Weekly Quizes Flashcards
A 35 year old man has 6 months of lower back pain. He is otherwise well. An MR scan of his pelvis performed.
Which joint is highlited by the white arrows?
Iliac crest
Sacrococcygeal joint
Lumbosacral joint
Sacroiliac joint
Symphysis pubis
Sacroiliac joint
What is the function of the structure labelled X?
Provides growth factors to allow endometrial proliferation
Prevents fertilisation of gamete until entry into the uterus
Provide lymphatic drainage from the ovary
Regulates menstruation
Transport gametes and eaerly embryos to the body of the uterus
Transport gametes and eaerly embryos to the body of the uterus
The structure is the fallopian or uterine tube which acts both as a site of early fertilsation and transport of gametes and embryo to the uterine body. These tubes can be ligated to enable sterilisation, which some women choose as a firm of birth control once they have finished their family.
What is the structure indicated by the X label?
Deep transverse
External anal spincter
Levator Ani
Superficial transverse perineal
Urethral sphincter
Urethral sphincter
The image shows a male pelvis with some of the muscles of the perineum. The highlighted structureis the urethral sphincter which has important roles in maintaining continence.
A 30 year old woman vists her GP to get advice about pregnancy. She has a previous unplanned pregnancy which was termintaed as the baby had anencephaly. She drinks 10 units of alcohol per week. Her BMI is 29.
What advice is most likely to reduce the risks of a subsequent neural tube defect?
Abstinence from alcohol
Oral folic acid once she has a positive pregnancy test
High dose oral folic acid while trying to conceive
High dose vitamin D while trying to conceive
Avoid any antibiotics while trying to conceive
High dose oral folic acid while trying to conceive
Anencepahly is a form of neural tube defect. Patients who have had a previous baby so affected should be advised to take high dose folic acid as part of the pre-conception counselling. Although alcohol abstinence and vitamin D supplementation are advised during pregnancy they do not alter risks of NTD.
What is the first step in the cellular production of sperm in the testes?
Differentiation of germ cells
Meiosis of spermatogonia
Mitosis of spermatogonia
Meiosis of germ cells
Mitosiss of sertoli cells
Mitosis of spermatogonia
Spermatogonia are the testes stem cells. the first step is mitosis (so mantaining a full complement of chromosomes). So of these cells remain as stem cells to produce further sperm. it is after this initial mitotic step that some daughter cells go on to meiosis.
Which part of the intestinal tract does the pancreas drain into?
Duodenum
Gall bladder
Jejunum
Ileum
Stomach
Duodenum
The pancreatic and main biliary duct drain into the duodenum through papilla.
A 34 year old man has 3 months of indigestion and heartburn.
He is prescribed lansoprazole to relieve his symptoms.
What is the mechanism of action of this drug?
Blocks histamine receptors on gastric parietal cells
Increases tone of the oesophageal sphincter
Increases bicarbonate production by gastric mucus cells
Inhibits hydrogen ion secretion by gastric parietal cells
Inhibits proliferation of Helicobacter pylori
Inhibits hydrogen ion secretion by gastric parietal cells
Lansoprazole is part of a class of drugs known as proton pump inhibitors. This reduce acid secretion (hydrogen ions) by gastric parietal cells. Hydrogen ions are pumped out of the cell in exchnage for potassium ions.
What is the name of the anatomical region of the GI tract indicated by the arrow?
First part of the duodenum
Cardia of the stomach
Fundus of the stomach
Body of the stomach
Pylorus of the stomach
Pylorus of the stomach
The stomach nas 4 main anatomical regions. The area highlighted is the pyloris of the stomach. This has a sphincter which regulates flow of partially digested food into the duodenum.
A 56 year old woman is reviewed by her GP as part of a health screen. She is well.
Her BMI is 30. Her blood pressure is 132/85 mmHg.
Investigations
Creatinine 72 μmol/L (60-110)
Haemoglobin A1c 58 mmol/mol (20-42)
Cholesterol 4.8 mmol/L (<5.0)
What is the most appropriate treatment at this stage?
Give lifestyle advice about diet, exercise and weight loss
Start insulin treatment
Start metformin
Start a sulphonylurea
Start a statin
Give lifestyle advice about diet, exercise and weight loss
The patient probably has type 2 diabetes mellitus (Haemoglobin A1c is the amount of haemoglobin with glucose attached) and a further test will be performed to confirm the diagnosis. At this stage in the absence of symptoms the initial focus would be to give lifestyle advice to help achieve weight loss.
A 55 year old man has two days of right upper quadrant abdominal pian, nausea and vomiting. He has type 2 diabetes mellitus.
His temperature is 37.7°C, pulse 92 bpm and blood pressure 122/90 mmHg. he has tenderness in the right upper quadrant with guarding. His BMI is 30.
Investigations
White cell count 16.4 x 109/L (4.0-11.0)
Ultrasound scan abdomen is inconclusive.
CT scan abdomen is performed.
What is the structure highlighted by the arrow?
Duodenum
Gallbladder
Pancreas
Liver
Stomach
Gallbladder
This is the presentation of acute cholecystitis, which is inflammation in the gallbladder normally due to stones. The gallbladder wall is thickened with multiple stones within it.
A 25 year old man is admitted to the Emergency Department following a bike crash.
He has tenderness on the right side of his chest.
Chest X-ray: see image
Which anatomical structure,highlighted in the black circle, has been damaged?
10th thoracic vertrbra
Right hemidiaphragm
9th right rib
8th right rib
7th right rib costal cartilage
9th right rib
The X-ray shows a fracture of the 9th right rib. You should practcie counting down the ribs from 1 or counting up from the 12th.
Which anatomical structure is highlighted by the yellow arow as it passes over the first right rib?
Vertebral vein
Internal jugular vein
External carotid artery
Superior vena cava
Subclavian vein
Subclavian vein
The subclavian vein is shown crossing anteriorly over the right rib which has agroove to accommodate it.
A 70 year old man has one year of wrosening breathlessness and cough. He is an ex-smoker with a 40 pack year smoking history. He has hypertension and takes amlodipine.
His pulse is 72 bpm and blood pressure 131/80 mmHg. He has occasional expiratory wheeze.
Investigations
Spirometry:
FEV1 1.4 L (predicted 2.6)
FVC 2.3 L (predicted 3.2)
FEV1/FVC 60%
Post bronchodilator
FEV1 1.4 L (predicted 2.6)
FVC 2.4 L (predicted 3.2)
FEV1/FVC 58%
What is the most appropriate description of the spirometry?
Obstructive pattern without significant reversibility
Obstructive pattern with reversibility
Mixed obstructive and restrictive pattern
Restrictive pattern
Mixed obstructive and restrictive pattern with reversibility
Mixed obstructive and restrictive pattern
But also without significant reversibility
They say:
The results show an obstructive pattern, most likely due to COPD. The small increase in FEV1 is not sufficient to show reversibility. This requires an increase in FEV1 of >400 mL or >12%.
But this feels wrong, low FVC implies a level of restriction also due to severity of COPD
A study is conducted on 10,000 people of a new lateral flow test for Covid-19 and compared to the reference standard of PCR testing using 3 separate primers.
A summary of the resuts is provided in the table.
What is the false negative rate for the index test?
0.00002%
5.6%
58.4%
41.5%
71.0%
41.5%
The false negatives are those which are negative on the lateral flow test (index test) but positive on the PCR test (reference standard). That is 220/530 X 100= 41.5%
A 62 year old man has six months of increasing breathlessness. He has smoked 30 cigarettes per day from age 18 until his 50th birthday.
How many pack years is his smoking history?
48
A pack year is 20 cigarettes for one year. He has smoked 30 cigarettes per year for 32 years, which is 1 and half packs per year. Thus 20 x 1.5=48 pack years
An 18 year old man is admitted with breathlessness and anxiety. He feels light-headed and has tingling in his fingers. He has had previous episodes of panic attacks associated with hyperventilation. He has no other medical history.
His pulse is 100 bpm and respiratory rate 30 breaths per minute.
What is the most likely effect on his arterial blood gas compared to before the panic attack?
Decrease oxygen and carbon dioxide level
Increased oxygen level, no change in carbon dioxide level
No change in oxygen level, decreased carbon dioxide level
No change in oxygen or carbon dioxide level
Increased oxygen and carbon dioxide level
No change in oxygen level, decreased carbon dioxide level
Hyperventilation is common clinical presentation. arterial evel of carbon dioxide is reduced as this is removed more rapidly, but there is no significant chnage in the level of oxygen.
A 5 month old baby boy presents in december with two days of fever, cough and wheezing. This was preceded by nasal congestion and dicharge.
His temperature is 38.7°C, pulse 160 bpm (normal 110-160) and respiratory rate 48 breaths per minute (normal 30-40). His oxygen saturation is 90% breathing air. Wheeze can be heard in the chest.
What is the most likely microbial cause?
Beta-haemolytic streptococcus
Bordatella pertussis
Respiratory syncytial virus
Influenza A
Streptococcus penumoniae
Respiratory syncytial virus
Respiratory distress in a baby is most likely due to bronciolitis. This is most commonly due to respiratory syncytial virus (RSV) infection (~80% cases). it is most common is the winter months.
A study is looking at the role of car pollution in risk of developing chronic obstructive pulmonary disease. The shows that there is an increased prevalence of chronic obstructive pulmonary disease in people who live closer to A roads in a city. It is lower in those who live in residential streets with lower flows of traffic and lower still in those living in rural areas. The level of pollution measured near the A roads is higher than in the quieter residential streets and in rural areas.
Which aspect of the Bradford Hill criteria for causality does this best fit?
Biological gradient
Confounding
Strength
Temporality
Specificity
Biological gradient
The lower the level of pollution the lower the prevalence of COPD. This is an example of biological gradient. There may also be a degree of analogy as smoking and dust exposure are also implicated in development of COPD.
A study is conducted looking at incidence of birth defects in women who took an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) during the first trimester of pregnancy. The study found that the relative risk of birth defects was 1.8 in births in women who took these drugs compared to all other births. However more women had diabetes mellitus in the cohort taking an ACEi or ARB compared to the control group.
What is the best epidemiological description of diabetes mellitus in this study?
Causal
Confounder
Association
Non-specific
Non-significant
Confounder
This is well recognised confounder that needs to be controlled for. So it is unclear if the risk is definitely due to taking an ACEi or ARB or is a risk factor associated with diabetes mellitus.
A 65 year old man has four days of increasing breathlessness and productive cough. He has COPD with an exercise tolerance of no more than 100 m.
His temperature is 38.2°C, pulse 96 bpm, blood pressure 119/80 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 82% breathing air.
Investigations:
Arterial blood gas breathing air
pH 7.22 (7.35-7.45)
PaO2 7.4 kPa (12-15)
PaCO2 8.2 kPa (4.5-6.0)
Bicarbonate 32 mmol/L (22-28)
Which is the best description of the arterial blood gas result?
Acute respiratory acidosis with metabolic compensation
Type 1 respiratory failure with metabolic alkalosis
TYpe 2 respiratory failure with metabolic acidosis
Type 1 respiratory failure
Type 2 respiratory failure with acute on chronic respiratory acidosis
Type 2 respiratory failure with acute on chronic respiratory acidosis
The type 2 respiratory failure is defined by hypoxamia and elevated carbon dioxide. There is a respiratory acidosis due to the elevated CO2. The presence of elevated serum bicarbonate indicates that this patient has been retaining CO2 before this acute presentation.
The following diagram shows lung volunes during inspiration at rest and after maximal breath in and out.
Match the numbers to the correct description
Expiratory reserve volume
Tidal volume
Residual volume
Inspiratory reserve volume
Vital capacity
1
Tidal volume
2
Expiratory reserve volume
3
Inspiratory reserve volume
4
Vital capacity
5
Residual volume
Which mediastinal structure is highlighted by the arrow?
Azygos vein
Superior vena cava
Oesophagus
Trachea
Right main bronchus
Trachea
The central highlighted structure is the trachea. It appears black as it contains air. The oesophagus will be psoterior to the trachea.
A 32 year old woman has 5 days of headache with fever and purulent nasal discharge.
Her temperature is 38.0°C. She is tender over the right cheek with mild overlying erythema.
What is the most likely anatomical site of infection?
Ethmoid sinus
Frontal sinus
Maxillary sinus
Nasal turbinates
Sphenoidal sinus
Maxillary sinus
This is a typical presentation of sinusitis most likely affecting the maxillary sinus.
What is the name of the structure highlighted in green and indicated by the arrow?
Cricoid cartilage
Cricotracheal ligament
Thyroid cartilage
Thyrohyoid membrane
Hyoid bone
Thyroid cartilage
This strucrure is the thyroid cartilage. It is a large C shaped cartilage that is deficient posteriorly.
A baby girl is born prematurely at 28 weeks. She has respiratory distress with tachypnoea, grunting and hypoxaemia.
What is the primary abnormality in this baby’s condition?
Anaemia
Immunoglobulin deficiency
Patent ductus arteriosus
Pulmonary fibrosis
Surfactant deficiency
Surfactant deficiency
In the premature lung, inadequate surfactant activity results in high surface tension leading to instability of the lung at end-expiration, low lung volume, and decreased compliance. These changes in lung function cause hypoxemia due to a mismatch between ventilation and perfusion primarily due to collapse of large portions of the lung (atelectasis), with additional contributions of ventilation/perfusion mismatch from intrapulmonary and extrapulmonary right-to-left shunts.
A 27 year old woman is admitted with increasing cough and wheeze. She has asthma.
Her pulse is 120 bpm, blood pressure 118/78 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 97% breathing high flow oxygen. She has widespread expiratory wheeze.
She has received nebulised salbutamol and remains breathless.
What additional treatment will be most effective in causing relaxation of airway smooth muscle?
Beta-1 adrenoceptor agonist
Beta-2 adrenoceptor antagonist
Muscarinic receptor antagonist
Phosphodiestarase inhibitor
Leukotriene receptor antagonist
Muscarinic receptor antagonist
The patient has an acute exacerbation of asthma. This will be treated with nebulised salbutamol (Beta-2 adrenoceptor agonist) and ipratropium , which is a muscarinic antagonist.
A study is conducted which looked at the mortality of 65,000 women over the age of 65 diagnosed with breast cancer. The researchers aim to look at relative survival.
What group should the patients be compared with to answer this question?
All adult women
Adult women aged over 65 without breast cancer
Adult women aged under 65 with breast cancer
Adult women aged 65 with any other type of cancer
Adult women aged over 65 with medical diagnoses other than cancer
Adult women aged over 65 without breast cancer
This study is looking at relative survival and the comparator group is women matched for age who do not have breast cancer. They may by chance have other diagnoses.
A 68 year old man has 3 months of intermittent palpitations and occasional breathlessness on exertion.
His pulse is 88 bpm, irregular and BP 134/80 mmHg.
Investigations:
ECG:
What complication is most commonly caused by this cardiac rhythm abnormality?
Hypertension
Pulmonary emboli
Ventricular fibrillation
Syncope
Stroke
Stroke
The ECG shows atrial fibrillation. This rhythm can lead to systemic emboli in particular strokes. Patients are normall started on anticoagulation. It may also increase risk of heart failure.
Atrial fibrillation - no distinguishable P waves
The attached diagram shows the pressure in the left ventricle and aorta.
What event happens at the point indicated by the arrow?
Aortic valve opens
Mitral valve opens
Mitral valve closes
Pulmonary valve opens
Tricuspid valve opens
Aortic valve opens
The arrow indicates the point at which ventruclar pressure equals aortic pressure so the aortic valve will open allowing blood to pass into the aorta.
The following diagram shows a ventricular action potential.
What is the main electrochemical cellular movements during phase 2?
Sodium and potassium cell entry
Calcium cell entry, potassium efflux
No electrochemical movement
Sodium cell entry, calcium efflux
Potassium cell entry, calcium efflux
Calcium cell entry, potassium efflux
This is the plateau phase of the cardiac action potential with inward slow calium current and potassium cell efflux along an electrochemical gradient.
A 60 year old man has a 24 hour ambulatory blood pressure measurement average of 162/96 mmHg. He has chronic obstructive airway disease. His BMI is 28. He is recommended to start on blood pressure lowering treatment.
What is the main benefit of treating his blood pressure?
Increased exercise capacity
Reduced risk of atrial fibrillation
Reduced risk of type 2 diabetes mellitus
Slow progression of COPD
Reduced risk of stroke
Reduced risk of stroke
Treating hypertension reduces the risk of cardiovascular disease with the bigest relative risk reduction being for stroke.
When listening with a stethoscope over the apex what is the cause of the first heart sound?
Aortic valve opening
Aortic valve closing
Mitral valve closing
Mitral vale opening
Ventricular filling
Mitral valve closing
The first haert sound is that caused by the mitral (at the apex) and tricuspid (over the left sternal edge) closing.
The attached image shows an ECG rhythm strip.
What event happens at the point indicated by the red arrow?
Mitral and tricuspid valves open
Active ventricular filling from atria to ventricles
Aortic and pulmonary valve open
Aortic and pulmonary valve close
Passive ventricular filling from atria to ventricles
Active ventricular filling from atria to ventricles
The P wave on the ECG represents atrial depolarisation, causing atrial contraction. This results in active ventricular filling, optimising the venticular volume prior to ventricular systole. The miral and tricuspid valves are already open atbthis point as they open as soon as the ventricular pressure falls below that in the atria.
What is the UK’s current expenditure on healthcare as a proportion of gross domestic product (please use nearest whole percentage)?
The UK spends around 10% of its GDP on healthcare which is slightly below the European average.
A study is conducted on the effects of introducing a diet restricting carbohydrates in 220 patients with type 2 diabetes. 110 take a carbohydrate reduce diet and 110 continue with their normal diet. The study looked at the effect on glycated haemoglobin. At the end of two years a carbohydrate restricted diet produced a greater fall in glycated haemoglobin.
What sort of data best describes glycated haemoglobin in this study?
Demographic
Quantitative discrete
Qualitative continuous
Quantitative continuous
Normally distributed
Quantitative continuous
Glycated haemoglobin is used to monitor control of diabetes mellitus. It is quantitative and continuous data.
A 60 year old woman has 6 hours of severe central chest pain radiating through to her back. She has hypertension and takes amlodipine and lisinopril.
Her blood pressure is 90/60 mmHg in her right arm and 180/90 mmHg in her left arm. Her radial pulse cannot be felt at the right wrist. her right carotic pulse is weak.
Investigations
CT scan chest with contrast: aortic dissection of ascending and thoracic aorta.
Which arterial ostium is most likely to have been occluded in this patient?
Left subclavian artery
Right brachiocephalic trunk
Right subclavian artery
Right internal carotid
Right brachial artery
Right brachiocephalic trunk
An aortic dissection such as this will occlude arterial ostia as they arise from the aortic arch. On the right side this is the brachiocephalic trunk which will divides to form the right subclavian and carotid artery. The flow of blood is reduce through these but the ostia are patent.
The attached image shows the abdominal aorta highlighted in pink.
Match the letters to the correct artery?
Coeliac trunk
Superior mesenteric artery
Inferior mesenteric artery
Renal artery
A is the left renal aretry
B is the coeliac trunk which supplies the hepatic artery, splenic artery and left gastric artery
C is the superior mesenteric aretry
D is the inferior mesenteric artery
A 65 year old woman presents with headache and blurred vision. She has a history of intermittent claudication. She smokes 10 cigarettes per day.
Her blood pressure is 220/120 mmHg. Her femoral pulses are weak and a bruit can be heard on listening with a stethoscope over the abdomen.
Investigations:
Doppler ultrasound of kidney suggest reduced flow in the right renal artery.
Which hormone is most likely being produced by the right kidney to lead to severe hypertension?
Aldosterone
Angiotensinogen
Cortisol
Erythropoeitin
Renin
Renin
Feedback
This patient might have renal artery stenosis. The bruit is a noise that is synchronous with systole that occurs due to turbulent flow of blood through a stenosed artery (in this case the renal artery). A Doppler ultrasound can look at blood flow in renal artery and vein and can occasionally give an indication of inpaired aretrial flow. Soemform on angiogram is required to confirm the diagnosis. The reduced flow to the kidney leads to increased production of renin, this will senodarily lead to increased angiotensin II production and aldosterone synthesis.
Renin, angiotensin II and aldosterone are all hormones involved in the RAAS but the one produced by the kidneys directly is renin
A 72 year old woman becomes acutely short of breath. She had a laparscopic cholecystectomy three days ago for acute cholecystitis.
Her temperature is 37.1°C, pulse 116 bpm, blood pressure 122/75 mmHg and oxygen saturation 90% breathing air. Her abdomen is soft and chest clear. Her BMI is 30.
Investigations
Haemoglobin 127 g/L (115-165)
Chest X-ray: normal with clear lung fields
What investigation is most likely to confirm the diagnosis?
CT pulmonary angiogram
Serum D-dimer
Echocardiography
Arterial blood gas
Ultrasound abdomen
CT pulmonary angiogram
This patient is most likely to have a pulmonary embolus.The risks of this are increased by her age and surgery. A CT pulmonary angiogram should be performed to confirm the diagnosis. Although the arterial blood gas may be done to assess the degree of hypoxia this will not confirm the diagnosis. The serum D-dimer is not useful in this setting as it will be elevated due to recent surgery.
A 75 year old man is admitted with community acquired penumonia. He is started on intravenous antibiotics and supplemental oxygen. He has a history heart failure.
Investigations
Creatinine 80 μmol/L (60-110)
What DVT prophylaxis should he receive?
Asprin
Apixaban
Dalteparin
Heparin
No DVT prophylaxis indicated
Dalteparin
The patient is at increased risk of DVT due to age, underlying heart failure and immobility. Dalteparin is standard prophylactic medication.
Dalteparin is a low molecular weight heparin
A 70 year old woman is started on apixaban as prophylaxis for atrial fibrillation.
What is the principle mechanism of action of apixaban?
Activates plasminogen
Inhibits thrombin
Antagonises platelet ADP receptors
Inhibits activated Xa
Reduces synthesis of factor VII
Inhibits activated Xa
A 72 year old woman has 2 hours of severe pain in her left leg.
Her pulse is 80 bpm, irregular and BP 130/90 mmHg. Her left leg is cold below the knee with reduced sensation and inability to move the foot or toes. Her left femoral pulse is palpable buy not pulse are palpable at the knee or foot.
Investigations
ECG: atrial fibrillation, rate 81 bpm
What is the most likely diagnosis?
Embolus in the left femoral artery
Thoracic aortic dissection
Thrombus in the left femoral vein
Thrombus in the abdominal aorta
Thrombus in the left iliac vein
Embolus in the left femoral artery
This is typical presentation of an embolus from the left atrium travelling down and occluding the femoral artery, This means that neother the popliteal (felt behind the knee) or foot pulses are palpable. This is a surgical emergency that means immediate intervention to remove the embolus.
What structure lies immediately lateral to the common carotid artery at the level of the 5th cervical vertebra?
Inferior thyroid artery
Internal jugular vein
Brachial plexus
Subclavian artery
Superior vena cava
Internal jugular vein
The internal jugular vein lies lateral to the common carotid artery in the carotid sheath.
A 70 year old woman has three days of productive cough, breathlessness and confusion.
Her pulse is 108 bpm, blood pressure 95/50 mmHg, respiratory rate 32 breaths per minute and oxygen saturation 82% breathing air. She has bronchial breathing over the right lower zone.
Investigations
White cell count 18.9 x 109/L (4.0-11.0)
Urea 12.0 mmol/L (3.0-7.0)
Creatinine 94 μmol/L (60-110)
What is her CURB65 score?
The CURB65 score is 5.
They have confusion, urea >7.0 mmol/L, respiratory rate >30 and diastolic BP <60 mmHg.
The following image shows a blood test being taking to assess blood gases and hydrogen ion content.
Which vascular structure is being punctured to sample the blood?
Brachial artery
Deep palmar venous arch
Anterior interosseus vein
Radial artery
Ulnar artery
Radial artery
This blood sample is being taken from the radial artery. this is a common site to take arterial blood gas samples from.
A 55 year old man visits his GP. He had a recent cholesterol test which was 5.4 mmol/L (< 5.0). He has hypertension and takes lisinopril.
His blood pressure is 130/82 mmHg.
What additional assessment should the GP undertake to determine whether to prescribe a statin?
Calculate 10 year atheromatous cardiovascular disease risk
Perform an exercise ECG
Request CT coronary angiography
Arrange 24 hour ambulatory blood pressure measurment
Ultrasound kidneys
In this situation the GP will calculate his estimated 10 year cardiovascular disease risk if this ≥10% then a statin is indicated.
A 61 year old woman has one month of worsening headaches and blurred vision.
Her blood pressure is 200/130 mmHg. She has a quite ejection systolic murmur. She a bruit heard over the abdomen.
Investigations
Urea 12.5 mmol/L (3.0-7.0)
Creatinine 160 µmol/L (60-110)
What type of abnormality in which blood vessel is most likely to explain the presentation?
Dissection, ascending aorta
Thrombosis, inferior vena cava
Aneurysm, abdominal aorta
Stenosis, renal artery
Occlusion coeliac axis
Stenosis, renal artery
The patient probably has malignant hypertension and the presence of an abdominal bruit points to renal artery stenosis as the cause.
A 56 year old woman has 2 weeks with increasing swelling and redness of her legs. The discolouration was there previously but has worsened. Ahe has diet controlled type 2 diabetes mellitus.
Her temperature is 36.9°C. Her legs are shown (see image), Her BMI is 30.
What is the most likely underlying diagnosis?
Acute leg ischaemia
Diabetic neuropathy
Heart failure
Lymphoedema
Venous insufficiency
Venous insufficiency
The clinical picture is acute lipodermatosclerosis with haemosidrin deposition. This is due to venous insufficiency/hypertension.
A 70 year old woman is admitted with fever and diarrhoea.
Her temperature is 38.2°C, pulse 100 bpm and blood pressure 90/65 mmHg. Her hands feel warm. She has lower abdominal tenderness.
She is given intravenous 500 mL of 0.9% sodium chloride over 15 minutes and her blood pressure increases to 106/70 mmHg.
What mechanism best explains the increase in blood pressure?
Increased cardiac afterload
Decreased cardiac afterload
Increased cardiac preload
Reduced cardiac preload
Increased sympathetic activation
Increased cardiac preload
The patient is hypotensive due to sepsis and dehydration. The first step is to give an intravenous fluid challenge which will increase the cardiac preload, leading to increased cardiac output.
A 60 year old woman is found to have hypertension and hyperlipidaemia.
She is started on atorvastain 20 mg daily.
What is the mechanism of action of atorvastatin?
Anatgonises platelet ADP receptors
Inhibition of HMG CoA reductase
Reduces enterocyte cholesterol absorption
Activates intracellular peroxisome proliferator recptor α
Inhibits LDL receptor expression
Inhibition of HMG CoA reductase
Statins are widely prescribed as primary and secondary prevention of atheromatous cardiovascular disease. They inhibit HMG CoA reductase which leads to reduced cholesterol synthesis.
A 48 year old woman has 1 hour of central chest tightness, with nausea and breathlessness.
Her pulse is 60 bpm and blood pressure 140/90 mmHg.
Investigations:
ECG shows ST segment elevation of 3 mm in leads V2-V5.
She is given aspirin.
What effect will aspirin have?
Increase fibrin degradation
Reduce activation of factor Xa
Increase platelet ADP production
Reduce platelet Gp IIa/IIIb expression
Reduce platelet thromboxane A2 synthesis
Reduce platelet thromboxane A2 synthesis
Aspirin is first line treatment in ST elevation myocardial infarct. It inhibits the enzym cycloxygenase, which leads to reduced synthesis of thromboxane A2 ( a prostaglandin) which promotes platelet adherence. Reduced thromboxane A2 reduces platelet adhesivenes.
What measure do we use to give an overall measure of individuals fitness?
Force vital capacity
Resting heart rate
Oxygen saturation during exercise
Total lung capacity
VO2 max
VO2 max
Feedback
VO2 max is a global measure of fitness that is dependent on ventilatory capacity, circulation oxygen delivery and muscle oxygen utilisation.
A 71 year old woman has 3 months of a cough bringing up mostly white sputum. She has COPD and takes a long-acting muscarinic inhaler. She is an ex-smoker with a 35 pack year smoking history.
Her temperature is 37.1°C, pulse 80 bpm, BP 133/83 mmHg and oxygen saturation 95% breathing air. Her heart sounds are normal and chest is clear.
What is the most appropriate initial diagnostic investigation?
Arterial blood gas
Chest X-ray
CT pulmonary angiogram
Bronchoscopy
Sputum for microscopy, culture and sensitivity
Chest X-ray
A persistent cough should be investigated by initially ordering a chest X-ray to identify a lung tumour or other possible cause. If a lesion is identified the patient will require referral to lung cancer clinic and CT scan performed.
Which description best describes the function of histones?
Condense DNA into chromosomes
Enable binding or promoters
Reduce DNA mutation frequency
Terminate DNA transciption
Catalyse mRNA production
Condense DNA into chromosomes
Histones are a family of basic proteins that associate with DNA in the nucleus and help condense it into chromatin. Nuclear DNA does not appear in free linear strands; it is highly condensed and wrapped around histones in order to fit inside of the nucleus and take part in the formation of chromosomes.
Histones are basic proteins, and their positive charges allow them to associate with DNA, which is negatively charged. Some histones function as spools for the thread-like DNA to wrap around.
What is the nature of primers used in DNA polymerase chain reaction?
Pair of oligonucleotide RNA strands
Mixture of 8-10 oligonucleotide DNA strands
Pair of oligonucleotide DNA strands
Single oligonucleotide DNA strand
Single oligonucleotide RNA strand
Pair of oligonucleotide RNA strands
Two single stranded, oligonucleotide is synthesized and used as a primer. The primers thus produces binds to the denatured DNA and polymerase starts its synthesis in the 5’ to 3’ direction.
Which cellular structure is the location of mRNA translation to protein?
Golgi apparatus
Nucleus
Nucleosome
Mitochondria
Ribosome
Ribosome
mRNA binds to the small unit of the ribosome, which then brings in the large unit forming a sandwich with the mRNA molecule in the model. It is here that tRNA with a specific amino acid lines up with an mRNA codon and peptide bound is formed. The continuous sequence of this process leads to protein formation.
A 58 year old woman visits her GP as she would like advice about how to reduce her risk of cancer. Her mother died of ovarian cancer 10 years ago and her father has recently died of bowel cancer. He was 82. She does not smoke. She drinks half a bottle of wine per week. She has mixed diet and has red meat once per week and has fish twice per week. She normally has 5-6 portions of fruit and vegetables per day. She goes to Pilates class once per week and walks 15-30 minutes most days.
her blood pressure is 144/90 mmHg. Her BMI is 30.
What intervention or lifestyle change is likely to have the biggest impact on reducing her risk of cancer?
Abstinence from alcohol
Increase her daily exercise to 60 minutes per day
Annual colonoscopy
Vegetarian diet
Weight loss to a normal BMI
Weight loss to a normal BMI
This question looks at what interventions will have the biggest impact. The patient is obese and this will be having the greatest efect in increasing her risk of cancer. Alcohol also increasex the risk but a small anout such as here (4-6 units per week), will have less effect and you will need to counsel the patient accordingly.
A 67 year old woman has two months of cough and once episode of haemoptysis. She is otherwise well. She has never smoked.
Her examination is normal.
What is the most approriate initial diagnostic investigation?
Chest X-ray
CT scan chest
Sputum culture
Spirometry
Induced sputum for microscopy and culture
Chest X-ray
The concern is the patient has lung cancer and chest X-ray should be done first to look for a mass. TB is a possibility but assessment for that would come once the chest X-ray was reviewed.
Which part of the GI tract has the highest number of bacteria?
Colon
Duodenum
Ileum
Mouth
Stomach
Colon
There are bacteria throughout the GI tract but the greatest concentration is in the colon.
What chemical is produced by Helicobacter pylori to help it survive in the stomach microenvironment?
Ammonia
Bicarbonate
Mucopolysaccharide
Sodium chloride
Pepsin
Ammonia
H.pylori has an enzyme called urease which breaks down urea to release ammonia which acts as a buffer against gastric acidity.
A 47 year old woman presents with 3 days of fever, rigors and a spreading erythematous rash on her right leg.
Her temperature is 38.1°C, pulse 100 bpm and blood pressure 122/68 mmHg. She has a warm, red rash extending from her ankle to her mid-calf of the right leg.
Blood cultures are sent and a gram stain shows gram positive cocci (see image)
What is the most likely microbial cause for the infection?
Escherichia coli
Clostridium difficile
Group B streptococcus
Neisseria meningitidis
Staphylococcus aureus
Staphylococcus aureus
The clinical picture is a cellulitis, which is a skin infection. It is commonly caused by some gram positive bacteria. The Gram stain shows gram positive organisms in clusters which is typical of staphylococcal aureus.
An 80 year old woman presents to the Emergency Department with 3 days of diarrhoea. She lives alone and has a carer coming in once per day.
Her temperature is 38.0°C, pulse 100 bpm and blood pressure 110/80 mmHg.
What is the most appropriate location to manage her over the next 24 hours?
Arrange transfer home with district nurse visit
Admit to 4 bedded room on medical ward
Admit to side room on medical ward
Keep in Emergency Department
Admit to 4 bedded surgical ward
Admit to side room on medical ward
This question is about the principles of infection control. The patient is unwell and will need medical care, so cannot be sent home. They should be admitted to a side room to prevent transmission on infection to other patients.
A 47 year old man is admitted with 5 days of cough, fever and confusion. he has a history of alcohol use disorder and intravenous drug use.
His temperature is 38.2°C, pulse 96 bpm, blood pressure 122/70 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 95% breathing 40% oxygen via a venturi mask. He has inspiratry crackles in both lung.
Investigations:
Chest X-ray: shows left and right lower lobe consolidation
Urine Legionella antigen positive
He is receiving antimcrobial therapy.
What additional measure is indicated?
Give antibiotic prophylaxis to household contacts
Notify Public Health
No further action required
Give influenza vaccination
Give Covid-19 vaccination
Notify Public Health
The patient has Legionella pneumonia. Public health must be informed so they can identify potential environmental source. Vaccines are not give to patients when they are acutely unwell. Person to person spread of Legionella is very rare so no contatc prophylaxis is required.
What is the principle mechanism by which inhaled bacteria are removed from the lung?
Antibody binding
Neutrophil secreted anti-microbial peptides
Macrophage phagocytosis
Mucociliary escalator
Dendritic cell activation
Mucociliary escalator
The mucociliary escalator is an important part of your defenses that traps and removed bacteria before they are able to activate the innate immune system.
Which cell of the immune system is mostly responsible for clearing senescent red blood cells?
Bone marrow stem cells
Capillary endothelium
Pulmonary dendritic cells
Liver Kuppfer cells
Splenic macrophages
Splenic macrophages
Red blood cells become senescent after around 120 days due to accumulated damage and they are then removed primarily by splenic macrophages, with some contribution from liver macrophages (Kuppfer cells).
A 67 year old woman has 4 days of painful vesicular rash on her forehead (see image)
What aspect of ageing is most likely to have predisposed to this infection?
Dendritic cell senescence
Increased neutrophil activation
Loss of NK cell function
Reduced antibody production
Reduced skin keratinisation
Loss of NK cell function
This is the appearance of shigles affecting the ophthalmic branch of the trigeminal nerve. This is caused by reactivation of varcella zozter virus which causes chickenpox. The virus remains dormant in neurone cell bodies and infection is prevented by immune homeostasis, mostly due to NK cells. As we age we lose NK cell function and this allows viral activation.
What is the most likely effect of adipokines released by inflammatory adipose tissue?
Increased intestine GLP-1 production
Gut dysbiosis
Pancreatic beta cells apoptosis
Sympathetic immune system activation
Reduced muscle insulin sensitivity
Reduced muscle insulin sensitivity
The inflamed adipose tissue most likely found in obseity in a pro-inflammatory environment that releases a number of adipokines that impair muscle insuin sensitivity and glucose uptake. This contributes to insulin resistance and type 2 diabetes mellitus.
A 30 year old man has three months of bloody diarrhoea, having his bowels open 3-4 times per day and lower abdominal pain.
His temperature is 37.2°C, pulse 90 bpm and blood pressure 130/82 mmHg. He has tenderness in the left iliac fossa.
Investigations
Haemoglobin 104 g/L (130-180)
C-reactive protein 30 mg/L (< 5)
Sigmoidoscopy: inflammation and ulceration in the rectum and sigmoid colon
What is the most likely diagnosis?
Clostridium difficile infection
Inflammatory bowel disease
Camylobacter jejuni infection
Colorectal cancer
Norovirus infection
Inflammatory bowel disease
The patient has a picture of a chronic inflammation of the colon, confirmed on colonoscopy. This is typical of inflammatory bowel disease.
A 45 year old man has 12 months of pain and stiffness in both hands. He has joint swelling and tenderness over metacarpophalangeal joints in both hands.
An X-ray of his hands shows periarticular erosions (highlighted by the arrows).
Which cell type is responsible for the formation of erosions?
Chondrocyte
Macrophage
Osteoclast
Osteoblast
Synoviocyte
Osteoclast
The patient most likely has rheumatoid arthritis with evidence of bony erosions. these are due to activation of osteoclasts which resorb bone.
What is the function on innate lymphoid cells type 3?
Antigen presentation to T cells of any microbial antigen
Antibody production in response to virus
Activation of the immune system in reposne to extracellular bacteria
Intracellular killing of viruses and mycobacteria
Mucosal production of interferon-λ
Activation of the immune system in reposne to extracellular bacteria
ILC3 are are responsible activation of the immune system in response to extracellular vacteria and fungi. This response is antigen non-specific. They secrete interleukin-17 and 22.
Covid-19 virus enters cells of the respiratory tract and start to replicate. ILC1 and NK cells are activated by the presence of virus.
Which protein will they initially produce to activate and polarise the immune response?
Immunoglobulin G
Immunoglobulin M
Interleukin-17
Interferon-gamma
Reactive oxygen species
Interferon-gamma
ILC1 and NK cells produce interferon-gamma to activaye the immune system towards a Th1 response.
A 20 year old woman has itchy eyes and nasal congestion which has started in late spring.
Activation of which cells is rersponsible for the acute symptoms?
Eosinophil
Mast cell
Macrophage
Neutrophil
Plasma cell
Mast cell
This is a typical allergic response to pollen causing rhinoconjunctivitis. IgE on mast cells respond to the allergen and cause the cell to degranulate and initiating local inflammation.
A 24 year old woman has noticed an itchy rash and swelling on her arm having just come inside from her garden.
Which mediator is most likely to be directly responsible for the swelling and itch?
Adrenaline
Histamine
Interleukin-5
Cortisol
Tumour necrosis factor
Histamine
This is typical cutaneous allergic reaction, often called urticaria or hives. It is due to degranulation of mast cells which release large amounts of histamine which inturn result in vasdilation, increased endothelial permeability which cuase swelling and activate itch receptors in the skin.
Which of these risk factors is most strongly asscociated with the development peripheral vascular disease?
Age
Diabete Mellitus
Gender
Hypertension
Obesity
Diabetes mellitus
All of the options are potentially linked to cardiovacular disease (including PVD) but diabetes is the risk
factor most strongly associated.
