vsa

Question 1

A 50 year­old­man with a history of type 2 diabetes presents with left sided weakness and a headache. Examination reveals brisk reflexes in the left arm.

A.mgraine
B. GBS
c. brain tumour
D. stroke
E. MS

Answer 1

STROKE

Question 2

A 50­year­old male presents with severe epigastric pain. He has had a similar episode in the past and he admits to drinking an excess of alcohol, and smoking a pack per day.

Cholecystitis
Acute inferior MI
Peptic ulcer disease
basal pneumonia
acute pancreatitis

Answer 2

Acute pancreatitis

Question 3

A 40­year­old man presents with collapse and loss of consciousness witnessed by his wife. The episode lasted 3 minutes. He felt dizzy for a few seconds prior to the event and had some jerky movements during the event. He recovered spontaneously and was not confused afterwards. He had no previous cardiac history and in fact had never seen a doctor

Arrhythmia
seizure
TIA
hypoglycaemia
vasovagal attack

Answer 3

Vasovagal attack

Question 4

A 24 year old female presents with severe right sided back and abdominal pain and a

fever. She has no other previous medical or travel history.

Hepatitis
Campylobacter inf
actue pyelonephritis
Acute cholecystitis
Peptic Ulcer

Answer 4

Acute pyelonephritis

Question 5

A 50­year old woman presents with a severe headache and photophobia. Examination reveals brisk reflexes.

Extrdural haemorrhage
subdural haemorrhage
SAH
Encephalitis
Meningitis

Answer 5

SAH

Question 6

A 50­year­old smoker presents with lobar pneumonia. Examination reveals dullness at the right base with increased tactile vocal fremitus

Ecoli
Mycoplasma
Legionella
Strep
Haemophilius

Answer 6

Strep pneumoniae

Question 7

Abdominal examination of a 70­year old breathless man of no fixed abode reveals a palpable spleen. He is known to drink heavily and has had an anterior myocardial infarction previously.

Malaria
TB
Portal hypertensionSchistosomiasis
CCF

Answer 7

Portal HTN

Question 8

A 50­year­old woman presents with left calf swelling and tenderness. She has had a recent fracture and has been immobile. Her past medical history includes osteoarthritis. She has smoked 30/day for the last 30 years, but does not drink alcohol.

Baker's cyst rupture
Liver failure
DVT
Cardiac failure
Cellulitis

Answer 8

DVT

Question 9

A 45­year­old woman presents with a 1 day history of dizziness on standing up and vomiting. She had been started on a tricyclic antidepressant by her GP two weeks ago. Her past medical history includes type 2 diabetes diagnosed 4 years ago and treated with metformin.

Diabetic neuropathy
side effect of TCA
side effectof metformin
Amyloidosis
Hypovolaemia secondary to gastroenteritis

Answer 9

Side effect to TCA

Question 10

A 35­year­old male intravenous drug abuser is admitted to Casualty with a 3 day history of yellow discolouration of his skin, flu­like symptoms and nausea. On examination, he is cachectic and jaundiced, with smooth, tender hepatomegaly.

Paracetamol
Alcoholic liver disease
Gilberts
Hep C
HIV

Answer 10

Hep c

Question 11

Loud pansystolic murmur at the apex

Answer 11

mitral regurg

Question 12

ejection systolic murmur

Answer 12

aortic stenosis

Question 13

irregularly ireg pulse

Answer 13

AF

Question 14

slow rising pulse

Answer 14

Aortic stenosis

Question 15

collapsin pulse

Answer 15

Aortic regurgitation

Question 16

Very loud S1

Answer 16

Mitral stenosis

Question 17

early diastolic murmur at left sternal edge

Answer 17

Aortic regugitation

Question 18

Tapping apex beat

Answer 18

Mitral stenosis

Question 19

A 60 year old man complains of breathlessness, and has a third heart sound. What is the cause of a third heart sound?

Answer 19

A third heart sound is caused by rapid ventricular filling during normal diastole BEFORE the atrium contracts (which would cause a fourth heart sound if there is any stiffness). This occurs when the ventricle is dilated due to cardiac failure

Question 20

Cannon waves @neck

Answer 20

Complete heart block
only condition where the atrium can contract when the tricuspid valve is closed (randomly) because the atria and ventricles are contracting at different rates. When they both contract together, the tricuspid valve will be closed and if the atria contract at the same time, the blood of the atrium can only rush upwards. This is much more intense than the v-wave of tricuspid regurgitation

Question 21

Low pitched rumbling mid diastolic

Answer 21

mitral stenosis

Question 22

Examination reveals reduced expansion on the left side with dullness to percussion and increased tactile vocal resonance (when he says “99”)

Answer 22

pneumonia (consolidation)

Question 23

28. A 25 year old comes to casualty with Expiratory wheezes. What is the likely diagnosis?

Answer 23

acute severe asthma

Question 24

29. A 45 year old patient complains of a cough that lasts for 3 months every winter for the last three years. What is the likely diagnosis?

Answer 24

chronic bronchitis, exacerbation of COPD

Question 25

A 30 year old is on the oral contraceptive pill and becomes suddenly breathless. Examination of the respiratory system is normal.

Answer 25

PE

Question 26

Examination reveals reduced expansion on the left side with dullness to percussion and reduced tactile vocal resonance (when he says “99”).

Answer 26

left sided pleural effusion

Question 27

A 45 year old patient complains that they cough up a pot of purulent sputum every day. Examination reveals course crackles.

Answer 27

Bronchiectasis caused by CF

Question 28

32. A 65 year old complains of breathlessness and has fine crepitations at both bases.

Answer 28

Pulmonary oedema or pulmonary fibrosis

Question 29

33. A tall 19 year old suddenly complains of breathlessness and left sided chest pain .

Answer 29

Pneumothorax

Question 30

34. A 55 year old with known lung cancer complains of a swollen leg and then suddenly becomes breathless.

Answer 30

PE

Question 31

35. A 30 year old complains of weight loss and coughs up blood. He has a fever of 38 degrees centigrade and complains of night sweats

Answer 31

pulmonary TB

Question 32

Examination reveals a palpable mass in the right hypochondrium

Answer 32

Hepatomegaly

Question 33

37. Examination reveals a palpable mass in the left hypochondrium

Answer 33

splenomegaly

Question 34

38. A forty year old mother of five complains of abdominal pain after eating fish and chips. What is the likely diagnosis?

Answer 34

Gal stones

Question 35

39. A 40 year old man who drinks a bottle of vodka every night and is known to have chronic liver disease, developed severe abdominal pain with extreme tenderness. Examination revealed a rigid abdomen. What is the likely diagnosis? 40. What single diagnostic confirmatory blood investigation is required for the patient in question 39?

Answer 35

Acute pancreatitis Amylase

Question 36

41. A 50 year old complains of slowly worsening weakness in his left leg. This started gradually three months ago, and is now making him limp. Examination reveals increased tone, brisk reflexes and weakness in the left leg.

Answer 36

brain tumour

Question 37

42. A 50 year old complains that he has developed weakness in his left leg when he woke up this morning. He has great difficulty walking. Examination reveals increased tone, brisk reflexes and weakness in the left leg.

Answer 37

Stroke

Question 38

43. A 60 year old man complains of drooping of his left eyelid. Examination of his eyes reveals normal eye movements, but his left pupil is smaller than his right pupil.

Answer 38

Horner's syndrome

Question 39

44. A 50 year old man complains of drooping of his left eyelid, so that his left eye is almost closed. When you hold his left eye open, he complains of double vision, and the left pupil is larger than the right one.

Answer 39

complete 3rd nerve palsy

Question 40

45. Examination of the lower limbs reveals wasting of the muscles of the left calf with absent reflexes on that side.

Answer 40

Lower motor neurone

Question 41

A patient develops cerebellar atrophy due to alcohol abuse. The mnemonic “DANISH” is often used by students to list the six features of cerebellar disease.

Answer 41

``` D: dysdiadokinesia A: ataxia N: nystagmus I: intention tremor S: scanning/ staccato or slurred speech H: hypotonia ```

Question 42

A patient complains of a tremor when he smokes cigarettes. What is the likely cause if the tremor gets worse when he puts the cigarette into his mouth.

Answer 42

Ataxia w/ cerebellar disease

Question 43

53. What is the diagnosis when a patient complains of a tremor of one hand at rest?

Answer 43

Parkinsons, symtoms start one sided

Question 44

54. A 40 year old patient has brisk reflexes on the right hand side. What do you expect to find when you examine the tone on the same side?

Answer 44

Increased Tone, UMN

Question 45

55. Examination of the plantar responses reveals that the right plantar is upgoing and the left plantar is downgoing. What do these findings suggest?

Answer 45

Upgoing plantar suggests UMN in right leg | Caused by: brain tumour or stroke in LEFT side

Question 46

A 35-year old woman complains of weight loss, tremor of her outstretched hands and palpitations.

Answer 46

Hyperthyroidism graves

Question 47

57. A 40 year old woman complains of weight gain, thin skin and is noted to have stretch marks on the abdomen

Answer 47

Cushings syndtome

Question 48

58. A 40 year old woman complains of palpitations, and is noted to have a blood pressure of 190/120.

Answer 48

Phaemochromocytoma could also be conns

Question 49

59. A patient with type 2 diabetes is advised on a healthy diet, and to exercise regularly. Three months later, he has an HbA1c of 60 mmol/mol. What drug will you start him on according to NICE guidelines.

Answer 49

Metformin

Question 50

60. Three months after that, the patient still does not have adequate glucose control. What class of drug should you add? 61. Name one such drug.

Answer 50

Sulphonylurea: Gliclazide, Glibenclamide and Tolbutamide

Question 51

What CLASS of drug should be prescribed for a patient with diabetes and hypertension who is found to have microalbuminuria? 63. Name one such drug:

Answer 51

ACE inhibitor | Enalapril, Lisinopril, Ramipril

Question 52

What effect will ACEi have on the plasma potassium levels?

Answer 52

Increase

Question 53

65. What effect will ACEi have on plasma creatinine levels?

Answer 53

INCREASE

Question 54

66. What effect will ACEi drug have on the urinary albumin excretion?

Answer 54

DECREASE

Question 55

A patient has a lymph node biopsy which is sent for histology, Caseating granulomata are seen

Answer 55

TB

Question 56

A patient has a lymph node biopsy which is sent for histology, non-caseating granulomata are seen

Answer 56

Sarcoidosis

Question 57

NSAID

Answer 57

Ibuprofen

Question 58

corticosteroid

Answer 58

Prednisolone

Question 59

ACEi

Answer 59

Ramipril

Question 60

Ang-2 receptor antag

Answer 60

Lorsatan

Question 61

Beta block

Answer 61

Propanolol

Question 62

beta agonist

Answer 62

Salbutamol

Question 63

calcium antagonist for HTN

Answer 63

Amlodipine nifedipine

Question 64

Alpha block in HTN

Answer 64

Tamsulosin

Question 65

Aldosterone receptor antag for HTN

Answer 65

Spironolactone

Question 66

Dopamine agonist for prolactinoma

Answer 66

Cabergoline and bromocriptine

Question 67

dopamine antagonist for psychotic disorders/nausea

Answer 67

Metaclopramide

Question 68

Macrolide ABx

Answer 68

Clarythromycin

Question 69

``` A 70 year old lady is found to have low albumin on a routine blood test at her GP. A consequent urine dipstick is +++ for protein. The patient is otherwise well apart from a nasty chest infection 2 months ago and difficulty getting out of bed in the morning, which she attributes to old age. On examination the GP notices swellings in both the PIP and MCP joints of the hands, and oedema in the patients legs. What is the most likely diagnosis? A.Diabetic nephropathy B. Post-streptococcal glomerulonephritis C. IgA nephropathy D. SLE E. Amyloidosis ```

Answer 69

E: Amyloidosis The patient has presented with nephrotic syndrome most likely (would want to quantify the proteinuria) as there is no blood. Options B, C and D are more likely to give nephritic syndrome. There is no recent URTI to suggest IgA nephropathy and post-strep is normally 2-3 weeks after a infection. There is no suggestion of diabetes. SLE can lead to arthritis, but symmetrical arthritis in these joints typically suggests rheumatoid arthritis, and amyloidosis is a complication of this. Amyloidosis involves accumulation of misfolded proteins, here leading to structural damage of the glomerulus and so nephrotic syndrome.

Question 70

``` A 30 year old lady presents to A&E with severe pain in her left flank that started this morning. Upon further questioning, she reveals she hasn’t urinated in the last 12 hours, but had increased urgency and frequency for the last 3 days. She is febrile, but otherwise her observations are normal. Her urine is positive for protein, leucocytes and nitrites, and an ultrasound of her abdomen was normal. What is the most likely reason for her reduced urine output? A.Pre-renal AKI B.Post-renal AKI C. Acute tubular necrosis D. Acute interstitial nephritis E. Glomerulonephritis ```

Answer 70

D. Acute interstitial nephritis This patient has presented with AKI secondary to pyelonephritis. Her history suggests an initial UTI (increased frequency and urgency) that has progressed up the ureter to her kidney giving her flank pain and pyrexia. Pre-renal AKI would likely show haemodynamic compromise, post-renal is unlikely given the normal ultrasound. ATN would give brown cell casts in the urine, glomerulonephritis would likely give blood in the urine. Acute interstitial nephritis is a complication of pyelonephritis – the inflammatory cells get into the interstitial tissue of the kidney

Question 71

A 70 year old smoker presents to his GP with episodes of facial flushing. On further questioning, he reports his clothes have been looser lately but attributes this to his reduced appetite. The GP refers the patient to an oncologist who arranges a CTCAP. This demonstrates a lesion adjacent to the right main bronchus. What is the most likely diagnosis? ``` A.Squamous cell carcinoma B. Adenocarcinoma C. Small cell carcinoma D. Pancoast tumour E. Large cell carcinoma ```

Answer 71

C: small cell carcinoma The flushing here represents carcinoid syndrome, due to ectopic serotonin secretion. This is most commonly associated with small cell carcinoma, further supported by the fact the patient is male and a smoker, and the lesion is found proximally. Large cell and adeno are normally found distally, and adeno more in females who don’t smoke. Squamous is perhaps second most likely but less likely to give carcinoid. In wrong place to be Pancoast tumour.

Question 72

A 53 year old woman presents to her GP after an episode of haemoptysis, on a background of occasional jaundice and weight loss. She was a social smoker in her 20’s but hasn’t smoked for over 20 years. An X-ray arranged by the GP demonstrates a mass in the left lower lobe. What is the most likely diagnosis? ``` A. Squamous cell carcinoma B. Adenocarcinoma C. Small cell carcinoma D. Pancoast tumour E. Large cell carcinoma ```

Answer 72

B: adenocarcinoma The factors that point to adenocarcinoma include that the patient is a woman and non-smoker – she did socially smoke, but lung cancer is more associated with high levels of smoking. The jaundice suggests liver mets – adeno spreads earlier. Adeno is also found peripherally in keeping with the X ray

Question 73

``` A 4-year-old boy is brought to see A&E after his mother noticed some bruises along his legs. The child does not recall injuring his legs. On examination, he is pale with several bruises on his legs. What is the most likely diagnosis? A Non-accidental injury B Immune thrombocytopaenic purpura C Acute lymphoblastic leukaemia D Acute myeloid leukaemia E Haemophilia A ```

Answer 73

C: ALL

Question 74

``` A 73-year-old man presents to the gastroenterology outpatient clinic as he has as he has been suffering from constipation. He has also been feeling unwell for the past year. On examination, he is pale and has a grossly enlarged spleen. FBC reveals pancytopaenia. Given the most likely diagnosis, what would you expect to see on examination of the bone marrow? A More than 20% blast cells B Infiltration by mature lymphocytes C Dry tap D Band cells E Ringed sideroblasts ```

Answer 74

C: dry Tap Myelofibrosis: Clonal bone marrow disease characterised by excessive fibrosis and extramedullary haemopoiesis FBC initially variable (later pancytopaenia) Tear drop cells (blood film) Dry tap (bone marrow aspirate) MASSIVE splenomegaly

Question 75

``` A 74-year-old man presents to A&E with a fractured humerus with no history of trauma. An X-ray reveals a comminuted fracture with surrounding lytic bone lesions. FBC and U&Es are performed on admission, which showed the following significant results: Hb: 78 g/L (135-180) Ca2+: 2.89 mmol/L (2.2-2.6) Urea: 12 mmol/L (2-7) Creatinine: 289 µmol/L (55-120) Which investigation is most likely to offer a definitive diagnosis? A Serum protein electrophoresis B Bone marrow aspirate C Skull X-ray D Lymph node biopsy E Blood film ```

Answer 75

A: serum protein electrophoresis ``` Multiple Myeloma: CRAB C: hypercalcaemia Renal failure Anaemia Bone lesions/back pain ``` Blood film will show rouleaux formation Serum + urine electrophoresis: Bence-jones protein (monoclonal immunoglobulin light chain found in urine) + serum paraprotein Bone marrow aspirate: High plasma cells Osteolytic lesions without surrounding sclerosis