Past Paper (No Answer)

8/20/2019 Past Paper (No Answer)

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MBChB Year 4 & 5 Past Papers + Answers

Courtesy of PALI, Tina Bylinski, Sophie Coyle & Hannah Gower

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Question 1: Respiratory

A 42 year old man is admitted to hospital with left sided pleuritic chest pain with

haemoptysis and crepitations in the left base. You suspect he has a diagnosis of

pneumonia. He tells you that 3 months beforehand he was diagnosed as having a

carcinoma of the lung and he has been receiving chemotherapy.

● There are 4 different varieties of malignant lung tumors. lease list 2.

● !ist 4 common presenting symptoms of lung carcinoma.

● "hat would your first line treatment for the community ac#uired pneumonia$

● %ame 2 measures that can used to increase sputum production.

● As part of your investigation you discover that his platelet count in &'. !ist 3 possible

causes.

2


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Question 2: Gastrointestinal/ Hepatic

An (3 year old woman presents with a 2 wee) history of obstructive *aundice. +he has

been diabetic for 2 months and has lost &,g. +he has pale stools and dar) urine.

● "hat 2 initial investigations would your organise$

● "hat are the 2 main diagnoses consider$

● -nvestigations revealed a dilated biliary tree and /0 is planned. %ame 3 potential

complications of this procedure.

● 0ytology reveals malignant cells1 what 3 management options would you li)e to

discuss with the patient$


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A 23 year old asthmatic is brought into the A epartment with an acute

eacerbation. He has become increasingly short of breath over the last three wee)s.

You ma)e a diagnosis of acute asthma attac).

● 5ive 2 clinical factors you would wish to establish in the history from this patient inorder to assess the severity of her attac).

● 5ive 4 clinical factors you should establish in the eamination of the patient in order

to assess the severity of her attac).

! "hat immediate investigations might usually be performed in A and what

abnormality in each would cause you concern. !ist three"

● "hat 3 categories of treatment would consider for this patient$

#


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Question 4: Infection

An 6( year old university student is seen by his 5 with a 24 hour history of flu li)e

illness7 fever headache and nec) stiffness. He is noted to have a progressively

purpuric rash. There are no )nown drug allergies.

● "hat is the most li)ely diagnosis$

● 5ive 2 eamples of appropriate antibiotics which should be administered immediately

by the 5 and which route$

● How might a positive microbiological diagnosis be made$ +uggest 4 tests7

● %ame 2 public health implications of the suspected diagnosis$

● "hat is the main limitation of the currently available vaccine for this condition$

$


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Question 5: Orthopaedics/ M!

A 8( year old lady underwent total hip replacement for osteoarthritis of the left hp. The

operative procedure was uneventful. +he has increasing pain and swelling in her calf 3

days following surgery. 0linical eamination revealed swelling of the left leg and foot

but there is no colour change.

● "hat is the diagnosis$

● %ame any important causes in the lady9s case.

● "hat are the 3 factors which influence venous thrombosis7 )nown as :irchow9s triad$

● %ame any 2 prophylactic measures that are recommended to prevent this problem

after total hip replacement.

● "hat is the worst complication that can result from this problem$

%


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Question 6: ♀ Breast

A '& year old teacher is seen in the breast clinic. +he has been aware of a mass in her

left breast for 2 wee)s. +he is worried about cancer.

● "hat clinical features may suggest that the lesion may be malignant$ !ist 3.

● %ame 2 investigations which will help establish the diagnosis of breast carcinoma.

● %ame 2 main surgical approaches to treating breast carcinoma.

● !ist 3 pieces of code histological information re#uired from the pathologist that will be

needed by the oncology team to decide further treatment.


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Question ": #eurolo$y

While working as a FYI on a medical ward you are asked to asses Mr FK,

a ! year old woman who was admitted to hos"ital one week "re#iously

with a sudden onset o$ weakness in the right arm and leg% &n

e'amination you con(rm the weakness and also (nd that the muscle

tone in the right arm and leg is increased% )ensation is * on the rightside +lthough )he can talk, she sometimes has diculty (nding the

words she wants%

● "hat changes do you epect in the tendon reflees on the right leg$

● "hat is the mechanism of this alteration to the reflees$

● "hat do you epect the right plantar refle to be$

● "hich cranial n. is the most li)ely one to be affected$

● "hat visual field abnormality might you epect to find on eamination$

;ver the net 24 hours the patient


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(


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Question %: #eurolo$y

A 8( year old man presents to the medical clinic. He describes a several year history

of gradually reducing mobility and failure to cope at home. You eamine the patient7

and diagnose ar)insonism.

● "hat are the cardinal features of ar)insonism on eamination$

● %ame 3 possible causes of ar)insonism.

● You decide to treat the ar)insonism with opamine agonists. Apart from nausea and

5- upsets7 list 2 common side effects of treatment using !?;A.

● How can these side effects be minimised$

● %ame 2 other drugs used to treat ar)insonism.

1)


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Question &: Gastrointestinal/ Hepatic

@rs /.+. is a &' year old7 previously well7 woman who has been admitted to hospital

under your care as an emergency with a history of two hours of severe upper

abdominal pain and vomiting. ;n eamination she is obviously distressed with a

tachycardia but is otherwise hemodynamically stable. The abdomen is tender with

guarding in the upper part. owel sounds are diminished. There are no other relevantfindings.

● !ist 3 important li)ely diagnoses.

● "hat )ey early investigations may help you resolve the differential diagnosis$ !ist 3.

● After the patient9s initial assessment7 but before definitive treatment7 what 4 urgent

measures would you institute$

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Question 1': Gastrointestinal/ Hepatic

A 3B year old woman is admitted to the medical ward from the 59s surgery with a 2

hour history of vomiting fresh blood. +he is pale with cold peripheries. ulse 62CDmin7

(CD48 mmHg. Her breathing is satisfactory.

● !ist 3 common causes of severe upper 5- blood loss.

As the EY6 you ta)e 2C mls of blood and re#uest a cross?match7 blood count7

electrolytes and clotting studies. You also ta)e a brief history and perform a clinical

eamination.

● Apart from the above7 suggest 4 steps you would ta)e in your initial management of

this patient in the first 6' minutes after arrival on the ward.

● ;nce the patient is stable7 list 3 monitoring instructions that you would as) the nursesto carry out on the patient9s behalf.

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A &C year old man presents with a recent history of rectal bleeding and a change in

bowel habits so that he is now more constipated than usual. He has no past medical

or surgical history and rectal eamination reveals a hard mass 8 cm from the anal

verge.


● 5ive 4 other possible causes of rectal bleeding in a &C year old man.

● "hat urgent investigation is re#uired to confirm your li)ely diagnosis$

● -f the li)ely diagnosis is confirmed7 suggest 4 additional investigations which you

would li)e to underta)e and give a short reason for each.

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Question 12: #eurolo$y

An (6 year old woman is found collapsed on her bedroom floor by the sheltered

housing warden the day after a trip to her bingo. A 0T scan of the brain reveals an

area of ischaemia in the left parietal corte7 consistent with a recent cerebral infarct.

+he is badly bruised and has an obvious wea)ness on the right side of her body. +he

is confused and her speech sounds slurred.

● "hat is the definition of a stro)e$

A rapi*ly *e+elopin fo-al neuroloi-al *efi-it of +as-ular oriin lastin o+er 2# hours or

resultin in *eath"

! +uggest 4 ris) factors for stro)e"

↑ age

hypertension

atheros-lerosis

aneurys.s

A/

0

s.okin

Pre+ious TIAstroke

3CP use

-oaulopathy

se*entary lifestyle

hyper-holesterolae.ia

↑ Ht

-o-aine use

4

asian *es-ent

● A 0T scan of the brain reveals an area of ischaemia. plain the pathogenesis of this

cause of stro)e.

5arrowin6 5arrowin of the supplyin 7loo* +essels 8thro.7us or e.7olus9 -auses re*u-e*

7loo* flow 8an* thus o:yen an* lu-ose9 to an area of the 7rain

Penu.7ra6 There is a -entral area of ne-rosis surroun*e* 7y a penu.7ra that .ay 7e

sal+aea7le if 7loo* supply is reesta7lishe*

Is-he.i- Cas-a*e6 The is-hae.i- -as-a*e is initiate* -ausin infla..ation an* oe*e.a

that results in tissue *a.ae

0estru-ti+e ;n


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Aspiration pneu.onia

0=TP; *ue to i..o7ility

Co..uni-ation *iffi-ulties *ue to *ysphasia an* *ysarthria

0epression

Be* sores *ue to i..o7ility

This patient shows minimal improvement over the net three months.

● ;utline 2 management options that the ;T would be able to help with in cases li)e

this.

Ho.e assess.ent an* a*aptations where appropriate

Physi-al an* -oniti+e *efi-it s-reen an* pro+ision of ai*s where nee*e*

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A 3' year old manual labourer was lifting a heavy bo two wee)s ago when he noticed

sudden sharp low bac) pain. The pain increases on coughing or sneeFing and radiates

to his left leg and down to his toes. He has numbness of the dorsum of the left foot

and cannot etend his toes. Eorward fleion of lumbar spine is mar)edly restricted.

You suspect a prolapsed intervertebral disc.

● Erom the history and signs7 which disc would be involved and which nerve root is

being compressed$

L$

● "hat abnormality would you epect to see when eamining this patient9s )nee and

an)le reflees$

Both woul* 7e present

The ankle refle: is -ontrolle* 7y S1 so woul* only 7e lost 7y lesion there

The knee >erk is .ainly -ontrolle* 7y L# so woul* only 7e lost 7y a lesion there

● "hat 2 sign and symptom combinations might suggest a central disc prolapse$

Bilateral Le Pain ?eakness

@rinary etention In-ontinen-e

Perianal Perineal Sensory Loss

e*u-e* Anal Tone

● "ith the patient in a supine position7 what test would you perform to help establish

the diagnosis and what would this show$

Test → Straight leg raise

Result → Limitation of straight leg raising with ‘sciatica’ pain radiating down the

buttock and lower limb

● %ame 3 drugs used for initial treatment of this patient.

5SAI0s topi-al oral e i7uprofen

-o-o*a.ol if es-alation of analesia

para-eta.ol

a7apentin if n" pain

● "hich investigation might you consider to confirm the diagnosis$

I Lu.7osa-ral spine

● "hat can paramedical staff offer to support treatment in this condition$

Beha+ioural therapy

3--upational T D -an et E7a-k s-hoolsF in o--upational settin

Physiotherapy D stayin a-ti+e re-o..en*e*

● "hat surgical treatment could be considered$

*is-e-to.y

● -n G'C words define what surgical treatment is appropriate and eplain what

proportion of patients are li)ely to re#uire surgery.

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0is-e-to.y is the suri-al re.o+al of herniate* *is- .aterial that presses on a ner+e root"

i-ro*is-e-to.y is a .ini.ally in+asi+e pro-e*ure in whi-h a portion of a herniate* nu-leus

pulposus is re.o+e* 7y laser while usin a .i-ros-ope"

() resol+e at ' weeks with analesia" 1 year out-o.es are the sa.e in those who are

.anae* -onser+ati+ely an* those who et surery" Therefore only 1) of patients re-ei+e

surery" Also surery intensi+e e:er-ise prora..e lea*s to sinifi-antly i.pro+e*fun-tional status an* faster return to nor.al"

● %ame 2 local complications of surgical treatment.

elie+e* s-iati-a 7ut -ontinuin 7a-k pain

5er+e *a.ae

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Question 14: (ndocrinolo$y

A 4& year old medical secretary is seen in clinic complaining of weight loss7 sweating

and palpitations. +he has no previous relevant history. ;n eamination you detect a

symmetrically enlarged thyroid gland.

-nvestigations reveal a T4 of &' nmol !?6 reference range 6C?2' nmol !?6I and T+H GC.C6 Jmol!?6 reference range C.2?' Jmol!?6I.

● "hat is the most li)ely pathological mechanism causing thyrotoicosis in this

instance$

Graes’ !isease → "utoimmune condition resulting in production of #gG TSH

Receptor

"utoantibodies → oerstimulation of th$roid hormone

● %ame ( other signs you might detect on eamination.

/ine tre.or Pal.ar erythe.awar., sweaty han*s

Ta-hy-ar*ia 8.ay 7e irreular if A/9

Li* retra-tion

Li* la

;:ophthal.os

Ta-hy-ar*ia

● Apart from beta?bloc)ers7 list 2 drugs that are commonly used for medical

management of thyrotoicosis.

Car7i.a


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An 6( year old +ociology student presents to Accident and mergency with witnessed

episodes of arm and leg *er)ing. Although he is maintaining his airway without

assistance7 he is drowsy but responds to commands and you suspect he is post ictal.

His girlfriend states that he had a nonspecific viral illness for two days prior to

presentation but he is not on medication7 and has no past medical history.

● Apart from infection7 suggest 8 possible causes for his seiFures.

epilepsy

al-ohol

su7stan-e a7use

tu.ors 8SoL9

Trau.a 8HI9

Hypoly-e.ia

Hyponatre.ia

Stroke

Hypo:ia

Syn-ope

He remains drowsy and appears to have increased tone in his left arm with bris)

reflees but assessment of airway breathing and circulation shows no abnormality. He

doesn9t let you switch on the light7 and his nec) is very stiff. %urse mentions his

temperature is 3(.&o0. You suspect he has developed bacterial meningitis.

● "hat action should be ta)en immediately$

I= anti7ioti-s 8in a*ults Ceftria:one 29

● Aside from routine blood tests E07 K7 !ETsI7 list 3 other parts of your

management plan including treatment and investigationsI.

CT Brain 5o LP *ue to possi7le raise* ICP D in*i-ate* 7y sei


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Question 1): Gastrointestinal/ Hepatic

A 2' year old accountant is admitted as an emergency under your care with a one

wee) history diarrhoea with blood through the stool. He has no previous relevant

history. Abdominal eamination is unremar)able.

● %ame 3 common causes of these symptoms.

CrohnFs 0isease

@l-erati+e ColitisInfe-tious Colitis

! "hat investigations could help clarify the diagnosis and its underlying cause$ %ame

3"

A rule out any .asses, fae-al loa*in

Colonos-opy in+estiation lower GI tra-t

Biopsy histoloy *eter.ine presen-e of -olitis

● iopsies suggest mucosal inflammation with crypt abscesses. "hat is the most li)ely

diagnosis$CrohnFs *isease

● "hich classes of drug might be used in treating this condition$ %ame two.

$ASA

oral steroi* therapy #). 30 then taper *own to a 7alan-e 7etween sy.pto.s & lowest

*ose 7efore relapse

● -f the patient deteriorates despite drug treatment7 what urgent operation might be

appropriate$

-ole-to.y

2)


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Question 1": Gastrointestinal/ Hepatic

A 2( year old man presents with a two month history of increasingly fre#uent bowel

actions. He has been gradually losing weight. There is no relevant past medical

history. amination reveals a '')g man of normal height who loo)s pale and anious.

There are no abnormal abdominal findings.

! "hat additional history is it important to obtain from the patient at this stage$ !ist 4

items.

presen-e of P 7loo*any skin -hanes 8pyo*er.a anrenosu., erythe.a no*osu.9freJuen-y of stool .otionsany nausea +o.itin hae.ate.esisany u+eitis, iritis, -on>un-ti+itisany PH: spon*yloarthropathiesan$ s$stemic features% So&' ↑(c' night sweats' )g *' loss of appetite' thirst+any /H:6 luten enteropathy -oelia- *isease, IB0 8CrohnFs, @l-erati+e Colitis9, CC, /AP,H5PCCany re-ent tra+el any unwell -onta-tsany HI= risk fa-tors

! As the patient9s 5eneral ractitioner you would li)e to perform some simple

investigations before considering referral for a specialist opinionI. !ist 2.

0iital e-tal ;:a.

Bloo* tests K /BC, ;S, CP

Coelia- s-reen

/ae-al -alprote-tin

Stool Culture i-ros-opy & C"0iffi-ile test

3+a & Parasite ;:a.Thyroi* /un-tion Tests

@&;s *eree of *ehy*ration

HI= test

C;A le+el 8unlikely in youner patients 7ut if /H:9

! The patient as)s why he might be losing weight and you wonder about malabsorption.

5ive two tests that could help you identify whether the patient is suffering from

malabsorption.

=ita.in B12 seru. le+el

/olate & /erritin le+elsI5

! You decide to re#uest a +pecialist opinion. Your local 5astroenterologist arranges a

gastroscopy and a duodenal biopsy reveals flattening and irregularity of the villous

architecture7 crypt hyperplasia and raised numbers of intraepithelial lymphocytes.

"hat is the most li)ely diagnosis in this case$

Celia- 0isease

! "hat blood tests can be used to test for this condition$

seru. IA le+el, as a7out 2 of -oelia- *isease patients are IA*efi-ient

IG antiTTG an*or IG ;A if IA *efi-ien-y is -onfir.e*

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Question 1%: *ardio+ascular

A 32 year old woman7 who is a )nown alcoholic and abuser of intravenous drugs7

presents to Accident mergency complaining of gradual onset of malaise7 fever7

weight loss and night sweats. +he is pyreial 3(.' o0I. +he has a pansystolic murmur

which is thought to be a new finding and you suspect she has a diagnosis of infective

endocarditis.

● %ame 4 additional clinical signs that may be found on eamination in this patient.

ur.ur

Anae.ia

A7s-ess

Clu77in

oth Spots

3slerFs 5o*es

Splinter Hae.orrhaes

Spleno.ealyanewayFs Lesions

Hae.aturia

Pete-hiae

● %ame the 2 most li)ely organisms to be implicated in infective endocarditis.

strepto-o--us +iri*ans

staphylo-o--us aureus

● Your EY2 as)s you to test the urine. "hat would you epect to find and what is the

pathology behind this abnormality$hae.aturia lo.erulonephritis or renal infar-t

;n further eamination you can also hear the pansystolic murmur. This is loudest at

the left sternal edge and you demonstrate her L: is elevated with giant Mv9 waves. -n

addition she also has tender pulsatile hepatomegaly.

● "hat is the most li)ely cardiac lesion to be responsible for this7 given the above

history and eamination$

tri-uspi* reuritation

● %ame 2 investigations that are mandatory to confirm the clinical diagnosis of infective

endocarditis.

7loo* -ultures sets at *ifferent ti.es fro. *ifferent pla-es

TT; ;-ho *e.onstratin +eetation on affe-te* +al+es

! ;ther than intravenous drug abuse7 name 4 other ris) factors for infective

endocarditis.

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0ental Surery

Prostheti- Heart =al+e

Thora-oto.y

Pree:istin =al+ular 0isease i"e" heu.ati-, Conenital, A-Juire*

Catheterisation

PeripheralCentral Lines

I..unosuppression

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Question 1&: *ardio+ascular

A &2?year old lady has been treated for mild heart failure for a number of years. +he is

admitted to hospital as an emergency one night with a 4( hour history of worsening

shortness of breath. ;n eamination you find her to be severely unwell7 coughing pin)

frothy sputum7 with a mar)ed tachycardia and profuse fine crac)les at both lung

bases. %o murmurs are audible. You ma)e a rapid initial diagnosis of left ventricularfailure.

● "hat 2 immediate interventions would you ma)e$

sit her up

i+e 1)) 32 throuh fa-e.ask

! %ame 2 drugs which may be helpful.

thia


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Question 2': #eurolo$y

@rs /+ is an active &C year old woman with atrial fibrillation. As the EY6 you see her

when she attends the mergency epartment with a complaint of loss of vision in the

left eye7 unaccompanied by pain. +he thin)s she may have had previous episodes that

recovered and that the symptoms came on over a period of less than 3C minutes. +he

has not eperienced associated headaches.

● "hat is the most li)ely cause of these symptoms$

retinal a o--lusion

● %ame 2 other causes of sudden loss of vision in one eye

etinal Artery 3--lusion (Sudden)

etinal =ein 3--lusion (Sudden)

etinal 0eta-h.ent (Sudden)

3pti- 5europathy (esp. non-arteritic ischaemic ON which causes sudden painless loss of

VA)

0ia7eti- etinopathy (vitreous haemorrhage would cause sudden loss, but most retinopath

causes gradual loss)

● "hat 2 points from the history7 as given above7 help you to distinguish between the

possible causes of vision loss in this patient$

a7sen-e of hea*a-he typi-al presentation of GCA typi-ally in+ol+es hea*a-he

lastin un*er ) .inutes narrows *ifferential, +as-ular -ause .ore likely

", -. ↑ risk of retinal a/ occlusion due to embolus

● "hat features of the ophthalmic eamination would be important for you to note in

this patient$ !ist 4 points

threa*like arterioles

pro.inent fo+ea 8-herry re* spot at .a-ka9

pallor fun*us

* isual acuit$ 0123245

afferent pupil *efe-t

-attle tru-kin in retinal arterioles 8se.entation of 7loo* -olu.n in the arterioles9

● "hat investigation would you perform with regard to the carotid artery$

CT anioraphy atheros-lerosti- plaJues, stenosis

2$


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Question -.: / 01

A 8B year old man presents to mergency epartment with severe lumbar bac) pain7

which has been increasing for some months. There is no history of in*ury. He has not

seen a doctor for many years. There are no neurological symptoms. A spinal N?ray

reveals multiple sclerotic lesions in the lumbar spine suggestive of metastatic

prostatic cancer.

! !ist 2 investigations you would wish to carry out to investigate the prostate

enlargement.

PSA

Transre-tal @SSui*e* Biopsy

● !ist 2 investigations you would wish to carry out to investigate the degree of

metastasis.

Staging → 6T 6hest3"bdo37elis

&one scan → look speci8call$ for other bon$ metastases

!rostascint scan to loo" for soft-tissue metastases is NO# a valid answer as it is ver rarel

done

● "hat is the most common type of malignant tumour occurring in the prostate gland$

a*eno-ar-ino.a

! The diagnosis is confirmed and the patient is deemed unsuitable for lumbar spine

surgery. "hat other treatment options should be considered for this patient$ !ist

three.

"ndrogen "blation → Hormonal 0GnRH Receptor "ntagonists or Surgical e/g/

orchidectom$5

Palliati+e Che.otherapy

Palliati+e a*iotherapy to 7ony .etastases 8e:ternal 7ea.9

● plain the difference between stage and grade in the pathologicalDclinical

assessment of malignant tumours.

ra*e refle-ts the *eree of .itoti- a7nor.alities *ete-te* within the -an-erous -ells

stae is a refle-tion of a nu.7er of pronosti- risk fa-tors that refle-t patient out-o.es in

ter.s of .ortality an* .or7i*ity e sprea* 8T59

2%


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A &' year old man is admitted as an emergency under your care with a one?day history

of severe generalised abdominal pain. He has no previous relevant history. ;n

eamination he is shoc)ed and distressed. His abdomen is rigid7 diffusely tender and

silent and a chest N?ray suggests free intraperitoneal air.


sepsis 2N to 7owel perforation

● %ame 3 potential causes of this condition.

-onstipation

*i+erti-ulitis

.ural .alinan-y

● "hat initial therapeutic measures should be instituted$ %ame 3I

sepsis % *epen*in on whether o7ser+ations in*i-ate likelihoo*

5GT if o7stru-tion suspe-te*

ABC0; approa-h

analesia 1. Para-eta.ol 3 P5 8O#.9

suri-al re+iew *is-uss *ianosti- laparoto.y

! "hat investigation might you re#uest to support your clinical diagnosis$

CT s-an a7*o.en *ete-t perforation of 7owel

! The patient underwent a laparotomy. "hat aims would surgery attempt to achieve$

%ame 2I

-lose perforation, 7owel washout an* restore 7owel fun-tiona7ility

assess the presen-e of any -ontri7utin fa-tors e .alinan-y

2


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A 3(?year old man presents to the ;rthopaedic ;utpatient 0linic with a si month

history of pain in the right groin. amination reveals mild restriction of right hip

movements in all directions. You suspect avascular necrosis of the femoral head.

● %ame 2 common causes of avascular necrosis of femoral head.Trau.a

i*iopathi- espe-ially .i**le ae* .en affe-tin hips & knees

! %ame any 3 investigations in the diagnosis and evaluation of avascular necrosis of the

femoral head.

Both hips assess se+erity of *a.ae, any other patholoy, whether the left >oint is also

affe-te*

● %ame 2 other areas of the s)eleton that may be affected by a traumatic avascular

necrosis.

pro:i.al pole of s-aphoi* 7one

7o*y of talus

● "hat is an early radiological feature of hip avascular necrosis$

none

tra7e-ulae with s-lerosis

osteolysis areas

● "hat is a late radiological manifestation of hip avascular necrosis$

-res-ent sin

osteo-hon*ral fra-ture

flattenin of fe.oral hea*

● "hat surgical procedure is recommended in the late stage of the disease$

arthroplasty

2'


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A 82 year old housewife7 who has never wor)ed outside the home7 has a history of

four months weight loss and more recently breathlessness. You are wor)ing as a EY6

on the admissions unit. ;n eamination of the chest she has an area of right?sided

dullness to percussion.

! You consider that this is a pleural effusion. "hat would you epect to see on a plain

chest N?ray$ 5ive 2 featuresI

7luntin of -ostophreni- anles

opaJue -onsoli*ation in riht he.ithora: with -on-a+e .enis-us sin

● You consider performing a diagnostic aspiration. "hat additional imaging

investigation would be of use prior to the aspiration$

@ltrasoun* 8pleural9

● You proceed with the pleural aspiration. "hat position should the patient ideally adopt

in order to perform the aspiration$

on the 7e*, slihtly rotate* with ar. on the affe-te* si*e ele+ate* in or*er to e:pose the

a:illary area

● "hat 3 main diagnoses would you consider$

pleural effusion

hae.othora:

e.pye.a

● "hen you withdraw the fluid with a diagnostic tap it is clear and has a yellow

colouration. "hat 3 important investigations would you re#uest and why$

L!H and 7rotein in 7leural ,luid3Serum → determine whether e9usion is e:udate

or transudate

;9usion 6$tolog$ → to inestigate possible concerns of malignanc$

Glucose or pH of ;9usion → inestigate possible malignanc$ 0both should be low5

Her husband comes into the ward to see you.

● He tells you that he wor)ed in the shipyards for 2' years before he retired. "hy would

this be relevant$

His wife ma$ hae been e:posed to asbestos through him → increased risk ofpleural mesothelioma

2(


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Question 25: Hae,atolo$y

You are on cover for a surgical ward when you are called to @rs @c0ulloch7 who has

*ust commenced a blood transfusion for a low postoperative haemoglobin. Three

minutes after the start of the transfusion the patient develops lumbar pains7 rigors7

dyspnoea and hypotension.

● "hat is the name of this complication of the transfusion$

A-ute Hae.olyti- Transfusion ea-tion

● "hat is the most li)ely procedural reason for this complication to have arisen$

.is.at-hin of *onor 7loo* roup to that of the patientFs AB3 in-o.pati7ility

● %ame 2 immediate steps that need to be ta)en.

stop 7loo* transfusion & infor. the hospital Transfusion La7oratory

Take a post transfusion sa.ple fro. patient & sen* to Transfusion La7oratory

● !ist 3 treatments that the patient might then urgently re#uire.

Meep I= line open with saline )"(

Gi+e hih flow o:yen & I= flui* support

onitor urine output an* if falls 7elow 1)) .lhr pro+i*e furose.i*e #)'). I= infusion with

)"( saline

Pro+i*e inotropi- support *opa.ine 2$.-M.in

steroi*s

a*renaline I

-hlorphenira.ine

● "hat might you detect in the urine$

hae.olo7in

● !ist 3 further short term complications of blood transfusions.

Transfusion relate* ALI

/e7rile nonhae.olyti- rea-tion

alleri- & anaphyla-ti- rea-tion

)


31/170

Question 2): -rolo$y

A twenty?four year old woman is admitted with a history of acute pain in the left loin7

radiating to the groin. +he has dysuria and rigors and a temperature which is

measured at 4C.'O centigrade. ;n eamination she is acutely tender in the left renal

angle7 where palpation demonstrates an obvious renal mass.

● "hat is the li)ely diagnosis$

pyelonephritis

● %ame one aspect of the initial management

analesia para-eta.ol 1. 3 P5 8O#. *aily9

Anti7ioti-s

I= /lui*s

● 5ive 2 abdominal investigations which would help elucidate the cause of the mass.

Renal uids → ↑ risk of infection → sepsis

?bstruction → builds pressure → feedback pressure to kidne$ → chronic kidne$

damage

● 5ive 2 methods by which )idney stones may be managed.

6onseratie → analgesia 0=S"#!s 3 @orphine5' >uids' tamsulosin' nifedapine

Surgical → shock wae lithotrips$' laser probes' ureteroscopic lithotrips$' openlithotom$

1


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A &4 year old woman presents with severe pain in her left iliac fossa. +he is febrile7

has a tachycardia and her white cell count is raised.

● "hat systemic clinical syndrome is present as a result of the abdominal problem$

Syste.i- Infla..atory esponse Syn*ro.e 8SIS9

;n eamination there is peritonism localised to the left iliac fossa

● !ist 3 important differential diagnoses

A-ute 0i+erti-ulitis

Lo-ally Perforate* Si.oi* Car-ino.a

Infla..atory Bowel 0isease

Is-hae.i- Colitis

Leakin AAA

Si.oi* =ol+ulus

Pyelonephritis

● !ist 4 differential components of your initial management for this patient

Assess nee* for resus-itation usin ABC0;

Analesia

Bowel est i"e" 5il 7y outh I= flui*s

I= 7roa* spe-tru. anti7ioti-s as per lo-al ui*elines

● "hat single investigation could best clarify the diagnosis$

A7*o.inal CT with Contrast

● The following morning her signs have progressed and she has generalised peritonitis.

At laparotomy the sigmoid colon is found to be the cause of her peritonitis. "hat

operative procedure is indicated$

Hart.anFs Pro-e*ure

● !ist 2 features of the pathology of sigmoid diverticular disease.

/alse 0i+erti-ula i"e" herniation of 7owel wall that la-ks outer -oat of us-ularis propria

us-ular Hypertrophy of si.oi*

2


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Question -2: ♀ 01

A 6B year old female attends her 5 with dysuria five days following unprotected

seual intercourse. +he is not on any form of contraception and this was a casual

contact as she is not in a steady relationship at the moment

● %ame 2 seually transmitted infections this patient may have contracted which would

be consistent with these symptoms

-hla.y*ia

onorrhea

.y-oplas.a enitaliu.

tri-ho.onas +ainalis

HS=12

● !ist 2 additional relevant #uestions you would wish to as) the patient.

Has she noticed an$ discharge+ 0thin and water$ or thick3purulent → ST#5

Lower @TI uestions i"e" uren-y, freJuen-y, -lou*y urineoffensi+e s.ellin @rine@pper @TI uestions i"e" loin pain, fe+er, -hills

Any 7loo* in the urine

@se of topi-al hyiene pro*u-ts e"" s-ente* soaps, +ainal sprays et-

Any *yspareunia

Any syste.i- sy.pto.s e"" fe+er

Any PH of @TI

Any post -oital7lee*

If rele+ant, inter.enstrual 7lee*

! !ist 2 relevant eaminations you would wish to underta)e in this patient . "Spe-ulu. ;:a.ination

Bi.anual Palpation of =aina

● !ist 4 relevant investigations you might underta)e


34/170

A*+i-e Q a+oi* se: until testof-ure pro+es infe-tion is one 8pre+ents a--i*ental sprea*9

#


35/170

Question 2&: Respiratory

A 2& year old lady has returned from a holiday in Australia. +he has been admitted to

hospital with severe left?sided pleuritic chest pain and a haemoptysis. +he complains

of shortness of breath is cyanosed and tachycardic.

● "hat would be the most important radiological investigation to carry out in themergency epartment and why$

C e:-lu*e tension pneu.othora:

Her arterial blood gases are as followsP

Q p;2 &.2 normal range 6C.'?64IQ p0;2 3.C normal range 4.&?8IQ h &.3B normal range &.3&?&.42IQ icarbonate 2C

● "hat 4 investigations would you perform at this stage to help you with your further

elucidation of this patient9s problems and why$0*i.er if neati+e e:-lu*es likelihoo* of =T;

0oppler @ltrasoun* Lower Li.7 e:-lu*e =T;

Lun /un-tion Tests in*i-ate presen-e of o7stru-ti+erestri-ti+e *isease

,&6 A 6R7 - ↑ 6R7 A ↑ F66 indicate infectious process

● %ame 3 forms of treatment that you would prescribe while you are waiting for the

results to come bac)

analesia .orphine for -hest pain

↑ ,low 0l3min5 ↑ concentration 0IJK5 o:$gen therap$ ia nasal mask

I= /lui*s e 2$) .L saline )"(

● "hat would the most important diagnosis be to eclude in this lady9s instance$

P;

● "hich investigation would you use to confirm this diagnosis and what would it show$

CTPA o--lusion on pul.onary +as-ulature *istally threa*like +essels

$


36/170

Question 3': Geriatrics

An (2?year old lady is admitted to the mergency epartment after recurrent falls at

home. +he has attended your clinic with a previous history of hypothyroidism7

ar)inson9s isease and hypertension. Her drug therapy includes @adopar7

Thyroine7 endrofluaFide and %itraFepam at night. ;n eamination there are no acute

neurological findings7 her pulse is (C beatsDminute and regular7 blood pressure is638D(2 in a lying position and 6C2D8C when standing.

! !ist 3 possible causes of a fall in this lady9s case.

polyphar.a-y se*atory effe-ts of intera-tions of .ultiple .e*i-ations

postural hypotension

-ere7ellar *ysfun-tion *ue to ParkinsonFs

● !ist 3 changes you would ma)e to her drug therapy and eplain why.

Ben*roflua


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Question 31: -rolo$y

You are wor)ing as a EY6 on a surgical ward when a 'C year old man7 who has

previously en*oyed good general health7 presents to outpatients with a clear history of

painless haematuria7 without fre#uency or dysuria. Abdominal eamination reveals

bilateral palpable )idneys and a marginally elevated blood pressure. You suspect he

has polycystic disease of the )idneys.

● "hat other causes of painless haematuria are important to eclude in this instance$

!ist 4

prostati- -an-er

7enin prostate hyperplasia

renal stone *isease

7la**er tu.ours

● "hat initial investigations would you li)e to perform at this stage that would help most

with the diagnosis$ !ist 3

A e:-lu*e any a7*o.inal .asses to in*i-ate tu.ors

I= pyelora. e:-lu*e o7stru-tion *ue to renal stone *isease

renal @SS *eter.ine presen-e of poly-ysti- ki*ney *isease

You find bilateral polycystic )idney disease without any other abnormality of the lower

urinary tract. You are concerned about the possibility of renal impairment and wish to

assess the level of renal function more accurately.

! "hat tests are available to do this$ !ist 2.


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An 6( year old student presents with a B day history of persistent sore throat and

general malaise with an episodic fever. +he has now developed a widespread

erythematous rash. Three days ago she started ta)ing ampicillin capsules she had at

home7 left over from a previous illness.

● You suspect a diagnosis of infectious mononucleosis. !ist 2 abnormalities of a full

blood count that would support your diagnosis.

Ly.pho-ytosis

.ononu-leosis -ells 8atypi-al a-ti+ate* T -ells9

anae.ia

thro.7o-ytopenia

● 5ive 4 clinical signs you may find on eamination.

spleno.ealy

pete-hial hae.orrhaes -o+erin of soft palate

whitish e:u*ate -o+erin tonsils

ly.pha*enopathy

hepato.ealy

fe+er

● "hat is the causative organism for this condition$

;pstein Barr =irus

● "hat is the mode of transmission for this condition$

Sali+ary e:-hane e kissin

● "hat test would confirm your diagnosis$

onospot Test

● 5ive 4 complications of this disease.

Post=iral Chroni- /atiue Syn*ro.e

Spleni- upture 8esp if enain in -onta-t sports9

Guillain Barre Syn*ro.e

en-ephalitis

.eninitis

Cranial lesionsse+ere upper airway o7stru-tion

hepatitis

● "hat is the management of this condition$

supporti+e analesia, oral rehy*ration, stop anti7ioti-s

'


39/170


A 36 year old woman attends as an elective outpatient with a three?month history of

rectal bleeding and anal pain.

● -s this patient li)ely or unli)ely to have rectal cancer$

unlikely O$)yrs

● After ta)ing a full history7 what assessment would you underta)e in the clinic$ %ame

3I

0iital e-tal ;:a.ination assessin anal tone, presen-e of .ass,

GI e:a.ination assessin palpa7le .asses, other -auses

/e-al 3--ult Bloo* Test presen-e of 7loo*

● After appropriate assessment7 a diagnosis of haemorrhoids is made. "hat therapeutic

choices would you discuss with the patient$ %ame 3I

topi-al li*o-aine sy.pto.ati- relief

ru77er 7an* liation

in>e-tion s-lerotherapy

● "hat feature in the patient9s history would be the most important guide to choosing

an appropriate treatment$

whether there is any pain in*i-atin likelihoo* of stranulation

● %ame one condition which may predispose to the development of haemorrhoids.

o7esity

● %ame another common cause of rectal bleeding with anal pain in young adults.

* 8bre diet causing constipation leading to straining upon opening of bowels

(


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A 3( year old aid wor)er7 while on the flight home from +outh America7 has developed

cramping abdominal pain and profuse diarrhoea. You thin) he may have developed

cholera.

● !ist 2 clinical features which may occur as a result of the profuse diarrhoea that iscaused by cholera.

deh$dration - * skin turgor' sunken orbits' postural h$potension' confusion'

weight loss' oliguria

ele-trolyte *istur7an-e

sho-k

● 5iven the history of travel7 list 4 other organisms that should be loo)ed for as possible

causes of the diarrhoeal illness.

;nteroto:i- ;" Coli

Sal.onella

Ca.pylo7a-ter

Giar*ia

;nta.oe7a histolyti-a

Shiella

Cryptospori*iu.

ota+irus

5oro+irus

Plas.o*iu. /al-ipariu.

● "hat organism causes cholera and how does the disease result following infection$

Ba-teria =i7rio Cholera 8ra. neati+e ro*s9 K -lini-al features *ue to enteroto:in release

#t secretes an enteroto:in which stimulates aden$l$l c$clase that ↑ the

concentration of c$clic "@7 leading to persistent and e:cessie secretion of >uids

and electrol$tes/

● -ntravenous fluid replacement is essential in cholera infections. Apart from the water

replacement7 name the 2 most important constituents in the -: replacement fluid that

will help correct the se#uelae of the profuse diarrhoea.

So*iu. & Glu-ose

!ali suggest '&O- and but the *+emplar answers are the ones used above.

● "hat advice should be given to travellers to avoid diarrhoeal illness$

C0C $ 7asi- -holera pre+ention .essaes6

0rink an* use safe water 8i"e" seale* 7ottle water9

?ash han*s often with soap an* safe water

@se latrines or 7ury your fae-es *o not *efe-ate in any 7o*y of water

Cook foo* well 8Boil it, -ook it, peel it, or foret it"U9

Clean up safely in the kit-hen

Note A vaccine for cholera is available however, it confers onl brief and incompleteimmunit and is not recommended for travellers

#)


41/170

Question 35: *ardio+ascular

An (4 year old woman with well controlled hypertension is admitted after several falls

at home. Her daughter reports that she loo)s pale7 then falls and briefly loses

consciousness. There is no focal wea)ness or abnormal movements. +he ma)es a full

recovery each time.

● Apart from orthostatic posturalI hypotension7 suggest 3 other disorders which are

li)ely causes for these symptoms.

+aso+aal syn-ope

Arrhyth.ias e"" A*a.Stokes Atta-k 8-o.plete heart 7lo-k9, sinus arrest or nonsustaine*

=T

● ;n eamination you find that her blood pressure drops mar)edly on standing up and

she feels faint. +uggest 2 factors which should be considered that might be

aggravating this change.

phar.a-oloi-al therapy she is re-ei+in

antihypertensi+e .e*i-ation

o+er*iuresis

ae

● !ist 2 non?drug measures which may help to control postural hypotension.

A+oi*in rapi* postural -hanes i"e" stan* up slowly

Stayin well hy*rate*

;le+atin the hea* of the 7e* while sleepin 8re*u-es 5o-turia9

● "hat types of drug therapy would you consider prescribing in an effort to alleviate her

symptoms$ +uggest 6.

S$nthetic 6orticosteroid with ↑ @ineralocorticoid action e/g/ ,ludrocortisone

4/Img T!S for B week

! The patient improves on treatment and you plan discharge. "hat other factors will you

consider in your plans$ +uggest 2.

.e*i-ation re+iew

physiotherapy

3T assess.ent

*ieteti- assess.ent foo* & flui*s

#1


42/170

Question 3): Respiratory

A thin7 previously healthy 24 year old man presents to the Accident and mergency

department complaining of sudden onset of left sided pleuritic chest pain and

breathlessness. You suspect a spontaneous pneumothora.

! %ame 3 clinical signs would you epect to find on respiratory system eamination. ↑ resonance

*e-rease* 7reath soun*s

* e:pansion

no +o-al resonan-e ta-tile fre.itus

! %ame 2 groups of patients who are at increased ris) of developing spontaneous

pneumothora$

youn, thin, tall .ales

s.okers

patients affe-te* 7y arfanFs Syn*ro.e

/H: of pneu.othora:

patients with un*erlyin respiratory *isease e asth.a, C3P0, C/, TB

● %ame 2 factors that need to be ta)en into account when considering treatment of

spontaneous pneumothora.

Se+erity of sy.pto.s

Si


43/170

Question 3: / 01

A 24 year old professional cyclist complains of painless left testicular swelling. You

suspect he has a testicular tumour.

● !ist 2 other differential diagnoses of painfulDpainless testicular swelling.

testi-ular torsionepi*i*y.oor-hitis

hae.ato.a

ranulo.atous or-hitis

TB

● %ame 2 other causes of painless scrotal swelling.

hy*ro-ele

epi*i*y.al -yst

+ario-ele

inuinal hernia

● "hat would be the most standard radiological investigation to help with the

diagnosis$

S-rotal @SS

● %ame the 2 common histological types of testicular tumour.

se.ino.as

terato.as

● !ist 2 tumour mar)ers that may be raised.

7eta hu.an -horioni- ona*otrophin

alpha fetoprotein

● %ame 3 treatment options that are available for treating testicular tumour.

ra*i-al or-hi*e-to.y testi-ular prosthesis sper. storae

-he.otherapy if .etastases e pleo.y-in

ra*iotherapy 8e:ternal 7ea.9

#


44/170

Question 3%: Gastrointestinal/ Hepatic

A 23 year old woman comes to see you in your general practice. +he tells you she has

fre#uent episodes of diarrhoea. -nitial eamination reveals that she is short and thin.

Eurther #uestioning discloses that her bowel motions are often pale coloured and foul

smelling. This has been a recurring problem most of her adult life and you suspect

she may have coeliac disease

● !ist 3 conditions that you would include in your differential diagnosis.

-hroni- pan-reatitis

Infla..atory Bowel 0isease 8CrohnFs9

La-tose Intoleran-e

IA *efi-ien-y

Giar*ia Infe-tion

Cysti- /i7rosis

Eurther history reveals no tendency to chest infections. There is no family history of

note. hysical eamination is normal apart from her small stature and thinness.

● !ist 2 investigations that will help to refine your diagnosis.

Bloo*s6 /BC 8Anae.ia fro. .ala7sorption9, ;SCP to e:-lu*e infla..atory -ause

Seroloy6 IA, tissue transluta.inase A7, IA en*o.ysial A7

Stool Test6 Su*an stain to -he-k for steatorrhea

Peripheral Bloo* /il.6 i-ro-yti- Hypo-hro.i- 8/e *efi-ien-y9 *ue to re*u-e* iron

a7sorption

You refer her to a gastroenterologist7 who carries out an endoscopy and duodenal

biopsy. The biopsy report comes bac) as =suggestive of coeliac disease>.

● !ist 2 pathological features that might have been seen on the biopsy.

su7total +illous atrophy

-rypt hyperplasia

● Are typical biopsy appearances diagnostic for coeliac disease$

yes assu.in anti7o*y tests are +e an* patient is not on a self.e*iate* luten free *iet

! How would you suggest this patient should be treated and what investigation would

you suggest after treatment$patient e*u-ation to a+oi* luten *iet

repeat upper GI en*os-opy 7iopsy post%wks luten a7sent *iet whi-h shoul* re+eal

resolution of initial patholoi-al fin*ins

##


45/170

Question 3&: Hae,atolo$y

A 32 year old woman7 who is a mother of four children under aged 8 years7 presents

with increasing fatigue and shortness of breath over recent months. +he has no

significant past medical history.

You find her to be pale withP Hb 8.B gDdl /eference range 66?63 gDdlI7 @0: 83 fl/eference range &(?B8 flI7 @0H 24 pg /eference range 2&?32 pgI

● "hat is the name given to this blood picture$

Hypo-hro.i- .i-ro-yti- anae.ia

● "hat is the most li)ely haematological disorder in this lady$

iron de8cienc$ *hb

● %ame 2 possible significant factors underlying in this patient.

stress .other of four youn -hil*ren, insuffi-ient *iet

.ultiple prenan-ies

V

● "hat arterial p;2 result would you epect$

$1))..H nor.al as 32 -ontent falls in proportion to hae.olo7in

! You eamine the blood report to see if it provides a reticulocyte count. "hat are

reticulocytes$

i..ature enu-leate* 8-ontain r5A9 erythro-ytes for.e* in Bone .arrow

! The reticulocyte count is normal. "hat is the significance of this finding$

It in*i-ates the anae.ia is likely *ue to *ysfun-tional erythropoiesis an* not hae.olyti- in

oriin

;n further #uestioning you learn that her ethnic bac)ground is +outh Asian.

● "hat co?eisting blood condition may this patient have$ How would you test for this$

athalassae.ia

PC assay testin hae.olo7in ele-trophoresis

#$


46/170

Question 4': Orthopaedics/ M!

A &4 year old woman who was admitted to hospital via A having been found on the

floor at home. +he is unable to get up and complains of pain and wea)ness in the right

leg. You suspect a fractured nec) of femur.

● "hat 2 features would you loo) for on inspection of the legs to confirm yourdiagnosis$

iht affe-te* si*e is shortene* & e:ternally rotate* in -o.parison to the left

● The ?ray demonstrates an intra?articular fracture of the right hip. "hat is the

anatomical significance of a fracture at this site$

in+ol+e.ent of the >oint spa-e, *isruption of arti-ular -artilae an* s.ooth arti-ular 7one

surfa-e

Bloo* supply to the fe.oral hea* is in a *istal D pro:i.al fashion"

Site of intra-apsular fra-ture .eans that 7loo* supply to fe.oral hea* is potentially

-o.pro.ise* an* there is a risk of A=5 to the fe.oral hea*

● You are concerned about the diagnosis of osteoporosis in a lady with a previous

fracture. You proceed to underta)e a NA scan. "hich areas are routinely screened

for the presence of osteoporosis$

L1L# Lu.7ar Spine, fe.oral ne-k

● riefly G 3C wordsI describe how the NA scan wor)s.

two : ray 7ea.s with *ifferent enery le+els are ai.e* at the patientWs 7ones

soft tissue a7sorption is su7tra-te* out, the B0 -an 7e *eter.ine* fro. the a7sorption of

ea-h 7ea. 7y 7one"

B0 X total a7sor7e* D a7sor7e* 7y soft tissue

● 5ive 2 drug therapies which may be of benefit in osteoporosis.

alen*roni- a-i* 87isphosphonate9

-al-itriol

● 5iven the above information7 what operation would be most appropriate$

repla-e.ent he.iarthroplasty

● +he ma)es a good recovery from the operation. %ame 2 factors related to her social

situation that you would wish to ta)e into account when planning her discharge.home assessment and suitabilit$ of home enironment considering her * mobilit$

status

nee* for so-ial ser+i-es to help with *aily a-ti+ities

She li+es alone D who will look after her

?hat is her ho.e like D ha


47/170

Question 41: -rolo$y

A 38 year old female presents to her 5 with nocturia7 nausea and generalised pruritis.

+he has a history of enuresis and urinary infection in childhood and five year history

of hypertension. There is no other past history of note. The 5 finds her 6'CDBC

and serum creatinine to be 62CCJmolDl reference range '(? 624JmolDlI. The patient is

then referred to the medical unit where you are wor)ing as a EY6.

You re#uest a number of investigations blood and imagingI.

! 5ive 4 investigations that would help you to determine whether her renal failure was

chronic rather than acute"


48/170

Question 42: #eurolo$y

You are on a 5 attachment when a 24?year old shop assistant comes to see you with

a 3?day history of pain around the right eye7 associated with reduced vision in that

eye. +he is unable to see small ob*ects or distinguish colours. You find that her visual

acuity is 8D38 in the right eye and 8D8 in the left. The right optic disc is swollen and

there is a right afferent pupillary defect. You see in her notes that one year previouslyshe had eperienced an episode of numbness affecting both legs and associated with

urgency of micturition and temporary urinary incontinence. This had all resolved

spontaneously and had been attributed to a =trapped nerve>. You suspect a clinical

diagnosis of multiple sclerosis"

● "hat is the appearance seen in the eye$

swollen opti- *is-

● "hat is an afferent pupillary defect$

*ysfun-tion of pupil .us-ulature i.pa-tin a7ility to -onstri-t or *ilate iris nor.ally

In a ar-us Gunn pupil, there is re*u-e* afferent input an* the pupils fail to -onstri-t fully"

Sti.ulation of the nor.al eye pro*u-es full -onstri-tion in 7oth pupils" I..e*iate su7seJuent

sti.ulus of the affe-te* eye pro*u-es an apparent *ilation in 7oth pupils sin-e the sti.ulus

-arrie* throuh that opti- ner+e is weaker"

● "hat is the immediate cause of the visual loss$ina7ility to -on*u-t efferent sinals fro. the opti- n" to opti- lo7e of -ere7ral -orte: *ue to

neuropathy opti- neuritis

! +uggest 2 investigations that should be underta)en and what results you will epect

from them$

L7 A 6S, anal$sis - detection of intrathecal in>ammation' pleoc$tosis' ↑ protein'

oligoclonal bands

7rain & spinal -or* I with a*oliniu. la7ellin presen-e of plaJues in -orte:, 7rainste.,

spinal -or*

#'


49/170

! The further investigations confirm the diagnosis7 which has already been guessed by

the patient. +he is now well but comes to see you to =tal) things over>. "hat points

will you want to ma)e with regard to prognosis and management$ +uggest 4"

It is usual pra-tise to infor. the patient that there is no -ure for S

There is no .etho* for pre*i-tin the -ourse of S an* there is wi*e +ariation in its se+erity

any S patients li+e selfsuffi-ient li+es, while others are ra+ely *isa7le*

S tea. an* spe-ialise* ser+i-es for onetoone -ounsellin, support, e*u-ation an*infor.ation

Treat.ent6

,or Relapses → 6orticosteroids and #mmunosuppressants

,or S$mptomatic Relief → @uscle Rela:ants 0for spasticit$5 and "nticholinergics

0for tremor5

To * ,reQuenc$ of Relapses → 0e/g/ #=,-E5 but the$ onl$ work in select group of

patients and are limited in their ecac$

● "hat aetiological factors are associated with this condition$ +uggest 2.Genetic → HL"-"' #L-R"' #LIR"' Haing ,irst3Second-degree Relaties with @S'

&eing U

;nironmental → Liing further from the eQuator' Smoking' itamin ! !e8cienc$'

;& #nfection'

#(


50/170

Question 43: (,er$ency Medicine

2C?year old university student is brought into the A epartment by a friend having

ta)en an overdose of paracetamol approimately 2C tablets about ' hours agoI. +he is

fully conscious and cooperative but withdrawn and admits to feeling depressed

recently

● "hat is the most important investigation to underta)e at this stage and why$

Plas.a Para-eta.ol Le+els Con-entration will ui*e .anae.ent

● "hat would you administer orally to reduce the absorption of the paracetamol$

A-ti+ate* Char-oal

! !ist 3 other important investigations that would also be underta)en and why"

6oag Screen → hepatoto:icit$ of paracetamol ma$ impair lier s$nthesis of

clotting factors


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You are on a 5eneral ractice attachment. A '& year old man7 who is an infre#uent

attender but who has smo)ed approimately 2C cigarettes per day for the last 3C

years7 presents with an (?wee) history of difficulty in swallowing. He has been

previously well until his symptoms developed. +ince then the problem has become

progressively worse. The patient denies any symptoms of Mheartburn9. ;n direct

#uestioning he has lost ')g in weight over this time period.

● Apart from carcinoma of the oesophagus7 list 4 recognised conditions which could

cause dysphagia in any patient.

*iffuse oesophaeal spas.

a-halasia

foo* 7olus forein 7o*y

7enin oesophaeal stri-ture

e:ternal -o.pression fro. enlare* thyroi*

G30 K oesophaitis K oesophaeal stri-tureastri- -an-er

C=A stroke

pharyneal pou-h we7 *i+erti-ulu.

-ar-ino.a of 7ron-hus

● 5ive 2 features in any patient9s history which would suggest a malignant cause of the

dysphagia.

Proressi+e *ysphaia

?eiht loss

no PH: of reflu: S:rapi* onset YshortU history

PMH Smoking → NOT the best answer since the question is asking for features

not risk factors

● You decide that the patient9s symptoms merit investigation. "hat 2 )ey investigations

could you re#uest$

3G0 Biopsy of any a7nor.al tissue

Ba Swallow (onl wa of diagnosing functional%motilit problems)

● %ame the 2 main pathological types of oesophageal carcinoma.

a*eno-ar-ino.a

sJua.ous -ar-ino.a

$1


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● The referring consultant considers a surgical resection for this gentleman9s

oesophageal carcinoma. "hat investigation is now important and why would you

underta)e it$

CT 7rain -hest a7*o pel+is 6

stae the *isease

show tu.ors +ol

presen-e of .etastases

to assess appropriateness of rese-tion"

$f not invaded beond submucosa then surger alone is indicated since there is no evidence

of additional significant benefit from concurrent chemoradiotherap. 'owever, if an local

spread beond this then chemoradiotherap is indicated, while the presence of an

metastases would preclude e+cision. Another "e investigation is *ndoluminal S to assess

local invasion.

! +urgical resection proves impossible. "hat 2 courses of action will help to palliate his

symptoms$

en*os-opi- laser surery for lesions O' -. lonoesophaeal stentin with a Celestin tu7e if loner than '-.

Radiotherap$ → either e:ternal beam or brach$therap$ to alleiate d$sphagia

;n*os-opi- A7lation Stentin

?piates → pain relief

&hemotherap alone is not good palliation

$2


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You are a EY6 attending a general surgical outpatient clinic. A 8C year old man

presents with a si month history of intermittent rectal bleeding.

● Apart from rectal carcinoma suggest 3 other li)ely causes for these symptoms.

"natomical → !ierticular !isease' @eckel’s !ierticulum 0more common to presentin children)

ascular → 6olonic "ngiod$splasia

#nfection → #nfectie 6olitis e/g/ 6amp$lobacter' Salmonella' Shigella

"norectal → Haemorrhoids' "nal ,issures

#n>ammator$ &! → with blood more li"el & though both would tpicall present /

012rs

! %ame 3 further features in the history you would see) to support a diagnosis of rectal

carcinoma.

6hange in &owel Habit → ↑ freQuenc$ loose stools A3- mucus passedTenes.us

?eiht Loss

/a.ily History of Colore-tal -an-er 8/AP H5PCC9

7ast @edical Histor$ → #n>ammator$ &!' 7ol$ps or 6olorectal 6ancer

Awareness of ass

● Eurther investigations lead to the resection of a rectal carcinoma. rior to discharge

the patient as)s you about his prognosis. "hat important factors do you need to ta)e

into account in order to determine prognosis$ +uggest 3.

0@M;Fs6

Local Spread i/e/ whether it has penetrated the bowel wall or not 0$es → V22K C-

$r surial5

L$mphatic Spread i/e/ whether there is l$mph node inolement 0$es → VK C-

$r surial5

!istant @etastases i/e/ whether other structures are inoled 0$es → VCK C-$r

surial5

6 Su--ess of surery i"e" if it was -o.pletely or partially rese-te*, Co.or7i*ities

● %ame 2 medical conditions which may predispose patients to rectal carcinoma.

ul-erati+e -olitis -rohnFs *isease

a*eno.atous polypshere*itary polyposis

H5PCC 8Lyn-h Syn*ro.e9

$


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Question 4): *ardio+ascular

A 3B year old Asian man was admitted to the medical admissions unit with pains in his

chest and nec). He admitted to smo)ing 2C cigarettes per day7 and a blood cholesterol

had been measured at &.2mmolDl reference range 3.' R '.C mmolDlI. His average heart

rate on admission was BC beats per minute and his blood pressure was 6&CD6CC

mmHg. An initial diagnosis of unstable angina was made.

● "hat are his ris) factors for coronary artery disease$ !ist 4.

s.okin 2) -iarettes per *ay

Asian ethni-ity

hyperlipi*e.iahyper-holesterole.ia 8"2..olL -holesterol9

Hypertension 81)1))..H9

.ale

● You decide to admit him to hospital. "hat drug therapy could he be started on$ !ist 4

potentially beneficial drugs 2 mar)sI and give a reason for prescribing each 2

mar)sI.

Simastatin C-C4mg nocte ? - * cholesterol mortalit$

6alcium 6hannel &locker3amlodipine - * h$pertension b$ asodilation controls

angina

=itrates3 Gl$cer$l Trinitrate Spra$ 7R= - s$mptomatic relief of angina' * &7 b$

asodilation

@etoprolol B44mg &! - asodilate coronar$ arteries to maintain perfusion and *

ischemic episodes' * &7' HR' controls angina

Aspirin )). 3 7olus K). 3 30 pre+ent platelet areation & a-ti+ation

Clopi*orel ti-arelor (). 3 B0 alternati+e to aspirin an* re*u-es .ortality

Lisinopril Cmg &! -. C-B4mg ?!- * &7 * mortalit$

.orphine -ontrols pain an* helps patients feel at ease

/esults of blood tests revealed a Troponin T of C.3'ngDml. %P unrecordableI7 pea)

0reatinine )inase was 6(C iuDml reference rangeP 2'? 2CC iuDmlI on day two.

! !ist the 2 cardinal 05 features of an acute full thic)ness anterior myocardial

infarction and outline their electrophysiological cause"

ST ele+ation 8=1%9 8=1 & a=L9 -hanes in a-tion potentials pro*u-e* 7y ne-roti-

tissues, a7nor.al firin of a-tion potentials lea*s to early repolarisation se-on*ary to

is-he.ia -ausin this a7nor.al wa+e

Patholoi-al wa+es 8=1%9 8=1 & a=L9 *e+elop fro. li+in tissue 7ehin* the infar-t,

pi-ke* up 7y ;CG as *ownwar* .o+e.ent as i.pulses .o+e away fro. anterior lea*s

e-ipro-al ST *epression in inferior lea*s 8=IIIa=/9

$#


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A 4( year old gentleman presents to his 5 with a 8 month history of epigastric pain

which is made worse by eating.

● %ame 3 organs which may cause food related pain.

sto.a-hpan-reas

all7la**er

! ;n eamination there is mild tenderness in the epigastrium. Your consultant tells you

that the @urphy


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Question 4%: Hae,atolo$y

You are a 5 trainee and @rs L7 a 24 year old lady7 presents to the clinic. +he has *ust

registered at the practice7 her notes haven9t arrived at the surgery and she is

complaining of tiredness. +he doesn9t wish to be fully eamined but clinically you

suspect anaemia and you arrange a full blood count7 results of which are shown

below.

+he returns to the health centre and this time you notice that she is also slightly

icteric. Krine analysis shows urobilinogen but no bilirubin. There is no glycosuria7

haematuria or pyuria. The serum bilirubin concentration is 8' JmolsDl normal range 6'

R 22 JmolsDlitreI.

● Apart from investigations for haemolysis7 list 2 other investigations7 eplaining your

reason for doing the test7 to help elucidate the cause of the increased @0:.

&BI → de8cienc$ can cause @acroc$tic @egaloblastic "naemia

,olate Leels → de8cienc$ can cause @acroc$tic @egaloblastic anaemia

T,Ts → h$poth$roidism can be a cause of macroc$tic anaemia

Serum 7rotein ;lectrophoresis → check for paraproteinaemia 0m$eloma5

&one @arrow "spirate3Trephine → check for m$elod$splastic s$ndrome

● Apart from results given above7 list 2 biochemical or haematological abnormalities

that may occur in haemolysis.

&iochemistr$ → high L!H' high unconWugated serum bilirubin' haemoglobinuria'

haemosiderinuria

Haematolog$ → increased reticuloc$te count' methaemoglobinaemia

● plain in less than 'C wordsI why in haemolysis increased serum bilirubin may not

lead to increased renal ecretion of bilirubin.

Hae.olysis results in an in-rease* nu.7er of re* 7loo* -ells 7ein 7roken *own

The a7o+e -auses an in-rease in the a.ount of un-on>uate* 7iliru7in in the 7loo*@n-on>uate* 7iliru7in is not solu7le in water an* hen-e not e:-rete* 7y the ki*neys

! Apart from haemoglobinopathies7 list 6 defect in the red cells that can cause

haemolysis and give an eample.

A7nor.al e.7rane e"" Here*itary Sphero-ytosis or ;llipto-ytosis

A7nor.al ;n


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Strep" Pneu.oniae

Hae.ophillus Influen


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Question 4&: .nato,y

A 8( year old woman presents with an enlarging swelling in the area of the right groin.

● "hat 3 structures7 other than hernia7 might give rise to a lump in this area$

su7-utaneous fat 8lipo.a9

fe.oral ly.ph no*es 8ly.pha*enopathy9psoas ." 8a7s-ess9

fe.oral a" 8aneurys.9

After your eamination you are sure that you are dealing with a hernia.

● "hat factors would influence your advice to the patient about the possibility of

surgical repair$ %ame 4

lo-ation of hernia *istinuish whether fe.oral inuinal

whether it is re*u-i7le stranulate*

presen-e of sy.pto.s 8e pain9

ptFs *esire for surery fun-tional i.pa-t

ptFs -o.or7i*ities -ontrain*i-ations to surery

● "hat are the symptoms of obstruction in a groin hernia $

pain

-onstipation

ten*er *isten*e* a7*o.en

nausea +o.itin

$'


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Question 5': Respiratory

You are wor)ing in 5eneral ractice when @r TL7 a &C year old man7 attends your

surgery. He complains that his cough is now giving him some problems. He has had a

cough on and off for the past ' years7 but he has recently noticed that he is having

difficulty getting up stairs and he is producing more phlegm than usual. He has

smo)ed 2C cigarettes per day for approimately 'C years. You arrange for @r TL toundergo baseline spirometry. The results are reported as followsP

● !ist 2 parameters7 in the normal population7 that predict lung function in nonsmo)ing

sub*ects.

ae

heiht

● "hat pattern is demonstrated by the spirometry in this case$

o7stru-ti+e 8/;=1 O') pre*i-te* /;=16/=C O)"9

● !ist 2 further noteworthy features indicated by the results.e+ersi7ility testin is neati+e in*i-atin that the o7stru-tion is irre+ersi7le

TLC has in-rease* in*i-atin lun hyperinflation

=TLC is reatly in-rease* -onfir.in the o7stru-ti+e pattern

0LC3 is *e-rease* in*i-atin a-ti+e al+eolar surfa-e area has 7een re*u-e* *ue to e""

;.physe.a

● You also arrange for some baseline blood tests7 which show a raised haemoglobin of

6B.(gDdl. "hat is the physiological eplanation for the raised haemoglobin$

Gaseous e:-hane is i.paire*

As a result, less o:yen is rea*ily a7sor7e* into the 7loo*strea.Resulting h$po:ia is detected b$ kidne$s 0Wu:taglomerular app/5 → ↑

er$thropoietin production → ↑ Hb

You discuss with @r TL the need to stop smo)ing and provide him with a number of

medical reasons to encourage him to stop. You review @r TL four wee)s later7 only to

be informed that he has not been able to reduce his cigarette consumption.

$(


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● !ist 3 further methods of smo)ing cessation7 which you discuss with @r TL

Co..unity s.okin -essation roup

5i-otine repla-e.ent therapy 8pat-hes, u., lo


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A 36 year old woman attends her 5 practice with a history of weight loss7

palpitations7 sweating and sha)iness. +he has been previously well and had no

significant childhood problems. ;n eamination she might have a goitre and has a

rapid pulse at rest 66C beatsDminI.

! Apart from thyroid disease7 which other common condition do you wish to eclude$

an:iety

&an mimic the increased heart rate and agitation of hperthroidism but palms will be

clamm instead of warm. Other signs ma include the e+istence of goitre, ee signs,

pro+imal mopath and wasting.

● The patient9s Thyroid +timulating Hormone T+HI is undetectable GC.C'mKD!I. -n view

of this7 what diagnosis does this indicate$

Thyroto:i-osis .ost likely *ue to pri.ary hyperthyroi*is.

● "hy is the T+H low give an eplanation in no more than 3C wordsI$

TSH is pro*u-e* 7y the anterior pituitary, an* sti.ulates pro*u-tion of thyroi* hor.ones 8T

&T#9

In-rease* thyro:ine inhi7its the hypothala.i-pituitarythyroi* a:is as part of a +e fee*7a-k

loop

The aboe results is * production of TSH

;ther results includeP

● Thyroid peroidase antibodiesP 6CCC iKD! %P G8C iKD!I.

● "hite 0ell countP normal● Al)aline hosphataseP 2CC iKD! %P 4C?63C iKD!I.

● "hat is the li)ely specific aetiology of the disease$

Graes !isease → autoimmune condition resulting in h$per-actie th$roid

● -n no more than 3C words7 outline the pathogenesis of this disease.

Autoanti7o*ies to the TSH re-eptor thyroi* folli-ular epithelial -ells are -reate*

These autoanti7o*ies sti.ulate inappropriate a-ti+ation of thyroi* hor.one pro*u-tion

● ;utline 3 treatment options for this patient7 and provide one specific side effect thatyou would warn the patient about for each treatment option

"nti-th$roid !rugs e/g/ 6arbimaMole or 7rop$lthiouracil → can cause

agranuloc$tosis

Radioactie #odine → ma$ cause initial worsening in h$perth$roid s$mptoms

Th$roidectom$ → likel$ h$poth$roidism needing lifelong th$ro:ine treatment

7ropranolol → e:ercise intolerance

%1


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A '4 year old man with longstanding inflammatory bowel disease presents with an

increase in bowel fre#uency7 passage of mucus and blood per rectum and a two

month history of 4)g weight loss.

● 5ive 3 possible eplanations for the patient9s change in symptoms.;:a-er7ation of infla..atory 7owel *isease

Infe-ti+e Colitis

Colore-tal Can-er

Is-hae.i- Colitis

Coelia- 0isease

Chroni- 0i+erti-ulitis

● %ame 4 non?invasive routine investigations you would underta)e.

,&6 0↑F66 in infection3 check Hb to assess seerit$ of loss3chronic disease5

?CC 8 infla..ation9

;S-P 8 Infla..ation9

@;s 8.ay 7e *erane* if -hroni- *iarrhoea9

Al7u.in 8a-ute phase protein surroate .arker of nutrition9

6ulture → Stool and &lood 0e:clude infectie causes5

/ae-al Calprote-tin 8e+i*en-e of -oloni- infla..atory patholoy9

A 8e:-lu*e e+i*en-e of lare 7owel o7stru-tion to:i- .ea-olon9

CT A7*o.enPel+is 8will show -oloni- infla..atory -hane an* .ay i+e in*i-ation a7out

.esenteri- -ir-ulation9

● "hat urgent investigations would you consider to obtain a biopsy sample$

/le:i7le Si.oi*os-opy 8in pra-ti-e -olonos-opy in -ase patholoy turne* out to 7e

pro:i.al9

● %ame the characteristic features seen on pathological eamination of the biopsy

material.

Continuous u-osal Infla..ation 8@C9 or Skip Lesions 8CrohnFs9

Crypt A7s-esses

Trans.ural Infla..ation

@l-eration/issurin

Granulo.a 8CrohnFs9

● iopsies confirm chronic ulcerative colitis with areas of severe dysplasia. 5ive 2

treatment options.

Panpro-to-ole-to.y with ter.inal ileosto.y 3 -reation of pou-h an* ileoanal anasto.osis

Su7total -ole-to.y with en* ileosto.y for.ation 8e.eren-y situation9

%2


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Question 53: Hae,atolo$y

A 24 year old male attends medical outpatients with a four wee) history of unilateral

painless cervical lymphadenopathy. He denies any symptoms of a sore throat or upper

respiratory tract signs. He has lost &)g in weight over 2 months and has suffered

drenching night sweats and generalised itch.

● "hat is the single most li)ely diagnosis$

Ho*kinFs ly.pho.a

● "hat other clinical findings might be present$

spleno.ealy

sy.pto.s of anae.ia

↑(c

hepato.ealy

purpura, easy 7ruisin

● "hat initial laboratory investigations would you wish to perform$

/BC *ifferential thro.7o-ytopenia, pan-ytopenia

Bloo* s.ear nu-leate* BC, iant platelets

;:-isional -ore L5 7iopsy positi+e

L!H 0prognostic5 3 ;SR ↑

HI= testin e:-l HI= infe-tion

(usuall of little value) 45 aspirate 6 trephine - cellular marrow with few large binucleate

cells having moderate ctoplasm and prominent nucleoli (3eed Sternberg cells) in a

polmorphous bac"ground

● %ame 2 causes of cervical lymphadenopathy in any adult patient7 not including your

answer earlier

ea-ti+e followin +iral infe-tion 8e ;B=, C=, HI=9

sero-on+ersion in HI=

Lun .ets

heu.atoloy SL;, u+enile -hroni- arthritis

%


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@r /.T. is a 'B year old man who comes to see you in the "ell @an clinic. He has no

symptoms and urine dipstic) testing is negative. His blood pressure is 6'C systolic7 B(

phase ' diastolic.

● "hat is meant by phase '$the P at whi-h the soun* *isappears

! "hat will be your initial approach to this blood pressure result$ 5ive two eamples of

your net course of action.

.easure it aain in or*er to .ini.ise the risk of white -oat hypertension

offer a.7ulatory BP .onitorin or ho.e BP re-or*in to *: HT5

● You later decide to treat his raised blood pressure7 but @r /.T. is unhappy about long

term drug treatment and as)s what benefits are li)ely. +uggest 2 long?term

advantages.

* chance of haing a stroke 0HT= increase risk I:5

* chance of haing a @# 0HT= ↑ risk :5

* risk of deeloping H,

● "hat drug treatment will you consider$ +uggest three classes of drugs li)ely to be

most useful.

AC;i

CCB

Thia


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An anious 4&?year old man who comes to see you when you are a House ;fficer

attached to a 5eneral ractice. He has recently stopped smo)ing and has a family

history of ischaemic heart disease. He describes intermittent anterior central chest

pain and is worried that he may have angina.

● "hat two other common causes of such pain will you want to consider$

Peri-ar*itis yo-ar*itis

G30

-oronary a" spas.

atrial fi7rillation

aorti- stenosis aorti- reuritation

● You are unable to ma)e a diagnosis on the history and eamination is normal. You

decide to refer him for tests. +uggest two tests giving the rationale for each.

In+asi+e -oronary anioraphy ol* stan*ar* for assessin presen-e se+erity of CA0

Stress ;CH3 assist *ianosis an* pro+i*e infor.ation on pre-ipitatin -auses 8e aorti-

stenosis, H3C et-9

;:er-ise Stress Testin *eter.ine *eree of fun-tional i.pair.ent in CA0

● Angina is diagnosed. "hat medication will you consider to treat his pain$ +uggest

two groups of drugs

Short & lon a-tin 5itrates 7reakthrouh & prophyla:is 8e GT5 spray & isosor7i*e

*initrate9

&eta blockers - * freQuenc$ of attacks

Cal-iu. Channel 7lo-kers

5i-oran*il M -hannel aonist

anola


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Question 5): *ardio+ascular

@r 5H is a &( year old man who sustained a large myocardial infarction 2 years ago.

-nitially he seemed to recover well but recently has become more short of breath on

eertion and has developed swollen an)les This has failed to respond to your

treatment with Eurosemide and +low , and has necessitated his admission to

hospital. You suspect he may have developed heart failure.

● "hat additional points could you see) in the history that would support this

diagnosis$ +uggest 3.

&reathing → ;:ertional !$spnoea' ?rthopnoea' 7aro:$smal =octurnal !$spnoea

;:ercise → 7oor ;:ercise Tolerance' ,atigue and Feakness

Lungs → 6ardiac FheeMe' =octurnal 6ough with ,roth$ 7ink Sputum

?ther → #mpaired @ental Status' 6old 7eripheries' #mpaired


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Question 5": er,atolo$y

@iss EA is a 68 year old 0aucasian who has been seeing her 5eneral ractitioner

every 2?3 months since childhood7 with occasional visits to the ermatologist

complaining of widespread severe itching and dryness of the s)in. The condition has

fluctuated in severity over the years but had never cleared completely.

● You thin) that atopic ecFema atopic dermatitisI is the li)ely diagnosis. "hat two

further points in the history would you see) to support your diagnosis$

/a.ily history of atopy 8asth.a, e-


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If the pla-e of work e:poses the patient to irritants or allerens it is i.portant that the patient

takes ne-essary a-tions to eli.inate e:posure, as her e-


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Question 5%: Gastrointestinal/ Hepatic

A 2' year old accountant is admitted as an emergency under your care with a one?

wee) history of fever7 malaise with mar)ed diarrhoea with blood through the stool.

"hen he is weighed he notices that he has lost ' )g in weight but on #uestioning he

has no previous relevant history. Abdominal eamination shows tenderness in the left

side of the abdomen and you suspect a diagnosis of ulcerative colitis.

● %ame three common causes of these symptoms apart from ulcerative colitisI$

infe-ti+e astroenteritis

IB0

7lee*in pepti- ul-er

● Apart from underta)ing a colonoscopy and biopsy7 list two ways in which you could

help clarify the diagnosis.

Bloo*s6 /BC, @&;, ;S, CP, L/T

&lood culture and stool culture → e:clude infectie causes

Si.oi*os-opy an* re-tal 7iopsy

Colonos-opy

Bariu. ene.a

● "hat abnormalities are you li)ely to see in the rectal biopsy once this is performed$

+uggest one

@C

! !ist two classes of drugs that might be used to treat this condition and give one

eample of each.

Steroids → H$drocortiosone' 7rednisolone

C-"minosalic$lic "cid → SulfsalaMine' @esalaMine' ?lsalaMine

Steroid Sparing "gent → "Mathioprine

● The patient deteriorates despite the drug treatment and abdominal pain becomes more

of a feature with swelling. "hat acute complication would you be concerned about

and how would you investigate this$

To:i- .ea-olon perforation

● "hat urgent operation might be appropriate$

Su7total -ole-to.y with en* ileosto.y an* o+ersewin of the re-tal stu.p

%(


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Question 5&: *ardio+ascular

You are on a 5eneral ractice attachment. A &3 year old lady comes to see you

because she has developed a 6Ccm2 ulcer above her left medial malleolus

! %ame 3 pieces of information you would en#uire about in the history to support the

diagnosis of the ulcer being venous in origin. H: → enous disease' !Ts or trauma 0including surger$3fractures to leg5 - most

important points

e-urrent phle7itis

Pre+ious prenan-y

37esity

I..o7ility

History of prothro.7oti- ten*en-y

● "hat will you loo) for on eamination to support the diagnosis of the ulcer being

venous in origin$ +uggest 3 findings

"natomical Location → located around gaiter area

Shape → t$picall$ a shallow ulcer with >at margins though not necessaril$

Palpa7le peripheral pulses an* nor.al CT

Sins of +enous hypertension i"e6

=ari-osities

Hae.osi*erin Pi.entation

Lipo*er.atos-lerosis,

=enous ;-


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Question )': #eurolo$y

A 26 year old man has been in a fight outside a pub. He has received at least one blow

to the left side of his head from a baseball bat. He localises and opens his eyes to

pain. He has incoherent speech.

● -n no more than 3C words7 describe how you calculate his 5lasgow 0oma +core 50+I;yes6 2# i"e" open to pain

=er7al6 2$ i"e" in-o.prehensi7le soun*s

otor6 $% i"e" lo-alises to painful sti.uli

● "hat are the results in this case$

Total S-ore X (1$

● -s he in a coma$

5o as Co.a is a s-ore O

● "hat urgent investigation does he need$

Hea* CT

● "hat precaution needs to be ta)en first$

se-ure airway

● -n the contet of an intracerebral in*ury7 what is coning$

Conin refers to a tonsillar herniation i"e" when raise* ICP -auses the -ere7ellar tonsils to

.o+e *ownwar* throuh the fora.en .anu. an* press on the 7rainste. -ausin

potentially fatal respiratory an* -ar*ia- *ysfun-tion"

You suspect an etradural haematoma +HI.

! escribe 3 signs of an epanding H as it enlarges and before it ultimately results in

coning.

!ecreasing leel of consciousness 0* G6S5

C5 III Palsy i"e" nonrea-tin *ilate* pupil lookin *own an* out

Left Papilloe*e.a

In-reasin aitation

?orsenin Hea*a-he

5ausea an* =o.itin/o-al 5euroloi-al Sins

1


72/170

Question )1: Rheu,atolo$y

A 'C year old woman has had systemic lupus erythematosus +!I for 62 years. +he

has developed an)le oedema and has proteinuria on urinalysis. You suspect she has

developed nephrotic syndrome.

● "hat 2 laboratory results would confirm the clinical diagnosis of nephrotic syndrome$5ive figuresI

hypoal7u.inuria 8O)L9

proteinuria 8K"$2#hrs9

● "hat 3 investigations and their rationale which are essential before performing a renal

biopsy in this patient$

/BC Coa s-reen & 7lee*in ti.e 7iopsy .ay 7e -ontrain*i-ate* if risk of 7lee*in or in

7lee*in *isor*ers

)idne$


73/170

Question )2: Orthopaedics/ M!

@r L./.7 a 8'?year?old retired headmaster7 is well )nown to you7 having suffered from

increasingly severe osteoarthritis of his right hip for the past 3 years. He had been

very athletic in his youth and played rugby at one time for 5lasgow Kniversity. He has

come to you as his 5 for advice. @r L./. says7 =This hip is really getting me down

now. - have been wondering about a replacement operation. "hat do you thin)$> Youlisten to the patient9s symptoms and eamine him carefully.

● escribe two symptoms of hip osteoarthritis that @r L/ may be eperiencing

stiffness of >oints espe-ially in the .ornin or after perio*s of rest

pain *ull*eep thatFs ara+ate* 7y .o+e.ent

* functional abilit$

* range of moements

● escribe three signs of hip osteoarthritis that might be elicited on eamining this

patient

-repitus

Tren*elen7urFs sin

* actie and pa

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