VSA formative questions 2018/9 Flashcards
A 31 year old man has epigastric pain for 2 months, worsened by eating. His stool antigen test is positive.
Investigations: Haemoglobin 147 g/L (130–175) White Cell Count 7.2 x109/L (4.0–10.0) Platelets 349 x109/L (150–400) Mean Cell Volume (MCV) 86.0 fL (80–96)
PUD Gastric ulcer Duodenal ulcer Peptic ulcer Helicobacter pylori infection H. pylori
(not accepted: Coeliac GORD Gastritis IBD Pancreatitis Gallstones Crohns GI ulceration)
An 18 year old man has severe left sided pain in the scrotum, radiating to the abdomen.
The right testis appears normal but the left side is swollen and tender and is lying high in the scrotum.
What is the most likely diagnosis?
Torsion
Left testicular torsion
A 25 year old female has painful left lower limb swelling. She is 26 weeks pregnant. Distal pulses are intact and she has no other symptoms.
Investigations:
White Cell Count 10.2 x109/L (4.0–10.0)
C Reactive Protein (CRP) 8 mg/L (<5)
What is the most appropriate initial investigation?
Ultrasound leg USS leg (left) Ultrasound leg (left) USS left leg Doppler ultrasound leg (left) Doppler ultrasound left leg Ultrasound left leg Doppler ultrasound leg USS leg Ultrasound lower limb Doppler ultrasound lower limb USS lower limb Duplex ultrasound
A 71 year old man has a five-day history of confusion, personality change and headache. A diagnosis of encephalitis is made.
What is the most common causative organism in encephalitis?
Herpes simplex virus
HSV
Herpes simplex
Herpes simplex type 1
A 68 year old woman has a four week history of right-sided headache which is worse when she combs her hair. She also reports pain on chewing.
What is the next most appropriate investigation?
Erythrocyte sedimentation rate
ESR
(N.B. not CT head, trial pred., inflammatory markers)
A 24 year old woman has had two months of unilateral frontal pulsating headaches lasting 12-18 hours, occurring weekly. They are associated with nausea and relieved by over the counter ibuprofen and sleeping. Fundoscopy is normal.
She is otherwise fit and well.
What is the most likely cause of her headaches?
Migraine
Migraine without aura
(N.B. not cluster headaches, tension headaches etc.)
A 45 year old woman with rheumatoid arthritis has weakness in her arms, worse in the evening. She has trouble keeping her eyes open when reading long reports. She has a bilateral ptosis which develops after staring upwards for some time. What is the most likely diagnosis?
MG
Myasthenia gravis
(N.B. not MS, Horner’s, Graves)
A 51 year old man has epigastric pain radiating through to his back, and vomiting. He has a history of alcohol excess. His erect chest X-ray is normal. Investigations: Amylase 814 U/L (<220) ALT 98 IU/L (10–50) AST 156 IU/L (10–40) Bilirubin 28 μmol/L (<17) What is the most likely diagnosis?
Pancreatitis
Acute pancreatitis
Alcoholic pancreatitis
(N.B. not alcoholic hepatitis, chronic pancreatitis, alcoholic liver disease)
A 60 year old woman has dyspepsia and a three-month history of weight loss and fatigue. Investigations: Haemoglobin 88 g/L (115–165) Mean Cell Volume (MCV) 72.2 fL (80–96) White Cell Count 7.9 x109/L (4.0–10.0) Platelets 189 x109/L (150–400) Ferritin 6 μmol (12–200) What is the next most appropriate investigation?
OGD
Endoscopy
Upper GI endoscopy
A 21 year old student has two weeks of visual disturbance. She describes blurring of her vision which is worse after having a hot shower. She has no history of visual problems and is usually fit and well.
Eight months ago she had a three week episode of numbness in her right leg, which resolved spontaneously.
What is the most likely underlying diagnosis?
Multiple sclerosis
MS
Demyelinating disease
A 52 year old woman has malaise and fatigue. She has koilonychia and her cardiorespiratory examination is normal.
What is the most likely finding on blood tests?
Iron deficiency anaemia Microcytic anaemia Low iron Low ferritin IDA
An 18 year old man has had abdominal pain and vomiting for two days. He is usually fit and well.
An ABG is performed showing the following:
pH: 7.23 (7.35–7.45)
pO2: 12.5 kPa (10–14)
pCO2: 3.5 kPa (4.5–6.0)
HCO3: 11 mmol/L (22–26)
Lactate: 1.0 mmol/L (1–2)
Potassium: 5.5 mmol/L (3.5–5.0)
Glucose: 22 mmol/L (<6)
What test should be performed next to reach a diagnosis?
Urine ketones Ketones Blood ketones Urinary ketones Capillary ketones Capillary blood ketones Urine dipstick ketones
A 60 year old man has constipation, backache and abdominal pain. He has a four week history of urinary frequency, malaise and 6 kg weight loss. Investigations: Calcium 3.2 mmol/L (2.1–2.60) Phosphate 0.8 mmol/L (0.8–1.5) ALP 43 IU/L (25 –115) Creatinine 397 µmol/L (50–95) Urea 17.7 mmol/L (2.5–7.8) PTH 0.5 pmol/L (0.9–5.4) What condition is most likely causing this patients hypercalcaemia?
MM
Myeloma
Multiple myeloma
A 58 year old woman with a 24 year history of rheumatoid arthritis develops peripheral oedema. Investigations: HbA1c 40 mmol/mol (20–42) Echocardiogram: Normal systolic function Urinalysis: Nitrite negative Leukocytes negative Blood negative Protein 3+ What is the most likely cause of her peripheral oedema?
Membranous glomerulonephritis Amyloidosis Nephrotic syndrome AA amyloid Low albumin Hypoalbuminaemia Nephrotic syndrome protein loss
A previously fit 67 year old woman has a two-hour history of sudden onset left-sided arm weakness and slurring of speech. Her capillary blood glucose, full blood count and clotting are normal. What is the next most important investigation to perform prior to administering thrombolysis?
Head scan Head CT Brain scan CT scan CT head Brain CT CT brain
A 40 year old woman on prednisolone for rheumatoid arthritis has a wrist fracture after minimal trauma. She requires screening for osteoporosis as part of her work-up for this. What is the best method of investigating for osteoporosis?
DXA scan DEXA scan DEXA Bone density scan DXA Dual energy X-ray absorptiometry
A 70 year old man has a 2 day history of severe epigastric pain. He has no history of alcohol intake. He is diagnosed with acute pancreatitis. What is the most likely underlying cause of his pancreatitis?
Gallbladder stone Ductal stone Gallstones Choledocolithiasis biliary stones Cholelithiasis Gallstone causing obstruction
A 26 year old man develops an itchy vesicular rash on the extensor surfaces of his elbows and knees. He has a diagnosis of coeliac disease but is otherwise fit and well. What is the most likely diagnosis of the rash?
Dermatitis herpetiformis
N.B. not eczema, psoriasis, dermatitis herpaticum etc.
A 17 year old man has multiple neurofibromas. He has 8 large brown macules over his torso and axillary freckling. What is the mode of inheritance of this disease?
Autosomal Dominant
A 25 year old man develops a red eye. He has had two weeks of swelling of his fingers, a painful swollen right ankle and left knee. He has also been experiencing pain on passing urine. He had an episode of diarrhoea 2 weeks ago. He has mouth ulcers and a scaly brown maculopustular rash on the soles of his feet. Urethral swabs and urine culture are negative. What is the most likely diagnosis?
Reactive arthritis Reiter’s syndrome Reiter’s triad Seronegative arthritis Reiter’s disease
An 85 year old woman has 2 days of dysuria and frequency.
Urinalysis:
Nitrite 2+
Leukocytes 2+
Blood negative
Protein negative
Her urine is sent for culture and she is started on trimethoprim for suspected urinary tract infection (UTI).
What is the most common causative organism?
E. Coli
A 49 year old man with a 25 year history of ulcerative colitis develops nausea and jaundice. He has no abdominal pain.
Investigations:
ALT 57 IU/L (10–50)
AST 106 IU/L (10–40)
Bilirubin 98 μmol/L (<17)
ALP 43 IU/L (25 –115)
What is the most likely cause of these findings?
PSC
Primary Sclerosing Cholangitis
Sclerosing Cholangitis
(N.B. not hepatitis, PBC, cholangitis, haemolytic anaemia)
A 57 year old man has had fatigue for six weeks. He has no other symptoms. He has chronic kidney disease, hypertension and type 1 diabetes. He is found to have conjunctival pallor but the remainder of his examination is normal. Investigations: Haemoglobin 84 g/L (130–175) White Cell Count 6.9 x109/L (4.0–10.0) Platelets 229 x109/L (150–400) Mean Cell Volume (MCV) 85.2 fL (80–96) Ferritin 100 μmol/L (12–200) What is the most likely cause of his anaemia?
CKD Chronic kidney disease Erythropoietin deficiency EPO deficiency Lack of erythropoietin Chronic renal failure Lack of EPO Renal failure Low erythropoietin
(N.B. not perincious anaemia, anaemia of chronic disease, iron deficiency)
An 18 year old university student has a 3 day history of sore throat. She has bilateral grey exudate covering both tonsils. Examining the abdomen reveals splenomegaly. What is the most likely diagnosis?
Infective mononucleosis
EBV
Infectious mononucleitis
(N.B. not tonsillitis)
A 22 year old man has a one year history of progressive breathlessness on exertion and cough with sputum. He has never smoked. He reports his father died of a lung condition aged 45. He is cachectic with a barrel chest.
Investigations:
FEV1/FVC ratio 51% (Normal >75%)
Chest X-ray: hyperinflation, bullae and flat hemidiaphragms
What blood test should be sent to help diagnosis?
Alpha-1 antitrypsin A1-antitrypsin Alpha1 antitrypsin levels Alpha-1 anti-trypsin screen Alpha 1 antitripsin deficiency test
A 65 year old patient complains of breathlessness. He is examined by his GP who suggests that he has mitral regurgitation. What is the most likely abnormality on auscultation of the heart?
Pan-systolic murmur Systolic murmur (apical area) I+II+SM Pansystolic murmur Systolic murmur (mitral area) Apical pansystolic murmur Pansystolic murmur (loudest in mitral area and radiating to axilla)
A 71 year old woman has sudden onset chest pain radiating down her left arm. Her ECG shows ST elevation in leads II, III and aVF. Which coronary artery has been affected?
Right coronary artery
A 35 year old man has a one day history of severe loin pain radiating to his groin. His temperature is 36.5˚C, pulse rate 91 bpm, BP is 121/81, respiratory rate 16 breaths per minute and oxygen saturation 98% in air. Investigation: Urinalysis: Nitrite negative Leukocytes 1+ Blood 3+ Protein negative What is the next most appropriate investigation?
CT kidney, ureter, bladder without contrast CT kidney, ureter, bladder CT KUB without contrast CT KUB Helical CT KUB
A 25 year old man recovered from a viral upper respiratory tract infection last week. He now has central chest pain. The pain is relieved by sitting forward and by taking ibuprofen. On auscultation a scratching noise is heard. What ECG finding will best support the diagnosis?
PR depression Widespread ST elevation Saddle shaped ST elevation ST elevation (saddle shaped) Diffuse ST elevation
A 65 year old female has a one week history of palpitations. She is usually fit and well. Her ECG is as shown (see handout)
Atrial fibrillation
A 12 year old boy develops widespread urticarial rash, facial and lip swelling, and wheeze after being stung by a bee. He has eczema and asthma. What medication should be administered as a first step?
0.5mg IM adrenaline
‘adrenaline’ also acceptable
An 81 year old man with type 2 diabetes is admitted following a fall at home. His renal function was previously normal. Investigations: Sodium 142 mmol/L (135–146) Potassium 5.9 mmol/L (3.4–5.0) Creatinine 267 µmol/L (50–95) Urea 19.7 mmol/L (2.5–7.8) Creatine Kinase 8,000 U/L (<350) Glucose 14 mmol/L (3–6) Urinalysis: Nitrite negative Leukocytes negative Blood 2+ Protein negative
What is the most likely cause of his renal failure?
Long lie
Rhabdomyolysis
Trauma causing rhabdomyolysis
Rhabdomyolysis crush injury myoglobin
(N.B. not dehydration, rebak artery stenosis, trauma, HONK/HHS, diabetic nephropathy)
A 63 year old man has palpitations but feels otherwise well. His temperature is 37.1˚C, pulse rate 120 bpm, BP is 134/95, respiratory rate 18 breaths per minute and oxygen saturation 98% in air. His ECG shows runs of polymorphic ventricular tachycardia. What treatment should be given?
IV Magnesium
IV amiodarone
(also accepted without ‘IV’ written at start)
A 65 year old man has three weeks of painless haematuria. His renal function is normal. Investigations: Urinalysis: Nitrite negative Leukocytes negative Blood 3+ Protein negative What is the next most appropriate investigation?
Flexible cystoscopy
Cystoscopy
(N.B. not DRE, CT/USS KUB)
A 29 year old man has sudden onset occipital headache. He describes it as the worst headache of his life. He is photophobic and nauseated. Full blood count and clotting profile are normal. CT head is normal. What is the next most appropriate investigation?
CSF sample Cerebrospinal fluid Xanthochromia CSF analysis LP Lumbar puncture Spinal tap
A 24 year old man has a two week history of cramping abdominal pain, mouth ulcers and weight loss. He has a rapidly enlarging painful ulcer with violaceous margins on his left lower limb. What is the most likely cause of his abdominal pain?
Ulcerative Colitis IBD Inflammatory Bowel Disease Crohns Disease Crohn Disease UC
A 24 year old woman has two months of lethargy, dizziness, weight loss and nausea. She has type 1 diabetes and reports erratic blood sugars and one episode of loss of consciousness. She has hyperpigmentation in her palmar creases and her oral mucosa. Her temperature is 36.8˚C, pulse rate 101 bpm, BP is 78/61 (standing), respiratory rate 16 breaths per minute and oxygen saturation 99% in air. Her blood sugar is 3.2 mmol/litre. Investigations: Sodium 129 mmol/L (135–146) Potassium 5.4 mmol/L (3.4–5.0) Creatinine 67 µmol/L (50–95) Urea 7.7 mmol/L (2.5–7.8) What is the most likely diagnosis?
Addison's Disease Adrenal insufficency Addisons’ Addison’s Primary adrenal insufficency Hypoadrenalism Addisonian crisis
A 75 year old man with known Benign Prostatic Hyperplasia (BPH) has a two day history of oliguria and lower abdominal pain. A bladder scan shows a residual volume of 1.1L. He is found to have an Acute Kidney Injury (AKI) with a Creatinine of 590. Which immediate intervention is most likely to relieve his symptoms?
Insert catheter
A 40 year old woman with bipolar disease is found to be hypernatraemic. She is diagnosed with nephrogenic diabetes insipidus secondary to lithium use. Which hormone is implicated in the pathophysiology of diabetes insipidus?
Vasopressin
ADH
A 61 year old female has a lower respiratory tract infection. She then develops target-shaped erythematous macules and papules over her arms, legs, chest and back. What is the most likely diagnosis of the rash?
Erythematous multiforme
A 23 year old female has burning on urination for three days. She develops fevers, rigors and loin pain. Urinalysis: Nitrite 3+ Leukocytes 2+ Blood 1+ Protein 1+ What is the most likely diagnosis?
UTI leading to pyelonephritis
Ascending UTI
(N.B. ‘UTI’ on its own not accepted)
A 62 year old male has a new diastolic murmur, a fever of 39˚C and splinter haemorrhages on his fingernails. Fundoscopy shows retinal haemorrhages with a white centre. What is the name of clinical sign seen on fundoscopy?
Roth’s spots
N.B. not flame haemorrhages, cotton wool spots
A 41 year old woman has three months of increasing anxiety, weight loss and palpitations. She has bilateral erythematous palms, periorbital oedema and proptosis. Her BMI is 19.8 kg/m². An ECG shows a sinus tachycardia at 120 beats per minute. What would be the next most appropriate investigation for this patient?
Thyroid profile
TSH T3/4
Thyroid function tests
A 67 year old man has gradual onset of worsening breathlessness over a year. He has a dry irritating cough. He does not take any medications. He has no fevers, sputum production or haemoptysis. He has a 30 pack-year smoking history. He has finger clubbing and a raised JVP and bi-basal fine late inspiratory crepitations with no wheeze. His spirometry results show a restrictive defect. What is the likely diagnosis?
Interstitial fibrosis ILD IPF Lung fibrosis Primary pulmonary fibrosis Interstitial lung disease Pulmonary fibrosis Idiopathic pulmonary fibrosis
A 31 year old woman has recently returned from holiday. She has a four day history of headache, myalgia and fevers. Over the past two days she has had a cough and confusion. Her sodium level is 121 mmol/L (Reference range: 135–146). Her chest X-ray shows left lower lobe consolidation and diagnosis of Legionella pneumonia is suspected. What investigation will be most appropriate to confirm this diagnosis?
Urine sample – Legionella antigen
Urine antigen test
Legionella antigen
serum antigens
(N.B. blood/sputum cultures not accepted)
A 62 year old man with COPD develops sudden onset right-sided chest pain worse on taking a deep breath in, shortness of breath and has two episodes of haemoptysis. Two weeks ago he had a tibial fracture and is in a below knee cast. His temperature is 36.8 ˚C, pulse rate 121 bpm, BP is 118/91, respiratory rate 24 breaths per minute and oxygen saturation 96% in air. His full blood count and renal profile are normal. Chest X-ray shows clear hyperexpanded lung fields.
What will be the best diagnostic investigation?
CTPA
CT pulmonary angiogram
CT angiogram
Pulmonary angiogram
(N.B. not CT chest/thorax)
A 43 year old IV drug user is drowsy. Arterial Blood Gas in air: pO2: 9.5 kPa (10-13) pH: 7.23 (7.35-7.45) pCO2: 7.0 kPa (4.5-6.0) Bicarbonate: 22 mmol/L (22-24) What biochemical abnormality does his arterial blood gas (ABG) show?
Respiratory acidosis (with no metabolic compensation)
A 75 year old woman has a murmur, loudest at the apex. An echocardiogram confirms mitral stenosis. What is the most common cause of mitral stenosis?
Rheumatic heart disease
Rheumatic valve disease
Rheumatic fever streptococcus viridans
A 55 year old man has weakness of right foot dorsiflexsion and the small muscles of his left hand over the course of 3 months. He has wasting of the small muscles of the left hand and a right foot drop along with wasting of the anterior tibial and peroneal muscles. Fasciculations are seen. Sensory examination and reflexes are normal. Plantars are downgoing. What is the most likely diagnosis?
Motor Neuron Disease
Amyotrophic lateral sclerosis
(N.B. not MS/MG)
A 42 year old woman with pulmonary hypertension has two months of painful fingers which change colour in cold weather and pain on swallowing. She has shiny tight skin over her hands. What is the most likely diagnosis?
Cutaneous systemic sclerosis Scleroderma Systemic sclerosis Limited systemic sclerosis CREST
A usually healthy 17 year old girl has cramping periumbilical pain and vomiting; after several hours, the pain moves to the right lower quadrant and becomes constant. Investigations: Chest X-ray: normal Abdominal X-ray: normal Haemoglobin 101 g/L (115–165) White Cell Count 13.9 x109/L (4.0–10.0) Platelets 291 x109/L (150–400) Mean Cell Volume (MCV) 86.2 fL (80–96) Urinary βHCG negative Urinalysis: Nitrite negative Leukocytes 2+ Blood negative Protein negative
What is the most likely diagnosis?
(acute) Appendicitis
A 71 year old woman has severe central chest pain. Her troponin is raised and she is diagnosed with an acute myocardial infarction. Her ECG is as shown. (see handout)
Which coronary artery has been affected?
Left anterior descending artery
A 28 year old man has a severe headache. He cannot adduct or elevate his left eye and has a left sided ptosis. Which cranial nerve has been affected?
Oculomotor (CN3)
A 35 year old nurse sustains a needlestick injury whilst taking blood. She is usually well. She attends occupational health who send a set of bloods. Investigations: ALT 21 IU/L (10–50) AST 32 IU/L (10–40) ALP 81 IU/L (25–115) Bilirubin 35 μmol/L (<17) What is the most likely diagnosis?
Gilberts disease
N.B. not hepatitis, HIV, Wilson’s etc.
A 61 year old man presents with swelling in the right groin. Examination reveals an irreducible 3 cm lump. During surgery the mass is described as medial to the inferior epigastric artery and above the inguinal ligament. Which is the most likely diagnosis?
Direct inguinal hernia
N.B. answer must include word ‘direct’
A 34 year old woman has fatigue, weight gain and easy bruising. She has facial swelling. Visual fields are normal to confrontation. BP is 178/91 and a random blood sugar is 10.3 mmol/L. Her potassium is 3.2 mmol/L (Reference range 3.5–5.0). What is the most likely diagnosis?
Cushing’s syndrome
An 80 year old woman is treated for a community acquired pneumonia with co-amoxiclav. Five days later she has severe cramping abdominal pain and large volume profuse green diarrhoea, not associated with blood. White cell count is 14.9 x109/L (Reference range: 4.0–10.0).
Which organism is most likely responsible for her diarrhoea?
Clostridium difficile
A 60 year old man has a 2 day history of abdominal pain and nausea. He has had rigors and vomiting at home. He is jaundiced and tender in his right upper quadrant. His temperature is 38.3˚C, pulse rate 110 bpm, BP is 110/65, respiratory rate 20 breaths per minute and oxygen saturation 98% in air. Investigations: ALT 67 IU/L (10–50) AST 56 IU/L (10–40) ALP 381 IU/L (25–115) Bilirubin 88 μmol/L (<17) Amylase 45 U/L (<220) What is the most likely diagnosis?
Infective cholangitis
N.B. also accepted if you don’t say ‘ascending’
A 35 year old man has sudden onset, severe left sided chest pain radiating to his back. He is tall with a high-arched palate. He has persistent paraesthesia in his lower limbs.
His temperature is 36.5˚C, pulse rate 101 bpm, BP is 92/71, respiratory rate 22 breaths per minute and oxygen saturation 98% in air.
What is the most likely diagnosis?
Dissecting aortic aneurysm
Aortic dissection
A 65 year old woman has not opened her bowels in three days. She now has nausea and vomiting.
An abdominal X-ray is as shown. (see handout)
What is the most common cause of this presentation?
Adhesions
Post-op adhesions
Surgical adhesions
(N.B. not small bowel obstruction, hernia, malignancy, constipation, volvulus etc.)
