practice paper stuff Flashcards
A 78 year old man develops increasing confusion on the ward at night. He is wandering around naked asking for his wife, shouting, and threatening staff and patients. He was admitted this morning with 1 week of productive cough and temperature. He has a history of idiopathic Parkinson’s disease.
His temperature is 37.6°C, pulse rate 100 bpm, BP 132/71 mmHg and oxygen saturation 95% breathing air. His capillary blood glucose is 5 mmol/L.
Attempts to calm him with nursing measures do not improve the situation, and he begins hitting staff.
appropriate management?
lorazapam
A 78 year old woman has back pain and bilateral leg weakness. She had surgery for breast cancer 14 years ago. She had a minor fall at home a few days ago.
She has weakness of hip flexion bilaterally.
likely diagnosis?
spinal cord compression
A 28 year old man is investigated for polyuria and polydipsia. He has bipolar disorder for which he has taken lithium for 2 years. Initial investigations: Sodium 145 mmol/L (135–146) Potassium 3.9 mmol/L (3.5–5.3) Serum osmolality 296 mOsmol/kg (285–295) Urinary osmolality 356 mOsmol/kg (350–1000) Fasting glucose 5.8 mmol/L (3.0–6.0) Serum lithium 0.75 mmol/L (0.5–1.2)
Which is the most useful diagnostic investigation?
serum corrected calcium
It is essential to exclude hypercalcaemia due to hyperparathyroidism before progressing to a water deprivation test.
A 65 year old woman had a stroke 2 weeks ago causing right arm weakness and dysphasia. CT scan of head showed a left parietal lobe infarct. Her medication since the stroke includes aspirin and simvastatin. Her pulse rate is 82 bpm and irregular. Investigations: ECG: atrial fibrillation, rate 68 bpm.
Which is the most appropriate long-term plan for secondary stroke prevention?
Apixaban
For patients with a stroke and AF should start anticoagulation as secondary prevention.
A 67 year old man is due to have a CT scan of chest, abdomen and pelvis with intravenous contrast as assessment for possible lymphoma. He had a renal transplant 5 years ago. His medication includes prednisolone, tacrolimus and lisninopril.
His BP is 131/86 mmHg.
Investigations: Urea 12.9 mmol/L (2.5–7.8) Creatinine 165 µmol/L (60–120) eGFR 39 mL/min/1.73 m2 (>60)
Which is the most appropriate treatment to give before the scan?
Intravenous 0.9% sodium chloride infusion
The patient is due to receive IV contrast and has existing CKD. He is an increased risk of contrast nephropathy. Volume expansion with 0.9% sodium chloride infusion (1 mL/kg) is recommended and shown to reduce the incidence of contrast nephropathy.
A 78 year old woman is admitted after been found collapsed at home. She has been lying on the floor overnight. She has a history of hypertension and takes amlodipine. Her temperature is 35.8°C, pulse rate 88 bpm and irregular, and BP 102/60 mmHg. Investigations: Sodium 136 mmol/L (135–146) Potassium 5.8 mmol/L (3.5–5.3) Urea 20.9 mmol/L (2.5–7.8) Creatinine 180 μmol/L (60–120) Creatine kinase 870 U/L (25–175)
Urinalysis: glucose negative, ketones negative, blood 2+, protein 1+, leucocytes positive (catheter sample). She has passed 60 mL of urine over the past 2 hours.
Which is the most likely cause for her acute kidney injury?
Hypovolaemia
This 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.
A 76 year old woman has become increasingly confused over the past 2 weeks. She has a history of hypertension and cardiac failure. She is taking bendroflumethiazide, doxazosin, amlodipine, ramipril and atenolol.
Her BP is 108/71 mmHg.
Investigations: Sodium 121 mmol/L (135–146) Potassium 3.5 mmol/L (3.5–5.3) Urea 10.0 mmol/L (2.5–7.8) Creatinine 105 µmol/L (60–120)
Which medication is most likely to be responsible for her presentation?
A. Amlodipine B. Atenolol C. Bendroflumethiazide D. Doxazosin E. Ramipril
bendroflumethiazide
A 92 year old woman has severe neck, chest and back pain and tingling in her left hand following a mechanical fall. She has bruising around her right eye. Investigations: CT scan of head no intracranial injury or bleed, mild small vessel disease; right orbital fracture
Chest X-ray lung fields clear; left sided 4th rib fracture
Full blood count and clotting screen are normal.
Which is the most appropriate next investigation?
A. Cervical spine X-ray B. CT angiography C. CT scan of chest D. CT scan of neck E. MR scan of brain
CT scan of neck
The history and examination suggest a cervical spine fracture. This is best detected by a CT scan of the neck.
A 24 year old woman attends her GP with 2 months of intermittent palpitations. She describes the episodes as feeling as if the heart stops for a second followed by a pounding sensation. She reports episodes two to three times per week lasting 5–10 minutes, most commonly when she is going to sleep. She is otherwise well. She has been taking the combined oral contraceptive pill for 2 years. Her pulse rate is 68 bpm and BP 108/71 mmHg. Her heart sounds are normal.
Investigations: ECG: sinus rhythm, rate 70 bpm.
Which is the most likely diagnosis?
A. Paroxysmal atrial fibrillation B. Sinus arrhythmia C. Sinus tachycardia D. Supraventricular premature beats E. Supraventricular tachycardia
supraventricular premature beats
The description of the arrhythmias best fits with ectopics (either supraventricular or ventricular). Supraventricular are probably more common in this age group. There are no worrying features and the cause is most likely benign.
A 64 year old woman develops an acutely painful right knee 3 weeks after a prosthetic right knee replacement. Her temperature is 38.2°C and pulse rate 103 bpm. Her right knee is inflamed, with serous fluid discharging from the lower end of the wound.
Which is the most likely causative organism?
A. Corynebacterium species B. Enterococcus species C. Pseudomonas aeruginosa D. Staphylococcus aureus E. Streptococcus pyogenes
staph.auerus
A 52 year old man has 3 months of fatigue. He has a history of ulcerative colitis and takes mesalazine. He drinks 20 units of alcohol per week.
His temperature is 36.8°C and pulse rate 80 bpm. He has 3 cm hepatomegaly. Investigations: Albumin 36 g/L (35–50) ALT 65 IU/L (10–50) ALP 580 IU/L (25–115) Bilirubin 18 µmol/L (<17) γGT 230 IU/L (9–40)
Ultrasound scan of abdomen: bile duct wall thickening and dilatation
Which is the most appropriate next diagnostic investigation?
A. CT scan of abdomen B. Endoscopic retrograde cholangiopancreatography C. Liver biopsy D. MR cholangiopancreatography E. Percutaneous transhepatic cholangiography
MRCP
The patient has a classic cholestatic pattern of blood test abnormalities. PSC often has limited symptoms at presentation and bilirubin and albumin are often normal. There is a strong association with UC. Ultrasound shows evidence of abnormal bile ducts. MRCP is the typical initial diagnostic investigation as it is non-invasive. This usually shows typical beaded appearance of the bile duct.
A 60 year old woman has 6 weeks of a cough productive of blood streaked sputum.
Investigations: CT scan of chest: mass in left lower lobe
Needle biopsy: nuclei that are enlarged, hyperchromatic and pleomorphic
Which is the most likely diagnosis?
A. Adenoma B. Carcinoma C. Hamartoma D. Sarcoidosis E. Tuberculosis
Carcinoma
This is because nuclear enlargement, hyperchromasia and pleomorphism are features that suggest carcinoma in all sites of the body.
A 65 year old woman has an infective exacerbation of COPD. Her temperature is 37.8°C, pulse rate 108 bpm, BP 100/75mmHg, respiratory rate 26 breaths per minute and oxygen saturation 88% breathing 15 L/minute oxygen via a non-rebreather mask. She is alert. Investigations: Arterial blood gas on 15 L/min oxygen pH 7.28 (7.35–7.45) PO2 7.2 kPa (11–15) PCO2 8.9 kPa (4.6–6.4) Bicarbonate 31.3 mmol/L (22–30) Lactate 1.2 mmol/L (1–2)
Which is the most appropriate next management option?
A. Continuous positive airway pressure B. Invasive ventilation C. Nasal high flow oxygen D. Nasopharyngeal airway E. Non-invasive ventilation
non invasive ventilation
Respiratory acidosis needs to be corrected with ventilation in an alert patient
A 50 year old woman has acute onset of shortness of breath. She underwent a laparoscopic cholecystectomy 10 days ago.
Her temperature is 37.4°C, pulse rate 104 bpm, BP 122/80 mmHg, respiratory rate 24 breaths per minute and oxygen saturation 94% breathing air. Her chest is clear. She has minimal tenderness over the right hypochondrium.
Which is the most likely diagnosis?
PE
A 39 year old man has had fever, chills and generalised weakness for 1 month. He has a history of systolic heart murmur. He is an intravenous drug user.
Investigations: White cell count 15 × 109/L (3.0–10.0) Erythrocyte sedimentation rate 55 mm/hr (<20)
Blood cultures are awaited.
Which further investigation will help to establish the diagnosis?
A. Chest X-ray B. ECG C. Nasal swabs D. Transoesophageal echocardiogram E. Urine dipstick analysis
echo
The patient has a likely diagnosis of endocarditis and requires a TOE and blood cultures.
A 16 year old girl presents to the Emergency Department after an episode of loss of consciousness following a fall. She had consumed an excessive amount of alcohol at a party before the fall.
She has a dirty scalp wound and cannot remember recent events. Her pulse rate is 68 bpm, BP 110/80 mmHg and oxygen saturation 98% breathing air. She opens her eyes to command and is confused. Her capillary blood glucose is 6.0 mmol/L.
Her wound is cleaned and sutured.
Which is the most appropriate immediate management plan?
A. Admit and observe for 24 h B. CT scan of head C. Discharge with head injury instructions D. Refer to neurosurgeon E. X-ray of skull
head CT
A 47 year old woman has 1 year of increased urinary frequency, urgency and nocturia. She finds that she leaks urine if she is unable to get to the toilet promptly. She had three normal pregnancies with no complications.
The perineum appears normal and there is no uterine prolapse. Incontinence is not provoked by coughing or straining. Urinalysis is negative. A postmicturition ultrasound scan of bladder shows minimal residual urine volume.
Which is the most appropriate initial management plan?
A. Botulinum toxin type A injection into bladder wall B. Oral duloxetine C. Oral oxybutynin D. Percutaneous sacral nerve stimulation E. Topical oestrogen
oral oxybutynin
A 72 year old woman has 6 months of mild constipation.
Investigations: Haemoglobin 110 g/L (115–165) Creatinine 70 µmol/L (60–120) Calcium 2.90 mmol/L (2.2–2.6) Phosphate 0.65 mmol/L (0.8–1.5) 24 h urinary calcium 7 mmol (2–6) Parathyroid hormone 11.2 pmol/L (1.6–8.5) Vitamin D 65 nmol/L (>60)
Which is the most likely diagnosis?
A. Familial hypocalciuric hypercalcaemia B. Multiple myeloma C. Primary hyperparathyroidism D. Tertiary hyperparathyroidism E. Vitamin D intoxication
primary hyperparathyroidism
This is because primary Hyperparathyroidism is commoner in older female patients. In most cases symptoms are either mild, as in this case or absent. Biochemistry hypercalcaemia, elevated PTH and hypercalciuria point towards primary hyperparathyroidism. Tertiary hyperparathyroidism is possible but less likely as renal function is normal. There is no evidence for anaemia (malabsorption) and the patient is well.
A 52 year old man visits his GP for health screening. He is well.
His pulse rate is 80 bpm and irregular, and BP 128/84 mmHg. Investigations: Sodium 136 mmol/L (135–146) Potassium 3.9 mmol/L (3.5–5.3) Urea 4.9 mmol/L (2.5–7.8) Creatinine 80 μmol/L (60–120) HbA1c 40 mmol/mol (20–42)
Thyroid function tests are normal.
ECG shows atrial fibrillation, 76 bpm.
Which is the most appropriate treatment?
A. Apixaban B. Aspirin C. Diltiazem hydrochloride D. No treatment E. Warfarin sodium
no treatment
The patient has incidental non-symptomatic AF. This is a common way to pick up AF. The rate is controlled. He has no other risk factors and his CHA2DS2-VASc score is 0 and anticoagulation is not recommended
An 80 year old man presents to the Emergency Department with 2 hours of epistaxis that has not stopped despite compression. He has a history of hypertension.
A bleeding site is visible in the anterior nasal cavity. His BP is 160/95 mmHg.
Which is the most appropriate initial management option?
A. Anterior pack B. Antihypertensive medication C. Cautery D. Cryotherapy E. Ice pack
cautery
Minor bleeding from an accessible site can be treated with cautery using a silver nitrate stick or electrocautery. Anterior pack is for profuse bleeding with site difficult to localise. Anti hypertensives will only prevent further attacks of epistaxis. Cryotherapy and ice pack of little advantage and secondary.
A 65 year old man has abdominal distension and vomiting 48 hours after a sigmoid colectomy with primary anastomosis for bowel cancer. He has not passed any flatus for 24 hours. He is taking regular paracetamol and as required intravenous morphine.
His abdomen is distended with tenderness over the wound but no rebound or guarding. There are no bowel sounds.
His temperature is 37.6°C, pulse rate 96 bpm and BP 122/85 mmHg.
Which is the most appropriate initial management?
A. Give intravenous piperacillin with tazobactam B. Give Microlax ® enema C. Insert a nasogastric tube D. Start regular intravenous morphine E. Take to theatre for laparotomy
insert NG tube
The patient has evidence of a paralytic ileus. The initial treatment would involve making patient nil by mouth and inserting a nasogastric tube. Morphine would make the condition worse. There is no indication for antibiotics. An enema would not be appropriate and unlikely to be of benefit. There is no indication for immediate surgery as further investigations will be required to identify treatable causes.
A 23 year old man attends the sexual health clinic with a painful swelling in his groin and pain when opening his bowels. He had unprotected anal sex with a new male partner 4 weeks ago.
He has a perianal ulcer and tender inguinal lymphadenopathy.
Which is the most likely diagnosis?
A. Genital herpes B. Gonorrhoea C. HIV seroconversion D. Lymphogranuloma venereum E. Secondary syphilis
lymphogranuloma venereum
Proctitis and lymphadenopathy make LGV the most likely - and is endemic in MSM population in UK
A 25 year old man presents to the Emergency Department after vomiting a large quantity of blood.
At endoscopy, a deep ulcer is identified in the posterior wall at the junction of the first and second parts of the duodenum. There is a bleeding vessel in the base.
From which artery is the bleeding most likely to be arising?
gastroduodenal artery
The gastroduodenal artery runs posterior to the first and second parts of the duodenum and may be a source of major haemorrhage in peptic ulcer disease.
A 27 year old woman has a long history of irregular menstruation. She does not take any medication. Her BMI is 29.4 kg/m2.
Investigations: LH (pre-menopausal female) 15 U/L (follicular) (1–11) FSH 6 U/L (follicular) (2–8) Testosterone 3.5 nmol/L (0.2–2.9) Cortisol post 1 mg dexamethasone 40 nmol/L (<50) Prolactin 425 U/L (100–500)
Which is the most likely diagnosis?
PCOS
