Formative medicine assessment

Question 1

Question 1:

A 46 year old man presents with a 2-hour history of central chest pain. He is pain free at the time of presentation.

He had not had symptoms like these previously, but describes a burning pain over his sternum radiating to his neck and arms, waking him in the early hours. He also complained of sweating.

On examination, his pulse was 90 bpm, regular, BP 194/108 mmHg. He has quiet heart sounds and his chest is clear on auscultation.

His ECG is given below:

What is the most likely diagnosis?

A. Aortic dissection
B. Hypertrophic cardiomyopathy C. Myocardial ischaemia
D. Oesophageal spasm
E. Pulmonary embolus

Answer 1

MI

Explanation: All 5 conditions listed could cause chest pain. The symptoms are not classical, but the radiation of the pain is typical of ischaemia compared to the distractors. The ECG reveals widespread T wave inversion V1-V6. This is also known as LAD syndrome, mindful that a patient presenting with angina symptoms with this ECG is likely to have a proximal LAD stenosis. The troponin is likely to be elevated, but even if it is normal, this patient requires admission.

Question 2

A 46 year old man with type 1 diabetes has deteriorating vision. Investigation: haemoglobin A1c 11.9% (4.0–6.0)
107 mmol/mol (20-42)

What clinical findings best describe proliferative diabetic retinopathy?

Answer 2

new blood vessel growth

Question 3

A 56 year old man presents to the emergency department with haematemesis and melaena. He is known to have chronic liver disease and oesophageal varices and is not allergic to any medication. His current BP is 84/56. Blood investigations have been requested but are not available yet.

What is the most important next management step for him?

A. CT Angiogram
B. IV Omeprazole
C. IV Terlipressin & Co-Amoxiclav

D. OGD
E. Request a surgical review

Answer 3

C. IV Terlipressin & Co-Amoxiclav

Question 4

Question 8:

A 28-year-old man presents to the Medical Assessment Unit with a 2-day history of feeling unwell, fever, headache and neck stiffness.

He also has a non-blanching rash on his legs (see picture). He has no drug allergies.

What treatment should he receive as soon as possible?

IV Amoxicillin

IV Benzylpenicillin

IV Clarithromycin

IV Co-amoxiclav

IV Temocillin

Answer 4

IV benzylpenicillin

Question 5

Question 11:

A 63-year old man presents with a 3 week history of progressively worsening leg swelling. The swelling is now above his knees and into his scrotum. He has also noticed that his urine is now frothy in appearance. He has no past medical history and was previously fit and well.

What is the most likely diagnosis?

Acute Tubular Necrosis

Chronic Kidney Disease

Diabetic nephropathy

Nephrotic Syndrome

Polycystic kidney disease

Answer 5

Nephrotic Syndrome

• oedema
• frothy urine

Question 6

Question 12:

A 65 year old woman has been referred to the renal unit with the following blood results taking by her GP after she presented with fatigue for the past few months.

Blood results:

Hb 98 MCV 84 WCC 6.1 Plt 170

(115-165) g/L (80-99) fL (4-11)x109 /L (140-400)x109 /L

Na 137 K 5.6 Ur 24 Cr 440

(133-146) mM / L (3.5-5.3) mM / L (2.5-7.8)mM/L (60–120)uM/L

What is the most likely diagnosis?

Acute renal failure

Acute tubular necrosis

Iron deficiency anaemia

Chronic Renal Failure

Pyelonephritis

Answer 6

Chronic renal failure

Normocytic anaemia is often seen in cases of Chronic Renal Failure (Chronic Kidney Disease).

Question 7

A 38 year old man has a 2 year history of painful fingers and knuckles. An X-ray of his right index middle finger PIP joints is shown below.

What is the best description for the x-ray abnormality (as indicated by the arrows)?

A. Cysts

B. Marginal erosions

C. Periarticular osteopenia

D. Sclerotic lesions

E. Stress fractures

Answer 7

Marginal erosions

Explanation: The differential for this would be bone cysts or erosions. Bone cysts do sit near to end of the bones, but are deeper.

Question 8

A 34 year old man presents with diarrhoea. His pulse is 120 bpm and BP is 85/42 mmHg. His capillary refill is > 2 seconds and his peripheries are cold to the touch.

Investigations: serum sodium 139 (137–144 mmol/L) serum potassium 4.8 (3.5–4.9 mmol/L) serum urea 28.9 (2.5–7.0 mmol/L) serum creatinine 224 (60–110 μmol/L)

What would be the most appropriate IV fluid treatment?

A. 0.9% saline 500 ml over 15 minutes
B. 0.9% saline 250 ml over 30 minutes
C. 0.9% saline / 4% dextrose 500 ml over 15 minutes
D. 4.5% human albumin solution 500 ml over 30 minutes E. 5% dextrose 500 ml over 30 minutes

Answer 8

0.9% saline 500 ml over 15 minutes

Question 9

A 49 year old woman known to have bronchiectasis and sputum colonisation with haemophilus influenzae is admitted to the respiratory ward after presenting with symptoms of worsening cough and increased volume of green sputum. She has been febrile and her blood CRP level is 213. A diagnosis of a severe infective exacerbation of bronchiectasis is made. She is prescribed a course of intravenous co-amoxiclav. A few minutes after administration of the first dose of IV co-amoxiclav, her nurse informs you that the patient now has new lip and tongue swelling and is feeling breathless. The nurse has stopped the IV.

What should be given to the patient next?

Intramuscular Adrenaline (epinephrine) 1:1000 500 micrograms

Intramuscular Adrenaline (epinephrine) 1:1000 500 milligrams

Intramuscular Adrenaline (epinephrine) 1:10000 500 micrograms

Intravenous Adrenaline (epinephrine) 1:1000 500 micrograms

Intravenous Adrenaline (epinephrine) 1:1000 500 milligrams

Answer 9

Intramuscular Adrenaline (epinephrine) 1:1000 500 micrograms