Formative Qs

Question 1

A 6 month old child is dehydrated and unconscious due to an accident that resulted in burns over their head and upper body. The child needs urgent fluid replacement. What is your preferred access route for IV infusion?

Answer 1

A cut down, 1.5cm anterior and superior to the medial malleolus

Question 2

A 56 year old man reported the presence of a lump down below. It sits around the testicle, is non reducible, non tender, non pulsatile, soft, transilluminates and you are able to get above the swelling. What is it most likely to be?

Answer 2

Hydrocele: fluid in the tunica vaginalis

Question 3

A 27 year old woman is having her first baby and is in need of anaesthesia. An epidural would be the preferred option but there is a large patch of infected psoriasis on the thoracolumbar region of her back. Where else could be injected to achieve anaesthesia of perineum and vaginal canal?

Answer 3

Sacral hiatus

Question 4

Where is it best to access the radial artery when taking an arterial blood gas?

Answer 4

Lateral to the flexor carpi radialis tendon as the artery here is not covered by tendon or muscle

Question 5

During a lumbar puncture there are 2 resistances/pops as the needle advances at L4/5 level. What structure is pierced to produce the first pop?

Answer 5

Ligamentum flavum

Question 6

A 23 year old woman has a lump in her neck. It is located in the anterior triangle, it’s firm, smooth and subcutaneous, it does not move on swallowing and it is on the anterior border of sternocleidomastoid. What is the likely diagnosis?

Answer 6

Branchial cyst

Question 7

In a patient with a conductive hearing loss in the right ear, what Rinne and Weber test results would you expect?

Answer 7

Rinne test: bone conduction better than air in right

Weber test: sound lateralises to right ear

Question 8

In a lymph node biopsy, the histology report reads: germinal centres have lost polarity and are replaced by neoplastic uniform population of small lymphocytes with cleaved nuclei. Less than 5% of cells are undergoing mitosis. What is the likely diagnosis?

Answer 8

Centrocyte rich follicular lymphoma. Tumour is originating in germinal centres (follicles). Cleaved cells = centrocytes

Question 9

3 year old boy presents with severe oral herpes simplex virus which has spread to his nostrils. He has previously had severe chicken pox at 18 months, URI which lead to viral pneumonia at 24 months, extensive wart growth on feet treated with cryotherapy at 14 months. Which cells are likely functioning abnormally?

Answer 9

T lymphocytes
Viruses are intracellular organisms recognised by T cells which co ordinate a response to infection. Abnormal T cells means reduced viral recognition and so increased severity of infections

Question 10

Patient has a cough productive of green sputum and increasing SOB. HR 105, temp 38.1, RR 22, reduced chest expansion, crackles and dullness to percussion at left lung base. What is the likely causative organism?

Answer 10

Streptococcus pneumoniae

Community acquired pneumonia

Question 11

28 year old homeless man has chronic cough for 3 months, haemoptysis, weight loss and drenching night sweats. Evidence of consolidation in left lung apex, chest X-ray shows cavitating lesion in left apex. What histology is likely to be present?

Answer 11

Well formed granulomas with caseous necrosis - TB

Question 12

26 year old woman presents with a discrete breast lump. It is smooth, lobulated, rubbery and relatively mobile. No evidence of tethering or overlying skin changes. What is the most likely diagnosis?

Answer 12

Fibroadenoma - breast mice

Question 13

Histological examination of a wide local excision of breast tissue shows focal low grade ductal carcinoma in situ. All resection margins are clear by at least 5mm. What is the management implication of these findings?

Answer 13

No further treatment required

Question 14

Patient has mild pain on moving due to osteoarthritis. They are intolerant to NSAIDs. What other class of drugs is recommended for this type of pain in the WHO pain ladder?

Answer 14

Paracetamol

Question 15

Ebola is an example of what type of disease?

Answer 15

Zoonosis

Question 16

82 year old man with known SCLC has nausea, vomiting and increasing confusion. Clinically he is euvolaemic. Investigations show Na of 125mmol/L and plasma osmolality of 260mmol/kg. What type of clinical manifestation of the cancer does this acute problem likely represent?

Answer 16

Euvolaemic hyponatraemia. Differentials are SIADH, primary polydipsia and hypothyroidism. In SCLC, likely ectopic secretion of ADH from tumour causing problem - paraneoplastic effect

Question 17

In which combination of rhesus status parents, is a baby most at risk of rhesus isoimmunisation?

Answer 17

Second pregnancy of mother who is rhesus negative and father who is rhesus positive. First pregnancy, exposure to rhesus antigen in baby would mean mum develops antibodies, second pregnancy then at risk

Question 18

52 year old woman has eyelid drooping and double vision. She has generalised weakness which was worse recently when she had a viral illness. On examination you notice mild ptosis. What is the most likely pathological basis for this presentation?

Answer 18

Loss of function of ACh receptors: myasthenia gravis

Question 19

74 year old retired tyre worker has visible haematuria. A cystoscopy shows multiple papillary lesions arising from bladder mucosa. Exposure to which group of chemicals is most likely to underly this presentation?

Answer 19

Aromatic amines - transitional cell carcinoma

Question 20

A couple attend genetic counselling service seeking advice on recurrence of multifactorial cleft palate in their future offspring. What feature in the history would increase recurrence?

Answer 20

Bilateral cleft palate in proband
More severe phenotype, greater recurrence risk as proband will have greater numbers of genetic and environmental mutations associated with cleft palate

Question 21

24 year old shows azoospermia on sperm analysis and is found to have anti sperm antibodies. On questioning the patient reveals a history of testicular trauma as an adolescent. What is the likely factor underlying this presentation?

Answer 21

Release of hidden antigens
Testes normally has a blood:testes barrier which has been breached by trauma meaning that antigens which are usually hidden have been exposed. This means that anti sperm antibodies have been generated

Question 22

Patient is seen in clinic with suspected Haemophilia A. What blood test would be diagnostic?

Answer 22

Low plasma levels of factor VIII

Question 23

62 year old man seen in renal clinic with high BP, RBC present on urine dip, high levels of protein in urine, high urea and creatinine. What pattern of renal disease presentation is this?

Answer 23

Nephritic syndrome

Haematuria, proteinuria, hypertension, degree of renal insufficiency

Question 24

26 year old man has early onset emphysema and liver dysfunction. Genetic testing shows derangement in handling of alpha 1 anti trypsin. What is the pathological basis for the liver dysfunction in this patient? And for the dysfunction in the lungs?

Answer 24

Liver: Increased apoptosis. Mis-folding of protein in the liver, leading to endoplasmic reticulum stress, triggering apoptosis
Lungs: enzymatic digestion of tissues

Question 25

A man is cannulated via the cephalic vein over the anatomical snuffbox. The procedure took 2 attempts and caused iatrogenic damage to a nearby structure. What symptom is he most likely to complain of?

Answer 25

Paraesthesia over the first dorsal interosseous

Question 26

What is the agent responsible for tuberculosis?

Answer 26

Mycobacterium tuberculosis

Question 27

What is the mode of transmission of Tuberculosis?

Answer 27

Airborne - droplet spread

Question 28

What is the gold standard investigation for diagnosis of tuberculosis?

Answer 28

Discharged pus or biopsy material for direct staining and culture

Question 29

Describe the legal position regarding a child patients refusal of treatment, especially if their parents disagree with their decision

Answer 29

``` Competent child (under 16) can consent to treatment and no one can override that Refusal of treatment is different. Possible for refusal from competent child to be overridden by someone with authority to consent eg parent If there is parental disagreement, court can be asked to make decision on what is in child's best interests ```

Question 30

List the 8 stages in managing an outbreak of a communicable disease

Answer 30

``` Confirm diagnosis Immediate control Convene an Outbreak Control Team Review epidemiological and microbiological information Case finding Descriptive epidemiology Analytical study Declare outbreak over ```

Question 31

What is a vesicle?

Answer 31

Raised lesion filled with serous fluid that measures less than 5mm in maximum diameter

Question 32

What type of epithelium surfaces the labia minora?

Answer 32

Non keratinised stratified squamous

Question 33

With regards to sex and sexual behaviour, what issues would you discuss with a young person with symptoms in a GUM clinic?

Answer 33

``` Pregnancy STIs Side effects/risks of OCP/contraceptives Non volitional sex Emotional distress due to heartbreak Image sharing and consequences ```

Question 34

Why should partner notification be offered to patients with STIs?

Answer 34

Reduce risk of transmission from partner to people/ reduce risk of spread to wider population Protect patient from re infection Offer sexual partners tests for STIs Offer sexual partners treatment

Question 35

What is the major determinant of the clinical manifestations of a virus?

Answer 35

The tropism of the virus for specific tissues and cell types

Question 36

List cytopathic effects of viruses once they have entered cells

Answer 36

Prevention of critical host macromolecules Production of degradative enzymes Production of toxic proteins Induction of apoptosis

Question 37

What is the mechanism of action of a Topoisomerase inhibitor?

Answer 37

Cause permanent strand breaks in DNA by preventing resealing of nicked strands which leads to apoptosis

Question 38

Why are chemotherapy drugs given in combination?

Answer 38

Different modes of action of drugs so more effective Different toxicities so can tolerate better Reduces chance of cancer resistance

Question 39

What cell types production would be stimulated by a granulocyte colony stimulating factor drug?

Answer 39

Neutrophils Eosinophils Basophils

Question 40

What are the borders of the ante cubital fossa?

Answer 40

Superior: epicondylar line Lateral: brachioradialis Medial: pronator teres

Question 41

Which veins can be cannulated on the anterior surface of the elbow?

Answer 41

Cephalic Basilic Median cubital

Question 42

What things must be considered when determining what is in an unconscious patients best interests?

Answer 42

Whether they have an ADRT Whether they have a LPA Consider their past/present wishes, feelings, beliefs and values Take into account views of those caring for the person Clinical indications and consequences of the treatment

Question 43

In a paracetamol overdose, what LFT results would you expect to see in AST, albumin and PTT?

Answer 43

AST: raised Albumin: lowered PTT: raised

Question 44

An ABG result shows: pH 7.31, pCO2 4.6kPA, pO2 10.78kPa, HCO3 21mmol/L. State the pattern of blood gas abnormality present

Answer 44

Metabolic acidosis with partial respiratory compensation

Question 45

What act governs the removal of human organs for donation?

Answer 45

Human Tissue Act

Question 46

Name and explain the ethical principle prioritised by the opt in system of organ donation

Answer 46

Respect for autonomy Right of an individual to decide whether or not they wish to donate organs after death, right to self determination and to decide what happens to their body

Question 47

Name 2 types of living organ donation

Answer 47

Directed donation to a specified individual Paired donation Pooled donation Altruistic donation

Question 48

Give criteria that patient must meet in order for the local authority to provide housing under the statutory homelessness duty

Answer 48

Priority need Eligible for public funds Local connection Unintentionally homeless

Question 49

What is a hallucination?

Answer 49

Perception experienced in the absence of an external stimulus of any modality

Question 50

How does a second order/person auditory hallucination differ from a third person auditory hallucination? 

Answer 50

Second person auditory hallucination the voice is addressing the person experiencing the hallucination Third person auditory hallucination the person hears voices talking about them using the third person

Question 51

Define the term social stigma

Answer 51

Attributes, behaviours or pathological states that set people apart from others that mark them as less acceptable or inferior

Question 52

A homeless person has experienced abuse from other homeless people and local residents because of his hallucinations, what type of stigma is he experiencing?

Answer 52

Enacted stigma

Question 53

State 3 purposes for which it is possible to detain a person under the mental health act

Answer 53

Holding power to enable a formal psychiatric assessment to take place (72 hours) Psychiatric assessment of a patient with a view to treatment (28 days) Treatment for a psychiatric disorder (6 months)

Question 54

In a patient who has cut their wrists in a suicide attempt, what hand examination findings might you expect?

Answer 54

Thenar muscle wasting Sensory loss/ change over lateral 3.5 digits Laterally rotated thumb Weak/absent thumb opposition

Question 55

What types of nerve injury can occur?

Answer 55

Neuropraxia: nerve stun/ bruising Axonotmesis: internal tearing Neurotmesis: cut or ripping of nerve

Question 56

Which type of deficiency is likely to cause a microcytic hypochromic anaemia?

Answer 56

Iron deficiency

Question 57

What type of referral is done for a patient presenting with cancer symptoms?

Answer 57

2 week wait referral

Question 58

What type of malignant neoplasm is most likely in the sigmoid colon?

Answer 58

Adenocarcinoma

Question 59

What imaging modality would be used to stage a malignant neoplasm in the sigmoid colon?

Answer 59

Contrast enhanced CT of the chest, abdomen and pelvis

Question 60

Which lymph node group is likely to be the first site of Metastasis of a sigmoid colon cancer?

Answer 60

Inferior mesenteric nodes

Question 61

A neoplasm is resected. It has breached the aerosol surface of the colon and involves several lymph nodes What type of metastatic spread does breach of the serosal surface increase the risk of?

Answer 61

Transcoelemic

Question 62

An ECG of a patient shows atrial fibrillation, which form of dementia are they most at risk of?

Answer 62

Vascular dementia

Question 63

Why is AF a risk factor for vascular dementia?

Answer 63

Atrial fibrillation causes abnormal blood flow in the atria which predisposes to intra-atrial thrombosis which can lead to cerebral emboli

Question 64

Describe 3 ways in which dementia can impair decision making capacity with reference to the criteria in the mental capacity act

Answer 64

Dementia can affect short term memory so the patient may not be able to retain the relevant information Dementia can affect reasoning processes or judgment and so may affect the ability to understand relevant information or to weigh the information to make a choice In more advanced dementia patients may not be able to communicate and so fail the communication criteria in the assessment

Question 65

What is the mechanism underlying HbA1C formation?

Answer 65

Haemoglobin undergoes glycation in vivo at a rate proportional to the blood glucose concentration

Question 66

HbA1c reflects the glycaemic control over what timespan?

Answer 66

2-3 months

Question 67

Give 2 ways in which diabetes is atherogenic

Answer 67

Abnormalities of lipid metabolism occurring as a direct result of diabetes Glycation of lipoproteins leading to altered function Endothelial dysfunction Increased oxidative stress

Question 68

What is characteristic of the pain of intermittent claudication?

Answer 68

Brought on by exercise or relieved by rest 

Question 69

What is concordance?

Answer 69

A negotiated, shared agreement between clinician and patients concerning treatment regimes, outcomes and behaviours

Question 70

What are important factors relating to patient prescriber relationships that influence concordance?

Answer 70

Communication Patient’s trust in prescriber Empathy of prescriber towards patient

Question 71

Describe how sulfonylureas increase the secretion of insulin

Answer 71

Sulfonylureas inhibit ATP sensitive potassium channels in the plasma membrane Pancreatic beta cell depolarization occurs as potassium is not able to efflux leading to influx of calcium and activation of the secretory machinery that releases insulin

Question 72

Who can give consent to retention of human tissue for anatomical examination and public display?

Answer 72

Deceased person - written consent before death

Question 73

Which public policy will lead to the greatest population reduction in salt intake?

Answer 73

Regulation and marketing control

Question 74

Which component of the ECG complex does the plateau phase of the ventricular action potential correspond to?

Answer 74

ST segment

Question 75

A study stating that the risk of disease in a control group is 5% compared with risk of 3% in the intervention group. What is the relative risk reduction?

Answer 75

2/5x100 = 40% | Absolute risk reduction /control event rate

Question 76

Class 4 antiarrhythmic drugs predominantly act on which channels?

Answer 76

Calcium channels

Question 77

What type of heart block is shown by gradual prolongation of the PR interval until a QRS is skipped?

Answer 77

Second degree heart block type 1

Question 78

Movement of which ion is mainly responsible for phase 0 of the ventricular action potential?

Answer 78

Sodium channels

Question 79

Pathways involving which neurotransmitter are primarily involved in the pathogenesis of confusion?

Answer 79

Acetylcholine

Question 80

What percentage of encounters in the NHS are in general practice?

Answer 80

90%

Question 81

A 42 year old woman describes a two month history of unintentional weight loss, increased appetite and oligomenorrhoea. On examination she has bulging eyes and vitiligo. What pattern of changes of thyroid function tests would you expect to find?

Answer 81

Reduced thyrotropin releasing hormone Reduced thyroid stimulating hormone Increased thyroxine

Question 82

What is beta oxidation?

Answer 82

Oxidation of fatty acids in mitochondria to form Acetyl co A

Question 83

What pattern of electrolyte abnormality is likely to be seen in a patient on thiazide diuretics?

Answer 83

Decreased sodium and potassium

Question 84

What type of GLUT receptors are not insulin sensitive?

Answer 84

GLUT 2 expressed on pancreatic beta cells | High capacity but low affinity for glucose, acts as a glucose sensor

Question 85

A 21 year old man is seen by his GP. At the appointment he looks dishevelled and is withdrawn. He says he has had to give up work as the other staff had taken control of his mind to the extent that he had no control over his bodily movements. What phenomena is he describing?

Answer 85

Delusion

Question 86

What is a delusion?

Answer 86

A belief that is firmly held on inadequate grounds, not affected by rational argument or evidence to the contrary and is not a conventional belief that the person might be expected to hold given his educational, cultural and religious background

Question 87

A patient is diagnosed with schizophrenia. What will be the most important factor in reducing the patients risk of early mortality from cardiovascular disease?

Answer 87

Reduction of modifiable risk factors

Question 88

A 67 year old woman is admitted following a fall one hour ago. She is disoriented in time and place. The paramedics bring her medication which includes a thiazide diuretic. Which electrolyte abnormality is likely to account for her clinical features?

Answer 88

Hyponatraemia

Question 89

What group of mental health disorders account for the most disability adjusted life years globally?

Answer 89

Depressive and anxiety disorders

Question 90

A 52 year old patient has gradually declining cognitive function and is diagnosed as having dementia. The patient has not changed in personality and has no history of hallucinations. On genetic analysis, he has an additional copy of chromosome 21. What extracellular protein is likely to be responsible for his dementia?

Answer 90

AB amyloid

Question 91

How do class 1 antiarrhythmics such as Flecainide stabilise cardiac rhythm?

Answer 91

``` Slows conduction in all parts of the heart This is class 1c, slow dissociating sodium channel blocker ```

Question 92

What is the predominant physiological effect of Losartan that leads to blood pressure lowering?

Answer 92

Reduction in peripheral vascular resistance | Angiotensin II receptor blocker

Question 93

In a patient with diabetic ketoacidosis, what acid base changes are likely to be present?

Answer 93

Acidosis, low pCO2, low bicarbonate, raised anion gap

Question 94

A 66 year old man with type 2 diabetes attends clinic for his diabetic review. He is found to have isolated microscopic proteinuria. What is the likely responsible mechanism?

Answer 94

Increased intra glomerular pressure Efferent arteriolar vasoconstriction and mesangial expansion which leads to increased pressure, capillary hypertension and proteinuria

Question 95

A 68 year old Asian man with poorly controlled hypertension and diabetes Mellitus has mild hypertensive nephrosclerosis. The patient wants to prevent further kidney damage. Which risk factor could be modified?

Answer 95

HbA1c or hypertension control

Question 96

A 45 year old woman is diagnosed with hypertension secondary to renal artery stenosis. She is found to have abnormal plasma potassium. What hormone is likely responsible for this change?

Answer 96

Aldosterone Renal artery stenosis causes activation of RAAS Aldosterone causes upregulation of Na/K pump into basolateral membrane in renal tubules so leads to efflux of K and therefore hypokalaemia

Question 97

A 56 year old man has a seven month history of confusion and possible cognitive impairment. They have history of urinary incontinence and problems with balance when walking. What is the likely cause of their symptoms?

Answer 97

Normal pressure hydrocephalus