Past paper questions Flashcards
Which of the following is NOT a potential cause of obstructive renal impairment? A Benign prostatic hypertrophy B Recurrent kidney stones C Retroperitoneal fibrosis D Schistosomiasis E Systemic sclerosis
Benign prostatic hypertrophy can cause urinary retention and increased pressure in the urinary outflow tract,
Fibrosis or ureter by recurrent kidney stones = obstruction.
Schistosomiasis granulomas forming around the eggs of schistosomes = obstruction.
Systemic sclerosis [condition affecting small blood vessels] leads to
fibrinoid thickening of the afferent arterioles, leading to reduced renal perfusion and thus renal impairment [ckd], but it does not cause an obstructive uropathy.
A 60-year-old man who works for an oil company presents with a lesion
on the temple that is bothering him as it is growing. It bled once when he
knocked it. On examination, the lesion is 8 mm in diameter and is a flat,
mildly erythematous patch with a few scales and a larger keratotic horn
in the centre. There are no other lesions on inspection of his skin and no
personal or family history of skin cancer.
Which of the following is the most appropriate management plan? A Cryotherapy B Curettage C Excisional biopsy D Topical 5-fl uorouracil E Wide local excision
This lesion appears to be an actinic keratosis - Not at everted edges and well differentiated so unlikely to be SCC.
Treatment of isolated small lesions is by cryotherapy.
It has no concerning features to suggest that excision.
Which of the following best describes the MRI findings in multiple sclerosis?
A Cortical grey matter inflammatory lesions
B Longitudinally extensive transverse myelitis (more than three spinal
segments)
C Periventricular white matter lesions matching the clinical picture
D Periventricular white matter lesions not necessarily matching the clinical
picture
E White matter lesions exclusively in the cerebellum and brainstem
D Periventricular white matter lesions not necessarily matching the clinical picture.
This is because the central nervous system (CNS) inflammation does not
always cause demyelination or axonal damage of clinical significance, and
the CNS can recover from these foci of inflammation.
Which of the following is not a preventable risk factor for coronary artery
disease?
A Five cigarettes per day smoking history
B High low-density lipoprotein (LDL) cholesterol levels
C Hypertension
D Obesity
E 12 U/week alcohol history
12 U/week alcohol history
Low alcohol intake can reduce the risk.
A 55-year-old overweight pub landlord presents with a several-year history
of episodic acute painful joint swelling that started in his left big toe and
now affects his knees. Symptoms improve with use of diclofenac. Gout was
diagnosed on his first hospital visit, however this now appears recurrent.
He developed an acute attack in his left knee 2 days ago.
Which of the following represents the best plan for prophylaxis?
A Keep on long-term diclofenac with gastric protection
B Start allopurinol now with non-steroidal anti-inflammatory drugs
(NSAIDs) cover and increase until his urate is below 300 mmol/L
C Start allopurinol at least 2 weeks after the acute attack has settled with
NSAID cover and increase until his urate level is below 300 mmol/L
D Switch to long-term colchicine
E Switch to use of depot steroid injections
C Start allopurinol at least 2 weeks after the acute attack has settled with
NSAID cover and increase until his urate level is below 300 mmol/L.
Allopurinol can precipitate acute attacks so wait 2-4 weeks.
In which of the following circumstances should angiotensin-converting
enzyme (ACE) inhibitors be avoided where possible?
A Glomerulonephritis
B Lupus nephritis
C Renal artery stenosis
D Systemic sclerosis with renal involvement
E All of the above
Renal artery stenosis
Glomerulonephritis and lupus nephritis AND SYSTEMIC SCLEROSIS ACEI = renoprotection.
[43]Tetralogy of Fallot
An anxious mum has read on the internet about tetralogy of Fallot as she is
convinced her little boy may have it.
Which of the following does not fit the diagnosis?
A Her child is small for his age
B Her child is cyanotic
C His pulse exhibits a radio-femoral delay
D Her child exhibits a loud systolic murmur
E Her child can relive symptoms just by squatting
C His pulse exhibits a radio-femoral delay
Radio-femoral delay is a symptom of coarctation of the aorta, when the
coarctation (narrowing) occurs between the left subclavian artery and the aortic bifurcation.
Tetralogy of Fallot has four defining malformations:
1. Ventricular septal defect (VSD)
2. Pulmonary stenosis that turns the VSD into a right–left shunt, causing
cyanosis;
[acute attacks (due to increases in pulmonary vascular resistance)
can be managed by squatting, which raises peripheral vascular resistance
and therefore reduces the right–left shunt
3. Right ventricular hypertrophy
4. Overriding aorta, i.e. the aorta is connected to both ventricles and in this
sense acts like a second VSD, above which it sits
[44]Investigation of dysphagia
A 45-year-old man presents with intermittent difficulty in swallowing
for the last 4 months. This is associated with severe retrosternal pain and
regurgitation. He has no risk factors or sinister signs for malignancy.
What is the most important investigation in this case?
A Barium swallow
B Chest X-ray
C CT of the chest
D Endoscopy
E Iron studies
A - Achalsia - barium swallow is dx but
Dysphagia lasting more than 3 weeks, however, always warrants an endoscopy to exclude a malignant stricture.
[45] A 55-year-old Asian man with known thalassaemia trait registers with a new GP and is found to have a mild microcytic anaemia on routine testing. He does not complain of any symptoms. What is the most appropriate treatment? A Blood transfusion B Folate supplementation C Iron chelators D Iron supplementation E No treatment required
E
Individual Assymptomatic
A 72-year-old man is on warfarin for atrial fibrillation. Following a recent
chest infection his international normalised ratio (INR) rockets up to 5.2.
What was the most likely cause for this?
A Codeine phosphate
B Erythromycin
C Inappropriate high doses of warfarin
D International normalised ratio (INR) increased in concomitant infection
E Steroid inhalers
Erythromycin [potentiates the action of warfrin]
There is an interaction here with the antibiotics this woman is taking which has resulting in enhanced anticoagulation effects of warfarin
Cepahalosporins, chloramphenicol, ciprofloxacin, clarithryomycin, erythromycin and metronidazole are all examples which increase the effect of warfarin.
Any P450 inducer will have this effect as warfarin is a drug metabolised by cytochrome P450 enzymes. Antibiotics can also upset the gut flora which reduces vitamin K levels. [Remember that warfarin prevents the activation of vitamin K which is a cofactor in the synthesis of factors 2, 7, 9 and 10.]
Which of the following routine blood tests is most likely to indicate a cause
of an elderly patient’s acute confusional state?
A Calcium
B C-reactive protein (CRP)
C Liver function tests
D Sodium
E Urea
B- CRP
Infection = most common cause of acute confusional state in elderly.
Which of the following conditions is not associated with HLA-B27? A Crohn’s disease B Psoriasis C Scleritis D Ulcerative colitis E Uveitis
C Scleritis
HLA-B27 Conditions
PEAR
Psoriatic arthritis
Enteropathic arthritis [IBD related]
Ankylosing spomdylitis
Reactive arthritis
[6] A 70-year-old man presents to the emergency department with a cough
productive of blood-stained green sputum and shortness of breath. A chest
X-ray demonstrates a suspicious lesion in the right lower zone associated
with consolidation. On further questioning, he admits to recent weight loss
and back pain. Blood tests show:
Corrected Ca2+ [high]
PO4 0.33 mmol/L {low}
Alk Phos 450 mmol/L
Which of the following is NOT appropriate in the management of this
patient?
A Check patient’s urea and electrolyte level and serum calcium level twice
daily
B Consider starting intravenous bisphosphonate
C Consider starting loop diuretics
D Rehydration with intravenous normal saline
E Urgent isotope bone scan is uncecessary.
Urgent isotope bone scan is uncecessary.
PTH like peptide from squamous cell cancer.
Consider starting loop diuretics - can aid renal clearance.
Intravenous bisphosphonate (e.g. pamidronate) could cause a fall in calcium by causing bone reabsorption.
A 7-year-old boy presents with multiple erythematous patches, over both
sides of his face, head, neck, upper chest and left arm and shoulder, which
appear to be covered in a honey-coloured crust. His mother says that the
lesions have spread, over about a week, starting at the left neck and radiating
outwards. The child appears to be upset and the lesions are itchy. There is
no past medical history and no history of recent infections.
Which of the following diagnoses is most likely?
A Eczema
B Erysipelas
C Impetigo
D Psoriasis
E Staphylococcal scalded skin syndrome
impetigo - a sup[erficial infection by Staph Aureus that spreads from an initial starting point.
[21]A 69-year-old man recently diagnosed with metastatic prostate cancer
presents with weakness in his legs and urinary retention. He has had back
pain for years but in the last 24 hours this has become very severe in his
lower back. On examination he has a sensory deficit, loss of anal tone and
poor sensation in the skin around the anus. When catheterised he has a
residual volume of 1.5 L.
Which of the following is the most informative initial investigation?
A Computed tomography (CT) of the abdomen/pelvis
B Lumbar X-rays
C Magnetic resonance imaging (MRI) of the lumbar spine
D Serum calcium
E Ultrasound scan (USS) of the renal tract
Magnetic resonance imaging (MRI) of the lumbar spine - spinal chord compression
[21]A 69-year-old man recently diagnosed with metastatic prostate cancer
presents with weakness in his legs and urinary retention. He has had back
pain for years but in the last 24 hours this has become very severe in his
lower back. On examination he has a sensory deficit, loss of anal tone and
poor sensation in the skin around the anus. When catheterised he has a
residual volume of 1.5 L.
Which of the following is the most informative initial investigation?
A Computed tomography (CT) of the abdomen/pelvis
B Lumbar X-rays
C Magnetic resonance imaging (MRI) of the lumbar spine
D Serum calcium
E Ultrasound scan (USS) of the renal tract
Magnetic resonance imaging (MRI) of the lumbar spine - spinal chord compression.
Spinal chord compression =
lower Back pain with bowel/bladder/motor and sesnory dysfunction
[UMN signs]
[23]A 76-year-old man presents with a vesicular eruption on the left side of his
forehead only. It is severely painful and the vesicles have started to crust
over. On examination, the area affected is well-demarcated. You also note a
red eye with apparent conjunctivitis.
Given the most likely diagnosis, which of the following treatments is the
most appropriate?
A Intravenous aciclovir
B Oral aciclovir
C Topical aciclovir
D Topical antibiotic
E Topical steroids
B Oral aciclovir
Shingles - can affect branches of trigeminal nerve.
Most commonly the ophthalmic, where
it can also cause conjunctivitis, keratitis or iridocyclitis [Zoster opthalmicus]
[27] A 56-year-old man with a long history of alcohol abuse presents to the
emergency department with abdominal pain. On examination he has a
distended abdomen with shifting dullness and has a temperature of 38.2°C.
What is the most likely diagnosis?
A Bowel obstruction
B Liver cirrhosis
C Mallory–Weiss syndrome
D Perforated peptic ulcer
E Spontaneous bacterial peritonitis (SBP)
E Spontaneous bacterial peritonitis (SBP)
Patients with ascites are at risk of developing SBP, which usually presents
with severe generalised abdominal pain, worsening ascites, vomiting, fever
and rigors.
Intestinal luminal bacteria enter the circulation and colonise the ascitic fluid. SBP can lead to rapid decompensation of liver disease causing hepatic encephalopathy
and death.
The diagnosis of SBP is confirmed by paracentesis.
A 59-year-old woman with known polycythaemia vera presents to
the emergency department with right upper quadrant pain, tender
hepatomegaly and gross ascites, which has come on suddenly. There is no
jaundice.
What is the next most appropriate investigation?
A Cytomegalovirus (CMV) screen
B Gamma-glutamyl transferase (GGT) levels
C Hepatitis serology
D Hepatic vein Doppler ultrasound scan (USS)
E Human immunodeficiency virus (HIV) testing
Hepatic vein Doppler ultrasound scan (USS) -
Budd Chiari [sudden onset ascites, tender hepatomegaly + no jaundice due to blot clot obstructing hepatic portal vein - polycythaemia vera increased thrombosis risk in polycthaemia vera:
= stroke/heart attack/DVT/Budd-Chiari].
A 27-year-old man presents with a 3-month history of cough with
some blood streaking, loss of weight and night sweats. You suspect
tuberculosis.
Which of the following chest X-ray findings is not consistent with
tuberculosis?
A Cavitating lesion
B Consolidation of a lobe
C Diffuse 1–2 mm spots of increased opacity
D Perihilar ground-glass changes
E Pleural effusion
D Perihilar ground-glass changes [pulmonary fibrosis]
A 27-year-old man presents with a 3-month history of cough with
some blood streaking, loss of weight and night sweats. You suspect
tuberculosis.
Which of the following chest X-ray findings is not consistent with
tuberculosis?
A Cavitating lesion
B Consolidation of a lobe
C Diffuse 1–2 mm spots of increased opacity
D Perihilar ground-glass changes
E Pleural effusion
D Perihilar ground-glass changes [pulmonary fibrosis].
A 23-year-old man develops a urethral discharge and dysuria after a recent
change of sexual partner and urethral swabs are positive for Chlamydia.
Which of the following statements about antibiotic treatment is TRUE?
A His partners should be asked about symptoms and tested only if
symptomatic
B His partners should be tested for Chlamydia and treated only if positive
C His partners should be tested for Chlamydia and treated with antibiotics
regardless of outcome
D No antibiotic treatment is necessary provided he abstains from having
sexual intercourse for 2 weeks
E Only the patient who has presented needs antibiotic therapy
Common Sx of chlamydia = urethral discharge +
A 23-year-old man develops a urethral discharge and dysuria after a recent
change of sexual partner and urethral swabs are positive for Chlamydia.
Which of the following statements about antibiotic treatment is TRUE?
A His partners should be asked about symptoms and tested only if
symptomatic
B His partners should be tested for Chlamydia and treated only if positive
C His partners should be tested for Chlamydia and treated with antibiotics
regardless of outcome
D No antibiotic treatment is necessary provided he abstains from having
sexual intercourse for 2 weeks
E Only the patient who has presented needs antibiotic therapy
Common Sx of chlamydia = urethral discharge + dysuria [note same with ghonorrhoea - more discharge and yellow-green colour]
Pt can have absent Sx/mild sx that can resolve spontaneously - still be infectious so important to treat anyway [high likelihood].
RF - Epidymo-orchitis
Reactive arthritis
[Gonorrhoea = Rf for septic arthritis].
Which of the following is NOT a contraindication to renal transplantation?
A Active tuberculosis
B High-pressure urinary tract, e.g. posterior urethral valves
C Malignancy
D Severe arterial disease with stenosed iliac vessels
E Severe ischaemic heart disease with unstable angina and congestive
cardiac failure
Process of ellimination:
High-pressure urinary tract, e.g. posterior urethral valves
Active tuberculosis - Immunosuppression = disseminated TB.
Malignancy = Immunospuression worsen cancer/spread to transplant
Severe arterial disease with stenosed iliac vessels = Hypoperfucion = AKI.
Severe ischaemic heart disease with unstable angina and congestive
cardiac failure = Renal failure
[46]Thrombolysis in ischaemic stroke
Which of the following patients is eligible for thrombolysis with intravenous
recombinant tissue plasminogen activator?
A 2 hours post onset, BP 150/80 mmHg, GCS 11, MRI shows infarct
B 2 hours post onset, BP 160/90 mmHg, GCS 15, MRI shows haemorrhage
C 2 hours post onset, BP 160/95 mmHg, GCS 15, MRI shows infarct
D 2 hours post onset, BP 195/115 mmHg, GCS 15, MRI shows infarct
E 7 hours post onset, BP 135/80 mmHg, GCS 15, MRI shows infarct
Thrombolysis should only be done less than 4.5 hours from sx onset. [not E]
If greater than 4.5 hours, anti-coag with aspirin/clopidogrel 300mg.
Thrombectomy may be done on both cases.
Contra-indications of thrombolysis [anything that increases risk of bleed]:
- Previous surgery past 3 months
- On Anti-coagulation
- Hemaorrhagic stroke/previous haemorrage
- Very high BP [>180/110 mmHg]/low glascow scale [as increased likelihood that hemorragic]
Therefore answer is
C 2 hours post onset, BP 160/95 mmHg, GCS 15, MRI shows infarct
A 32-year-old man is diagnosed with Hodgkin’s lymphoma following a
recent history of weight loss and night sweats. Computed tomography
(CT) staging scan shows disease in the mediastinum bilaterally and some
abdominal lymphadenopathy, including the spleen, but no evidence of
disease in extranodal sites.
What is his stage of disease?
A Stage IIA
B Stage IIB
C Stage IIIA
D Stage IIIB
E Stage IVB
Ann arbour staging - Hodgkins lymphoma
Stage 1 = 1 lymph node
Stage 2 = 2+ ipsilaterally
Stage 3 = Bilateral lymph nodes
Stage 4 - Extra-nodal involvement
not A = Absence of B Sx
B = Presence of B Sx
[12] Which of the following scoring systems should be used to assess a patient’s
risk of developing a pressure score?
A Breslow score
B Confusion, Urea, Respiratory rate, Blood pressure, Age (CURB) score
C Ranson’s criteria
D Rockall score
E Waterlow score
Waterlow score
Breslow - Malignat melanoma
CURB 65 - pneumonia
Ranson’s - Pancreatitis
Rockall - upper GI bleed in PUD
A 35-year-old man presents with a 3-week history of pain and swelling in
the tips of his fingers. He has no history of bowel problems, recent infection
or skin disease, but his brother has Crohn’s disease. On examination you
find several swollen, red, tender distal interphalangeal joints, and the nails
have separated from the nailbed and have small pockmarks covering them.
The rest of the examination is unremarkable.
Which of the following diagnoses is most likely?
A Enteropathic arthritis
B Osteoarthritis
C Psoriatic arthropathy
D Reactive arthritis
E Rheumatoid arthritis
C Psoriatic arthropathy
"Brother has Crohn’s disease" - so likely to be HLA-B27 associated PEAR Psoriatic arthritis Enteropathic arthritis [IBD] Ankylosing spondylitis Reactive arthritis
Psoriatic arthritis Assymterical oligoarthritis Symmetrical polyarthritis DIP joint predominence Nail changes [POSH] Onycholysis [nail changes] means psoriatic arthritis most likely. Arthritis Muitilans [telescoping]
distal interphalangeal joints - so not Rheumatoid [PIP]
Which of the following is a recognised complication of coeliac disease? A Fistulae B Intestinal lymphoma C Primary sclerosing cholangitis D Toxic megacolon E Uveitis
B Intestinal lymphoma
Complications of Coeliacs
T-cell lymphoma
Small bowel cancer
A 59-year-old woman with advanced metastatic breast cancer presents to
the emergency department with severe abdominal pain. She has not opened
her bowels for 7 days and feels constipated. She has also noticed that she
has been passing water more frequently but has not been incontinent. On
rectal examination there is no loss of anal tone and normal sensation.
What is the most likely diagnosis?
A Hypercalcaemia
B Hypocalcaemia
C Metastatic spread to the bowel
D Opiate-induced constipation
E Spinal cord compression
Hypercalcaemia - secondary to bone mets
Stones, bones, groans, thrones, psychic moans
Pt has DIC secondary to Meningococcal sepsis:
Which of the following investigation results would you NOT expect in
disseminated intravascular coagulation?
A Increased activated partial thromboplastin time (APTT)
B Increased fibrinogen
C Increased international normalised ratio (INR)
D Decreased haemoglobin
E Decreased platelets
B Increased fibrinogen - Fibrinogen used in clot formation so will be depleated.
A 70-year-old woman who has been in hospital for 5 days with severe
pneumonia and treated successfully with intravenous co-amoxiclav and
oral clarithromycin develops profuse watery diarrhoea. Her pulse rises
to 110 bpm and she develops a temperature of 38.3°C. She is also taking
omeprazole for reflux disease. Stool samples are positive for Clostridium
difficile toxin.
Which one of the following is the best treatment plan?
A Barrier nursing in a side room
B Continue present antibiotic therapy
C Intravenous vancomycin
D Oral vancomycin
E Stop co-amoxiclav and omeprazole
C.did treatment = Ora; vancomycin/metronidazole
Note - Vancomycin used for MRSA also.
A 34-year-old woman with systemic lupus erythematosus (SLE) has had
multiple miscarriages and now presents with a painful right swollen leg. A
compression ultrasound scan confirms deep vein thrombosis.
Which blood test may now be indicated?
A Anti-phospholipid antibodies
B Clotting factors
C Haemoglobin
D Pregnancy test
E Tumour markers
Anti-phospholipid antibodies
Anti-phospholipd syndrome is characterised by:
Presence of anti-phospholipid antibodies
Pro-thrombotic state [arterial + Venous] and thrombocytopaenia
Recurrant miscarriages
Ass w/SLE
A 42-year-old woman attends to her GP complaining of non-specific
abdominal pain and an increasing abdominal girth. She is found to have
a large mass in her right lower abdomen and ascites on transvaginal
ultrasound imaging.
Which of the following tumour markers would be most useful?
A CA 125
B Ca 15-3
C Ca 19-9
D CEA
E Beta-hCG
CA 125 - Ovarian Cancer [FLAWS + abdo pain + abdo girth + ascites]
[21] You are asked by your registrar to see a 40-year-old woman and report back
your findings. On examination, you struggle to find an apex beat although
heart sounds 1 and 2 were audible with no murmur. On inspection, her
electrocardiogram (ECG) is normal except for inverted P-waves.
What is the most likely reason for these findings?
A Dextrocardia
B Cardiomyopathy
C Mitral stenosis
D Myocardial ischaemia
E Pulmonary hypertension
Dextrocardia
Inverted P-waves can be caused by dextrocardia or by the natural cardiac
pacemaker being situated elsewhere in the atrium other than the sino-atrial
node. In dextrocardia, the apex beat would be palpable on the right. The
ECG leads should be reversed to yield a “normal” trace.
[q1] You find an 80-year-old man collapsed in the street. He is unresponsive
and is making a snoring sound. An ambulance has been called but has yet
to arrive.
Which of the following is the best course of action?
A Cricothyroidotomy
B Do nothing till the ambulance arrives
C Finger sweep
D Head tilt chin lift
E Place in the recovery position
Head tilt chin lift - secure airway first
ABC
A 55-year-old man is being investigated for irregular heart rhythms. He has
a medical history of diabetes mellitus. He explains that exercise is diffi cult
for him due to joint pains. During the examination it is noted that he has
tan skin pigmentation and hepatomegaly.
Which of the following investigations could reveal the aetiology of his
symptoms?
A Haematinics
B Serum caeruloplasmin
C Short synacthen test
D Alpha-1 antitrypsin
E Gamma-GT
Haematinics - Haemochromatosis
{iron deposition in pancreas = DM
In joints = Koint pain
In heart = arrhythmias due to cardiomyopathy
Increased pigmentation - Fe in skin.
A 66-year-old man with a 10-year history of chronic obstructive pulmonary
disease is assessed in the respiratory clinic for eligibility for long-term
domiciliary oxygen therapy.
Which of the following is NOT a criterion for prescription of long-term
oxygen therapy?
A No exacerbation of chronic obstructive pulmonary disease (COPD) for
the previous 5 weeks
B Patient has stopped smoking
C Patient has chronic hypoxaemia with PaO2 <7.3 kPa
D Presence of pulmonary hypertension with PaO2 <8.0 kPa
E Two arterial blood gases showing PaO2 <7.3 kPa within 7 days
Two arterial blood gases showing PaO2 <7.3 kPa within 7 days
Must be >3 weeks apart
Criteria for long term O2 therapy: PaO2 of <7.3kpa [measured 3 weeks apart] PaO2 - 7.3 -8 w/ Pulm HyperT Secondary polycthaemia Peripheral odema Nocturnal hypoxia
No exacerbation of chronic obstructive pulmonary disease (COPD) for
the previous 5 weeks
A 35-year-old alcoholic homeless man with status epilepticus - management
A Diazepam 2 mg intravenously
B Diazepam 2 mg intravenously and Pabrinex intravenously
C Lorazepam 4 mg intravenously and Pabrinex intravenously
D Lorazepam 8 mg intravenously
E Lorazepam 8 mg intravenously and Pabrinex intravenously
4mg Lorazepam
or
10mg Diazepam
(+IV pabrinex)
A 55-year-old man presents to his GP with increasing lethargy and
polyuria. He has a past medical history of ischaemic heart disease and
congestive cardiac failure. He smokes 30 cigarettes per day and drinks
alcohol occasionally. He has a body mass index (BMI) of 32. His random
blood glucose is 14.0 mmol/L and fasting blood glucose level is 9.0
mmol/L.
Which of the following management is NOT appropriate in this patient?
A Advise the patient to change his diet and stop smoking
B Metformin should be considered as the first-line oral treatment option
for overweight patients
C Sulphonylureas and metformin could be considered as a combined
therapy if glycaemic control is not optimal
D Sulphonylureas should be considered if patient is intolerant to metformin
E Thiazolidinediones can be added to metformin and sulphonylurea
combination therapy if control is not optimal
E Thiazolidinediones can be added to metformin and sulphonylurea
combination therapy if control is not optimal.
Thiazolidinediones = acts on the adipocytes and addresses insulin resistance peripherally in fat and muscle [increases glucose uptake] but increase NA+ absorption = increasing fluid so contarindicated in CKD and CCF.
GLP-1 agonists and DDP4 inhibirtors - incretin effect * It stimulates insulin and suppresses glucagon
* It also increases satiety
- Metformin = Treat insulin resistance in the liver - It is an insulin sensitiser - reduces hepatic glucose output + = wt loss
- Sulphonylureas = it makes the existing pancreas secrete more insulin
- Alpha glucosidase inhibitor = delays glucose absorption [helps with 1st phase insulin defect]
- Thiazolidinediones = acts on the adipocytes and addresses insulin resistance peripherally in fat and muscle [increases glucose uptake].
- SGLT2 inhibitors - increase glucose excretion by the kidneys.
Which of the below results is the best indicator of poor liver function? A Raised alanine transferase B Raised albumin C Raised alkaline phosphatase D Raised bilirubin E Prolonged prothrombin time
E Prolonged prothrombin time - secondary to reduced synthetic ft of liver = reduces clotting factors.
[22] He will need physiological
fluid replacement when he is nil-by-mouth. He weighs 70 kg.
Which of the following regimens is closest to physiological needs?
A 1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose
in 24 hours
B 1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose
with 20 mmol potassium in 24 hours
C 2 × 1 L 0.9% normal saline with 20 mmol potassium and 1 L 5% dextrose
in 24 hours
D 2 × 1 L 0.9% normal saline with 20 mmol potassium and 1 L 5% dextrose
with 20 mmol potassium in 24 hours
E 3 L Hartmann’s in 24 hours
L 0.9% normal saline with 20 mmol potassium and 2x 1 L 5%
dextrose with 20 mmol potassium in 24 hours
A man weighing 70 kg needs 3L of water a day.
140mmol of Na+
60mmol K+
Normal saline contains 155 mmol of sodium.
Hartmann’s contains 130
mmol of sodium and 5 mmol of potassium, as well as chloride, calcium and
lactate. 3 L of Hartmann’s will give too much sodium and not
enough potassium, which could lead to fluid retention and hypokalaemia
[25] Which of the following diseases is the most common reason for misdiagnosis of Parkinson’s disease? A Corticobasal degeneration B Essential tremor/familial tremor C Progressive supranuclear palsy D Pugilist encephalopathy E Wilson’s disease
Essential tremor/familial tremor
[No other parkinsonian symptoms are present]
Sx improvement with beta blockers.
Usually the earliest sign of Parkinson’s disease,
and essential/familial tremor can present in late middle age, frequent
misdiagnosis is understandable. Essential and familial tremor are similar,
except essential tremor has no family history.
Progressive supranuclear palsy = parkinsonian symptoms with a
supranuclear gaze palsy
[A supranuclear gaze palsy is an inability to look in a particular direction as a result of cerebral impairment. There is a loss of the voluntary aspect of eye movements].
[38] A 24-year-old woman who has been travelling to India on a gap year
presents to clinic as she is concerned about a “funny-looking mole” on her
leg. She is unsure how long it has been there.
Which of the following is not a concerning feature of a mole when
considering a diagnosis of malignant melanoma?
A Asymmetry
B Bleeding
C Border irregularity
D Colour different to that of other moles on patient
E Itching
Colour different to that of other moles on patient
[37] A 74-year-old woman presents to hospital with an acute right-sided
hemiparesis, and is found to have a left middle cerebral artery infarct
on diffusion-weighted magnetic resonance imaging (MRI). It is her first
stroke. Her past medical history is unremarkable. Her blood pressure
is normal and her electrocardiogram (ECG) shows sinus rhythm with
occasional ventricular ectopics. Blood tests show normal cholesterol and
normal glucose. On carotid Doppler she is found to have an 85% stenosis
of the left carotid.
Which of the following treatments will NOT benefit her?
A ACE-inhibitor
B Aspirin
C Left carotid endarterectomy
D Statin
E Warfarin
E Warfarin
Warfarin is not indicated here as there is no atrial fibrillation,
it is her first stroke and there is nothing sinister in the past medical history
suggesting a drastic predisposition to thrombus formation. So Aspirin os sufficient anti-coag.
ACE-inhibitor
therapy has a beneficial effect even if the blood pressure was previously
normal.
[38] A 24-year-old woman who has been travelling to India on a gap year
presents to clinic as she is concerned about a “funny-looking mole” on her
leg. She is unsure how long it has been there.
Which of the following is not a concerning feature of a mole when
considering a diagnosis of malignant melanoma?
A Asymmetry
B Bleeding
C Border irregularity
D Colour different to that of other moles on patient
E Itching
Colour different to that of other moles on patient
ABCDE
Assymetry Border Irregularity Colour variation within smae mole Diameter [>7+mm] Evolution of lesion [size, shape, colour)
Other Sx - inflammation, bleading/itching/erythema et.c
A 43-year-old woman attends the GP with a 3-month history of a grey–white vaginal discharge which she says has a “fishy” odour. She is systemically well and has no menstrual abnormalities. What is the most likely diagnosis? A Bacterial vaginosis (BV) B Candida C Chlamydia D Gonorrhoea E Syphilis
Grey-white discharge w/fishy odour is classically bacterial vaginosis [not STI].
[43] An 83-year-old man is admitted with acute confusion. He has an extensive
medical history including atrial fibrillation, type 2 diabetes, osteoarthritis,
hypertension and some mild congestive cardiac failure, for which he takes
several medications. He appears clinically dry, with a pulse of 115/min, dry
mucous membranes and a capillary refill rate of 4 seconds. He is noted
to have a reduced urine output with concentrated urine. His creatinine is
235 μmol/L.
Which of the following medications does not need be reduced or stopped?
A Amlodipine
B Diclofenac
C Digoxin
D Furosemide
E Metformin
Presentaion suggests AKI - oligouria + relevant RFs.
calcium-channel blocker, a = safest antihypertensives for kidneys.
NSAIDs = nephrotoxic [interfere with effecternt arteriole = hypoperfusion of kidney]
Digoxin = nephrotoxic
Furosemide = exacerbation of hypovolaemia
Metformin = risk of met acidosis [hypoglycaemia] so should be stopped.
[50] A 30-year-old man presents to the medical assessment unit with a history
of excessive drinking and urination. He has been going to the toilet about
7–8 times per day for 1 month. His
results on admission show:
Urine osmolality 145 mOsm/kg Water deprivation test – urine osmolality 296 mOsm/kg after DDAVP 2 μg administered intramuscularly What is the most likely diagnosis? A Acute tubular necrosis B Cranial diabetes insipidus C Nephrogenic diabetes insipidus D Primary polydipsia E Type 2 diabetes mellitus
ADH results in increased urine osmolarity ∴ cranial diabetes insipidus.
A 60-year-old man visits his GP complaining of tiredness. He has noticed weight
loss over the last six months and irritation of the tip of his penis which appears
inflamed on examination. He mentions he has been visiting the toilet more often
than usual and feeling thirsty. The most appropriate investigation would be:
A. Oral glucose tolerance test
B. Measurement of glycated haemoglobin
C. Random plasma glucose test
D. Water deprivation test
E. Measurement of triglyceride levels
T2DM - Polydyspia, polyuria and wt loss
Opportunistic infection w/candida in pts with diabetes:
Females - Pruritius Vulvae
Males - Penile inflammation Balanitis
A 28-year-old woman has noticed a change in her appearance; most notably her
clothes do not fit properly and are especially tight around the waist. Her face
appears flushed and more rounded than usual, despite exercising regularly and
eating healthily her weight has steadily increased over the last 3 weeks. On visiting
her GP, he notices her blood pressure has increased since her last visit and she has
bruises on her arm. She is especially worried about a brain tumour. The next most
appropriate investigation would be:
A. Low-dose dexamethasone test
B. High-dose dexamethasone test
C. Urinary catecholamines
D. Computed tomography (CT) scan
E. Urinary free cortisol measurement
Urinary free cortisol [1st]
Then low dose dexamathasone in pt with Cushings.
A 55-year-old diabetic woman presents with altered sensations in her hands and
feet. She finds it difficult to turn pages of books and discriminating between
different coins. When walking, the floor feels different and she likens the sensation
to walking on cotton wool. The most likely diagnosis is:
A. Autonomic neuropathy
B. Diabetic amyotrophy
C. Acute painful neuropathy
D. Symmetrical sensory neuropathy
E. Diabetic mononeuropathy
Answer = Symmetrical sensory neuropathy - gloves and stocking distribution
Diabetic Neuropathy - weakness, reduced sensation and burning/shooting pain in known diabetic.
[tends not to be suymmetrical]
Diabetic amyotrophy - proximal thigh muscle Pain weakness and atrophy [quads]
Autonomic neuropathy - subtype of diabetic neuropathy = Autonomic sx [e.g postural hypotension, ED, bowel/bladder dysfunction, sweating anxiety]
A 38-year-old woman presents to clinic complaining of changes in her appearance
and weight gain. She has recently been through a divorce and attributed her weight
gain to this. However, despite going to the gym her clothes are still tight, especially
around her waist, her face seems puffy and flushed. The most likely diagnosis is:
A. Hyperthyroidism
B. Cushing’s disease
C. Acromegaly
D. Hypothyroidism
E. Diabetes
Facial plethora is a Sx of acromegaly alongside othger features such as coarse facial faeatures, prognathism, carpall tunnel, OSA …
Acromegaly often co-presents with hyperprolactinaemia.
A 67-year-old man is brought into A&E having been involved in a road traffic accident. On examination, he opens his eyes to pain, makes a few grunting noises and withdraws his legs from painful stimuli. What is his GCS? A 2 B 4 C 6 D 8 E 10
E= 2
V=2
M=4
Answer = 8
Eyes [1-4]
Verbal [1-5] 1 = no sound 2 = few incomprehensible sounds 3 = inappropriate responses 4= confused conversation 5= oriented in time and space
Motor [1-6] 1= no movement 2= abnormal extension 3= abnormal flexion 4= withdraws from pain 5= Moves to painful stimulus 6= obeys command for movement
56-year-old man with a history of alcoholism complains of intermittent epigastric pain that radiates through to his back. When questioned, he admits to losing about 3 kg in weight over the past 6 months and says that his stools have become pale and difficult to flush away. Which investigation would you request to aid the diagnosis?
A Serum amylase B Blood cultures C Faecal elastase D CA 19-9 E OGD
Chronic pancreatitis
C Faecal elastase = best marker for chronic pancreatitis
[amylase/lipase may not be raised due to exocrine insufficency]
A 46-year-old man, with a history of type 1 diabetes, visits the GP for an HbA1c reading. He has recently been feeling more tired than usual and has noticed that the skin on his hands has become darker over the past few months. On examination, hepatomegaly and a tanned complexion (despite not having been on any recent holidays) are noted. Haemochromatosis is suspected and iron studies are requested. Which set of results would be consistent with haemochromatosis?
A High serum iron, high ferritin, high transferrin, low transferrin saturation, low TIBC
B High serum iron, low ferritin, low transferrin, high transferrin saturation, low TIBC
C High serum iron, high ferritin, high transferrin, high transferrin saturation, low TIBC
D High serum iron, high ferritin, low transferrin, high transferrin saturation, high TIBC
E High
E
Haemochromatosis = Hereditary haemochromatosis (HH) is an autosomal recessive disorder of iron metabolism caused by excessive intestinal absorption of dietary iron. This results in iron deposition in tissues and organs (e.g. skin, joints, liver, pancreas and adrenal glands).
The main clinical features of HH are bronze skin, diabetes and hepatomegaly, due to iron deposition in the skin, pancreas and liver
High serum iron
Increased ferritin [responsible for intracellular storage of iron]
Low TIBC
High transferrin saturation [Fe2+ binds transferrin in blood]
Low Transferrin – increased serum iron leads to decreased transferrin levels to prevent more iron from becoming plasma protein bound in the blood
A 53-year-old man presents to A&E with severe pain in his right flank that radiates to his right groin. Ureteric colic is suspected and a CT-KUB is requested. The CT-KUB confirms the diagnosis but it also shows an abdominal aortic aneurysm with a diameter of 4.7 cm. When questioned, the patient denies any back pain (other than the pain caused by ureteric colic) or symptoms of vascular disease. What is the most appropriate management option for this patient?
A Reassure and discharge
B Surveillance with an ultrasound scan every 1 year
C Surveillance with an ultrasound scan every 6 months
D Surveillance with an ultrasound scan every 3 months
E Surgical repair of the aneurysm
D Surveillance with an ultrasound scan every 3 months
AAA
- 5-4.5 cm = yearly monitoring
- 5-5.5 = 3 monthly monitoring
> 5.5/ expands > 1cm a year = Endovascular annerysm repair.
A 68-year-old male visits his GP complaining of constipation, rectal bleeding and itchiness around his anus. He often feels ‘a lump’ hanging out after defecating which he has to push back in himself. On examination, anal tone is weak and a protruding mass is felt which has palpable muscular rings. What is the most likely diagnosis? A Grade 3 haemorrhoids B Grade 4 haemorrhoids C Perianal abscess D Type 1 rectal prolapse E Type 2 rectal prolapse
E Type 2 rectal prolapse
A lump that has to be pushed back in on defecation = either a stage 3 hemorrhoid or rectal prolapse.
Haemorrhoid = an enlarged vascular cushion that has the tendency to protrude, bleed and prolapse.
Rectal prolapse = colapse of the rectum/part of the rectum out of the anus.
Type 1 = incomplete prolapse [just mucosa] - due to chronic straining, hemorrhoids, CONSTIPATION
Type 2 - complete prolapse[entire wall] hence palpable muscular rings - due to weaking of pelvic/anal musculature secondary to;
chronic STRAINING
Increasing age
NEUROLOGICAL DISORDER/SPHINCTER PARALYSIS
A 24-year-old female, who has recently returned from a 3-week trip to Vietnam, complains that she has been feeling ‘under the weather’ with fevers and joint pain. On direct questioning, she reveals that she had unprotected sexual intercourse with a stranger whilst in Vietnam. She is jaundiced and has right upper quadrant tenderness. Hepatitis B serology is requested. The results are shown below: HBsAg + HBeAg - HBcAb IgM + HBcAb IgG + HBsAb - What is the hepatitis status of this patient? A Acute infection B Chronic infection C Cleared D Vaccinated E Susceptible
HBsAb - so hasn’t cleared the infection or been vaccinated as this needed to provide immunity.
Individuals that have been vaccinated against hepatitis B will only be HBsAb+. Previously infected patients who have cleared the virus will be HBsAb+ and HBcAb IgG+.
HBsAg + indicates infection
HBcAb IgM +
HBcAb IgG +
The earliest mark of acute infection will be a rise in HBsAg. This will be followed by a rise in HbcAb IgM and HBcAb IgG. HBcAb IgM will only be present during the acute phase of the infection.
Therefore this person has acute infection not a chronic infection.
If HBsAg is detected in the serum 6 months after an acute infection, it suggests that the patient has developed chronic hepatitis B. These patients will also have HBcAb IgG
A 61-year-old man is brought to A&E by his daughter as he has become increasingly breathless over the past 24 hours and he has been coughing up a large amount of green sputum. He has a past medical history of COPD. Arterial blood gases are requested which show the following results (on room air): pH : 7.33 (7.35-7.45) PaO2 : 6.7 kPa (> 10.6 kPa on air)
PaCO2 : 9.6 kPa (4.7 - 6 kPa on air) HCO3- : 33 mmol/L (22 – 28 mmol/L) Respiratory Rate : 22 /min
What is the diagnosis?
A Partially compensated respiratory acidosis B Fully compensated respiratory acidosis C Partially compensated metabolic acidosis D Fully compensated metabolic acidosis E Acute type 1 respiratory failure
A Partially compensated respiratory acidosis
pH = acidosis so not fully compensated
PaO2 = low PaCo2 = high [so resp acidosis]
HCO3- : High [partially compensated]
A 73-year-old man has come to the outpatient clinic with his wife. She says that her husband seems very confused on some days and then seems completely normal on others. During the consultation, the patient appears confused with an AMTS of 4/10. He is distressed and claims that he can see little men running across the desk towards him. The doctor also notices a resting tremor. What is the most likely diagnosis? A Lewy body dementia B Alzheimer’s disease C Depressive pseudodementia D Frontotemporal dementia E Vascular dementia
A Lewy body dementia = fluctuation of confusion, HALLUCINATIONS + resting tremor [parksinsons like sx]
Accumulation of abnormal aggregates of proteins, called Lewy bodies in the cytoplasm of neurons. It also leads to a loss of dopaminergic neurons in the substantia nigra, resulting in features of parkinsonism (resting tremor, postural instability, bradykinesia and rigidity).
Frontotemporal dementia tends to first present with a change in personality or behaviour. Vascular dementia is caused by multiple small cerebral infarcts, leading to a loss of brain function. Patients may have a history of experiencing stroke-like symptoms. The patient’s state tends to undergo a step-wise decline in vascular dementia. Depressive pseudodementia is when dementia-like symptoms result from underlying depression. SBAs are likely to mention a recent bereavement or traumatic life event when alluding to depressive pseudodementia.
A 22-year-old teacher visits her GP after fainting several times over the past 2 months. She does not experience any palpitations, light-headedness or auras before she faints, and she recovers very quickly. She has not bitten her tongue or become incontinent at any point. When questioned about the timing of these episodes, she reveals that she has only ever collapsed at work after she has been writing on the whiteboard for quite some time. On examination, a firm, immobile lump is palpated in her left supraclavicular fossa. What is the most likely diagnosis? A Paroxysmal atrial fibrillation B Transient ischaemic attack C Atonic seizures D Subclavian steal syndrome E Vasovagal syncope
Subclavian steal syndrome
Aetiology - compression [lump/extra rib] /stenosis [atheroscleorosis] proximal to vertebral artery.
Increased Q to arm = reduced Q to brain via vertebral artery [responsible for posterior circulation].
A 62-year-old diabetic on metformin sees his GP for a routine blood test. He claims that he has been compliant with his treatment and has not experienced any symptoms recently. His blood test reveals: Na+ : 116 mmol/L (135-145) K+ : 3.7 mmol/L (3.5-5) Ca2+ : 2.4 mmol/L (2.2-2.6) Total Cholesterol : 9.2 mmol/L (< 5) Serum Albumin : 48 g/L (35 -50) TFT - Normal SST - Normal
What is the most likely cause of his hyponatraemia? A Addison's disease B Hypothyroidism C Erroneous result D Drug side-effect E Nephrotic syndrome
Main findings:
Low sodium
High Cholesterol
Moderate hyponatremia [>125] = Headaches/nause+V/cramps [think about retired hurt cricket game]
Severe {<120] = [Neuro Sx- seizures, hallucinations, confusion, memory loss]
Pt is assymptomatic so must be an erronous result.
