practice paper stuff

Question 1

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?

Answer 1

lorazapam

Question 2

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?

Answer 2

spinal cord compression

Question 3

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?

Answer 3

serum corrected calcium

It is essential to exclude hypercalcaemia due to hyperparathyroidism before progressing to a water deprivation test.

Question 4

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?

Answer 4

Apixaban

For patients with a stroke and AF should start anticoagulation as secondary prevention.

Question 5

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?

Answer 5

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.

Question 6

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?

Answer 6

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.

Question 7

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

Answer 7

bendroflumethiazide

Question 8

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

Answer 8

CT scan of neck

The history and examination suggest a cervical spine fracture. This is best detected by a CT scan of the neck.

Question 9

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

Answer 9

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.

Question 10

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

Answer 10

staph.auerus

Question 11

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

Answer 11

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.

Question 12

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

Answer 12

Carcinoma

This is because nuclear enlargement, hyperchromasia and pleomorphism are features that suggest carcinoma in all sites of the body.

Question 13

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

Answer 13

non invasive ventilation

Respiratory acidosis needs to be corrected with ventilation in an alert patient

Question 14

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?

Answer 14

PE

Question 15

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

Answer 15

echo

The patient has a likely diagnosis of endocarditis and requires a TOE and blood cultures.

Question 16

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

Answer 16

head CT

Question 17

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

Answer 17

oral oxybutynin

Question 18

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

Answer 18

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.

Question 19

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

Answer 19

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

Question 20

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

Answer 20

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.

Question 21

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

Answer 21

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.

Question 22

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

Answer 22

lymphogranuloma venereum

Proctitis and lymphadenopathy make LGV the most likely - and is endemic in MSM population in UK

Question 23

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?

Answer 23

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.

Question 24

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?

Answer 24

PCOS

Question 25

A 30 year old woman attends 3 months after a diagnosis of iron deficiency anaemia. She was advised to take oral iron supplements and has been taking these regularly. She has some looseness of her stools, and her periods are scanty on a combined oral contraceptive.

Investigations: Haemoglobin 92 g/L (115–165) MCV 70 fL (80–96) Ferritin 8 µg/L (12–200)
Which antibody test is most likely to diagnose the underlying cause?
A. Anti-gastric parietal cell B. Antimitochondrial C. Antinuclear D. Anti-smooth muscle E. Anti-tissue transglutaminase

Answer 25

anti TTG

coeliac is the most likely diagnosis

Question 26

A 75 year old man is admitted with weakness in his legs. He has a squamous cell lung cancer treated by radiotherapy 18 months previously.

He is cachetic. He has 4 out of 5 power in hip flexion and knee flexion bilaterally. Sensation and reflexes are normal, and sphincter function is preserved. His BMI is 17 kg/m2. MR scan of spine shows destructive bony lesions of T12 and L2–L4 vertebral body.
Which treatment is most appropriate to preserve neurological function?
A. Chemotherapy B. External beam radiotherapy C. Intravenous bisphosphonates D. Radiation brachytherapy E. Surgical decompression of the spinal cord

Answer 26

external beam radiotherpay

History and examination findings suggest cord compression. He has multiple lesions and is too frail for surgery. Radiotherapy is best treatment option.

Question 27

A 34 year old woman has headaches for 3 months. Her mother developed hypertension at the age of 38 years.

Her BP is 180/92 mmHg. Otherwise, examination, including fundoscopy, is normal. Investigations: Sodium 136 mmol/L (135–146) Potassium 3.3 mmol/L (3.5–5.3) Chloride 97 mmol/L (95–106) Urea 4.0 mmol/L (2.5–7.8) Creatinine 94 µmol/L (60–120) Plasma aldosterone:renin ratio 50 (<25) Cortisol (9am) 307 nmol/L (200–700)

Urinalysis is normal.
Which is the most likely diagnosis?
A. Essential hypertension B. Glucocorticoid excess C. Phaeochromocytoma D. Primary hyperaldosteronism E. Primary hypoadrenalism

Answer 27

primary hyperaldosteronism

Question 28

A 20 year old man has 2 days of visible haematuria. Three days before the haematuria started, he developed tonsillitis and was treated with phenoxymethylpenicillin. He has no significant medical history.

His BP is 112/54 mmHg.

Investigations: Urea 3.2 mmol/L (2.5–7.8) Creatinine 61 µmol/L (60–120)

Urinalysis: glucose negative, ketones negative, blood 3+, protein 3+, nitrites negative, leucocytes negative.
Which is the most likely cause of his haematuria?
A. Alport’s nephropathy B. Drug reaction C. Granulomatosis with polyangiitis D. IgA nephropathy E. Postinfectious glomerulonephritis

Answer 28

IgA nephropathy

Question 29

A 38 year old man has 2 months of epigastric pain that radiates into his back. It is worse at night and sometimes wakes him up. It is better after eating. He has been very busy at work. He occasionally misses lunch, which worsens the pain. He has not lost weight. He smokes 10 cigarettes per day and drinks two bottles of wine per week.

Examination is normal.
Which is the most likely diagnosis?
A. Cholecystitis B. Chronic pancreatitis C. Duodenal ulcer D. Gastric ulcer E. Gastric carcinoma

Answer 29

duodenal ulcer

Question 30

A 26 year old woman has 12 months of back pain, located in the low lumbosacral region. She has intermittent bilateral thigh pain. The back pain disturbs her sleep. The pain is improved by activity but not relieved by resting. She finds it difficult to bend down during the day to pick things up from the floor.
Which clinical feature is most specific for inflammatory back pain?
A. Improvement with activity B. Nocturnal pain C. Radiation to leg D. Stiffness during the day E. Young age

Answer 30

improvement on activity

Question 31

A 68 year old man has a swollen tender knee for 3 days and cannot weight bear. He has had previous episodes of big toe swelling. He has a history of chronic kidney disease stage 4.

Investigations: Fluid analysis of knee aspirate: White cell count 55 000/mL, 95% neutrophils Gram stain negative Copious 10 μm intracellular needle shaped crystals
Which is the best initial treatment for his acute knee pain and swelling?
A. Arthroscopic joint washout B. Intravenous flucloxacillin C. Oral allopurinol D. Oral naproxen E. Oral prednisolone

Answer 31

oral prednisolone

The presentation is likely due to an acute attack of gout. Although infection is not completely excluded at this stage it is less likely as G stain is negative and there are several positive features of gout in the history. IA or oral steroids, colchicine or NSAIDs are all effective treatments for acute gout. NSAIDs are contraindicated in CKD of this stage. Allopurinol will not help the acute attack.

Question 32

An 18 year old man is in the intensive care unit with septic shock as a result of a compound fracture of his leg. His urine output has been <30 mL for the past 2 hours.

His pulse rate is 125 bpm, BP 85/40 mmHg and JVP 4 cm above the sternal angle. There are basal crackles on auscultation of the chest.

Investigations: ECG shows sinus rhythm, 125 bpm.

He is being treated with intravenous 0.9% sodium chloride at 125 mL/h and antibiotics.
Which is the most appropriate additional intravenous treatment?
A. 500 mL 0.9% sodium chloride over 15 min B. 500 mL Hartmann’s solution over 15 min C. Dopamine hydrochloride D. Furosemide E. Noradrenaline/norepinephrine

Answer 32

noradrenaline

Description of adequate (if not over) hydration. Needs vasoconstriction.

Question 33

A 34 year old man has pain in his right shoulder and upper arm for 6 weeks that worsens when elevating his arm above his head. He does not recall any injury.

There is no deformity, tenderness or reduced range of movement. There is pain on abduction of the right shoulder that is worse with the arm in internal rotation and when abduction is resisted. He is treated with ibuprofen.
Which is the most appropriate next step in management?
A. MR scan of shoulder B. Refer for orthopaedic opinion C. Refer for physiotherapy D. Ultrasound scan of shoulder E. X-ray of shoulder

Answer 33

refer to physio

Question 34

A 65 year old woman with advanced carcinoma of the breast with cerebral and liver metastases is rapidly deteriorating and is recognised to be dying. She becomes confused and agitated.
Which is the most suitable initial treatment?
A. Diamorphine hydrochloride B. Glycopyrronium C. Hyoscine hydrobromide D. Midazolam E. Mirtazapine

Answer 34

midazolam

Question 35

In which part of the brain are changes most likely to be found in early Alzheimer’s disease?

Answer 35

temporal lobe

Question 36

prolonged QRS after trycyclic overdose

initial management?

Answer 36

IV sodium bicarbonate

Question 37

A 76 year old man undergoes an abdominoperineal resection for a low rectal carcinoma. He has a history of severe COPD and hypertension.
Which is the most appropriate method for providing analgesia during the early postoperative period?
A. Epidural anaesthesia B. Intramuscular opioid C. Oral non-steroidal analgesia D. Patient controlled intravenous analgesia E. Spinal anaesthesia

Answer 37

epidural

This is because for major abdominal surgery in respiratory disease opioid, by whatever route, should be avoided. Epidural is best because it can be topped up and titrated; spinal anaesthesia cannot. Transcutaneous electrical nerve stimulation has been used for postoperative pain, but trial results are contradictory. Intramuscular injection is difficult to titrate.

Question 38

A 75 year old woman becomes breathless while receiving the third unit of a blood transfusion. She was admitted with melaena and a haemoglobin of 65 g/L (115–165). She has a history of ischaemic heart disease and takes aspirin and lisinopril.

She now has bibasal inspiratory crackles and occasional wheeze. Her temperature is 37.3°C, pulse rate 96 bpm, BP 120/80 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 90% breathing air.

She is treated with high flow oxygen. The nursing staff have stopped the blood transfusion.
Which is the most appropriate additional treatment?
A. Intramuscular adrenaline/epinephrine B. Intravenous chlorphenamine maleate C. Intravenous furosemide D. Intravenous hydrocortisone E. Nebulised salbutamol

Answer 38

furosemide

they have fluid overload

Question 39

A researcher is seeking to examine whether long-term mobile phone use is linked to acoustic neuroma risk. The information on mobile phone usage is collected from participants with acoustic neuroma and a comparable group of participants without acoustic neuroma, selected from the general practice register.
Which type of study design is being used?

Answer 39

case control study

Question 40

A 56 year old woman has home blood pressure readings averaging 160/90 mmHg.

Hypertension is confirmed on 24 hour ambulatory monitoring. She has type 1 diabetes mellitus.

Investigations: Urinary albumin: creatinine ratio 42 mg/mmol (<3.5) eGFR 43 mL/min/1.73 m2 (>60)
Which type of antihypertensive is most appropriate?

Answer 40

ACEi

Question 41

A 70 year old man has dry cough and breathlessness on exertion for the past 3 months. He has lost 4 kg is weight. He has a history of ischaemic heart disease and atrial fibrillation. He takes warfarin sodium, ramipril and amiodarone hydrochloride. He is a never smoker.

His temperature is 37.5°C, pulse rate 70 bpm, respiratory rate 18 breaths per minute and oxygen saturation 91% breathing air. He has fine bibasal inspiratory crackles. There is no finger clubbing.

Investigations: Haemoglobin 141 g/L (130–175) White cell count 14.0 × 109/L (3.0–10.0) Erythrocyte sedimentation rate 65 mm/hr (<20)

Chest X-ray shows bilateral reticular opacities in both bases.
Which investigation is most likely to confirm the diagnosis?
A. Blood cultures B. Bronchoscopy C. Echocardiography D. High resolution CT scan of chest E. Induced sputum for microscopy and culture

Answer 41

high resolution CT scan of chest

This is because the patient has pulmonary fibrosis as a complication from amiodarone therapy. This classically does not cause clubbing. Patients present with cough and dyspnoea. Fever and reactive blood changes (raised WCC, ESR) are not uncommon. An HRCT would confirm changes of interstitial lung disease. Blood cultures are indicated but this is unlikely to be an infective cause. Bronchoscopy is not indicated. The features are not those of heart failure so an echo will not confirm the diagnosis. An induced sputum is not indicated at this stage.

Question 42

A 31 year old woman is admitted with 24 hours of confusion. She is having visual hallucinations of snakes and mice on the floor. Her partner says that she often drinks 80 units of alcohol per week. He has not seen her for the past week. She has a history of depression and takes fluoxetine. Her temperature is 37.6°C, pulse rate 100 bpm and BP 162/98 mmHg. She is disorientated in time and place. She has no focal neurological deficit.
Which is the most likely diagnosis?
A. Delirium tremens B. Fluoxetine overdose C. Hepatic encephalopathy D. Korsakoff’s psychosis E. Wernicke’s encephalopathy

Answer 42

delirium tremens

The patient has typical features of delerium tremens with confusion, visual hallucinations, tachycardia and pyrexia on the background of heavy alcohol use. This normally occurs on reduction or abstinence, which may not be clear from the history

Question 43

A 61 year old woman is admitted with 2 days of confusion. She has a history of hypertension and takes nifedipine. She smokes 20 cigarettes per day. She is confused but has no focal neurological deficit. Her pulse rate is 75 bpm, BP 139/87 mmHg and JVP 2 cm above the sternal angle. Investigations: Sodium 117 mmol/L (135–146) Potassium 4.2 mmol/L (3.5–5.3) Urea 1.9 mmol/L (2.5–7.8) Creatinine 57 μmol/L (60–120) Serum osmolality 252 mOsmol/kg (285–295) Urine osmolality 585 mOsmol/kg (100–1000)
Which mechanism best explains the development of hyponatraemia?
A. Increased sodium secretion in the distal tubule B. Increased water absorption in the collecting duct C. Increased water ingestion D. Reduced cortisol secretion E. Reduced sodium reabsorption in the proximal tubule

Answer 43

increased water absorption from collecting duct

The picture is of syndrome of inappropriate ADH secretion with hyponatraemia and inappropriately concentrated urine. ADH stimulates synthesis of aquaporin-2 in the apical membrane of the collecting duct which promotes water absorption. This leads to a dilutional hyponatraemia.

Question 44

A 43 year old woman has a sudden severe headache that started 24 hours ago. She has a history of autosomal dominant polycystic kidney disease.

Her temperature is 36.8°C, pulse rate 92 bpm and BP 140/100 mmHg. Neurological examination is normal. CT scan of head is normal.
Which is the most appropriate next step in management

Answer 44

LP

This is because APKD is associated with subarachnoid haemorrage. A lumbar puncture should be performed. MRA would be reasonable, but not MRI.

Question 45

A 74 year old man has progressively worsening muscle aches that are now causing him to struggle to get up from a chair or raise his arms above his head. He has a history of oesophageal cancer treated surgically and ischaemic heart disease. He is taking bisoprolol, clopidogrel, ramipril and simvastatin.

Investigations: Haemoglobin 125 g/L (130–175) White cell count 7.8 × 109/L (3.0–10.0) Platelets 391 × 109/L (150–400) Erythrocyte sedimentation rate 105 mm/hr (<20)
Which is the most appropriate therapeutic change?
A. Start co-codamol B. Start ibuprofen C. Start prednisolone D. Stop bisoprolol E. Stop simvastatin

Answer 45

start prednislone

classic PMR

Question 46

A 59 year old woman has 6 months of pain affecting her hips and lower back. She is Libyan and has lived in the UK for 10 years. She has chronic kidney disease stage 3 and hypertension. She is taking lisinopril and simvastatin. She has weakness of hip flexion bilaterally. There is no muscle or bony tenderness. Investigations: Urea 7.8 mmol/L (2.5–7.8) Creatinine 122 μmol/L (60–120) Calcium 2.1 mmol/L (2.2–2.6) eGFR 41 mL/min/1.73 m2 (>60) Alkaline phosphatase 230 IU/L (25–115) Parathyroid hormone 14.5 pmol/L (1.6–8.5)
Which additional investigation is most likely to confirm the diagnosis?
A. Creatine kinase B. Erythrocyte sedimentation rate C. Serum 25-OH cholecalciferol D. Ultrasound scan of neck E. X-ray of thoracic and lumbar spine

Answer 46

Serum 25-OH cholecalciferol

The clinical features suggest osteomalacia. She has hypocalcaemia and proximal muscle weakness. The low serum calcium is not adequately explained by CKD. Serum vitamin D would establish the diagnosis. 24 hour urinary calcium is sometimes performed in primary hyperparathyroidism but not in a secondary case such as this. The presentation is not one of myositis and this is unlikely to be significantly elevated. Ultrasound of neck is another primary hyperparathyroidism test. The lumbar spine X-ray is most likely to show osteopenia but does not give diagnostic features (unlike in children).