MSCAA Practice Paper 2020

Question 1

• 42, M
• 1 day severe upper abdominal pain
• Vomited 5 times
• 13 cigarettes/day / 17 units alc/week
• Temp 38, PR 93bpm, BP 140/82
• Tender epigastrium, right upper quadrant
• Voluntary guarding (tensing of abd. muscles to avoid pain)

White cell count 15 × 109/L (3.8–10.0)
ALT (alanine aminotransferase) 41 IU/L (10–50)
Alkaline phosphatase 125 IU/L (25–115)
Bilirubin 14 μmol/L (<17)
Amylase 222U/L (<220)
CRP 42 mg/L (<5)

Most likely diagnosis?

Answer 1

Acute cholecystitis

Question 2

• 55, F
• 3 weeks memory problems and confusion
• Headaches worse when coughing/sneezing
• Associated w/ vomitng
• Resected melanoma and treated w/ adjuvant immunotherapy 2 years ago
• BP 169/100 mmHg
• No focal neurological signs

Most likely diagnosis?

Answer 2

Cerebral metastases

Question 3

• 66, M
• Advanced gastric cancer
• Morphine sulfate (modified release, 90mg twice daily) for abd. pain
• In last days of life, unable to swallow oral meds
• Not needed doses for breakthrough pain

eGFR = >60 mL/min/1.73 m2 (>60)

Continous subcut. infusion of morphine sulfate required, as direct conversion from oral morphine sulfate. Correct dose over 24 hrs?

Answer 3

90 mg
(Morphine sulfate SC in 24 hrs = 0.5 x Total Morphine sulfate oral dose in 24 hrs)

Question 4

• 40, F
• Low back pain day after falling while playing tennis
• Usually well, no regular meds
• Lab technician

Answer 4

Continue usual activity - short duration acute low back pain in fit person

Question 5

• 50, F
• Burning pain in right leg
• Advanced cervical cancer compressing sciatic nerve
• As part of EOL care, takes morphine sulfate modified release (20mg twice daily)
• Requests further pain medication

Most appropriate medication to add?

Answer 5

Oral amitryptiline

Question 6

• 75, M
• Presents to ED feeling generaly unwell
• No specific symptoms
• Treated w/ neoadjuvant chemotherapy for rectal cancer
• Underwent 2nd cycle 8 days ago
• 38.4 temp, PR 97 bpm, RR 12 breaths/min, Oxygen Sat 98% breathing air
• Blood test results not available yet

Next management step?

Answer 6

IV broad-spectrum antibiotics

Question 7

• 41, F
• 1 day painful, swollen left knee and fever
• History of rheumatoid arthritis
• Takes methotrexate and abatacept
• 38.2 temp, PR 100 bpm, BP 119/83 mmHg
• Left knee swollen and erthythematous

White cell count 15.2 × 109/L (3.8–10.0)
Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 μmol/L (60–120)
CRP 154 mg/L (<5)
Joint aspiration: no organisms on Gram stain,
white cell count 2645/μL (<200), mostly neutrophils, no crystals.

Appropriate additional management?

Answer 7

IV flucloxacillin

Question 8

• 64, F
• White British visits GP for NHS health check
• BMI 30, BP 110/84
• Normal urinalysis

Glycated haemoglobin 44 mmol/mol (20–42)

Appropriate next step?

Answer 8

Diabetes Prevention Programme

Question 9

• 82, F
• 5 days worsening abdominal pain
• Recent constipation
• No rectal bleed
• 38.1 temp
• PR 105 bpm, BP 140/85
• Tenderness in left iliac fossa with rebound tenderness
• Normal bowel sounds
• Rectal exam shows hard stools only

Most likely diagnosis?

Answer 9

Sigmoid diverticulitis (changes in bowel habit, left iliac fossa pain, features of infection such as pyrexia)

Question 10

• 23, F
• Bloody diarrhoea 5x day for past 4 weeks
• Feeling unwell
• Urgency to pass stool
• Cramping abdominal pain
• Itchy right eye, not painful
• 38.5 temp, PR 100 bpm, BP 110/70
• RR 22 breaths/min
• Negative stool culture

Answer 10

Ulcerative colitis

Question 11

• 41, M
• Nausea, fever, rigors
• Cough productive of green sputum
• Discharged 2 days ago after being treated for a PE
• Low molecular weight heparin injections 2x daily since diagnosis
• Appendicetomy 1 yr ago
• 38.3 temp
• PR 108 bpm, BP 90/45

Activated Partial Thromboplastin Time 43 seconds (22–41)
Prothrombin Time 18 seconds (10–12)

Answer 11

Disseminated intravascular coagulation