Y3

Question 1

organism that causes a sexually transmitted infection. It does not stain with Gram stain. It is an intracellular organism that produces both elementary bodies and reticulate bodies during its reproductive cycle. It is diagnosed by PCR.

Answer 1

Chlamydia trachomatis

forms both elementary and reticulate bodies

Question 2

A 42 year old man presents with abnormal movements in his limbs that he can’t control. His memory is not as good. His father died young with a further problem.

Answer 2

huntingtons disease
presents in the 40s age group and is an inherited autosomal dominant disorder (the clue with this is his father dying young). Patients classically present with chorea (involuntary movements of the limbs) which leads to cognitive decline

Question 3

An 80 year old man has a tremor, visual hallucinations, a decline in cognition and falls. These symptoms fluctuate.

Answer 3

Lewy body disease
exhibits classical symptoms of dementia, hallucinations, falls and Parkinsonism symptoms (tremor). These symptoms classically fluctuate

Question 4

A 35 year old pregnant woman at 34 weeks gestation. As she was feeling tired, her haemoglobin was checked at her recent antenatal visit and has come back as 88 g/l (120-160 g/L). Iron deficiency anaemia is diagnosed on further investigations.

Select the best management plan

Answer 4

Oral iron is the recommended first line treatment. Blood transfusion is not recommended when a haemoglobin is over 8g/l

Question 5

A 17 year old woman presents to the emergency department with a 2 day history of diarrhoea. On examination, she looks unwell and has purpura. Her full blood count shows haemaglobin 98g/L (low), white cell count 14.4x109/L (high), platelets 46x109/L (low) and her creatinine is 587µmol/L (high). A blood film shows marked red blood cell fragmentation and polychromasia

diagnosis?

Answer 5

HUS due to E.coli 0157

Red cell fragmentation and thrombocytopenia occurs when there is intravascular destruction of red blood cells due to overactivation of the complement system or of platelets. This is known as microangiopathic haemolytic anaemia. The most likely cause in this case is haemolytic uraemic syndrome due to E.Coli due to the history of diarrhoea.

Question 6

A 35 year old presenting with a severe unilateral headache lasting for 6 hours, associated with nausea

Answer 6

Migraines are severe headaches lasting between 4 and 72 hours associated with at least two of the following: unilateral, pulsating, moderate to severe, aggravated by routine activities, accompanying symptoms may include photophobia, phonophobia, nausea and vomiting

Question 7

An obese 28 year old woman recently started on the combined oral contraceptive pill, complains of a constant headache, worse in the morning and exacerbated by sneezing

Answer 7

Benign intracranial hypotension usually presents with a generalised throbbing headache, associated with nausea and vomiting. The headache can be made worse by any activity that further increases the intracranial pressure such as coughing and sneezing. It can be caused by taking the combined oral contraceptive pill

Question 8

A 55 year old man complains of a moderately severe continuous frontal headache, worse in the evenings.

Answer 8

acute tension HA

Typically an acute tension headache is mild to moderate only, non-pulsating and bilateral

Question 9

Which of the following is LEAST LIKELY to happen in the first week of life for a preterm infant born at 29 weeks of gestation:

Sepsis

Respiratory distress syndrome

Intraventricular haemorrhage

Patent ductus arteriosus

Chronic lung disease (Broncho pulmonary dysplasia)

Answer 9

All the above are known complications of prematurity, except for chronic lung disease which describes a condition in which the preterm infant will require oxygen supplementation beyond 28 days or beyond 36 weeks corrected gestation

Question 10

treatment for:
A 29 year old female presents with acute mania. There are concerns she might be pregnant after a brief period of sexually disinhibited behaviour.

Answer 10

olanzapine

Question 11

treatment for:
A 30 year old male has been diagnosed with schizophrenia. He has been prescribed quetiapine for 8 weeks and this was changed to haloperidol for 8 weeks due to poor symptom control. He remains very psychotic, with troublesome extra pyramidal symptoms

Answer 11

Patients with treatment resistant schizophrenia should be offered a trial of clozapine

Question 12

Which neurotransmitter is most involved in appetitive and approach systems

Answer 12

Dopamine. The function of the appetitive and approach systems is to mediate seeking and approach behaviours including pleasure; they involve the ascending dopamine systems which project to the mesolimbic areas and the cortex, as well as the striatum, amygdale, anterior cingulate and orbitofrontal cortex.

Question 13

Most people over 60 years old in the UK are immune to this type of hepatitis. It is acquired via faecal-oral route

Answer 13

hep A

Question 14

Where does fertilisation normally occur?

Answer 14

ampulla of the uterine tube

Question 15

what is the infundibulum of the uterine tube

Answer 15

the broad end of the uterine tube that receives the oocyte at ovulation

Question 16

what is the isthmus of the uterine tube

Answer 16

where the uterine tube narrows to enter the uterus

Question 17

A woman has induction of labour at 42 weeks gestational age. Following an artificial rupture of membrane, there is a prolonged fetal bradycardia to 50 beat per minute. Some fresh vaginal bleeding is noted and on examination the uterus is soft and non-tender.
diagnosis

Answer 17

Vasa praevia is a rare condition where cord vessels cross the fetal membranes. It presents with severe fetal distress with a relatively small intrapartum bleed following rupture of membranes

Question 18

A woman is admitted at 38 weeks gestation age with severe abdominal pain and a heavy vaginal bleed. On examination her uterus is tense and the fetal heart is 50 beats per minute.
diagnosis

Answer 18

Placental abruption is when there is a retroplacental haemorrhage. If there is severe bleeding the uterus becomes tender, tense and there can be severe fetal distress and sadly sometimes intra-uterine death

Question 19

What is the main mechanism of action of lamotrigine?

Answer 19

Blockade of voltage sensitive sodium channels. Lamotrigine antagonises voltage sensitive sodium channels and this reduces the release of glutamate, the main excitatory neurotransmitter

Question 20

what goes in an orange waste bag

Answer 20

non sharp clinical waste

Question 21

A 25 year old primigravida has a 2 hour second stage of labour and is exhausted after 1 hour of pushing. Her CTG (cardiotocography) is reassuring. On examination there is a cephalic presentation in a direct occipitoanterior position with a station of 2cm below the ischial spine.
what is the most appropriate action

Answer 21

A mid-forceps delivery (e.g. haig ferguson) is appropriate as the position is direct occipitoanterior and the foetal head is below the ischial spine

Question 22

Myasthenia gravis is an autoimmune condition in which antibodies are directed against what?

Answer 22

postsynaptic acetylcholine receptors. The autoantibodies compete with acetylcholine released from the presynaptic nerve endings

Question 23

what do autoantibodies act on in lambert eaton syndrome

Answer 23

calcium fluxes in presynaptic calcium channels

Question 24

what causes rouleaux formation (when red cells are stacked like coins)

Answer 24

when the charge on the surface of cells is altered as a consequence of cell being labelled with proteins. The proteins could be acute phase proteins (as one would find in a reactive process (e.g. infections) or a paraprotein (intact immunoglobulin)) found in plasma cell dyscrasias

Question 25

which neurotransmitter will be low:

A 21 year old man with known illicit drug use who attends the Emergency Department following a suspected epileptic fit.

Answer 25

In withdrawal from sedative-hypnotic drugs there is a reduced GABA

Question 26

which neurotransmitter will be low:
A 24 year old man brought to the Emergency Department after an episode of bizarre behaviour indicating third party auditory hallucinations. He has no previous medical history.

Answer 26

dopamine
In schizophrenia there appears to be an excessive activation of dopamine receptors and treatment with antipsychotic medications which suppress dopamine are the main treatment

Question 27

which neurotransmitter will be low:
A 50 year old woman attends her GP with a 3 month history of low mood and poor concentration following a relationship breakdown.

Answer 27

In depressed patients 5-hydroxytryptamine is low.

Selective serotonin re-uptake inhibitors are frequently used in the treatment of depression

Question 28

what do most patients on haemodialysis require to maintain adequate Hb levels

Answer 28

erythropoietin

anaemia v common in CKD due to decreased renal erythropoietin

Question 29

Which of the following suggests congenital cardiovascular disease in a new-born infant?
A: Delay in femoral pulses

B: Early neonatal jaundice

C: Polycythaemia

D: Peripheral cyanosis

E: Splitting of the second heart sound

Answer 29

Delay of femoral pulses is highly suggestive of coarctation of the aorta. Other symptoms and signs mentioned are normal findings in newborn infants

Question 30

A 76 year old man presents with back pain. His 2nd and 3rd lumber vertebrae are very tender. Urinalysis shows proteinuria and microscopic haematuria. Blood tests are carried out: Haemoglobin 96g/L (low); WBC and platelet count are normal, Urea 12mmol/L (high); Creatinine 160μmol/L (high); Corrected Calcium 2.9mmol/L. (high)

Answer 30

Multiple myeloma is a cancer of the plasma cells, which accumulate in the bone marrow. It commonly causes bone pain in the ribs and spine, anaemia and renal failure

Question 31

A 56 year old non-smoking female with rheumatoid disease, is breathless on exertion walking 200yds on flat ground, has finger clubbing, and a CXR shows shrunken lungs with bilateral infiltrates. What would be MOST LIKELY finding on spirometry?

Answer 31

FEV1 reduced, FVC reduced, FEV1/FVC normal, PEF normal

In a restrictive pattern due to DPLD (ie fibrosing alveolitis secondary to rheumatoid disease), the dynamic forced expiratory lung volumes [FEV1 and FVC] are both reduced in proportion so that the ratio is preserved, but the PEF is normal as there is no obstruction to airflow.

Question 32

Rapidly contracting human muscle cells start producing lactic acid.

Which of the following statements BEST explains this finding?

OPTIONS:

A: The cells have to convert NADH into NAD+.

B: Lactic acid acts as a substrate for gluconeogenesis.

C: Lactic acid is oxidised in the Krebs cycle.

D: Most cells utilise lactic acid as an energy source.

E: Lactic acid is a normal waste product of aerobic metabolism.

Answer 32

The correct answer is A because rapidly contracting muscle cells require a large amount of energy in the form of ATP, and if they can’t produce enough by oxidative phosphorylation, e.g. because not enough oxygen can be supplied quickly enough, these cells require another way of regenerating NAD+. Without regenerating NAD+, these cells would not be able to produce ATP by glycolysis either

B is a correct statement, but does not explain why muscle cells produce it. C is not possible. D is not a correct statement and would not explain the observation. E is also wrong; lactic acid is only synthesised under anaerobic conditions, when a cell has to rely entirely on glycolysis for ATP generation.

Question 33

Which area of the brain is affected first in Alzheimer’s disease?

Answer 33

The nucleus basalis of Meynert is the first area of the brain to be affected by the neuropathology of Alzheimer’s disease. It is the main source of the cholinergic projections to the rest of the brain and this is thought to be one of the mechanisms by which Alzheimer’s causes cognitive impairment. The fact that cholinesterase inhibitors only delay progression of the symptoms rather than causing complete resolution of symptoms shows that lack of acetylcholine is not the only problem in Alzheimer’s

Question 34

what is the most common circulating WBC

Answer 34

neutrophil

Question 35

what is the bodies first line defence against pyogenic organisms

Answer 35

neutrophils

Question 36

what does a neutrophil look like

Answer 36

segmented nucleus (3-5 segments) and blue granules which contain proteins including anti-microbial enzymes. In an activated neutrophil (e.g. in response to infection), prominence of granules is noted, described by the term toxic granulation or toxic neutrophilia (where the neutrophil count is raised)

Question 37

which cranial nerve:

Can be injured by pituitary adenoma.

Answer 37

optic nerve

Question 38

which cranial nerve:

Pain across the posterior triangle of the neck

Answer 38

facial nerve (CN VII)

Question 39

what visual defect if this damaged:

Lateral optic nerve lesion immediately anterior to the chiasma.

Answer 39

Junctional scotomas are caused by lesions just anterior to the optic chiasm and cause different visual field disturbances in each eye

Question 40

what visual defect if this damaged:

Optic chiasma

Answer 40

Damage to the optic chiasm causes bitemporal field defects

Question 41

what visual defect if this damaged:

Right optic tract

Answer 41

left homonymous hemianopia

Question 42

diagnosis:
A 40 year old woman who smokes 20 cigarettes a day complains of a green nipple discharge and a non-tender lump below the nipple

Answer 42

duct ectasia
Patients with duct ectasia have a green/cream nipple discharge and this is more common in smokers. A lump (thickened duct) can be felt under the nipple.

Question 43

diagnosis:
A 38 year old woman has noticed a 2cm lump in the upper outer quadrant of her right breast. She was involved in a car accident 2 months ago but was not hurt. Her aunt had breast cancer at the age of 80 years.

Answer 43

Fat necrosis of the breast usually presents after trauma which can be minor enough to be forgotten by the patient. The history of her grandmother with breast cancer is a red herring but these patients must still undergo triple assessment (examination/mammogram for over 35y of age/FNAC) before this diagnosis is reached.

Question 44

diagnosis:
A 70 year old woman develops a hot tender breast with overlying cellulitis. She recently had two courses of antibiotics to treat this.

Answer 44

inflammatory breast cancer
In elderly patients with inflammatory changes in the breast with no resolution despite an adequate course of antibiotics, inflammatory breast cancer must be suspected

Question 45

Which of the following statements about transport in the proximal tubule is true?

OPTIONS:

A: 100% of filtered glucose and amino acids are reabsorbed.

B: About 10% of salt and water are reabsorbed.

C: Reabsorption is by paracellular mechanisms only

D: Urea is secreted.

E: Hydrogen ions are reabsorbed

Answer 45

A. 100% of filtered glucose and amino acids are reabsorbed

The proximal tubule is involved in regulation of pH and also is where 100% of filtered glucose and amino acids are absorbed

Question 46

which nerve root:

biceps reflex

Answer 46

C5/6

Question 47

which nerve root:

ankle reflex

Answer 47

S1

Question 48

which nerve root:

knee reflex

Answer 48

L3/4

Question 49

Someone with an IQ of 45 would be described as having which severity of learning disability?

Answer 49

moderate (35-49)

Question 50

A 22 year old nulliparous woman is in spontaneous labour at 40 weeks gestation. She has had an uncomplicated pregnancy and has been progressing well in labour. On vaginal examination the midwife documented the following on vaginal examination: cervix 9 cm dilated, station 0, direct occipito-anterior with meconium liquor draining. Her contractions are described as moderate, every 2-3 minutes. The CTG is reassuring.

What management is appropriate?

Answer 50

reassure and re-examine in 2 hours

The CTG is reassuring despite there being meconium stained liquor. She is likely to achieve a normal spontaneous vaginal delivery and should be re-examined in 2 hours. There is no sign of fetal distress so fetal blood sample/delivery is not required. She requires continuous CTG monitoring throughout labour because of the meconium stained liquor

Question 51

most likely cause of anaemia:
An 18 year old woman presents with tiredness and dizziness. She also has heavy periods. Her full blood count shows haemoglobin 99g/L (low), MCV 72.4fL (low), white cell count 6.4x109/L (normal), platelet 351x109/L (normal) and her ferritin is 3µg/L (low)

Answer 51

iron deficiency anaemia. Although ferritin can be raised in acute inflammation, a low ferritin always means iron deficiency.

Question 52

most likely cause of anaemia:
A 38 year old man presents to the acute medical unit with painless jaundice and exertional dyspnoea. His full blood count shows haemoglobin 59g/L (low), MCV 115fL (high), white cell count 8.8x109/L (normal), platelet 204x109/L (normal) and reticulocyte count 358x109/L. A blood film shows polychromasia and spherocytes and the Direct Antiglobulin Test (DAT) is strongly positive.

Answer 52

autoimmune haemolytic anaemia

Anaemia and jaundice should also make you consider the possibility of haemolysis. The bone marrow is working hard to make new red cells and the reticulocyte is usually very high as in this case. Spherocytes on the blood film could mean autoimmune haemolysis or hereditary spherocytosis but the history and the strong direct antiglobulin test indicate that this is autoimmune. Note that crossmatching blood in this condition is difficult.

Question 53

A 62 year old woman has been diagnosed with chronic congestive heart failure secondary to ischaemic heart disease.

Which of the following medications improve survival in chronic congestive heart failure?

A:Calcium channel blockers

B:Loop diuretics

C:Statins

D:ACE inhibitors

E:Nitrates

Answer 53

ACE inhibitors

ACE inhibitors block the conversion of angiotensin I to angiotensin II by angiotensin converting enzyme (ACE). Chronic up-regulation of the renin-angiotensin-aldosterone system (RAAS) in congestive heart failure places an extra strain on the heart by increasing cardiac preload and afterload. Medications which interfere with the RAAS may help improve survival in heart failure. Other medications, which improve survival in heart failure, include beta-blockers.

Question 54

An 85 year old man is admitted with confusion. You suspect delirium. Which three features are essential for a diagnosis of delirium?

Answer 54

acute onset plus, inattention with fluctuating course, plus one of: disorganised thinking or altered level of consciousness.

Question 55

MOST APPROPRIATE treatment for a 30 year old woman, who has sudden episodes of inability to speak, associated with altered hearing and loss of spatial awareness, lasting 1-2 minutes.

Answer 55

The symptoms described are most likely to be due to a simple partial seizure in which consciousness is not lost and a variety of short lasting symptoms can occur. The first line treatment is oral lamotrigine or carbamazepine

Question 56

best treatment:
A 25 year old female attends her GP for a sexual health screen and is diagnosed as having Chlamydia trachomatis infection. She is asymptomatic

Answer 56

Oral azithromycin is the treatment of choice for uncomplicated chlamydia infection

Question 57

best treatment:
A 35 year old female patient with an offensive vaginal discharge who is diagnosed as having Trichomonas vaginalis infection by her GP.

Answer 57

Oral metronidazole is the treatment of choice for Trichomonas vaginalis infection

Question 58

best treatment:
A 21 year old female who attends the sexual health clinic with vaginal discharge who is diagnosed as having Neisseria gonorrhoeae. She has no symptoms or clinical signs of pelvic inflammatory disease.

Answer 58

ceftriaxone IM + oral azithromycin

ensure you do test of cure

Question 59

Select the most appropriate daily supplement you would recommend in a woman attending an antenatal clinic at 8 weeks into her first pregnancy. She is low risk apart from having diabetes mellitus.

Answer 59

Folic acid 5mg and Vitamin D 10mcg

Question 60

area of brain responsible for:

receptive aphasia

Answer 60

wernickes

Receptive aphasia is due to a temporo-parietal lesion, an area of the brain known as Wernicke’s area (hence this type of aphasia is sometimes called Wernicke’s aphasia). In this type of aphasia, a patient’s speech is fluent, but the words that are spoken are incorrect. This can vary from a few incorrect words to complete nonsense. Those who recover say that they are unable to understand what other people are saying.

Question 61

what is aphasia

Answer 61

acquired language disorder caused by damage to frontal, temporal and/or parietal lobes of the dominant hemisphere

Question 62

area of brain responsible for:

Expressive aphasia.

Answer 62

brocas area

lesions in the frontal lobe of the dominant hemisphere, in an area known as Brocca’s area (and so, not surprisingly, this is also known as Brocca’s aphasia). While patients are able to understand language they lose fluency, and those who recover describe being unable to get the words out, despite knowing what they want to say.

Question 63

area of brain responsible for:

nominal aphasia

Answer 63

Angular gyrus

Nominal aphasia occurs when patients are unable to name familiar objects, but language is otherwise preserved. It can occur as part of other aphasic syndromes, but when it occurs on its own, it suggests an inferior parietal lesion, and area known as the angular gyrus

Question 64

Unfractionated heparin is best dosed by performing which test?

Answer 64

The APTT is used to monitor heparin

Question 65

which hormone to measure:

To determine whether a woman has ovulated.

Answer 65

Progesterone

secreted by the corpus luteum, peaking approximately 7 days after ovulation

Question 66

which hormone to measure:

To assess ovarian reserve prior to in vitro fertilisation treatment.

Answer 66

Anti-mullerian hormone (AMH) is used to measure ovarian reserve and is useful to predict response to supra-ovulation in IVF treatment

Question 67

which hormone to measure:

To perform serial assessment to help with the possible diagnosis of an ectopic pregnancy

Answer 67

Human chorionic gonadotrophin (HCG)

secreted by the trophoblast and in an ectopic pregnancy will fail to rise at an appropriate level (should double every 48 hours)

Question 68

At what stage does the embryo implant into the uterus?

Answer 68

blastocyst (forms around day 5, has inner cell mass and trophoblast)
implantation occurs days 6-10

Question 69

most likely cause of lymphadenopathy:
A 65 year old man presents to his GP with lumps under his arms. On examination, he has cervical, axillary, and inguinal lymphadenopathy up to 2cm in size. His Full Blood Count shows Haemoglobin 124g/L (normal), White Cell Count 231x109/L (high), lymphocytes 223x109/L (high) , Platelets 332x109/l.(normal)

Answer 69

Chronic lymphocytic leukaemia

With the lymphocyte count so high this can only really be CLL. Lymphocytosis can be seen in non-Hodgkin’s lymphoma and acute viral infection but never this high (rarely more than 20x109/L)

Question 70

most likely cause of lymphadenopathy:
A 16 year old girl presents with a 1 week history of general malaise and is found to have small tender cervical and axillary lymphadenopathy. Her FBC shows Haemoglobin 143 g/L (normal), White Cell Count 10.2x109/L (high), lymphocytes 7.6x109/L (high), Platelets 177x109/l (normal) and her ALT is 569U/L (high) with otherwise normal liver function tests. Blood film shows atypical mononuclear cells and a monospot test is positive.

Answer 70

Acute Epstein-Barr virus infection

Atypical mononuclear cells are often seen in acute viral infections and are activated (predominantly T) lymphocytes responding to the viral infection. They are classiclly seen in acute EBV infection, hence its other name of infectious mononucleosis. Lymphadenopathy and acute hepatitis are also common. This is usually a self-limiting infection but some people experience chronic fatigue after EBV infection. Immune medicated cytopenias such as neutropenia, thrombocytopenia, and even autoimmune haemolytic anaemia can occur with EBV infection and may require specific therapy

Question 71

most likely cause of lymphadenopathy:
A 23 year old woman from Nigeria who is studying at University goes to see her GP because she is feeling run down. On examination, she has widespread small volume lymphadenopathy, oral candidiasis and oral hairy leukoplakia.

Answer 71

HIV

is a cause of generalised lymphadenopathy that should not be forgotten - unexplained cytopenias (especially lymphopenia and thrombocytopenia) or lymphadenopathy should trigger HIV testing even in low risk individuals. HIV is also associated with many types of lymphoma and many authorities recommend testing all patients diagnosed with lymphoma as it will affect management

Question 72

What is the most common mode of inheritance of Hereditary Spherocytosis?

Answer 72

autosomal dominant

This is due to mutations in one of several red cell membrane proteins and is one of the commonest genetic disorders in the UK. It is usually autosomal dominant although rare autosomal recessive cases are described (where the mutation is not in one of the typically described proteins). Patients have chronic haemolysis and may require splenectomy or cholestectomy for pigment gallstones.

Question 73

A patient presents with a 3 week history of low mood, early morning wakening, poor energy and anhedonia. They have lost significant weight. There are no other known problems with their physical health.

Which antidepressant would you start with?

Answer 73

SSRIs e.g. citalopram

Question 74

A patient presents with a 3 week history of low mood, early morning wakening, poor energy and anhedonia. They have lost significant weight. There are no other known problems with their physical health.

Which antidepressant would you start with?

Answer 74

SSRIs e.g. citalopram

Question 75

Which of the following is a recognised maternal adaption to pregnancy?

A: Blood pressure decreases in second trimester, and returns to pre-pregnancy level by the third trimester

B: Cardiac output decreases by 30-50% from 6 weeks gestational age and then increases back to normal in the last 8 weeks of pregnancy

C: Erythropoiesis decreases by 25% resulting in anaemia

D: Glomerular filtration rate stays the same through-out pregnancy

E: Vital capacity increase by 50%

Answer 75

A

The blood pressure decreases in the second trimester due to the expansions of uteroplacental circulation and decreased peripheral resistance. Cardiac output and glomerular filtration rate increases by 30-50%. Erythropoiesis increases by 25% and haemoglobin is reduced by dilution. Tidal and minute volumes increase, but vital capacity is unchanged.

Question 76

The thoracic duct drains into the left “venous angle”. This is the angle between which vein and the subclavian vein?

Answer 76

internal jugular vein

Question 77

Drains into the chamber of the heart in which the sinoatrial node (SA) is located.

Answer 77

IVC (or coronary veins) (SA node in RA)

Question 78

Intercostal veins from the anterior aspect of the intercostal spaces drain into this vein

Answer 78

internal thoracic vein

Deoxygenated blood from the structures in the intercostal spaces drains into the internal thoracic vein anteriorly and the azygous vein posteriorly (oxygenated blood to the structures in the intercostal spaces arises from the internal thoracic artery anteriorly and the thoracic aorta posteriorly

Question 79

A 53 year old woman attends her GP surgery with troublesome hot flushes and night sweats. Her GP decides to start her on combined sequential hormone replacement therapy.

Which of the following is a contraindication to hormone replacement therapy?

A:Current smoker

B:Well controlled angina

C:Obesity with BMI of 37kg/m2

D:Sister with breast cancer

E:Osteoporosis

Answer 79

B

Active or recent arterial thromboembolic disease (e.g. angina or MI) are contraindications for HRT

Question 80

Which artery is MOST LIKELY to be the cause of bleeding during the following surgical procedures?

Insertion of a lateral abdominal port, during female laparoscopic sterilisation

Answer 80

The inferior epigastric artery

branch of the external iliac artery and runs on the posterior surface of the lower half of the rectus abdominis muscle. Care must be taken when inserting lateral ports to avoid injuring this artery

Question 81

Which artery is MOST LIKELY to be the cause of bleeding during the following surgical procedures?

Incision of a Bartholin’s abscess.

Answer 81

Internal Pudendal Artery

Branches from the internal pudendal artery supply to the labia and clitoris. A Bartholin’s abscess forms in the labia

Question 82

Which artery is MOST LIKELY to be the cause of bleeding during the following surgical procedures?

Dissection of the lower end of the ureter.

Answer 82

uterine artery

The lower end of the ureter passes under the uterine artery as it passes through the base of the broad ligament beside the cervix, before entering into the trigone of the bladder

Question 83

A 14 month old child presents with acutely painful and swollen fingers. Both parents have recently moved here from Nigeria. A blood film shows abnormal red bloods cells.

Which of the following tests is MOST LIKELY to give a definitive diagnosis?
A:Bone marrow biopsy

B:Haemoglobin high performance liquid chromatography of whole blood lysate(HPLC)

C:Lymph node biopsy

D:Serum protein electrophoresis

E:Peripheral blood immunophenotyping

Answer 83

Haemoglobin high performance liquid chromatography of whole blood lysate(HPLC)

This is a clinical description of dactylitis, which is a common presentation of sickle cell anaemia. Clinical manifestations of sickle cell disease are rare in younger infants because of the protective effect of foetal haemoglobin (hbF). Haemoglobin S (HbS) carrier status is much more common in sub-Saharan Africa and it is likely that both parents are carriers. A sickle solubility test can give a rapid indication of the presence of sickle cells but note this is also positive in carriers of the disease. Haemoglobin high performance liquid chromatography is the best method to confirm the presence of HbS.

Question 84

Which of the following allows detention of a patient in hospital for 6 months in the first instance?
A:Compulsion order

B:Compulsory treatment order

C:Short term detention

D:Emergency detention

E:Assessment order

Answer 84

A compulsory treatment order (CTO) is a civil order allowing detention in hospital for 6 months in the first instance

Question 85

test that is MOST USEFUL for monitoring the therapeutic effect of anticoagulation:
A 24 year old woman is 30 weeks pregnant and is on therapeutic dose Dalteparin (low molecular weight heparin) for a pulmonary embolus she had 3 weeks ago.

Answer 85

Anti-Xa assay

It is only necessary to monitor a patient on dalteparin in special circumstances such as pregnancy or renal impairement. The APTT is useful for monitoring intravenous unfractionated heparin but is often normal in patients on low molecular weight heparin. The anti-Xa assay measures the inhibition of Factor X by LMWH and other drugs. This is the main mechanism of action of LMWH. Note that the timing of the sample in relation to the dose is very important and that this test should be done 3-4 hours post dose

Question 86

test that is MOST USEFUL for monitoring the therapeutic effect of anticoagulation:
A 75 year old woman is found to be in atrial fibrillation. She has hypertension and a history of transient ischaemic attacks. Her renal function is normal and she is started on dabigatran (direct thrombin inhibitors).

Answer 86

No routine monitoring required

Dabigatran is a new oral direct thrombin inhibitor. It is licensed for use in atrial fibrillation to prevent stroke and studies show that it is at least as good as warfarin for this and causes fewer intracranial haemorrhages than warfarin. It is largely renally excreted and is contraindicated if the GFR is less than 30ml/min. One of the major benefits of the new anticoagulents is that routine monitoring is not required although it is recommended to monitor renal function as if this deteriorates then a change of therapy will be required

Question 87

You are asked to see a 19 year female prisoner who was moved to the segregation unit of a young offender’s institute 4 weeks ago. She has been describing hearing some of the other prisoners talking about her and has fashioned a weapon from her toothbrush as she believes that the prison officers wish to kill her. Diagnosis?

Answer 87

paranoid schizophrenia

Question 88

You see a 25 year old woman in the Emergency Department who is suffering from problems related to smoke inhalation following a fire which killed her 14 day old baby. She is tearful and is distracted by loud voices stating “they told me to start the fire”. Diagnosis?

Answer 88

puerperal psychosis

Question 89

A 32 year old asks her community midwife for contraceptive advice two days after the delivery of her third child. She has a BMI of 41kg/m2 and her husband has a vasectomy booked for three months’ time.

Select the MOST APPROPRIATE contraception:

Answer 89

Progesterone only pill (Cerazette)

The combined pill is contraindicated in women with a BMI of over 39kg/m2. Long term contraception is not appropriate in view of her husband’s planned vasectomy. The correct answer is E.

Question 90

A 32 year old asks her community midwife for contraceptive advice two days after the delivery of her third child. She has a BMI of 41kg/m2 and her husband has a vasectomy booked for three months’ time.

Select the MOST APPROPRIATE contraception:

Answer 90

Progesterone only pill (Cerazette)

The combined pill is contraindicated in women with a BMI of over 39kg/m2. Long term contraception is not appropriate in view of her husband’s planned vasectomy.

Question 91

An 85 year old woman presents with incontinence. She is unable to get to the toilet in time. The very thought of the toilet makes her incontinent. What type of incontinence does she have?

Answer 91

urge

Question 92

what consent is needed?

A 14 year old girl who is about to undergo a termination of pregnancy and who appears to fully understand the procedure.

Answer 92

A patient under the age of 16 years can be shown to have the capacity to consent. Written consent is required for a surgical procedure

Question 93

what consent is needed?
A 77 year old man is admitted to the Emergency Department unconscious, requiring emergency repair to a fractured hip which will take place later in the day. His wife accompanies him.

Answer 93

written consent from relative

An emergency procedure can be performed without consent if it is not possible to obtain consent and treatment is immediately required to save their life or prevent serious deterioration of a patient’s condition. As treatment is not immediately necessary, there is time to discuss treatment with the patient’s wife. The patient’s wife is able to consent to treatment on his behalf as she is his nearest relative

Question 94

what consent is needed?
A 30 year old severely brain damaged woman with menorrhagia. Her husband is requesting a total hysterectomy to improve her personal hygiene.

Answer 94

Court of law decides overriding need for consent

Question 95

A patient is seen in the neurology clinic, complaining of abnormal head movements and neck pain. He also notes that his head has a tendency to turn to the left, and indeed he finds it uncomfortable to keep his head facing forward.

What is the most likely diagnosis?

Answer 95

cervical dystonia

A dystonia is a sustained abnormal posture caused by persistent contraction of large trunk or limb muscles. Cervical dystonia, AKA spasmodic torticollis, is typified by the head turning to one side due to contraction of the sternocleidomastoid muscle. The aetiology and pathology are unknown. It can be treated with anticholinergics, phenothiazines and injections with Botulinum toxin.

Question 96

what is blepharospasm

Answer 96

twitch/spasm of the eyelid

Question 97

what is hemiballismus

Answer 97

uncontrolled flailing of limbs. It is due to either a structural lesion or metabolic dysfunction of the subthalamic nucleus

Question 98

What LP results would you expect to see in acute bacterial infection?

Answer 98

Cloudy

glucose <50%

protein Increase

Neutrophils

oligoclonal bands -ve

Question 99

what does Xanthochromic CSF indicate

Answer 99

the presence of blood, and is likely to be seen in a patient with subarachnoid haemorrhage

Question 100

when is CSF clear

Answer 100

viral meningitis, Guillaun-Barré syndrome, multiple sclerosis and normal samples

Question 101

when is CSF cloudy

Answer 101

bacterial meningitis and tuberculous meningitis (although in the latter it may also be clear)

Question 102

when are lymphocytes raised in CSF

Answer 102

viral and tuberculous meningitis, and in multiple sclerosis

Question 103

when is protein raised in CSF

Answer 103

in most conditions, but are very raised in bacterial meningitis

Question 104

what do oligoclonal bands suggest

Answer 104

MS

Question 105

An 80 year old woman presents with a 3 month history of falls. Her right knee gives way when she is walking. She has chronic kidney disease, mild dementia, osteoarthritis and is awaiting a knee replacement. She has been struggling to climb stairs due to the pain in her knees. She takes paracetamol and was started on codeine two weeks ago for pain.

From the options below choose the ONE MOST APPROPRIATE action you would take.

A:Add a nonsteroidal anti-inflammatory drug for pain relief

B:Stop Codeine as this can cause confusion and falls.

C:Strength and balance training before knee replacement.

D:Advise her to stop climbing stairs.

E:Increase physical activity after knee replacement.

Answer 105

Strength and balance training before and after surgery will improve quadriceps strength, increase stability of the knee joint, and help improve outcomes. Patients should be encouraged to continue their physical activity while awaiting surgery. NSAIDs in older people can increase their risk of renal impairment and gastrointestinal bleeding and should be avoided. Although opiates can cause confusion and falls, her falls have preceded the addition of codeine with no history of increased confusion

Question 106

Which drug is the best choice for a patient with hyperactive delirium secondary to a urinary tract infection and no other medical problems?

Answer 106

haloperidol

Question 107

do benzodiazepines help delirium

Answer 107

no they worsen and lengthen it

Question 108

A 35 year old complains of severe premenstrual pain and dyspareunia caused by known severe endometriosis.
what Tx

Answer 108

The combined oral contraceptive pill is an effective treatment for endometriosis, as is any treatment that reduces menstruation

Question 109

A 34 year old is currently taking the combined oral contraceptive pill for contraception. Which of the following drugs is known to reduce the contraceptive efficacy of the combined oral contraceptive pill?

A:Methyldopa

B:Phenytoin

C:Mefenamic acid

D:Amoxycillin

E:Codeine

Answer 109

Phenytoin reduces contraceptive efficacy as it induces liver enzymes

Question 110

what inheritance:

Wilson’s disease.

Answer 110

autosomal recessive

condition in which copper accumulates in tissues. It causes neurological, psychiatric and hepatological conditions. Copper can be deposited around the iris, forming Kayser-Fleischer rings

Question 111

what inheritance:

Becker’s muscular dystrophy.

Answer 111

X-linked recessive condition.

Various defects can be implicated, but all affect the dystrophin gene. Some cases occur de-novo, and individuals can be affected to varying degrees due to genetic mosaicism

Question 112

what inheritance:

Myoclonic epilepsy with ragged red fibers.

Answer 112

mitochondrial disease

Clumps of mitochondria accumulate in muscle fibres giving a ragged, red appearance. Other features include progressive myoclonic epilepsy, short stature, hearing loss, lactic acidosis, exercise intolerance and poor night vision.

Question 113

A 35 year old attends the Emergency Department in the morning concerned that she has forgotten to take her oral contraceptive pill last night. This would have been the 19th pill in the packet. She had sexual intercourse 2 nights ago.

What would be the best advice to give?

Answer 113

She should be advised to take her forgotten pill now and the next one at the usual time. Additional precautions are only required if she missed 2 or more pills

Question 114

A 16 year old girl presents with her mother to the family GP, complaining of abdominal cramps. Her mother is concerned that her daughter has never had a menstrual period although her breasts have developed. You observe that she is a suitable height and weight for her age.
Diagnosis?

Answer 114

The usual presentation of an imperforate hymen is in a girl approximately 2 years after starting puberty who complains of abdominal pain

Question 115

A 32 year old woman presents to her GP with secondary amenorrhoea for 6 months, excited because she and her husband have been trying for a baby for the past year. She had chemotherapy as a child as treatment for a renal tumour. Her GP carries out a urine pregnancy test which is negative.
Diagnosis?

Answer 115

Premature ovarian failure

can be caused by previous chemotherapy or radiotherapy and can be diagnosed by elevated serum levels of FSH. In this case it is important to exclude a pregnancy with a urinary pregnancy tes

Question 116

A 35 year old woman presents to her GP with secondary amenorrhoea for 9 months. She is embarrassed regarding increasing facial and abdominal hair growth. Her GP carries out a urine pregnancy test which is negative.
Diagnosis?

Answer 116

Polycystic ovarian syndrome

diagnosed when at least 2/3 of the following are present: Oligo or amenorrhoea, clinical or biochemical increase androgens, enlarged ovaries with multiple peripheral cysts on scan.

Question 117

MOST ACCURATE psychopathology term:

“All my food has a metallic taste, like someone is poisoning me”

Answer 117

Gustatory hallucination

Question 118

MOST ACCURATE psychopathology term:

“Everywhere I go there is this terrible smell, I keep washing but I can’t get rid of it, other people say they can’t smell it but I think they’re just being polite”

Answer 118

Olfactory hallucination

Question 119

A 19 year old female presents to the Genitourinary Medicine clinic with a vaginal discharge. She is sexually active with multiple partners. She has a foul smelling discharge and microscopy shows a flagellated protozoa.

What is the MOST LIKELY diagnosis?

Answer 119

Trichomonas vaginalis

Question 120

what GU infection has clue cells

Answer 120

gardnerella vaginalis

Question 121

what GU infection is diplococci

Answer 121

neisseria gonorrhoea

Question 122

Which of the following changes results in a right shift of the oxyhaemoglobin dissociation curve?

A:Decreased carbon dioxide

B:Decreased pH

C:Decreased temperature

D:Decreased 2,3 - DPG (diphosphoglycerate)

E:Decreased hydrogen ions

Answer 122

decreased pH

Right shift of the oxyhaemoglobin dissociation curve is caused by acidosis (reduced pH or increased hydrogen ion concentration), increased CO2, increased concentration of 2, 3-DPG and increased temperature. The opposite changes result in a left shift of the oxyhaemoglobin dissociation curve

Question 123

what is the most likely cause:
24 with schizophrenia brought into hospital by the police v agitated. he is given 5mg haloperidol and becomes calmer but an hour later he begins screaming and complains of a severely sore back and neck which he cannot move

Answer 123

acute dystonic reaction

is an EPSE that occurs within hours of antipsychotic administration

Question 124

what is the most likely cause:

55 on olanzapine for schizoaffective disorder has MI

Answer 124

metabolic syndrome

Question 125

what should you assess before starting the COCP

Answer 125

BP and BMI

Question 126

what blood test should be done prior to initiation of lithium carbonate

Answer 126

urea and electrolytes- lithium can cause renal impairment

Question 127

which of these in CI in breastfeeding: 
warfarin 
labetalol
tetracycline
amoxicillin 
amitriptylin

Answer 127

tetracycline (absorbed into breast milk and is CI as can cause dicolouration of the infants teeth)

Question 128

which term describes:
30 y/o women with borderline personality disorder pretends to have seizures so that she can claim disability living allowance

Answer 128

malingering- faking illness for secondary gain

Question 129

which term describes:
30 y/o woman with borderline personality disorder has episodes where she loses consciousness and appears to have a tonic clonic seizure but her EEG is normal

Answer 129

non epileptic seizures

often involve childhood abuse- like Borderline personality disorder

Question 130

diagnosis:
72 y/o man with advanced parkinsons presents v unwell, SOB, cough, pyrexia, reduced O2 saturation. normally he needs thickened fluids due to a poor swallow

Answer 130

aspiration pneumonia

PD affect swallow in advanced stages