DCIS) C. fibroadenoma Correct D. invasive lobular carcinoma E. medullary carcinoma
Fibroadenomas of the breast are small, solid, rubbery, noncancerous, harmless lumps composed of fibrous and glandular tissue. Microscopically (below) the proliferation forms duct-like spaces. These are surrounded by fibroblastic stroma. There is also normal but proliferating epithelium.
A 76 year old man has breathlessness and a noisy wheeze over three months. His flow volume loop is below. reduced PEFR FEV1 normal Reduced inspired flows Preserved expiratory flows Which is the single most likely diagnosis? Select one: A. asthma Incorrect B. bronchial carcinoma C. COPD D. hypertrophy of the tonsils E. vocal cord paralysis
This pattern fits extrathoracic obstruction due to a subglottic tumour or vocal cord problem –see flow volume loops below.
The correct answer is: vocal cord paralysis
Which single condition is a recognised complication of essential (primary) hypertension?
Select one:
A. aortic stenosis
B. cerebral infarction
C. chronic glomerulonephritis Incorrect
D. extradural haemorrhage
E. right ventricular outflow tract hypertrophy
Feedback: Hypertension is the most significant risk factor for stroke.
The correct answer is: cerebral infarction
A 67 year old man has had central chest pain radiating to the jaw and shoulder, with associated nausea and sweating for two hours. What is the single most appropriate initial investigation for his complaint? Select one: A. arterial blood gas B. chest x-ray C. echocardiogram D. electrocardiogram E. ventilation - perfusion (V/Q) scan
Feedback: Given the high of this presentation representing ischaemic heart disease, an ECG is the most appropriate thing to do
The correct answer is: electrocardiogram
The section below shows tissue from the transplanted heart of a 32 year old with cardiomyopathy. Biopsy was taken six months after transplantation. The section has been exposed to an antibody that detects CD3+ antigen and counterstained with an immunoperoxidase reagent (brown colour = positive).
CD3 detected on section
Which is the single most likely explanation for these findings?
Select one:
A. ciclosporin toxicity
B. cytomegalovirus infection
C. recurrence of viral myocarditis, the cause of the cardiomyopathy
D. rejection episode Correct
E. vasculitis due to immune complex deposition
The positive staining which is CD-3 positive suggests T cell activation associated with acute rejection in transplant tissue.
The correct answer is: rejection episode
A 65 year old woman who smokes has lobar shadowing on her cest x-ray and rusty coloured sputum. Which single organism is the most likely cause of her pneumonia? Select one: A. Haemophilus influenzae B. Influenza A C. Mycobacterium tuberculosis D. Mycoplasma pneumoniae E. Streptococcus pneumoniae
Strep pneumoniae commonest cause of community acquired pneumonia when organisms are isolated.
The correct answer is: Streptococcus pneumoniae
A 45 year old man has 48 hours of flu like symptoms and a cough with clinical and radiological signs of consolidation. Which single variable below indicates a poor prognosis from this illness?
Select one:
A. arterial saturation of oxygen on air of 96%
B. blood pressure of 125/90 mmHg
C. plasma urea concentration of 5.1 mmol/L
D. respiratory rate of 35 breaths/min
E. temperature 38.5ºC
CURB 65 score – the R refers to Resp rate > 30
The correct answer is: respiratory rate of 35 breaths/min
CURB 65
Confusion (AMT 7
Resp rate >30
BP 65 years old
A 68 year old woman has a sudden collapse after a flu like illness lasting seven days. She is cyanotic, hypotensive, and tachycardic with a high jugular venous pressure. Which is the single most likely cause? Select one: A. mitral valve prolapse B. myocardial infarction C. pulmonary embolism D. subarachnoid haemorrhage E. thyrotoxic storm
Infections, respiratory or otherwise, have been associated with an increased risk of venous thromboembolism. Thus a sudden collapse as in this case suggests a PE
The correct answer is: pulmonary embolism
A 57 year old man has palpitations and dyspnoea. He has peripheral cyanosis, an undisplaced tapping apex beat and mid diastolic murmur with an opening snap. Which is the single most likely diagnosis? Select one: A. atrial fibrillation B. atrial myxoma C. atrial septal defect D. mitral regurgitation E. mitral stenosis
These are the clinical signs of mitral stenosis. The patient may also be in atrial fibrillation, have a malar flush, often thin, may have a weak or “thready” (low volume) pulse, palpable heart sounds, a RV heave.
The correct answer is: mitral stenosis
A 70 year old man has bilateral basal fine crackles on auscultation of his chest. He has noticed slight breathlessness on stairs but no other symptoms. There is no significant previous medical or drug history. Which is the single most likely diagnosis? Select one: A. asthma B. bronchiectasis C. fibrosing alveolitis D. pneumonia E. tuberculosis
The pulmonary crackles in the absence of other signs of heart failure would suggest a diagnosis of fibrotic lung disease
The correct answer is: fibrosing alveolitis
A 21 year old asthmatic woman has worsening breathlessness and wheeze over 24 hours. Which single investigation would be most helpful in her initial management? Select one: A. chest x - ray B. full blood count C. peak expiratory flow rate D. serum concentration of potassium E. sputum culture
A peak flow would have most value in assessing severity in acute asthma.
The correct answer is: peak expiratory flow rate
A 19 year old cleaner in an apiary has developed facial swelling (picture). A provisional diagnosis of a type I immune reaction to bee sting is made.
Which is the single most important future risk from this reaction?
Select one:
A. auto immune uveitis
B. bronchospasm
C. hypertension
D. Reiter’s syndrome
E. Sjogren’s syndrome involving the lacrimal gland
She has been sensitized to the antigen and this is likely to lead to anaphylaxis. Bronchospasm is a feature of anaphylaxis
The correct answer is: bronchospasm
A 76 year old woman with repeated falls is investigated with a 24-hour Holter monitor. She dies with the monitor in place. A segment of the trace is below.
trace shows wiggly line - no pattern
Which is the single best diagnosis? Select one: A. alternating current interference B. movement artefact C. torsade des pointes D. ventricular fibrillation E. ventricular tachycardia
This is a trace of VF
The correct answer is: ventricular fibrillation
An 80 year old woman has weight loss. She has a chest x-ray performed.
Which is the single most important finding?
CXR shows opacity in L lower zone by heart border
Select one: A. abnormal right diaphragmatic shadow B. enlarged right hilum C. hyper-expanded lung fields D. lesion in the left lower lobe Correct E. normal chest x-ray
There is an area of shadowing in the lower zone, with speculated appearances which is consistent with a malignancy
The correct answer is: lesion in the left lower lobe
A 67 year old woman has worsening breathlessness over 12 months. There is no diurnal variation and except for a productive cough she has no other chest symptoms. She was a smoker of 20/day from the ages of 18 to 63. Which is the single most likely diagnosis? Select one: A. anaemia B. asthma C. COPD D. fibrosing alveolitis E. pleural effusion
chronic breathlessness in a longstanding smoker with productive cough suggest COPD. Lack of diurnal variation makes ashma less likely
The correct answer is: COPD
A 24 year old man has sudden onset stabbing chest pain and breathlessness, he has had one similar episode in the past. He has no other past medical history. Which single diagnosis is most likely to account for his presentation? Select one: A. asthma B. bronchial carcinoma C. pulmonary embolism D. pulmonary oedema E. spontaneous pneumothorax
pain and breathlessness would suggest PE or pneumothorax, pleuritic pain would favour PE . The previous episode without risk factors for PE or other thromboembolic features would favour pneumothorax
The correct answer is: spontaneous pneumothorax
A 37 year old woman has joint pains and shortness of breath. She is known to have asthma. She smokes 4 cigarettes a day and works as a restaurateur. She has mild wheezes throughout the chest. It was noted that she had bilateral erythematous lesions in the legs as shown below. Her chest x-ray is also shown. Which is the single most appropriate next investigation? Select one: A. angiotensin converting enzyme level B. arterial blood gas estimation C. CT pulmonary angiogram D. electrocardiogram D E. ventilation - perfusion (V/Q) scan
she has bihilar lymphadenopathy and erythema nodosum, suggesting Sarcoidosis best confirmed by serum ACE
The correct answer is: angiotensin converting enzyme level
A 43 year old HIV positive man has a cough and haemoptysis. He takes efavirenz, tenofovir and emtricitabine but mentions that he frequently forgets to take his medications. His chest x-ray is shown below. Which is the single most likely infecting organism? CXR - solid mass in L upper zone Select one: A. Aspergillus fumigatus Correct B. Coxiella burnetti C. Legionella pneumophilia D. Mycobacterium tuberculosis E. Pseudomonas aeruginosa
A solid mass within a larger cavity in an immunocompromised patient would suggest aspergillus. Other agents mentioned would cause more diffuse pneumonic involvement
The correct answer is: Aspergillus fumigatus
A 22 year old man has had asthma for two years. His takes a salbutamol inhaler twice a day. He now has breathlessness during the day and wakes up at night feeling wheezy. A diary of his peak flow shows that measurements average at 450 and a predicted peak flow is 600. Which is the single most appropriate medication to prescribe him? Select one: A. inhaled anticholinergic B. inhaled antimuscarinic C. inhaled corticosteroid D. inhaled long acting β2 agonist E. oral prednisolone
poorly controlled asthma despite regular b agonists would require corticosteroids, initially inhaled.
The correct answer is: inhaled corticosteroid
Asthma prescribing
- inhaled short acting beta 2 agonist
- inhaled corticosteroid (400mcg)
- LABA
- If benefit from LABA but not sufficient control, increase corticosteroid to 800mcg/day
If no benefit from LABA - stop
Increase corticosteroid to 800mcg
- consider trial of leukotriene receptor antag or theophylline
or increase steroid to 2000mcg/day - consider oral steroid tablet + 2000mcg inhaled steroid
A 23 year old intravenous drug user has a temperature of 38.4˚C and rigors. There is an early diastolic murmur. His urinalysis is positive for blood. Which is the single most appropriate investigation? Select one: A. coronary angiography B. dobutamine stress-echocardiography C. erythrocyte sedimentation rate D. trans-oesophageal echocardiography E. ventilation - perfusion (V-Q) scan
the likely diagnosis is infective endocarditis with an immune complex glomerulonephritis, which may be confirmed by TOE. He needs blood cultures also
The correct answer is: trans-oesophageal echocardiography
A 64 year old man with a 50 pack a year history has breathlessness on exertion. His apex beat is displaced by 2 cm laterally and inferiorly. He has an early diastolic murmur, heard loudest at the tricuspid area. Which is the single most likely diagnosis? Select one: A. aortic regurgitation B. aortic stenosis C. mitral regurgitation D. mitral stenosis E. tricuspid regurgitation
A displaced apex suggests volume loaded ventricle(MR or AR) and an early diastolic murmur goes with AR
The correct answer is: aortic regurgitation
A 26 year old woman with asthma attends the Emergency Department with increasing breathlessness, wheeze, a respiratory rate of 40, oxygen saturation 88% on air. Which is the single most appropriate initial management? Select one: A. intravenous aminophylline B. high flow oxygen C. nebulised ipratropium D. nebulised salbutamol E. oral prednisolone
he is hypoxic on room air, so the first thing to do is supplement his inhlaed oxygen
The correct answer is: high flow oxygen
A 87 year old woman attends her GP surgery. She has been getting chest pain which lasts a few minutes, is made worse by walking up the steps or after having a big meal. When she rests it seems to settle pretty quickly. Which is the single most likely diagnosis? Select one: A. chronic stable angina B. myocardial infarction C. peptic ulcer disease D. pleurisy E. pulmonary embolus
her symptoms are induced by exertion and resolve with rest, suggestive of angina. There are no features to suggest that this is unstable- prolonged pain at rest or at night.
The correct answer is: chronic stable angina
A 73 year old woman has three months of palpitations, consisting of a sudden onset of fast chaotic heart beat, with gradual offset after about an hour. She feels a little short of breath and light headed if she walks around during the episodes. She takes bendroflumethazide for high blood pressure. Which is the single most likely cause of her symptoms? Select one: A. atrial flutter B. paroxysmal atrial fibrillation C. sinus arryhthmia D. ventricular ectopics E. ventricular tachycardia
Intermittent FAST and chaotic palpitations suggest an irregular tachyarrthymia such as paroxysmal AF, common in elderly patients with IHD.
The correct answer is: paroxysmal atrial fibrillation
An 81 year old man has collapsed in the street. His ECG is below. Which is the single most likely diagnosis?
P waves present
Slow rhythm
Select one: A. aystole B. bigemini C. complete AV block D. sinus bradycardia E. ventricular ectopics
he has a slow rhythm, rate of aproximately 42 with clear p waves , demonstrating sinus bradycardia
The correct answer is: sinus bradycardia
A 67 year old man has had pleuritic chest pain, shortness of breath and a small haemoptysis on three occasions over the past month. Which single investigation is most likely to result in a diagnosis? Select one: A. arterial blood gas B. CT pulmonary angiogram C. chest x-ray D. electrocardiogram E. ventilation-perfusion (V/Q) scan
the pleuritic nature of the pain suggests a peripheral lesion, and the haemoptysis would go with a PE, best diagnosed bya V/Q scan as not likeley to be proximal in nature
The correct answer is: ventilation-perfusion (V/Q) scan
A 36 year old woman has thickening of her skin over her fingers and Raynaud's phenomenon. She has multiple telangiectasia over her face and difficulty swallowing. Which single antibody is most likely to be present? Select one: A. anti centromere antibody B. anti Jo-1 antibody C. anti topoisomerase antibody D. c-ANCA E. high titre of anti-DNA antibody
Anti centromere antibody is frequently in limited systemic scleroderma, (CREST Syndrome), and, occasionally are found in the diffuse form of scleroderma
The correct answer is: anti centromere antibody
CREST Calcinosis Raynaud's Esophageal dysmotility Sclerodactyly Telangiectasia
Which is the single best treatment for the prevention of variceal bleeding in a 43 year old alcoholic man with portal hypertension and varices? Select one: A. amlodipine B. metoclopramide C. ompeprazole D. ondansetron E. propranalol
The beta blocker lowers portal blood pressure, bleeding is more likely if this is above 12mmHg
The correct answer is: propranalol
A 70 year old man has pain on chewing his food. He has tenderness in the temporal region and proximal muscle weakness in his arms. Which is the single most appropriate treatment for him? Select one: A. aspirin B. ibuprofen C. hydrocortisone D. methyl prednisolone E. prednisolone
The diagnosis is giant cell arteritis and the treatment for this is oral prednisolone.
The correct answer is: prednisolone
A 35 year old man has severe heartburn. Endoscopy confirms severe oesophagitis. Which is the single most appropriate therapy for him?
Select one:
A. amoxicillin and clarithromycin
B. amoxicillin, clarithromycin and lansoprazole
C. lansoprazole
D. no treatment, but repeat endoscopy in 6 weeks time
E. ranitidine
A PPI would be the most effective treatment for oesophagitis
The correct answer is: lansoprazole
A 78 year old man has a plasma calcium concentration of 2.50 mmol/L , phosphate of 1.10 mmol/L and alkaline phosphatase of 1120 IU/L on a routine blood screen. Which is the single most likely diagnosis? Select one: A. osteomalacia B. osteopetrosis C. osteoporosis D. Paget's disease of bone E. primary hyperparathyroidism
In Paget’s disease there is increased osteoclastic and osteoblastic activity in the bone, but the calcium and phosphate levels are usually normal. However, in the setting of immobilization, hypercalcemia may occur.
The correct answer is: Paget’s disease of bone
(enlarged and misshapen bones - excessive breakdown and formation of bones)
ALP -protein particularly found in liver, bone and bile ducts. Elevated in: Billiary Obstruction Bone conditions Osteoblastic bone tumors Osteomalacia Liver disease or hepatitis Leukemia Lymphoma Paget's Disease Sarcoidosis hyperparathyroidism
A 47 year old woman has bone pain and erythema at the site of an orthopaedic procedure two weeks ago. Which single investigation will best exclude osteomyelitis? Select one: A. C reactive protein B. CT scan C. leucocyte count D. magnetic resonance imaging Correct E. plain x-ray
In osteomyelitis, MRI has high sensitivity in the detection of bone marrow changes, it may provide detailed information regarding the extent and activity of the process by allowing the detection of the intramedullary site of infection and its complications. MRI may also be used to distinguish soft tissue involvement, allowing differential diagnosis such as cellulitis.
The correct answer is: magnetic resonance imaging
A previously well 25 year old man has had bloody diarrhoea associated with mild cramps and lower abdominal pain for three months. He denies recent travel and cannot recall any unusual food items or friends or colleagues with similar symptoms. He has lost weight. He is mildly tender on abdominal palpation with no masses. PR is normal. He is mildly anaemic and stool cultures are negative. Which is the single most likely diagnosis? Select one: A. carcinoma of the caecum B. coeliac disease C. inflammatory bowel disease D. irritable bowel disease E. giardiasis
The history of bloody diarrhoea is consistent with inflammatory bowel disease. Carcinoma of the caecum is less likely in a young patient. There is no travel history suggestive of giardiasis.
The correct answer is: inflammatory bowel disease
A 42 year old man with Crohn’s disease has a full blood count which reveals a macrocytosis and mild anaemia. He is found to be folate deficient. Which is the single most likely mechanism by which this has occurred? Select one: A. deficient dietary intake B. disordered folate metabolism C. effect of azathioprine therapy D. failure of absorption E. increased physiological demand
Folate absorption is mostly in the small intestine, thus both Coeliac and crohn’s disease can lead to folate deficiency
The correct answer is: failure of absorption
A 38 year old man with alcohol dependence has abnormal liver function tests. A hepatologist performs a liver biopsy. Which is the single most likely microscopic finding in the liver biopsy?
Select one:
A. epithelioid granulomata
B. lymphocytic infiltration of hepatocytes
C. haemosiderin deposits
D. lack of bile ducts in portal tracts
E. steatosis
Fatty liver, or hepatic steatosis, is a reversible condition where large vacuoles of triglyceride fat accumulate in liver cells via the process of steatosis. Fatty liver can occur in those with excessive alcohol intake and those who are obese. Below is the typical appearance of hepatic steatosis.
The correct answer is: steatosis
A 76 year old woman has a rash and chronic joint pain. A photograph of her hands is shown below. - very deformed hands
shortened fingers
luxation, phalangeal and metacarpal bone absorption, and skeletal architecture loss in the fingers
Which is the single most likely diagnosis?
Select one: A. osteoarthritis B. osteogenesis imperfecta C. psoriatic arthropathy D. rheumatoid disease Incorrect E. tophaceous gout
She has arthritis mutilans, a severe erosive arthropathy associated with psoriasis
The correct answer is: psoriatic arthropathy
Which is the single best treatment for severe osteoarthritis of the hip? Select one: A. allopurinol B. gold C. joint replacement surgery Correct D. methotrexate E. prednisolone
Joint replacement is a definitive treatment option in OA
The correct answer is: joint replacement surgery
A 35 year man has abdominal pains, weight loss and diarrhoea. He has coeliac disease. He has a generalised itchy rash. A picture of the skin is shown below: Which is the single most likely diagnosis? Select one: A. erythema marginatum B. dermatitis herpetiformis C. erythema chronicum migrans D. pityriasis rosea Incorrect E. tinea versicolor
Dermatitis herpetiformis is a typical rash (which is pruritic) and associated with celiac disease. The skin changes are erythematous, urticarial plaques; and papules with vesicles.
The correct answer is: dermatitis herpetiformis
A 63 yr old woman with type 2 diabetes has severe constant upper abdominal pain. Her pulse is 105bpm, BP 115/75mmHg and temperature 37.5oC. Her abdomen is tender with guarding and reduced bowel sounds. Her blood tests show:
haemoglobin 11.8 g/dL
sodium 145 mmol/L
bilirubin 65 µmol/L
WCC 17x109/dL
potassium 3.9 mmol/L
ALP 105IU/L
platelets 194x109/dL
urea 6.2 mmol/L
ALT 64IU/L
glucose 15.5 mmol/L
creatinine 84 µmol/L
albumin 39g/L
amylase 1310IU/L
Which is the single most likely diagnosis?
Select one:
A. acute cholecystitis
B. acute pancreatitis
C. diabetic ketoacidosis
D. perforated peptic ulcer
E. urinary tract infection
The raised amylase and severe epigastric pain suggests acute pancreatitis
The correct answer is: acute pancreatitis
A 24 year old woman with systemic lupus erythematosus is under clinic review. Which is the single most likely finding in her serum? Select one: A. decreased IgM levels B. decreased levels of C4 C. decreased levels of Interleukin 1 D. increased levels of C1 inhibitor E. increased levels of C3
In SLE, a decrease in C3 and C4 are both common.
The correct answer is: decreased levels of C4
An 83 year old woman has a third osteoporotic vertebral fracture. She is taking calcium and vitamin D supplementation and has oesophagitis. Which is the single most appropriate drug to add to her current regime? Select one: A. daily etidronate B. daily strontium ranelate C. salmon calcitonin D. teriparetide injections E. weekly risedronate
Bisphosphonates ( alendronate (Merck) and risedronate) are first line but are known to worsen upper GI symptoms, hence the second line drug for bone protection would be strontium
The correct answer is: daily strontium ranelate
For post-menopausal women raloxifene (selective oestrogen receptor modulator) can be used instead of bisphosphenates
A 46 year old woman has pruritis and worsening jaundice. Which single finding would most likely result in a diagnosis of primary biliary cirrhosis?
Select one:
A. presence of a high titre of auto-antibodies against smooth muscle
B. presence of auto-antibodies against aceteldehyde-altered liver cell membrane antigens
C. presence of auto-antibodies against components of the pyruvate dehydrogenase complex
D. presence of auto-antibodies against cytochrome p450
E. raised serum IgG
The pyruvate dehydrogenase complex is located in the mitochondria and the antibody to it is typically found in primary biliary cirrhosis (in clinical practice, an anti-mitochondrial antibody is sent).
The correct answer is: presence of auto-antibodies against components of the pyruvate dehydrogenase complex
A 60 year old man is admitted with acute decompensation of his alcoholic liver disease. Which single drug would help prevent Wernicke’s encephalopathy and Korsakoff’s psychosis? Select one: A. amitriptyline B. chlordiazepoxide C. vitamin B1 (thiamine) D. vitamin B12 E. vitamin C
Replacement of thiamine is an important first step in preventing hepatic encephalopathy
The correct answer is: vitamin B1 (thiamine)
A 31 year old woman has pain in her right arm and difficulty with holding small objects. She has wasting of the muscles of the right hand and her grip is weak. An x-ray of her cervical spine is shown. Which is the single most likely cause of her symptoms? CXR - no cervical rib Select one: A. ankylosing spondylitis B. cervical rib C. cervical spondylosis D. metastatic bony destruction E. Pancoast tumour
The picture in the question does not show a cervical rib.
Cervical ribs are an anomaly that arise from the lowest cervical vertebrae but their relationship to thoracic outlet syndrome (TOS) is not so constant that the two conditions should be seen as synonymous. Perhaps no more than 10% of people who have cervical ribs develop TOS and the syndrome may well occur in the absence of ribs. Diagnosis of TOS may be difficult and depends upon a thorough history and examination together with supportive tests.
A 36 year old woman has tiredness, joint pain, dry eyes and dry mouth. No joints are swollen and there is no rash. Her blood results show: Full blood count normal ESR 96 mm/hr C reactive protein 10mg/L Anti-nuclear antibody strongly positive Rheumatoid factor strongly positive Anti-CCP negative Anti-Ro positive Anti-La positive Which is the single most likely diagnosis? Select one: A. Reiter’s syndrome B. rheumatoid arthritis C. Sjögren’s syndrome D. systemic sclerosis E. Wegener’s granulomatosis
The high ESR, dry eyes and dry mouth, as well as the combination of positive Ro and La makes Sjögren’s Syndrome likely
The correct answer is: Sjögren’s syndrome
A 36 year old man with type 1 diabetes has an ulcer on his right foot. He develops a hot, red and painful swollen right knee. His temperature is 39oC. His knee is aspirated. Investigation results on peripheral blood are below: haemoglobin 1.0 g/dL white cell count 15 x 109/L platelets 450 x 109/L serum urate 2.76mmol/L CRP 67mg/L Plain radiograph of right knee joint shows no bony abnormality. Which is the single most likely diagnosis? Select one: A. gout B. haemarthrosis C. pseudogout D. rheumatoid arthritis E. septic arthritis
A hot swollen knee, raised inflammatory markers and normal urate level suggests septic arthritis.
The correct answer is: septic arthritis
A 47 year old woman has generalised pruritis, jaundice, dry eyes and mouth. She is otherwise well and drinks no alcohol. She has a markedly raised alkaline phosphatase. Which is the single most useful investigation? Select one: A. anti IgM antibody B. anti-nuclear antibody C. hepatitis B surface antigen D. liver function tests E. mitochondrial antibodies
The history and the type of patient suggests primary biliary cirrhosis, (F:M ratio10:1). Anti Mitochondrial antibodies will help to confirm the diagnosis
The correct answer is: mitochondrial antibodies
A 42 year old woman with tiredness and a macrocytic anaemia has a small bowel biopsy suggesting coeliac disease. Which is the single most sensitive and specific serum antibody which confirms this diagnosis? Select one: A. anti endothelial antibody B. anti gliadin antibody C. anti intrinsic factor antibody D. anti mitochondrial antibody E. anti transglutaminase antibody
Anti transglutaminase antibody and anti gliadin antibodies are associated with celiac disease
The correct answer is: anti transglutaminase antibody
A 46 year old woman requires a blood transfusion but is concerned about the possibility of contracting viral hepatitis. Which single combination of hepatitis viruses are routinely tested for in blood for transfusion? Select one: A. hepatitis A and C B. hepatitis A, B and D C. hepatitis B and C D. hepatitis B, C and E E. hepatitis C and D
Hep B and C are routinely tested in blood
The correct answer is: hepatitis B and C
A 65 year old woman has slowly worsening lower back pain. Her investigation results are below. Which is the single most likely diagnosis?
alkaline phosphatise normal
corrected calcium normal
phosphate normal
Xray - no mets visible Vertebral collapse Select one: A. bony metastases B. osteomalacia C. osteoporosis D. myeloma E. Paget's disease
There is vertebral collapse on the lateral spine x ray (another example in the arrow below) and normal calcium, which is consistent with osteoporosis.
A 50 year old man is acutely confused. He drinks excessive alcohol and has an enlarged liver. His blood tests show: haemoglobin 8.5 g/dL MCV 105 fl WCC 6 x 109/L platelets 200 x 109/L INR 2.2 ALT 125IU/L AST 96 IU/L ALP 230IU/L GGT 132IU/L bilirubin 85µmol/L Which is the single most likely diagnosis? Select one: A. alcoholic hepatitis B. chronic active hepatitis C. cirrhosis of the liver D. hepatocellular carcinoma E. viral hepatitis
The high MCV and mild anaemia combined with the deranged LFTs is consistent with alcoholic hepatitis.
The correct answer is: alcoholic hepatitis
A 42 year old man felt a sharp pain at the back of his ankle while playing badminton. He thought that somebody may have kicked him from behind. He is now unable to walk normally. Which is the single most likely diagnosis? Select one: A. achilles tendon rupture B. ankle sprain C. tibialis posterior rupture D. tibial stress fracture E. undisplaced ankle fracture
The acute pain occurring during a sudden movement is typical of tendon rupture, the anatomy fits an Achilles tendon site.
The correct answer is: achilles tendon rupture
A 24 year old man has right sided abdominal pain, diarrhoea, poor appetite and weight loss. His temperature is 37.5˚C; he has oral apthous ulcers, and a tender right lower quadrant. Rectal examination is normal. His blood tests show: haemoglobin 12.5g/dL white cell count 14 x 109/L platelets 550 x 109/L urea 8 mmol/L creatinine 90 μmol/L CRP 105 mg/L Which is the single best test to confirm the most likely diagnosis? Select one: A. barium meal and follow through B. stool cultures C. surgical laparotomy D. ultrasound of abdomen E. upper GI endoscopy
The diagnosis is Crohn’s disease, and typically the terminal ileum is affected. This can be imaged with a barium meal and follow through.
The correct answer is: barium meal and follow through
? perhaps colonoscopy would be a better imaging modality
Which is the single most appropriate initial therapy in a 60 year old man with bilateral knee pain due to osteoarthritis? Select one: A. amitriptyline B. aspirin C. celecoxib D. ibuprofen E. paracetamol
The most simple analgesic should be used first, and a step up in therapy following that.
The correct answer is: paracetamol
In gout, which is the single most likely joint to be inflamed? Select one: A. elbow B. first metacarpo-phalangeal joint C. first metatarso-phalangeal joint D. gleno-humeral E. temporo-mandibular joint
The big toe joint is commonly involved in gout.
The correct answer is: first metatarso-phalangeal joint
A 22 year asthmatic woman has a painful right hip and inability to weight bear. She is otherwise well. She has had a number of recent admissions during which she needed high dose steroids. Her x-ray shows some destruction of her right femoral head. Which is the single most likely diagnosis? Select one: A. avascular necrosis B. gouty arthritis C. myositis ossificans D. osteoid osteoma E. septic arthritis
One of the side effects of steroid therapy is avascular necrosis
The correct answer is: avascular necrosis
A 61 year old woman with NYHA stage 4 heart failure is admitted with pneumonia. She is accompanied by her son. She is drowsy and confused and lacks capacity to give consent for treatment. Which is the single most appropriate management option?
Select one:
A. ask the son if his mother had expressed any wishes about treatment
B. gain consent for antibiotic treatment from the son
C. palliate the patient’s symptoms only as curative treatment would not be in her best interests
D. treat the pneumonia as the doctors have a duty to preserve life
E. treat the pneumonia as this would be in the patients’ best interests
before embarking on treatment it is important to ascertain whether the patient had expressed wishes about treatment she should or shouldnt receive.
The correct answer is: ask the son if his mother had expressed any wishes about treatment
You are a year 4 medical student on a medical ward. You have been asked to take a history from a 50 year old man with chest pain. Which is the single most effective way to encourage the patient to provide the maximum amount of clinically relevant information during your consultation?
Select one:
A. ask the patient to list all his symptoms at the outset, and say that you will ask about each in turn.
B. empathise with the patient’s concerns about his chest pain.
C. reflect back what the patient says throughout the consultation
D. start with an open ended question.
E. when the patient mentions a symptom, keep asking ‘is there anything else’ until he says there is nothing else.
open ended questions allow for the most information to be forwarded by the patient
The correct answer is: start with an open ended question.
A 5 year old boy has acute osteomyelitis affecting his right tibia. He is normally well but his mother reports that he had a severe allergic reaction to amoxicillin two years previously. Which is the single most appropriate management?
Select one:
A. intravenous ceftriaxone plus oral sodium fusidate
B. intravenous co-amoxiclav plus oral sodium fusidate
C. intravenous doxycycline plus oral sodium fusidate
D. intravenous flucloxacillin plus oral sodium fusidate
E. intravenous vancomycin plus oral sodium fusidate
avoid penicllins and cephalosporins and use drugs that will penetrate bone
The correct answer is: intravenous vancomycin plus oral sodium fusidate
A 46 year old woman with primary biliary cirrhosis is being considered for liver transplantation. Which is the single most likely indication for the procedure?
Select one:
A. high levels of serum alkaline phosphatase
B. intractable pruritus
C. low serum albumin
D. raised IgM levels
E. rising titre of anti-mitochondrial antibodies
A low serum albumin suggests hepatic failure and usually occurs in patients who have serious illness. The others are features of the PBC and suggest progression.
The correct answer is: low serum albumin
A 62 year old woman with constipation has pain and bleeding on defaecation. Examination is impossible due to discomfort. Her anus is shown in the picture: Which is the single most likely diagnosis? Select one: A. fissure in ano B. fistula in ano C. haemorrhoids D. perianal abscess E. pruritis ani
A fissure in ano. Haemorrhoids would cause these symptoms but there is either a prolapsed pile or nothing to see in this case
The correct answer is: fissure in ano
A 74 year old woman has carcinoma of the colon. Which is the single most likely associated condition? Select one: A. Crohn's disease B. familial polyposis coli C. Hirschsprung's disease D. sporadic adenomatous polyps E. ulcerative colitis
The majority of carcinoma at this age is due to sporadic polyps.
The correct answer is: sporadic adenomatous polyps
A 72 year old woman has dysphagia, regurgitation of food and severe halitosis. She has a small mass on the left side of her neck. Which is the single most appropriate investigation? Select one: A. barium swallow B. cervical x-ray C. MRI of neck D. oesophagoscopy E. ultrasound of mass
She has a pharyngeal pouch, The best way to delineate this would be by barium swallow.
The correct answer is: barium swallow
A 43 year old man has pancreatic adenocarcinoma. Which single factor conveys risk in the development of this disease? Select one: A. acute pancreatitis B. chronic gastritis C. chronic recurrent pancreatitis D. hepatic steatosis E. low fat diet
Chronic pancreatitis is associated with an increased risk of developing pancreatic carcinoma.
The correct answer is: chronic recurrent pancreatitis
A 72 year old woman has breathlessness one day after a dynamic hip screw. Her respiratory rate is 25 breaths per minute; pulse rate 90bpm, BP 110/70 mmHg and oxygen saturation 90% on room air. Her heart sounds are normal and her chest is clear. Which is the single most appropriate treatment? Select one: A. aspirin B. clopidogrel C. low molecular weight heparin D. unfractionated heparin E. warfarin
The most likely diagnosis is that of pulmonary embolus as this patient has developed the symptoms following surgery. The best treatment at this stage is low molecular weight heparin.
The correct answer is: low molecular weight heparin
A 22 year old man has bloody diarrhoea and abdominal cramps. He ate chicken the previous night. Which is the single most likely diagnosis? Select one: A. Campylobacter enteritis B. Cholera C. Clostridium difficile enteritis D. Coxsackie virus enteritis E. cryptosporidiosis
This is the commonest cause of food borne diarrhoea in the country
The correct answer is: Campylobacter enteritis
A 42 year old man with active Crohn’s colitis, treated with high dose steroids and azathioprine has severe upper abdominal pain and vomiting. Which is the single most likely diagnosis? Select one: A. acute pancreatitis B. ischaemic colitis C. perforated peptic ulcer D. small bowel obstruction E. toxic megacolon
The high dose steroids use in the long term predisposes to peptic ulceration. This acute presentation could be due to a perforated ulcer
The correct answer is: perforated peptic ulcer
Forty eight hours after undergoing surgery, a 47 year old man becomes slightly jaundiced. His serum bilirubin concentration is 80µmol/L and results of other liver function tests are normal. His urine tests negative for bilirubin. There is no previous history of jaundice. Which is the single most likely explanation? Select one: A. idiosyncratic reaction to anaesthetic B. Gilbert’s disease C. occult sepsis D. resorption of haematoma E. undiagnosed cirrhosis
Gilbert’s syndrome is the commonest cause of unconjugated hyperbilirubinaemia. It typically presents with jaundice and no other symptoms. It is has an autosomal dominant pattern of inheritance affecting up to 5% of the population
The correct answer is: Gilbert’s disease
A 46 year old woman has recurrent episodes of chronic pancreatitis. She has a palpable abdominal mass. The CT scan of her abdomen is shown below. Which is the single most likely diagnosis? Select one: A. carcinoma of the pancreas B. hydronephrosis C. pancreatic pseudocyst D. renal cell carcinoma E. renal cyst
This is the appearance of a pancreatic pseudocyst. If surgical treatment is required then a fistula is created between the cyst and the GI tract to allow drainage. A similar picture pointing to a moderate sized pseudocyst is shown below
A 58 year old man with mild mitral valve disease is about to undergo cholecystectomy. Which single intervention is required at anaesthetic induction? Select one: A. prophylactic intravenous antibiotics B. salbutamol nebuliser C. saline nebuliser D. sedative pre-medication E. TED stockings
DVT Prophylaxis is priority. For uncomplicated cardiac valve lesions, prophylactic intravenous antibiotics are not recommended by NICE guidelines.
The correct answer is: TED stockings
A 45 year old man has had an anterior resection for carcinoma of the rectum and received post operative radiotherapy. One year after treatment he has bilateral lower limb oedema. Which is the single most likely cause?
Select one:
A. anastomotic cancer recurrence
B. deep inguinal and para-aortic lymph node recurrence
C. deep venous thrombosis
D. hypoalbuminaemia
E. liver metastasis
This would cause the symptoms described, whereas DVT is unlikely to be bilateral, hypoalbuminaemia occurs late and the symptoms would be a late manifestation of hepatic metastases.
The correct answer is: deep inguinal and para-aortic lymph node recurrence
A 68 year old woman has an anterior resection of the rectum and sigmoid colon because of bowel obstruction. The surgical specimen is below, opened to show the mucosal surface. Which is the single most likely pathological diagnosis? Select one: A. adenocarcinoma B. adenoma C. signet ring carcinoma D. squamous cell carcinoma E. transitional cell carcinoma
Adenocarcinoma is the most likely colorectal carcinoma
The correct answer is: adenocarcinoma
People with which single condition require annual influenza vaccination? Select one: A. chronic arthritis B. chronic renal disease C. inflammatory bowel disease D. premature infants E. thyrotoxicosis
Patients who should have vaccination are those with immunosuppression, chronic heart, renal or hepatic disease.
The correct answer is: chronic renal disease
A 42 year old Bangladeshi man has had low back pain for three months. He sweats at night, and has recently lost weight, x-rays show loss of normal architecture and some collapse of his L3 vertebra. Which is the single most likely diagnosis? Select one: A. muscle strain B. osteoporotic fracture C. renal stone D. spondylolisthesis E. tuberculous infection
TB is most likely due to his symptoms of weight loss and night sweats. If this was an elderly patient who had a fall, then osteoporotic fracture would be likely.
The correct answer is: tuberculous infection
In clinical trials, treatment groups of subjects are often similar with respect to their characteristics at baseline. Which single statement best describes the method which accounts for this? Select one: A. blinding B. informed consent C. intention to treat analysis D. placebo effect E. randomisation
This describes the intended effect of randomization
The correct answer is: randomisation
A 72 year old man has acute pancreatitis. Which single finding is most likely to be associated with a poor prognosis? Select one: A. high PaCO2 B. high serum amylase C. hyperglycaemia D. hypoalbuminaemia E. hypocalcaemia
All are typically present but hypocalcaemia conveys most risk of a poor outcome. The modified Glasgow criteria is one cretireia for predicting severity - P.A.N.C.R.E.A.S. PaO2 55 years Neutrophils (WBC > 15) Calcium 16 mmol/L Enzymes LDH > 600iu/L, AST > 200iu/L Albumin 10 mmol/L The correct answer is: hypocalcaemia
