Kings 2017 (Jan) Flashcards

1
Q

A man has SOB at rest, which gets worse with exertion. He denies having palpitations but feels his heart is going fast. Based on his symptoms and the ECG below, what is the diagnosis?

atrial flutter
AVNRT
junctional tachy
sinus tachy
ventricular tachy

A

Atrial Flutter

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2
Q

A patient comes to clinic with T2DM and PAD. What is the single most effective way to reduce the risk of gangrene?

start human insulin
arterial transplant
education about foot care

A

educational about foot care

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3
Q

61 yo man, 2 months ankle swelling. 30 year history seronegative polyarthritis and has hypertension. On sulfasalazine, hydrochloride something? and one other drug.
Pitting oedema up to calves. Some joint swelling.

bloods:
high CRP
low albumin
high urine protein:creatinine ratio

Urine dip: positive for protein. No nitrates or leukocyte.
BP: 117/70Renal biopsy is organised.
what would be seen on biopsy?

A. follicular segmental necrotising glomeruloscelrosis
B. ‎interstitial inflammation
C. ‎renal amyloidosis

D. ‎no change

A

‎renal amyloidosis

Causes of nephrotic syndrome

Secondary to systemic disease:

  • DM: glomerulonephrosclerosis
  • SLE: membranous
  • Amyloidosis: which is seen in all conditions causes chronic inflammation

FSGS:

  • Commoner in Afro-Caribs
  • Idiopathic or Secondary: VUR, Berger’s, SCD, HIV
  • Biopsy: focal scarring, IgM deposition
  • Rx: steroids or cyclophosphamide/ciclosporin
  • Prog: 30-50% → ESRF (may recur in transplants)

Membranous nephropathy:

  • 20-30% of adult nephrotic syndrome
  • Associations
    • Ca: lung, colon, breast
    • AI: SLE, thyroid disease
    • Infections: HBV
    • Drugs: Penicillamine, gold
  • Biopsy: subepithelial immune complex deposits
  • Rx: immunosuppression if renal function declines
  • Prog: 40% spontaneous remission

Minimal change (children)

Memransoproliferative (rare)

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4
Q

59 year old woman presents with weight gain, tiredness, cold intolerance…

blood results:
tsh high/N
t4 slightly low
cortisol normal
thyroid peroxidase antibodies elevated

A. toxic multinodular goitre

B. ‎primary hypothyroidism

C. ‎central thyroiditis (pituitary tumour)
D. Graves’ disease

A

‎primary hypothyroidism

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5
Q

Child with hip pain, fever, difficulty walking and cannot weight bear. Blood results show raised WCC, and raised CRP. What is the most likely diagnosis?

  1. Transient synovitis
  2. Reactive arthritis
  3. Septic arthritis
  4. Juvenile arthritis

Answer: primary hypothyroidism – presents with high TSH and low T4 and thyroid peroxidase antibodies elevated which points to Hashimotos (type of primary hyperthyroidism). Toxic multinodular goitre and graves disease would cause hyperthyroidism and pituitary tumour would cause low TSH and low T3/T4

A

Septic arthritis

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6
Q

65 y/o man. Has had pain in right leg when walking certain distance. Right calf is now painful and swollen. O/E pulses are felt in left leg, but no pulses can be felt below the femoral level of right leg. Right foot is pale and cold. What is the diagnosis?

  1. Saddle embolus
  2. DVT
  3. Iliac artery embolus
  4. Superficial femoral artery embolus
A

Superficial femoral artery embolus

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7
Q

73 y/o gentleman presents to A and E with confusion and trouble speaking (i think). Is known alcoholic. Had a fall at home 10 days ago. What is the most likely diagnosis?

  1. Extradural hemorrhage
  2. Subdural haematoma
  3. Wernicke’s encephalopathy
A

Subdural haematoma

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8
Q

Man, fever, bruising? Bloods: Increased APTT, Prothrombin Time, D Dimer.

A
  1. Christmas disease
  2. DIC
  3. Haemophilia Disease

Answer: DIC

Typical presentation, think patient was septic in this question. Results also are typical of a DIC.

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9
Q

A healthy 46 year old gentleman undergoes a routine vasectomy, an hour after the procedure he develops a temperature of 40.5C, BP: 80/50. His muscles become stiff.

A. Acute MI

B. Allergy to muscle relaxant

C. Myotonic

D. Malignante hyperthermia

E. Porphyria

A

Malignant hyperthermia

Overview

  • condition often seen following administration of anaesthetic agents
  • characterised by hyperpyrexia and muscle rigidity
  • cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
  • associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
  • neuroleptic malignant syndrome may have a similar aetiology

Causative agents

  • halothane
  • suxamethonium
  • other drugs: antipsychotics (neuroleptic malignant syndrome)

Investigations

  • CK raised
  • contracture tests with halothane and caffeine

Management: dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum

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10
Q
  1. A 42 year old gentleman attends the A&E department vomiting blood and he is taken in for an urgent endoscopy. On endoscopy there is an ulcerated lesion in the second part of the duodenum. Which artery?

A.

B. Celiac Trunk

C. Gastroduodenal A

D. Hepatic Artery

E. Superior mesenteric A

A

Gastroduodenal A: is bleeding

SMA supplies distal duo from second part of duodenum

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11
Q

10 year old boy with sore throat and fever. On examination the pharynx appeared red and tonsils swollen.
Mum wants abx which symptoms would allow abx to be prescribed.
1) sore throat and coryzal symptoms
2) pyrexial, tender lymph nodes and no cough
3) apyrexial, tender lymph nodes and no cough
4) apyrexial, tender lymph nodes and no cough

A

pyrexial, tender lymph nodes and no cough

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12
Q

80 yo COPD suffer with Ankle oedema on Salmeterol, Beclametasone, tiotropium has breathlessness and has had 4 admissions in the past few months with no improvement. Has regular carers visiting her. Best next step for breathlessness?

Home Oxygen

IV Fentanyl

IV Morphine

Nebulised Salbutamol

Something else

A

Home Oxygen

Assess patients if any of the following:

  • very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be ‘considered’ for patients with severe airflow obstruction (FEV1 30-49% predicted)
  • cyanosis
  • polycythaemia
  • peripheral oedema
  • raised jugular venous pressure
  • oxygen saturations less than or equal to 92% on room air

Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.

Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:

  • secondary polycythaemia
  • nocturnal hypoxaemia
  • peripheral oedema
  • pulmonary hypertension
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13
Q

28 yo female who’s 22 week pregnant has PE (?or DVT). What is the treatment?

Sub Cut LMWH

Sub Cut Unfractionated Heparin

Oral Warfarin

Oral Bivilarudin

Something else

A

Sub Cut LMWH

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14
Q

49yo woman with schizophrenia, scheduled for a routine inguinal hernia operation. On the morning of the operation, she does not give her consent. She is able to understand the information given and the consequences. She is currently on antipsychotic medication and has no active symptoms. What is best next step?

  1. Call psychiatrist
  2. Discharge and call General Practitioner
  3. Proceed with the operation
  4. Increase dose of antipsychotic medication
  5. Do not discharge under the Mental Health Act
A

Discharge and call General Practitioner

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15
Q

80~ yo woman with a history of recent falls. A hip fracture is suspected, brought in and scan demonstrated displaced intracapsular fracture of the neck of femur. What treatment is indicated?

  1. Compression
  2. Brace & Mobilise
  3. Dynamic Hip Screw
  4. Femoral Nail
  5. Hemiarthroplasty
A

Hemiarthroplasty

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16
Q

An 80 year old female presents with a red, swollen leg. She has been feeling unwell and nauseous over the past week. She has also lost her appetite. She has a past medical history of hypertension, T2DM, vitamin B12 deficiency.

Obs:

BP: 92/50, HR: 120, sats 92% on air, glucose 18 mmol/L

What is the most likely cause of her hypotension?

  1. Autonomic neuropathy
  2. Hyperosmolar hyperglycemic state
  3. Pulmonary embolism
  4. Sepsis
  5. Silent MI
A

Sepsis

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17
Q

A 45 year old male presents with a sixth month history of increasing dragging of his right leg. His wife said that his right hand sometimes shakes. On examination there was some stiffness in the right leg, but power and reflexes were normal. Right foot tapping was weak.

What is the most likely diagnosis?

  1. Huntington’s disease
  2. Left cerebral hemisphere tumour
  3. Multiple sclerosis
  4. Multisystem atrophy
  5. Parkinson’s disease
A

Left Cerebral hemisphere tumour

Huntington’s disease is an inherited neurodegenerative condition. It is a progressive and incurable condition that typically results in death 20 years after the initial symptoms develop.

Genetics

  • autosomal dominant
  • trinucleotide repeat disorder: repeat expansion of CAG
  • results in degeneration of cholinergic and GABAergic neurons in the striatum of the basal ganglia
  • due to defect in huntingtin gene on chromosome 4

Features typical develop after 35 years of age

  • chorea
  • personality changes (e.g. irritability, apathy, depression) and intellectual impairment
  • dystonia
  • saccadic eye movements
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18
Q

2 month baby- bronchiolitis-resus at home, brought to ed, cxr shows posterior healing rib fractures of 3,4,5, what is cause of fractures?

Birth trauma

resus injury

Non Accidental injury

A

Non -accidental injury

Birth trauma would probably have been picked up at birth and it’s not typical to have rib fractures. He stopped breathing and was resuscitated but the ribs would not be healing as this happened within hours.

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19
Q

45yo man who had left diverticular disease, left hemicolectomy , started vomiting, 400mls of billous vomit, nil bowel opening, axr showed dilated small bowel loops-whats first action

NG tube

CT abdo

Barium enema

A

NG tube

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20
Q

70 year old woman with new dx t2dm with polyuria poly dips iA, with a BMI of 35. Drinker 2-3 units of alcohol a week and is a non smoker. She stopped exercising since her dog died 2 years ago. What’s the most important part of patient education?

a) Importance of regular exercise
B) Switching to a high fibre diet
C) Blood glucose monitoring and symptoms of hypos
D) Decrease salt intake

A

Importance of regular exercise

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21
Q

50 year old man presents to neurology clinic complaining of difficulty walking. Diabetic? Was initially able to walk so far but now has reduced. On examination, calves are slightly wasted. Globe and stocking distribution tingling sensation with decreased proprioception, absent reflexes, and depressed plantar response. 20 units alcohol a week.

a) vitamine B12 deficiency
B) Diabetes?

A

vitamine B12 deficiency

SACD symptoms

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22
Q

Lady wants to renew prescription for Orlistat despite no weight loss in 6 months. She smokes, no alcohol, no exercise. Guidelines state if no weight loss with Orlistat in 12 weeks, change medication. What do you tell her?

A). Renew her prescription and review after 3 months

B). Refuse to renew and try to find out about her lifestyle and make appropriate changes

C). Renew her prescription only if she agrees to make lifestyle changes

D). Refer for bariatric surgery as she has exhausted all non-surgical management

E). Refuse to prescribe as she doesn’t meet the guidelines

A

Refuse to renew and try to find out about her lifestyle and make appropriate changes

120 mg up to 3 times a day, dose to be taken immediately before, during, or up to 1 hour after each main meal, continue treatment beyond 12 weeks only if weight loss since start of treatment exceeds 5% (target for initial weight loss may be lower in patients with type 2 diabetes), if a meal is missed or contains no fat, the dose of orlistat should be omitted.

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23
Q

Man has left red swollen cheek and pain and bleeding from left nostril. He can’t tolerate nasal endoscopy. What investigation would you do next

A). CT head

B). X-ray skull

C). Intranasal steroids

D). Sinus washout

E). Antibiotics

A

CT Head

Squamous cell carcinoma of the nasopharynx

  • Rare in most parts of the world, apart from individuals from Southern China
  • Associated with Epstein Barr virus infection
  • PC:
    • Systemic symptoms: Cervical lymphadenopathy
    • Nasal:
      • Otalgia
      • Unilateral serous otitis media
      • Nasal obstruction, discharge and/ or epistaxis
      • Cranial nerve palsies e.g. III-V
  • Investigation:
    • Imaging: Combined CT and MRI.
  • Treatment
    • Radiotherapy is first line therapy.
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24
Q

Female, 2 month history of abdo pain/discomfort, weight loss, no blood or mucus in stool.

Results:

Normocytic Anaemia

Low folate

  1. Coeliac
  2. IBS
  3. Ulcerative Collitis
A

Coeliac

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25
Q

Female, acute upper abdo pain radiating to the back, on a background of two years of intermittent RUQ pain.

Results: high amylase I think

Which of the following is most likely to be a factor:

  1. Pituitary adenoma
  2. Hyperlipidaemia
  3. Gallstones
A

Gallstones

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26
Q

8 year old boy fell from tree had displaced closed fracture suprcondylar what structure most likely to get damaged. (/most likely complication?)

  1. Brachial artery
  2. Radial nerve
  3. Biceps
  4. Compartment syndrome
  5. Avascular necrosis is the capitulum
A

Compartment synbdrome:

  • This is a particular complication that may occur following fractures (or following ischaemia re-perfusion injury in vascular patients). It is characterised by raised pressure within a closed anatomical space.
  • The raised pressure within the compartment will eventually compromise tissue perfusion resulting in necrosis. The two main fractures carrying this complication include supracondylar fractures and tibial shaft injuries

Symptoms and signs

  • Pain, especially on movement (even passive)
  • Parasthesiae
  • Pallor may be present
  • Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
  • Paralysis of the muscle group may occur

Diagnosis

  • Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.

Treatment

  • This is essentially prompt and extensive fasciotomies
  • In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
  • Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
  • Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
  • Death of muscle groups may occur within 4-6 hours
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27
Q

53yo man. Hx of ald. Present with fever and abdo pain. On ex abdo is distended and tender.. but no guarding. Bs present and has been opening bowels. Evidence of a thrill and shifting dullness.

Ix: neutrophils in peritoneal fluid >500

Dx?

Sbp
Portal hypertension
Small bowel obstruction

A

Sbp

28
Q

23 year old uni student, episodes of dry eyes, headache & increased heart rate. Episodes last 15 minutes. Dog died recetly.

Somatization

Generalised anxiety

Panic attack

Performance anxiety

Bereavement reaction

A

Panic attack

29
Q

A 19 year old student presents to hospital with fever, fatigue, sore throat and swelling in throat, axilla and groin. On examination there is bilateral tonsillar swelling and petechia on palate. Heart Rate 99 Blood Pressure 110/70

Blood results as follow

HB 120g

WBC 4

Platlets 380

What is the diagnosis

A) ALL

B) herpes simplex virus

C) infectious mononucleosis

D) streptococcal pharyngitis

E) toxic shock syndrome

A

infectious mononucleosis

30
Q

A 39 year old lady comes in who has been pregnant 4 times before, as she has noticed a 2cm mass in her left breast. She started her periods at the age of 15 and had 4 normal deliveries. All children were breast fed and well, she is a smoker and obese. Which of the risk factors increase the likelihood of developing breast cancer?

Late menarche

Breast feeding

Obseity

Smoking

A

Obseity

31
Q

Patient had loss of vision, curtain shadow in lower visual field, flashing, severe myopia

  1. retinal detachment
  2. Retinal artery occlusion
  3. Retinal vein occlusion
  4. Vitreous haemorrhage
A

retinal detachment

32
Q

sore eyes, watching tv/reading made it worse, visual acuity 6/9 both eyes with glasses. Punctate scarring on fluorescein

  1. Bacterial Conjunctivitis
  2. Viral Conjunctivitis
  3. dry eye syndrome
A

dry eye syndrome

When we examine patients with dry eye syndrome, there can be small spots on the surface of the cornea from dryness. By using special stains or dyes like fluorescein, rose bengal, or lissamine green in the tear film, we can see areas on the cornea where there is dryness. These small spots are called Punctate Epithelial Erosions, (PEE) or sometimes they will be called SPK (superficial punctate keratitis).

33
Q

A 7 year old boy presents to his GP surgery with his mother after having suffered from two/recurrent episodes of right ear pain, hearing loss and discharge from the right ear. Between these episodes he is completely well. What is the most likely diagnosis?

  1. Acoustic Neuroma
  2. Cholesteatoma
  3. Otitis Externa
  4. Otitis Media
  5. Mastoiditis
A

Otitis Media

34
Q

A 35 year old man with known HIV develops a silvery rash on his elbows. He also goes on to develop arthritis and nail changes including pitting of the nails and onycholysis. What is the most likely diagnosis?

  1. Reactive arthritis
  2. Discoid lupus
  3. Psoriatic arthritis
A

Psoriatic arthritis

35
Q

Women brought into A.E. with acute asthma attack. Given nebulised salbutamol, ipatropium and IV Hydrocortisone. She cannot complete sentences and sats are 88% on a non-breather mask 15L. pH - 7.3, o2 - 7.9, Co2 - 7.5. What would be the next step in management?

  1. CPAP
  2. Decrease PiO2 by 40%
  3. Intravenous aminophylline
  4. Intubate and ventilate
  5. Norepinephrine/adrenaline injection
A

Intubate and ventilate

36
Q

Elderly women had a fall and was found by neighbour next morning. She has had urinary incontinence and is on Ramipril. ECG shows Q wave in Lead III. Urea - 13mmol/L and creatinine kinase - 11000. What is the most likely cause of her raised creatinine kinase?

  1. Acute kidney injury
  2. Acute myocardial infarction
  3. Dermatomyositis
  4. Rhabdomyolysis
  5. A
A

Rhabdomyolysis

>10,000.

nb in AS mock: the patient is hypovolaemic due to long lie without hydration and the probably sepsis. The level of CK is compatible with minor soft tissue injury. Rhabdomyolysis would give a CK of >10,000. There is no indicators of glomerulonephritis and the urinalysis abnormalities are compatible with a catheter sample +/- urosepsis. Renal emboli are rare and would give loin pain. Ureteric obstruction is unlikely as the patient is still passing some urine.

37
Q

Elderly patient is diagnosed with terminal colorectal cancer. Doctors discussed the options following a cardiopulmonary arrest, the decision has been made not to attempt resuscitation in such case. The patient’s daughter is unhappy with the decision and would like the decision reversed. Which of the following options is advised?

  1. Reverse the decision
  2. Ask for a court order
  3. Stick with the decision and explain to the daugher
  4. Temporarily reverse the decision till the next morning after arranging an MDT
A

Stick with the decision and explain to the daugher

38
Q

Patient on long term ramapril develops drop in blood pressure. What is the mechanism by which ramapril may cause such effects.

  1. constriction of the efferent
  2. Dilatation of afferent arterioles
  3. dilation of efferent arterioles
A

constriction of the efferent

ACE causes constriction of the efferent

ACE inhibitors block the conversion of Angiotensin I (ATI) to Angiotensin II (ATII). They thereby reduce angiotesnin IIs effects.

angiotensin II has these effects:

Vasoconstriction and vascular smooth muscle hypertrophy -> increased blood pressure and hypertension.

  • Vasoconstriction of the efferent arterioles of the kidney leads to increased perfusion pressure in the glomeruli. - ACEi = Vasodilitation of the efferent arterioles
  • It contributes to ventricular remodeling and ventricular hypertrophy of the heart through stimulation of the proto-oncogenes c-fos, c-jun, c-myc, transforming growth factor beta (TGF-B), through fibrogenesis and apoptosis (programmed cell death). -ACEi = reduce remodelling
  • Stimulation by ATII of the adrenal cortex to release aldosterone, a hormone that acts on kidney tubules, causes sodium and chloride ions retention and potassium excretion. Sodium is a “water-holding” ion, so water is also retained, which leads to increased blood volume, hence an increase in blood pressure.- ACEi=reduce aldosterones, reduce water retention
    *
39
Q

38 yr old known cirrhosis/ oesophag varices, 2 week hiss of malaena. BP = low.which of following most likely suggests ACUTE gi bleed

  1. Hunger
  2. Heart rate of 114 bpm
A

Heart rate of 114 bpm

40
Q

38 yr old lady referred to gene clinic with 4 previous miscarriages, cannot carry a baby to full term. brother with microcephaly/ learning disorders. Most likely disorder?

  1. Downs syndrome
  2. Edwards syndrome
  3. Fragile X syndrome
  4. Robertsonian translocation
  5. Disorders of number of sex chromosomes
A

Robertsonian translocation problems

Long arms of two chromosomes join and the short arms are lost

Parents will be phenotypically normal but 50-75% of gametes will be unbalanced. Patients should be referred to a clinical geneticist.

41
Q

Man has right-sided scrotal swelling and discomfort for a while. Can get above it, can’t palpate testicle. Swelling trans-illuminates.

  1. Epididymo-orchitis
  2. Hydrocele
  3. Inguinal hernia
A

Hydrocele

Hydrocele:

  • Non painful, soft fluctuant swelling
  • Often possible to ‘get above it’ on examination
  • Usually contain clear fluid
  • Will often transilluminate
  • May be presenting feature of testicular cancer in young men

Epididymo-orchitis:

  • Often history of dysuria and urethral discharge
  • Swelling may be tender and eased by elevating testis
  • Most cases due to Chlamydia
  • Infections with other gram negative organisms may be associated with underlying structural abnormality

Inguinal hernia:

  • If inguinoscrotal swelling; cannot ‘get above it’ on examination
  • Cough impulse may be present
  • May be reducible
42
Q
  1. Women gives vaginal birth. She had hypertension. Cant wear TED stockings coz of discomfort. She can walk out twice a day for a smoke. Suddenly collapses day after giving birth.
    1. Hypoglycaemia
    2. MI
    3. Stroke
    4. Eclamptic fit
A

PE (if option)

43
Q

70 year old woman presents with history of urinary incontinence when coughing or sneezing. She underwent an operation for a lumbar disc prolapse a few months ago. On further questioning, she admits to incontinence when standing up. What is the diagnosis?

  1. Neuropathic bladder
  2. Detrusor instability
  3. Stress incontinence
  4. Chronic obstruction with overflow
A

Stress incontinence

44
Q

70 year old woman presents with 6 hour history of abdo pain. She had HR 140, BP 80/40, RR 28. Abdomen is soft and non tender. A routine ECG shows Atrial fibrillation. What is the diagnosis?

  1. Bowel ischemia
  2. Bowel obstruction
  3. CHolecystitis
A

Bowel ischemia

45
Q

Girl has allergy to egg and peanuts. Her dermatitis is poorly controlled. Her parents use an emolient cream for her skin. How best to manage her condition?

  1. Moderate topical steroid cream
  2. Oral steroids
  3. Avoid eggs and peanuts
A

Avoid eggs and peanuts

46
Q
  1. (coombs test positive q)
    1. Warm hemolytic anemia
    2. Cold hemolytic anemia
A

Warm AIHA
In warm AIHA the antibody (usually IgG) causes haemolysis best at body temperature and haemolysis tends to occur in extravascular sites, for example the spleen. Management options include steroids, immunosuppression and splenectomy
Causes of warm AIHA

  • autoimmune disease: e.g. systemic lupus erythematosus*
  • neoplasia: e.g. lymphoma, CLL
  • drugs: e.g. methyldopa

Cold AIHA
The antibody in cold AIHA is usually IgM and causes haemolysis best at 4 deg C. Haemolysis is mediated by complement and is more commonly intravascular. Features may include symptoms of Raynaud’s and acrocynaosis. Patients respond less well to steroids
Causes of cold AIHA

  • neoplasia: e.g. lymphoma
  • infections: e.g. mycoplasma, EBV
47
Q

A 65 year old woman has presented with tiredness, tanning, weight loss and hair loss. Her blood pressure is measured as 135/85, dropping to 105/65 on standing. Which test would you perform to confirm the diagnosis?

  1. Dexamethasone suppression test
  2. Short synacthen test
  3. Thyroid function tests
A

Short synacthen test

48
Q

A woman with COPD has become breathless. Her oxygen saturation has dropped from 90% to 85%. What oxygen should be given to this patient?

  1. Nasal specs 15L oxygen
  2. Continuous positive airway pressure
  3. Non-rebreather mask
  4. Venturi mask 24% oxygen
A

Venturi mask 24% oxygen

49
Q

45 yo man on ramipril and bendroflumethiazide for hypertension. GFR dropped from 60 to 50 from last year. What is the most appropriate step in management?

  1. Refer to renal clinic
  2. Take urine for cultures and dip
  3. Reduce Rampiril dose
A

?reasure (if an option)

eGFR <50 = stage 3

The majority of patients with chronic kidney disease (CKD) will require more than two drugs to treat hypertension. ACE inhibitors are first line and are particularly helpful in proteinuric renal disease (e.g. diabetic nephropathy). As these drugs tend to reduce filtration pressure a small fall in glomerular filtration pressure (GFR) and rise in creatinine can be expected. NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, although any rise should prompt careful monitoring and exclusion of other causes (e.g. NSAIDs). A rise greater than this may indicate underlying renovascular disease.

50
Q

A patient presents with ulcers above her medial malleolus. She has a history of venous disease. What is tge most appropriate form of management?

  1. Hyperbaric oxygen
  2. Compression bandaging
  3. Angioplasty
A

Compression bandaging

51
Q
  1. A patient with long term cancer finds themselves vomiting. What is the cause?
A

Cancer and nausea are associated in about fifty percent of people affected by cancer. This may be as a result of the cancer itself, or as an effect of the treatment such as chemotherapy, radiation therapy, or other medication such as opiates used for pain relief. About 70 to 80% of people undergoing chemotherapy experience nausea or vomiting. Nausea and vomiting may also occur in people not receiving treatment, often as a result of the disease involving the gastrointestinal tract, electrolyte imbalance, or as a result of anxiety. Nausea and vomiting may be experienced as the most unpleasant side effects of cytotoxic drugs and may result in patients delaying or refusing further radiotherapy or chemotherapy.

The strategies of management or therapy of nausea and vomiting depend on the underlying causes. Medical treatments or conditions associated with a high risk of nausea and/or vomiting include chemotherapy, radiotherapy and malignant bowel obstruction.Anticipatory nausea and vomiting may also occur. Nausea and vomiting may lead to further medical conditions and complications including: dehydration, electrolyte imbalance, malnutrition, and a decrease in quality of life.

52
Q

10 year old kid drinking excessively, has polyuria and polydipsia. Has glucose 16, Protein 4+, Keton 1+. No vomiting. What test would you do next.

  1. Fasting glucose tomorrow
  2. Random glucose tomorrow
  3. Urgent referral to pediatrics
  4. tell the patient not to eat meat before the test
  5. Non urgent referral to pediatrics
A

Urgent referral to pediatrics

53
Q
  1. What is the best prophylaxis for osteoporosis in patients with rheumatoid arthiritis?
    1. Bisphosphanates
    2. calcium tablets
    3. more calcium in diet
    4. hormone replacement therapy
    5. IV alendronate
A

Bisphosphonates

54
Q
  1. 75 year old lady presents with cough and increasing confusion, she is only able to consume non-solid foods. She has: raised temp; Hr 115; bp 95/60; 90%sats
    1. CAP
    2. Hospital acquired pneumonia
    3. Aspiration pneumonia
    4. Exacerbation of COPD
A

Aspiration pneumonia

Aspiration pneumonia is a pneumonia that develops as a result of foreign materials gaining entry to the bronchial tree, usually oral or gastric contents such as food and saliva. Depending on the acidity of the aspirate a chemical pneumonitis can develop, as well as bacterial pathogens adding to the inflammation. Aspiration pneumonia often results from an incompetent swallowing mechanism, such as those that occur in neurological disease or injury such as stroke, multiple sclerosis and intoxication. Iatrogenic causes, such as intubation, can also result in aspiration pneumonia developing. Risk factors for the development of aspiration pneumonia include:

  • Poor dental hygiene
  • Swallowing difficulties
  • Prolonged hospitalization or surgical procedures
  • Impaired consciousness
  • Impaired mucociliary clearance

The bacteria often implicated in aspiration pneumonia are aerobic, and often include:

  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Haemophilus influenzae
  • Pseudomonas aeruginosa
55
Q

A 6 month child comes into gp with excorciation and lichenified plaques.

There is a family history of asthma and dry itchy skin what is the most lkiekly diagnosis

  1. Atopic dermatitis
  2. Sebhoreic dermatitis
  3. Contact dermatitis
  4. Psoriasis
  5. Scabies
A

Atopic dermatitis

56
Q

An 82 yr old woman admitted to hospital with confusion and a chest infection. Her chest infection is successfully treated but beyond recovery her confusion persists. On asking her family it turns out she has been struggling at home and her memory has been deteriorating for several years.

What’s the most likely diagnosis

  1. Alzheimer’s
  2. Lewy body dementia
  3. Myxoedema
  4. Huntington disease
  5. Vascular dementia
A

Alzheimer’s

57
Q

Young man comes in to the clinic with with ascending pins and needles in his legs in glove and stocking distribution, and complains of tripping over regularly. He has recently recovered from an infection a few weeks ago. What condition does he have?

  1. Guillian-Barre Syndrome
  2. Multiple Sclerosis
A

Guillian-Barre Syndrome

58
Q

74 yr woman
Worsening fatigue and malaise
Increasing pain and stiffness in shoulders and more recently in pelvis
Blood tests show raised ESR crp and WBC

  1. Polymyalgia rheumatica
  2. Rheumatoid arthritis
  3. Ankylosing sponylitis
  4. Bone metastases
  5. Sepsis
A

Polymyalgia rheumatica

59
Q

64 yr obese male. Complains of dysphagia. Endoscopy shows squamous cloumnar junction at 32cm from incisors.Biopsy shows intestinal coloumanar metaplasia

  1. Adenocarcinoma
  2. Barret’s mucosa
A

Barret’s mucosa

60
Q

Patient has Thyroidectomy done, histology of tissues shows calcitonin uptake, what type of cancer is it?
A. Anaplastic
B. Follicular
C. Medullary
D. Parathyroid

A

Medullary

61
Q

A baby is born, not thriving well, examination shows 3cm hepatomegaly, 60 resp rate, heart rate 120, pansystolic murmur heard throughout the precordium, what is the most likely diagnosis?
A. Atrial septal defect
B. Ventricular septal defect
C. Critical Pulmonary stenosis

A

. Ventricular septal defect

62
Q

Person has PE, is given LMWH, how do you monitor the treatment.

  1. INR
  2. Activate partial thromboplastin time
  3. Factor Xa
  4. Prothrombin time
A

LMWH = Factor Xa

Heparin = Activate partial thromboplastin time

Warfarin = INR/Prothrombin time

DOAC = monitor for bleeding and bruising

63
Q

Lady comes in for colonography, then faints. Hasn’t passed urine in past 12 hours. What caused her to faint?

  1. Bowel perforation
  2. Purgative induced dehydration
  3. MI
A

Bowel perforation

64
Q

78 year old lady with abdo pain, shocked and in AF. Bowel sounds present. Abdo tenderness but no guarding. Patient shocked and hypertensive. WBC could 13.7. What is the most likely cause of her abdo pain?

  1. Ischaemic bowel
  2. Bowel perferation
  3. Pancreatitis
  4. Peptic ulcer
  5. Myocardial infarction
A

Myocardial infarction

65
Q

Bilateral enlarged tonsils, axillary, groin and neck lymphadenopathy, enlarged spleen

ALL

glandular fever

A

EBV