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MedED Year 3 Mini Mock Delivered by: SHRUTI, SACHI, AYESHA, MICHAEL and LIZZIE Slides by: LOUISE PITSILLIDES and ROB GROGANDisclaimer & sponsor • “MedED does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We haccurate and in line with Learning Objectives featured on SOFIA,s however, this guide should not be used to replace formal ICSM teaching and educational materials.” The mock exam has been produced by students. We have made ewhere information differs between this session and official teachingt material, please refer to the official ICSM teaching materials. Thank you.MedED Mock Instructions Answer all questions. the real exam.uestions. The time limitis 1hr- the same amount of time as would be given in Please write your answers down on a piece of paper If you usually get extra time, please feel free to take longer, and watch the explanationsback when the recording is released within the next few days Good luck!1. Terence Williams, a 63-year-old man, comes to his GP feeling short of breath. It started three days ago, alongside which he has felt feverish. On questioning, he reports expectorating small amounts of yellow-green sputum. He denies the presence of any red streaks or blood. His past medical history is remarkable for Hypertension, which is controlled with 10 mg Amlodipine once daily and 20mg Ramipril once nightly. He is allergic to penicillin. He is a non-smoker, drinks 2 pints of lager every weekend and takes no recreational drugs. He is construction site manager and an amateur runner and canoeist. On examination, he appears mildly dyspnoeic. His pulse is regular and his hands warm to the touch. Heart sounds I + II are present with no added sounds. Chest expansion is bilateral and equal. On auscultation, coarse crepitations are heard over the right lung base, elsewhere vesicular breaths sounds are heard. His observations: Given the likely diagnosis, how should Terence be managed? Temp 38.0°C HR 96 bpm A. Amoxicillin BP 138/87 B. Clarithromycin RR 20 C. Tazocin SpO 97% on RA D. Amoxicillin and Clarithromycin 2 E. Refer for further assessment in secondary care including Blood Urea Nitrogen GCS 152. A 21-year-old student has been feeling very tired for the past 2 months. She has attributed this to working hard towards her upcoming exams in her room. Her housemates urged her to visit her GP and she had some bloods taken. The results are below. What is the most likely diagnosis? Hb 1.35 g/dL (1.15-1.60) 9 WCC 5.0 *10 /L (4.0-11.0) A Exhaustion Platelets 200 *10 /L (150-400) B Anxiety Calcium 2.02 mmol/L (2.1-2.6) Phosphate 0.56 mmol/L (0.8-1.4) C Anaemia D Primary hyperparathyroidism PTH 8.9 pmol/L (0.8-8.5) ALP 254 umol/L (30-100) E Secondary hyperparathyroidism3. A 40-year-old woman with a history of multiple sclerosis presents with headache and weight loss. On direct questioning she reveals that she has stopped eating as this leads to a headache which whilst lasting only for a couple of seconds, is very sharp and intense, feeling like an electric shock in her cheek. Which is the most likely diagnosis? A. Trigeminal neuralgia B. Temporal arteritisa C. Cluster headache D. Migraine E. Meningitis4. A 27-year-old man returns from a trip to Thailand where he had sexual intercourse with multiple people. He presents with a right upper quadrant pain, fever and raised ALP and AST . Which is the most likely causative agent? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E5. A 42yr old man is admitted on to the respiratory ward for a moderately severe community acquired pneumonia. After starting him on IV antibiotics, the nurse looking after him noted that the man started to look very unwell, and that a rash had erupted across his face and body. His observations are as follows: Which of the following is the next best step in the management of this patient? A. IM chlorphenamine Temp: 36.7 °C B. IM adrenaline 500mg 1:10,000 HR: 140 C. IM adrenaline 500mg 1:1000 BP: 90/50 RR: 32 D. IV chlorphenamine O2 sats: 91% E. Stop the IV antibiotics6. A young woman presents with fatigue to her GP. On examination, there is macroglossitis and angular stomatitis. There is reduced pinprick sensation up to the level of her mid calf and proprioception is impaired. Similar findings are found in the hands. Her Ankle reflexes are absent. Given the likely diagnosis, which of the following is likely to be positive? a) pANCA b) cANCA c) Anti-tTG d) Anti-Islet cell e) Anti-Parietal Cell7. A 66 year old man is in hospital after suffering from a stroke. He has permanent motor and sensory deficits, is unable to mobilise, and the SALT team have assessed him to have an unsafe swallow. During the ward round, the consultant neurologist hears crackles in the right lung base. The patient has shortness of breath and his O 2ats are 94%. What is the most appropriate treatment? A. Lung transplant B. Short-acting beta-agonist C. Amoxicillin + metronidazole D. Amoxicillin + clarithromycin E. IM adrenaline8. An overweight 72-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. The doctor notes the lump is lateral and inferior to the pubic tubercle on closer inspection. What may be the most appropriate management step and why? A. Surgical referral due to future risk of strangulation B. Surgical referral to rectify the discomfort caused C. Call an ambulance as this as an immediate surgical emergency D. Watchful waiting because there is no major risk E. Do nothing because there is no major risk9. A 59 y/o man is out shopping with his wife when he develops acute onset crushing chest pain radiating to the left arm and jaw. He is sweating and feels nauseous. His wife is concerned and drives him to the nearest hospital. On arrival to the emergency department, he is treated with aspirin and clopidogrel and an ECG is taken that shows ST-elevation in leads I, II, V1-V6. The nearest PCI hospital is 3 hours away. What is the most appropriate management? A. Blue-light the patient to the PCI hospital B. Send him for immediate coronary angiography C. Start fondaparinux D. Start alteplase E. Start NSAIDs10. A 45-year-old man is worried about a lump on his back. Upon closer inspection, the GP notices that the lesion consists of a central ulcer, with rolled pearly edges and central fine telangiectasia. The patient does not have any other symptoms. What is the most likely diagnosis? A Squamous cell carcinoma B Malignant melanoma C Basal cell carcinoma D Melanocytic naevus E Molluscum contagiosum 11. A 67 year old man has 3 weeks of progressive ankle oedema. He has a history of hypertension, treated with amlodipine. He is a lifelong heavy smoker and drinks 12 units of alcohol per week. His BP is 125/85 mmHg and oxygen saturation 98% breathing air. His JVP is 4 cm above the sternal angle. He has marked bilateral pitting ankle oedema. He has dull percussion note at both bases with reduced breath sounds. Creatinine 85 µmol/L (60-120) Which is the most likely diagnosis? Fasting Glucose 5.7 mmol/L (3.0-6.0) A. Cardiac failure B. Nephritic syndrome Total Cholesterol 9 mmol/L (<5.0) C. Nephrotic syndrome D. Rapidly progressive glomerulonephritis Albumin 15 g/L (35-50) E. Dehydration Urinary protein: 568 Mg/mm (<30) creatinine ratio ol Urine microscopy no cells, no casts12. A 23yo male presents to GP with refractory and severe peptic ulcer disease. The patient doesn’t smoke, eats healthily and has tested negative for H. Pylori tests. He does not take any medications. On further questioning the patient also mentioned he sometimes has stomach upsets, finds it hard to concentrate and has upper and lower back pain. Which of the following will best aid the diagnosis of this patient? A) Fasting serum gastrin Level B) OGD C) Colonoscopy D) Ultrasound E) C-13 Urea breathe test13. A 60 year old man presents to A&E having collapsed. On examination he has a slow rising pulse, his apex beat is not displaced. Heart sounds S1 and S2 are present. S2 is soft with a systolic murmur heart heard loudest over the aortic area radiating to the carotids. His BP is 110/85. What is the most likely diagnosis? a) Atrial septal defect b) Ventricular septal defect c) Aortic Stenosis d) Aortic regurgitation e) Mitral regurgitation14. A 19-year-oldman attends his GP after noticing a lump in his scrotumwhile showering. He reports some discomfortin the area but no pain. He is in a long-term relationshipwith his girlfriend and his last sexual health screen two weeks previouslywas clear. On examination,there is a soft mass on the anterior aspect of the left testis that is indistinguishable from the testis itself. It is not tender to touch and transilluminates. Which of the followingis the most likely diagnosis? A. Testicular seminoma B. Varicocele C. Epididymal cyst D. Hydrocoele E. Sperm granuloma15. A previously healthy 61-year-old woman presents with a 3-month history of sinusitis and nasal drainage. Multiple courses of antibiotics has barely improved it. The nasal drainage is purulent and frequently haemorrhagic. She also has a 2-week history of migratory joint pain, mainly affecting wrists, knees, and ankles. She reports having less energy and has lost 10 pounds in weight over the past 2 months. She has no respiratory, urinary, neurological, or other symptoms. On examination there is a saddle-shaped deformity of the nose and nasal septal perforation. In-office urinalysis reveals 3+ microscopic haematuria and 2+ proteinuria. Given the most likely diagnosis, which of the following antibodies would you expect to be raised? A. Perinuclear Anti-Neutrophil Cytoplasmic Antibody (pANCA) B. Cytoplasmic Anti-Neutrophil Cytoplasmic Antibody (cANCA) C. Anti-Glomerular Basement Membrane Antibody (anti-GBM) D. Anti-nuclear Antibody (ANA) E. Anti-Smooth Muscle Antibody (ASMA)16. A 75-year-old female presents with symptoms of heart failure. On auscultation, an ejection systolic murmur is present, and echocardiography reveals aortic stenosis. What additional sign would you most likely observe? A. Bibasal crepitations B. Raised JVP C. Ascites D. Ankle oedema E. Osler’s nodes17. A 53-year-old woman presents to her GP with a 2 year history of weight loss, irritability and heat intolerance. The GP had requested blood tests to investigate the underlying cause. The findings are as follows: Thyroid Stimulating Hormone (TSH) Low Free thyroxine (T4) High TSH receptor stimulating antibodiesPositive Which of the following additional features would most support a diagnosis of Graves' disease rather than other causes of hyperthyroidism? A. Anti-thyroid peroxidase autoantibodies B. Exophthalmos C. Onycholysis D. Goitre E. Weight loss18. A 45 y/o man comes to GP as he has noticed a lump in his neck that has continued to grow slowly for the last few years. He is concerned as he has also noticed that his voice has become more hoarse and his eyelid has started to droop. He has no systemic symptoms, weight loss, fevers or other lumps. He is otherwise fit and well as an account manager living with his wife. O/E the lump is just inferior to the left mandible and mobile side to side but not up and down. It is pulsatile and not fluctuant or tender. What is the likely diagnosis? A. Cervical Lymphadenitis B. Branchial Cyst C. Paraganglioma D. Cystic hygroma E. Lymphoma19. A 49 year old man with a long-standing history of alcoholism and known cirrhosis attends A&E vomiting large volumes of blood. BP=95/60 Hb=6 g/dL What is the next step in the management of this patient? A. Blood transfusion and IV propranolol B. Take the patient to endoscopy for variceal ligation C. IV fluids and IV ceftriaxone D. Blood transfusion and IV terlipressin E. Take the patient to catheter lab for Transjugular intrahepatic portosystemic shunt (TIPS)20. Mrs B is a 46-year-oldfemale who was diagnosed with type II diabetes mellitus 6 months ago. The GP prescribed standard-release metformin and advised her to aim for an HbA1c of 48mmol/Lor below. Six months later she has returned for a diabeticreviewwith the nurse practitioner,and the HbA1c has risen to 59mmol/L.Mrs B assures you she has taken the metformin as prescribed and her partner who is with her confirms this. What is the next step in the management of this patient? A. Stop metformin and initiate a sulphonylurea B. Continue with metformin alone C. Continue metforminbut add a DPP-4inhibitor D. Initiate insulin therapy E. Swap standard-releasemetformin for modified-releasemetformin21. A 26 year old male who is under gastroenterology,presented a year ago with bloody diarrhoea. Investigations showed: raised fecal calprotectinand a double contrast barium enema showed lead pipe appearance. He was then given oral Mesalazine and oral beclomethasone.A year later he has been symptomfree for 4 months now. Which of the followingis the next best step in the management of this patient? A) Total colectomy B) Vedolizumab C) Colonoscopy D) Daily oral prednisolone E) Azathioprine and Infliximab22. Mr Holmes, a 60-year-old man, with a history of hypertension and type 1 diabetes mellitus, was watering the flowers in his garden. Suddenly, he dropped the watering can and his face and right arm started to look weird. His wife brought him to A&E where followinga CT scan, thrombolysiswas given. Mr Holmes is now recovering in the stroke unit. Which of the followingshould be part of his lifelong management? A. Alteplase B. Clopidogrel C. Aspirin D. Warfarin E. Diclofenac23. A 70-year-old man has come to the GP complaining of pain in his calf for the past 3 months. The pain only comes on when he is walking and is relieved by rest. He alwaysfeels the pain in the same area of his leg. His past medical history includes hypertension and high cholesterol levels. What is the most likely diagnosis? A. Critical limb ischaemia B. Acute limb ischaemia C. Deep vein thrombosis D. Intermittent claudication E. Vasculitis24. A 56-year-old woman presentswith a 3-month history of intermittentdizziness and nausea. The episodes have been occurring daily and appear to be triggered by household chores such as hangingwashing. Each episode reportedlylasts 2-3 Neurological examination is entirely normal. ] headache, or vision changes. Which of the followingfindings would confirm the likely diagnosis? A. Delayed onset (2 seconds) torsional nystagmus unilaterally on Dix-Hallpike manoeuvre B. Delayed onset (2 seconds) torsional nystagmus bilaterally on Dix-Hallpike manoeuvre C. Immediate onset torsional nystagmus unilaterallyon Dix-Hallpike manoeuvre D. High frequency conductive hearing loss on pure tone audiometry E. Low frequency sensorineural hearing loss on pure tone audiometry25. A 4-year-old male presents with testicular swelling and, on examination, there is lymphadenopathy and bone tenderness. He is diagnosed with acute lymphoblastic leukaemia and treated with chemotherapy, which leads to tumour lysis syndrome. Which of the following is a feature of tumour lysis syndrome? A. Podagra B. Inverted T waves C. Hypercalcaemia D. Constipation E. Hepatosplenomegaly26. A 40-year-old man presents to his GP complaining that his fingers go extremely cold and white at random times of the day. It is worse outdoors and particularly in the winter. On examination, you see small white deposits on his arms. There are a large number of spider naevi on his cheeks. The skin on the top of hands is thickened and he struggles to straighten out his fingers. Considering the likely diagnosis, which of the following features are you most likely to see? A. Dysphagia B. Glomerulonephritis C. Uveitis D. Gottron’s papules E. Heliotrope rash27. A 25-year-old man presents to A&E with palpitations. He has noticed over the past day that he has been feeling more thirsty than usual and urinating a lot more often. His blood pressure was taken which was 170/100, even though he was placed on Amlodipine by his GP 4 weeks ago. Bloods were taken for U+Es which showed an electrolyte abnormality. What is the most likely diagnosis? A. Hyponatraemia caused by dehydration B. Hypokalaemia caused by Conn’s syndrome C. Hyperkalaemia caused by renal failure D. Hypokalaemia caused by diuretic use E. Hyperkalaemia caused by adrenal insufficiency28. A 33-year-old tall man is breathless in the A+E department. His respiratory examination is grossly abnormal with tracheal deviation to the right and no breath sounds on the left. There is reduced expansion on the left side. Which is the next step in this patient’s management? A. Immediate Chest X-ray B. Immediate surgical pleurodesis C. Immediate Chest drain insertion D. Needle thoracocentesis at the 2 ndintercostal space mid-clavicular line E. Needle thoracocentesis at the 5 intercostal space mid-clavicular line29. A 55-year-old man presents to A&E with nausea. He seems overly anxious about being in hospital. His wife says that he has been urinating more frequently recently. His blood results are shown. How should he be immediately managed? Hb 1.51 g/dL (1.15-1.60) A Total parathyroidectomy WCC 6.0 *10 /L (4.0-11.0) B Calcium infusion Platelets 257 *10 /L (150-400) Calcium 3.2 mmol/L (2.1-2.6) C Antibiotics Phosphate 0.47 mmol/L (0.8-1.4) D Vitamin D supplements PTH 9.3 pmol/L (0.8-8.5) E IV fluids ALP 80 umol/L (30-100) Glucose Normal30. Mrs White, a 50-year old woman is brought to A&E by her husband with extreme headache, which started suddenly half an hour ago. Eliciting a clear history and performing an examination is difficult as the patient is clearly distressed refuses to open her eyes to be examined. Her husband tells the doctor that Mrs White does not have a significant PMH and he reveals that her father died at the age of 50 because of a kidney problem, whose name he cannot recall. Given the most likely diagnosis, which is the most likely underlying condition in this case? A. Renal cell carcinoma B. Renal artery stenosis C. Nephrotic syndrome D. Chronic Kidney Disease E. Polycystic Kidney Disease31. and photophobia at his GPl. He has a non-blanching rash.neck stiffness What would be the initial management? A. IV Ceftriaxone B. IM Ceftriaxone C. IV Benzylpenicillin D. IM Tazocin E. IV Aciclovir32. A 75-year-old man has presented to A&E with a persistent cough that is non- productive. A chest x-ray is conducted and the radiograph is shown What is the most likely diagnosis? A Bacterial pneumonia B Viral pneumonia C TB D Primary lung cancer E Secondary lung cancer33. A 38 y/o female presents to A+E with palpitations and sweating that started 3 hours ago. She was hoping it would pass but it continued. She has been vomiting profusely with some diarrhoea since this morning and admits to taking laxatives for the last 3 days as an attempt to lose weight before her beach holiday. On examination she looks very pale and clammy, her obs, bloods and ECG are as follows: What is the best treatment initial treatment option? A. DC Cardioversion HR 112bpm B. Flecainide RR 19 T 36.0 C. Bisoprolol SaO2 96%. D. IV fluids BP 86/40 K+ = 2.4 (3.5-5.5) E. Amiodarone34. Sarah, a 55 year old lady, has presented to A&E with a painful red patch on her cheek that is well-demarcated. It is warm and tender when examined by sweaty and shaky since the onset of her rash. She thinks an insect may have bitten her during her sleep. What is the most likely diagnois? A Erythema nodosum B Psoriasis C Molluscum contagiosum D Cellulitis E Erysipelas35. A 63yo male presents to his GP with abdominal pain and weight loss. He says he has been smoking a pack of cigarettes since a day he was 14yo and has always had reflux since his 30’s. On examination you notice there is a swollen lymph node above his left clavicle. What is the next best step in the investigations for this patient? A) PET scan B) Chest Xray C) OGD and Biopsy D) FBC E) Cancer Marker levels36. A 75 year old man presents to the GP complaining of palpitationsthat feel irregular. On inspection you notice a rash on his cheeks. A low volume pulse is felt, apex beat is not displaced, with a long diastolic murmur heard in expiration with opening snap heard soon after S1. CXR shows a double right heart border. Given the likely diagnosis, which of the followingwould you look for as a sign of severity? a) Irregular palpitations b) Soft/absentS2 c) Increased length of murmur d) Opening snap heard soon after S1 e) Double right heart border37. A 34-year-old man presents to an emergency surgery with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has had no similar pain previously and is normally fit and well. Examination reveals a man who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management? A. Oral ciprofloxacin B. Scrotal exploration C. Oral co-amoxiclav and metronidazole D. PR diclofenac E. Bendroflumethiazide PO38. A 35-year-old female presents with breathlessness and says that she needs 5 pillows at night. On further questioning, she reveals that she has been feeling hot all the time and has lost weight easily for the past year. What is the most likely diagnosis? A. Right heart failure B. Plummer’s disease C. Hashimoto’s thyroiditis D. High output heart failure E. Constrictive pericarditis39. A young woman comes to GP complainingthat her breasts are very lumpy and can get painful. She has noticed they have gotten more lumpy over the last year. O/E the nipples, skin, size and temperatureof the breast are normal. There are smooth, regular lumps in both breasts and some are fluctuantin nature with others feeling rubbery. She states that since she started having her period 4 years ago, the lumpsgot more in number and are worse around her period. Which of the followinginvestigation and results would fit this history? A. FNA – Straw B. FNA – Green C. FNA – Bloody D. Core biopsy – Intraductal neoplasm E. Core biopsy – Lobular neoplasm40. A 44 year old female attends ED with excruciating right upper quadrant pain. She says the pain has had intermittent RUQ pain over the last couple of weeks which was particularly bad after eating, but now it’s unbearable. O/E tympanic temperature was 39.3°C, there is involuntary guarding on the right side of the abdomen and scleral icterus. What is the most likely diagnosis? FBC WBC 18 x 10^9/L (4-11) A. Acute cholecystitis LFTs B. Biliary cholic Albumin 43 g/L (35-51) ALT 54 IU/L (<40) C. Choledocholithiasis AST 62 U/L (<40) D. Perforated duodenal ulcer ALP 354 U/L (35-51) E. Ascending cholangitis GGT 298 U/L (11-42) Bilirubin 280 umol/L (<17)41. A worried mother brings her 15-year-oldson into the emergency department with tummy pain with severe nausea and vomiting. The pain is located in the umbilical region. He said he last past stools before bed, 14hrs ago. When conducting your examination,tympanic temperatureis 37.0°C, his abdomen is soft but tender, and he has reduced skin turgor- he drinks 2 cups of water whilst you are at the bedside. His mother says he has been drinking a lot of water recently and has lost weight overthe last few weeks. Given the most likely diagnosis, which is the most appropriateimmediate management? A. IV hydrocortisone+ IV ciclosporin+ IV fluids B. Keep nil by mouth and prescribe adequate analgesia with antibiotics C. IV insulin D. Calcium gluconate + insulin + glucose E. IV fluids + potassium replacement42. A 76yo male present to his GP with alternating diarrhoea and constipationthis past month. On further questioning he mentions that “Yes, Indeed my favorite jeans feel looser”. On examinationhe has a BMI of 30, the GP also feels a mass in the left iliac fossa. Which of the followingwill best aid the diagnosis of this patient? A) OGD B) FBC C) CT Chest / Abdo / Pelvis D) Colonoscopyand Biopsy E) Double contrast barium enema43. A 20-year-oldwoman with no significant past medical history presents with lower back pain and bilateral foot and hand tingling. Her symptoms rapidly progress over4 days to include lower extremity weakness to the point that she is unable to mobilise her lower extremities. She reports coryzal symptoms2 weeks ago. Which of the following is NOT consistentwith a diagnosis of Guillain-Barrésyndrome? A. Low nerve conduction velocity B. Low CSF protein C. Albuminocytological dissociation D. Reduced vital capacity on spirometry E. Detectionof C. jejuni in stool culture44. A 62-year-old-man presents to A+E with severe abdominal pain which radiates to his back. The pain started about 45 minutes ago and is a 9/10. On examination he looks systemically unwell and has cool peripheries to touch. What is the most likely diagnosis? Observations: A. Pancreatitis HR = 140bpm B. Ruptured abdominal aortic aneurysm BP = 80/56. C. Aortic dissection D. Myocardial infarction E. Splanchnic artery occlusion45. A 58-year-old man presents to A&E late at night with an acutely painful right eye, poor vision, and extreme nausea. He reports that the pain examination, the right cornea is injected, and the pupil appears semi- dilated and fixed. What is the most likely diagnosis? A - Anterior Uveitis B - Corneal Abrasion C - Angle Closure Glaucoma D - Herpes simplex Keratitis E - Cataract46. An 80-year-old male attends a routine GP appointment and complains that he has been feeling tired all the time. His FBC reveals a high WCC, and some remnants of cells are visible on the blood film. What is the most likely diagnosis? A. Acute Myeloid Leukaemia B. Hodgkin’s Lymphoma C. Burkitt Lymphoma D. Chronic Lymphocytic Leukaemia E. Polycythaemia Vera47. A 34-year-old gentleman presents with red, sore eyes, photosensitivity, mouth ulcers and a 3-month history of symmetrical arthralgias. Which of the following featureswould be consistentwith a diagnosis of SLE? A. Psoriasis B. Back ache C. Pericarditis D. Lupus pernio E. Type 1 Diabetes48. A 30 year old woman presents to A&E complaining of severe muscle weakness for the past 3 days. On examination, there are purple marks all over her back and her face is very swollen. What would be the first line investigation to confirm the diagnosis? A. High dose dexamethasone suppression test B. Plasma aldosterone:renin ratio C. Morning cortisol level D. Short Synacthen test E. Low dose dexamethasone test49. of thick, yellow sputum, that sometimes becomes blood-tinged. Her pastive medical history includes recurrent chest infections. A diagnosis of bronchiectasis is suspected. What would be the best investigation to confirm the diagnosis? A Chest X-ray B Sputum culture C ABG D High resolution CT E Spirometry50. A 64-year-old man who is recovering from an ischaemic stroke on the stroke ward was found to have a low sodium of 118 mMol/L (135-145). He shows no signs of fluid overload or hypovolaemia and thyroid function tests are ordered which are normal. You suspect syndrome of inappropriate ADH secretion. Which of the following tests would confirm this diagnosis? A. Short synACTHen test B. Dexamethasone suppression test C. 9am cortisol D. CT brain E. Fluid restriction and monitor sodium THANK YOU PLEASE FILL IN THEFEEDBACK!!!!ANSWERS AND EXPLANATIONS1. Terence Williams, a 63-year-old man, comes to his GP feeling short of breath. It started three days ago, alongside which he has felt feverish. On questioning, he reports expectorating small amounts of yellow-green sputum. He denies the presence of any red streaks or blood. His past medical history is remarkable for Hypertension, which is controlled with 10 mg Amlodipine once daily and 20mg Ramipril once nightly. He is allergic to penicillin. He is a non-smoker, drinks 2 pints of lager every weekend and takes no recreational drugs. He is construction site manager and an amateur runner and canoeist. On examination, he appears mildly dyspnoeic. His pulse is regular and his hands warm to the touch. Heart sounds I + II are present with no added sounds. Chest expansion is bilateral and equal. On auscultation, coarse crepitations are heard over the right lung base, elsewhere vesicular breaths sounds are heard. His observations: Given the likely diagnosis, how should Terence be managed? A. Amoxicillin He is allergic B. Clarithromycin CORRECT Temp 38.0°C C. Tazocin Not indicated HR 96 bpm BP 138/87 D. Amoxicillin and Clarithromycin Allergic RR 20 E. Refer for further assessment in secondary care including Blood Urea Nitrogen SpO2 97% on RA Innapropriate based on his CRB score which is 0 GCS 152. A 21 year old student has been feeling very tired for the past 2 months. She has attributed this to working hard towards her upcoming exams in her room. Her housemates urged her to visit her GP and she had some bloods taken. The results are below. Hb 1.35 g/dL (1.15-1.60) WCC 5.0 *10 /L (4.0-11.0) What is the most likely diagnosis? Platelets 200 *10 /L (150-400) A Exhaustion wouldn’t have these results Calcium 2.02 mmol/L (2.1-2.6) B Anxiety wouldn't have these results Phosphate 0.56 mmol/L (0.8-1.4) C Anaemia no low Hb etc PTH 8.9 pmol/L (0.8-8.5) D Primary hyperparathyroidism would have high Ca ALP 254 umol/L (30-100) E Secondary hyperparathyroidism CORRECT3. A 40-year-old woman with a history of multiple sclerosis presents with headache and weight loss. On direct questioning she reveals that she has stopped eating as this leads to a headache which whilst lasting only for a couple of seconds, is very sharp and intense, feeling like an electric shock in her cheek. Which is the most likely diagnosis? A. Trigeminal neuralgia CORRECT B. Temporal arteritisa "when brushing teeth" C. Cluster headache recurrent, severe, unilateral headaches D. Migraine last 4-72hrs E. Meningitis no photophobia, neck stifness etc.4. A 27-year-old man returns from a trip to Thailand where he had sexual intercourse with multiple people. He presents with a right upper quadrant pain, fever and raised ALP and AST. Which is the most likely causative agent? A. Hepatitis A faeco oral route B. Hepatitis B blood-blood (sexual transmission, needles etc) C. Hepatitis C bloo-blood D. Hepatitis D Requires Hep B first E. Hepatitis E Faeco-Oral route5. A 42yr old man is admitted on to the respiratory ward for a moderately severe community acquired pneumonia.After startinghim on IV antibiotics,the nurse looking after him noted that the man started to look very unwell, and that a rash had eruptedacross his face and body. His observationsare as follows: Which of the followingis the next best step in the management of this patient? A. IM chlorphenamine Temp: 36.7 °C HR: 140 B. IM adrenaline 500mg 1:10,000 BP: 90/50 C. IM adrenaline 500mg 1:1000 SECOND STEP RR: 32 D. IV chlorphenamine O2 sats: 91% E. Stop the IV antibiotics FIRST STEP6. A young woman presents with fatigue to her GP. On examination, there is macroglossitis and angular stomatitis. There is reduced pinprick sensation up to the level of her mid calf and proprioception is impaired. Similar findings are found in the hands. Her Ankle reflexes are absent. Given the likely diagnosis, which of the following is likely to be positive? a) PANCA Churg strauss syndrome b) cANCA Wegener's, UC, PSC c) Anti-tTG Coeliac disease d) Anti-Islet cell T1DM e) Anti-Parietal Cell CORRECT7. A 66 year old man is in hospital after suffering from a stroke. He has permanent motor and sensory deficits, is unable to mobilise, and the SALT team have assessed him to have an unsafe swallow. During the ward round, the consultant neurologist hears crackles in the right lung base. The patient has shortness of breath and his O2sats are 94%. What is the most appropriate treatment? A. Lung transplant B. Short-acting beta-agonist C. Amoxicillin + metronidazole Covers GI anaerobes + lung infection D. Amoxicillin + clarithromycin E. IM adrenaline8. An overweight 72-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. The doctor notes the lump is lateral and inferior to the pubic tubercle on closer inspection. Whatmaybethemostappropriatemanagementstepandwhy? A. Surgicalreferraldueto futureriskofstrangulationFemoralherniasmorepronetostrangulation B. Surgical referral to rectify the discomfort caused C. Call an ambulance as this as an immediate surgical emergency D. Watchful waiting because there is no major risk E. Do nothing because there is no major risk9. A 59 y/o man is out shopping with his wife when he develops acute onset crushing chest pain radiating to the left arm and jaw. He is sweating and feels nauseous. His wife is concerned and drives him to the nearest hospital. On arrival to the ED he is treated with aspirin and clopidogrel and an ECG is taken that shows ST-elevation in leads I, II, V1-V6. The nearest PCI hospital is 3 hours away. What is the best option? A. Blue-light the patient to the PCI hospital Not enough time (<2hrs) B. Send him for immediate coronary angiography C. Start fondaparinux D. Start alteplase CORRECT E. Start NSAIDs10. inspection, the GP notices that the lesion consists of a central ulcer, with rolled pearly edges and central fine telangiectasia. The patient does not have any other symptoms. What is the most likely diagnosis? A Squamous cell carcinoma Bleeding, Growing B Malignant melanoma Sun exposed pts C Basal cell carcinoma "rodent ulcer" D Melanocytic naevus aka typical mole E Molluscum contagiosum "pearly umbilicated papules" in groin 11. A 67 year old man has 3 weeks of progressive ankle oedema. He has a history of hypertension, treated with amlodipine. He is a lifelong heavy smoker and drinks 12 units of alcohol per week. His BP is 125/85 mmHg and oxygen saturation 98% breathing air. His JVP is 4 cm above the sternal angle. He has marked bilateral pitting ankle oedema. He has dull percussion note at both bases with reduced breath sounds. Creatinine 85 µmol/L (60-120) Which is the most likely diagnosis? A. Cardiac failure – proteinuria, low Alb point to renal path Fasting Glucose 5.7 mmol/L (3.0-6.0) B. Nephritic syndrome- would be haematuria/red cell casts C. Nephrotic syndrome Total Cholesterol 9 mmol/L (<5.0) D. Rapidly progressive glomerulonephritis- not rapid Albuminypoalbumina15ia g/L (35-50) E. Dehydration- patient has fluid overload not dehydration Urinary protein: Mg/mm creatinine ratio 568 ol (<30) Pulmonary oedema does not necessarily= heart failure! Proteinuria Urine microscopy no cells, no castsNephrotic and nephritic syndrome • 2 different manifestations of glomerular disease • Nephrotic (EASY!) • Damaged glomerular filtration barrier allows PROTEINURIA(>3.5 g/day)merulus into urine  • If albumin is being lost in urine, there is less in Albumin the blood  HYPOALBUMINAEMIA • If there is less albuminin the blood, fluid stays in tissues  OEDEMA • synthesis  HYPERLIPIDAEMIA) increased lipid• Nephritic syndrome • Damage to renal endothelium • Haematuria, (proteinuria), high creatinine and systemic hypertension These are syndromes, various diseases can causes each syndrome See Renal lecture/use osmosis12. Tough SBA A 23yo male presents to GP with refractory and severe pepticulcer disease. The patient doesn’t smoke, eats healthily and has tested negative for H. Pylori tests. He does not take any medications. On further questioningthe patient also mentioned he sometimes has stomach upsets, finds it hard to concentrate and has upper and lower back pain. Which of the followingwill best aid the diagnosis of this patient? A) Fasting serum gastrin Level B) OGD - already know there are ulcers C) Colonoscopy - Q presents upper GI problem • H PyloriFs for peptic ulcers: D) Ultrasound- not indicated for peptic ulcer disease • NSAIDs E) C-13 Urea breathe test - questionssays no H. Pylori Neither of these in the QZollinger-Ellison Syndrome • “Gastrinomas”  secrete gastrin  increased stomach acid production  refractorypeptic ulcers • A neuroendocrine tumour, sometimes associated with MEN1 • Hypercalcaemia is a PC for MEN1 (this patient has back pain)13. A 60 year old man presents to A&E having collapsed. On examination he has a slow rising pulse, his apex beat is not displaced. Heart sounds S1 and S2 are present. S2 is soft with a systolic murmur heart heard loudest over the aortic area radiating to the carotids. His BP is 110/85. What is the most likely diagnosis? a) Atrial septal defect  “fixed split S2” (does not fit with Hx) b) Ventricular septal defect  radiates to axilla/back c) Aortic Stenosis d) Aortic regurgitation  diastolicnot systolic murmur e) Mitral regurgitation  radiates to axilla 14. A 19-year-old man attendshis GP after noticing a lump in his scrotum while showering. He reportssome discomfort in the area but no pain. He is in a long-term relationship with his girlfriend and his last sexual health screen two weeks previously was clear. indistinguishable from the testis itself. It is not tender to touch and transilluminates. Which of the followingis the most likely diagnosis? A. Testicular seminoma  importantdifferential.Usually smooth, firm, non-fluctuating mass B. Varicocele  “bag of worms” – dilated veins C. Epididymal cyst  usually separate from testes D. Hydrocoele  most likely, due to “transilluminates”and “soft” E. Sperm granuloma  solid structure 15. A previously healthy 61-year-old woman presents with a 3-month history of sinusitis and nasal drainage. Multiple courses of antibiotics has barely improved it. The nasal drainage is purulent and frequently haemorrhagic. She also has a 2-week history of migratory joint pain, mainly affecting wrists, knees, and ankles. She reports having less energy and has lost 10 pounds in weight over the past 2 months. She has no respiratory, urinary, neurological, or other symptoms. On examination there is a saddle-shaped deformity of the nose and nasal septal perforation. In-office urinalysis reveals 3+ microscopic haematuria and 2+ proteinuria. Given the most likely diagnosis, which of the following antibodies would you expect to be raised? Granulomatosis with polyangiitis (Wegener’s disease) A. Perinuclear Anti-Neutrophil Cytoplasmic Antibody (pANCA) - Churg-Strauss (+ eosinophilia/asthma) and Microscopic polyangiitis (no sinusitis) B. Cytoplasmic Anti-Neutrophil Cytoplasmic Antibody (cANCA) C. Anti-Glomerular Basement Membrane Antibody (anti-GBM)- Goodpasture’s (not on Sofia) D. Anti-nuclear Antibody (ANA)- SLE/Sjorgen’s E. Anti-Smooth Muscle Antibody (ASMA)- Autoimmune hepatitis Wegener’s is the C disease: Curvy nose, Chronic sinusitis, cANCA16. A 75-year-old female presents with symptoms of heart failure. On auscultation, an ejection systolic murmur is present, and echocardiography reveals aortic stenosis. What additional signwould you most likely observe? A. Bibasal crepitations -Aortic stenosis is a cause of left heart failure which leads to pulmonary oedema  bibasal crepitationsand SOB B. Raised JVP - RHF C. Ascites - RHF D. Ankle oedema - RHF E. Osler’s nodes - infective endocarditis (can  valvular disease) A 53-year-old woman presents to her GP with a 2 year history of weight loss, irritability and heat 17. intolerance. The GP had requested blood tests to investigate the underlying cause. The findings are as follows: Free thyroxine (T4) HormonLowTSH)High TSH receptor stimulating aPositives Which of the following additional features would most support a diagnosis of Graves' disease rather than other causes of hyperthyroidism? A. Anti-thyroid peroxidase autoantibodies - also seen in Hashimotos, Plummers and thyroid cancer B. Exophthalmos, pretibial myxoedema and thyroid acropachy are more specific to Graves (caused by TRAb binding to receptors) C. Onycholysis - nails detach from bed D. Goitre - not specific to graves, seen in hypo and hyperthyroidism E. Weight loss - non-specific sign of hyperthyroidism18. A 45 y/o man comes to GP as he has noticed a lump in his neck that has continued to grow slowly for the last few years. He is concerned as he has also noticed that his voice has become more hoarse and his eyelid has started to droop. He has no systemic symptoms, weight loss, fevers or other lumps. He is otherwise fit and well as an account manager living with his wife. O/E the lump is just inferior to the left mandible and mobile side to side but not up and down. It is pulsatile and not fluctuant or tender. What is the likely diagnosis? A. Cervical Lymphadenitis B. Branchial Cyst C. Paraganglioma  carotid body tumour, causing compression of sympathetic chain, and Horner’s syndrome, recurrent laryngeal nerve ( Hoarseness) D. Cystic hygroma E. Lymphoma See “breast/lump lecture”19. A 49 year old man with a long-standinghistory of alcoholism and known cirrhosis attends A&E vomiting large volumes of blood. BP=95/60 What is the next step in the management of this patient? Hb=6 g/dL Ruptured oesophageal varices- emergency. A. Blood transfusion and IV propranolol - propranololfor prophylaxis B. Take the patient to endoscopy for variceal ligation - only if pt haemodynamically stable C. IV fluids and IV ceftriaxone - Both indicated,but better option D. Blood transfusion and IV terlipressin - Blood indicated when Hb<7g/dL. Vasopressor e.g., terlipressin indicated immediately. Reduces blood to porto-systemi. anastomoses A. Take the patient to catheter lab for Transjugularintrahepaticportosystemicshunt (TIPS) - for recurrent bleeds following EVL and b-blocker therapy20. Mrs B is a 46-year-old female who was diagnosed with type II diabetes mellitus 6 months ago. The GP prescribed standard-release metformin and advised her to aim for an HbA1c of 48mmol/L or below. Six months later she has returned for a diabetic review with the nurse practitioner, and the HbA1c has risen to 59mmol/L.Mrs B assures you she has taken the metformin as prescribed and her partner who is with her confirms this. What is the next step in the management of this patient? If HbA1c still rising after metformin, consider dual therapy. Don’t stop metformin unless poorly tolerated A. Stop metformin and initiate a sulphonylurea - shouldn’t stop metformin B. Continue with metformin alone - failing to control sugar C. Continue metformin but add a DPP-4 inhibitor- correct, an example of dual therapy D. Initiate insulin therapy - possible next step if sugar not controlled followingdual therapy E. Swap standard-releasemetformin for modified-releasemetformin - when standard- release metformin is poorly tolerated (i.e., not for intensificationof therapy)21. A 26 year old male who is under gastroenterology,presented a year ago with bloody diarrhoea. Investigationsshowed: raised fecal calprotectin and a double contrast barium enema showed lead pipe appearance. He was then given for 4 months now.nd oral beclomethasone.A year later he has been symptom free Which of the followingis the next best step in the management of this patient? A) Total colectomy Cure but not next best step B) Vedolizumab Not indicated C) Colonoscopy Would not help with management D) Daily oral prednisolone Not used for maintenance of remission E) Azathioprineand Infliximab CORRECT22. Mr Holmes, a 60-year-old man, with a history of hypertension and type 1 diabetes mellitus, was watering the flowers in his garden. Suddenly, he dropped the watering can and his face and right arm started to look weird. His wife brought him to A&E where following a CT scan, thrombolysis was given. Mr Holmes is now recovering in the stroke unit. Which of the following should be part of his lifelong management? A. Alteplase In hyperacute setting (<4,5hrs) B. Clopidogrel CORRECT – lifelong C. Aspirin Acute mx of ischaemic stroke D. Warfarin Lifelong anticoagulant in AF pts E. Diclofenac NSAID – not indicated here23. A 70-year-old man has come to the GP complaining of pain in his calf for the past 3 months. The pain only comes on when he is walking and is relieved by history includes hypertension and high cholesterol levels.. His past medical What is the most likely diagnosis? A. Critical limb ischaemia 6 P's (>2 weeks) B. Acute limb ischaemia the 6 P's- Pain, Pallor, Perishingly Cold, Paresthesia, Paralysis, Pulsesness C. Deep vein thrombosis may mention long haul flight/immobility/recent surgery etc D. Intermittent claudication CORRECT E. Vasculitis incorrect24. A 56-year-old woman presents with a 3-month history of intermittent dizziness and nausea. The episodes have been occurring daily and appear to be triggered by household chores such as hanging washing. Each episode reportedly lasts 2-3 minutes in total. She denies any hearing loss, headache, or vision changes. Neurological examination is entirely normal. ] Which of the following findings would confirm the likely diagnosis? A - Delayed onset (2 seconds) torsional nystagmus unilaterally on Dix-Hallpike manoeuvre B - Delayed onset (2 seconds) torsional nystagmus bilaterally on Dix-Hallpike manoeuvre C - Immediate onset torsional nystagmus unilaterally on Dix-Hallpike manoeuvre D - High frequency conductive hearing loss on pure tone audiometry E - Low frequency sensorineural hearing loss on pure tone audiometry25. examination, there is lymphadenopathy and bone tenderness. He is diagnosed with acute lymphoblastic leukaemia and treated with chemotherapy, which leads to tumour lysis syndrome. Which of the following is a feature of tumour lysis syndrome? A. Podagra uric acid released causes gout – Big toe gout. B. Inverted T waves Tented T waves due to Hyperkalemia C. Hypercalcaemia Hypocalcemia in TLS D. Constipation Feature of Hypercalcemia E. Hepatosplenomegaly Not a feature of TLS.26. A 40-year-old man presents to his GP complaining that his fingers go extremely cold and white at random times of the day. It is worse outdoorsand particularly in the winter. On examination, you see small white deposits on his arms. straighten out his fingers. spider naevi on his cheeks. The skin on the top of hands is thickened and he struggles to Considering the likely diagnosis, which of the following features are you most likely to see? and Telangiectasia (i.e., spider naevi). Note CREST seen in both limited and diffuse scleroderma!ia), Sclerodactyly Differentiating limited and diffuse scleroderma, by LOCATION OF SKIN THICKENING: A. Dysphagia - part of CR E ST! B. Glomerulonephritis - renal disease more common in diffuse C. Uveitis- infection (HSV/HZ), HLA b27-spondyloarthropathies (ank spond, reactive arthritis, IBD, psoriatic), sarcoid, Behcets D. Gottron’s papules - Dermatomyositis (red lesion over knuckle) E. Heliotrope rash - Dermatomyositis (purplish oedematous rash over eyes)27. day that he has been feeling more thirsty than usual and urinating a lot more often. His blood pressure was taken which was 170/100, even though he was placed on Amlodipine by his GP 4 weeks ago. Bloods were taken for U+Es which showed an electrolyte abnormality. Young with HTN despite amlodipine  think about 2° causes e.g., Conn’s syndrome What is the most likely diagnosis? A. Hyponatraemia caused by dehydration B. Hypokalaemia caused by Conn’s syndrome C. Hyperkalaemia caused by renal failure D. Hypokalaemia caused by diuretic use E. Hyperkalaemia caused by adrenal insufficiency28. A 33-year-old tall man is breathless in the A+E department. His respiratory examination is grossly abnormal with tracheal deviation to the right and no breath sounds on the left. There is reduced expansion on the left side. Spontaneous primary pneumothorax (tracheal deviation shows this is a tension pneumothorax) Which is the next step in this patient’s management? A. Immediate Chest X-ray Not suitable for emergency B. Immediate surgical pleurodesis Used for repeated pneumothoraces (not immediate intervention) C. Immediate Chest drain insertion Sterile procedure taking time and expertise- not fast enough D. Needle thoracocentesis at the 2 ndintercostal space mid- clavicular line th E. Needle thoracocentesis at the 5 intercostal space mid-clavicular line – wrong location for needle insertion29. A 55 year old man presents to A&E with nausea. He seems overly anxious about being in hospital. His wife says that he has been urinating more frequently recently. His blood results are shown. How should he be immediately managed? A Total parathyroidectomy- likely definitive Mx not immediate B Calcium infusion- not for hypercalcaemia! Hb 1.51 g/dL (1.15-1.60) 9 C Antibiotics- not in the Mx of hypercalcaemia WCC 6.0 *10 /L (4.0-11.0) D Vitamin D supplements- not in the Mx of Platelets 257 *10 /L (150-400) hypercalcaemia ↑ Calcium 3.2 mmol/L (2.1-2.6) E IV fluids- correct Mx of symptomatic hypercalcaemia ↑ Phosphate 0.47 mmol/L (0.8-1.4) 4-6L 0.9% saline solution in first 24hrs ↑ PTH 9.3 pmol/L (0.8-8.5) ALP 80 umol/L (30-100) Glucose Normal30. Mrs White, a 50-year old woman is brought to A&E by her husband with extreme headache, which started suddenly half an hour ago. Eliciting a clear history and performing an examination is difficult as the patient is clearly distressed refuses to open her eyes to be examined. Her husband tells the doctor that Mrs White does not have a significant PMH and he reveals that her father died at the age of 50 because of a kidney problem, whose name he cannot recall. Given the most likely diagnosis, which is the most likely underlying condition in this case? Sudden onset, extreme headache with photophobia likely a SAH SAH usually caused by rupture of “berry (i.e., saccular) aneurysm” in Circle of Willis. This is associated with PKD, Ehrlos-Danlos, Marfan’s, neurofibromatosis type 1 A. Renal cell carcinoma B. Renal artery stenosis C. Nephrotic syndrome D. Chronic Kidney Disease E. Polycystic Kidney Disease31. A 21-year-old wild medical student presents with fever, neck stiffness and photophobia at his GP . He has a non-blanching rash. What would be the initial management? A. IV Ceftriaxone B. IM Ceftriaxone C. IV Benzylpenicillin CORRECT – Meningitis MX D. IM Tazocin E. IV Aciclovir32. A 75 year old man has presented to A&E with a persistent cough that is non-productive. A chest x-ray is conducted and the radiograph is shown What is the most likely diagnosis? A Bacterial pneumonia B Viral pneumonia C TB "Cannonball Metastases" D Primary lung cancer E Secondary lung cancer33. VERY HARD SBA !!!! A 38 y/o female presents to A+E with palpitations and sweating that started 3 hours ago. She was hoping it would pass but it continued. She has been vomiting profusely with some diarrhoea since this morning and admits to taking laxatives for the last 3 days as an attempt to lose weight before her beach holiday. On examination she looks very pale and clammy, her obs, bloods and ECG are as follows: What is the best treatment initial treatment option? A. DC Cardioversion HR 112bpm RR 19 B. Flecainide T 36.0 C. Bisoprolol SaO2 96%. D. IV fluids BP 86/40 K+ = 2.4 (3.5-5.5) E. Amiodarone34. on her cheek that is well-demarcated. It is warm and tender whened patch examined by the junior doctor. She has also described having a temperature and has felt sweaty and shaky since the onset of her rash. She thinks an insect may have bit her during her sleep. A Erythema nodosum usually in legs arms B Psoriasis red silvery scales on extensor surfaces C Molluscum contagiosum umbilicated papules D Cellulitis NOT WELL DEMARCATED E Erysipelas35. A 63yo male presents to his GP with abdominal pain and weight loss. He says he has been smoking a pack of cigarettessince he was 14yo and has always had reflux since his 30’s. On examination you notice there is a swollen lymph node above his left clavicle. Virchow's node – Gastric Ca What is the next best step in the investigations for this patient? A) PET scan not indicated straight away B) Chest Xray not indicated C) OGD and Biopsy CORRECT FIRST LINE D) FBC not first line E) Cancer Marker levels not first line36. A 75 year old man presents to the GP complaining of palpitations that feel irregular. On inspection you notice a rash on his cheeks. A low volume pulse is felt, apex beat is not displaced, with a long diastolic murmur heard in expiration with opening snap heard soon after S1. CXR shows a double right heart border. Given the likely diagnosis, which of the following would you look for as a sign of severity? a) Irregular palpitations doesn't suggest severity b) Soft/absent S2 Sign of severe aortic stenosis c) Increased length of murmur CORRECT d) Opening snap heard soon after S1 in severe mitral stenosis opening snap is heard after s2 e) Double right heart border doesn't suggest severity37. A 34-year-old man presents to an emergency surgery with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has had no similar pain previously and is normally fit and well. Examination reveals a man who is flushed and sweaty but is otherwise unremarkable. RENAL COLIC What is the most suitable initial management? A. Oral ciprofloxacin B. Scrotal exploration C. Oral co-amoxiclav and metronidazole D. PR diclofenac FIRST STEP IN MX – ANALGESIA E. Bendroflumethiazide PO38. A 35-year-old female presents with breathlessness and says that she needs 5 pillows at night. On further questioning, she reveals that she has been feeling hot all the time and has lost weight easily for the past year. What is the most likely diagnosis? A. Right heart failure no oedema or other signs of RHF B. Plummer’s disease no evidence of toxic nodular goitre C. Hashimoto’s thyroiditis is hypothyroid D. High output heart failure CORRECT E. Constrictive pericarditis usually presents with RHF signs like oedema raised JVP, SOB.39. A young woman comes to GP complainingthat her breasts are very lumpy and can get painful. She has noticed they have gotten more lumpy over the last year. O/E the nipples, skin, size and temperatureof the breast are normal. There are smooth, rubbery. She states that since she started having her period 4 years ago, the lumps got more in number and are worse around her period. Which of the followinginvestigation and results would fit this history? A. FNA – Straw CORRECT B. FNA – Green more infective cause C. FNA – Bloody in carcinoma D. Core biopsy – Intraductal neoplasm does not match clinical picture (ca) E. Core biopsy – Lobular neoplasm does not match clinical picture (ca)40. A 44 year old female attends ED with excruciating right upper quadrant pain. She says the pain has had intermittent RUQ pain over the last couple of weeks which was particularly bad after eating, but now it’s unbearable. O/E tympanic temperature was 39.3°C, there is involuntary guarding on the right side of the abdomen and scleral icterus. FBC What is the most likely diagnosis? WBC 18 x 10^9/L (4-11) LFTs A. Acute cholecystitis would not have jaundice Albumin 43 g/L (35-51) ALT 54 IU/L (<40) B. Biliary cholic AST 62 U/L (<40) C. Choledocholithiasis ALP 354 U/L (35-51) D. Perforated duodenal ulcer GGT 298 U/L (11-42) E. Ascending cholangitis CORRECT Bilirubin 280 umol/L (<17) 41. A worried mother brings her 15-year-oldson into the emergency department with tummy pain with severe nausea and vomiting.The pain is located in the umbilical region. He said he last past stools abdomen is soft but tender, and he has reduced skin turgor- he drinks 2 cups of water whilst you are at the bedside. His mother says he has been drinking a lot of water recently and has lost weight over the last few weeks. Remember Addison’s/DKA as endocrine causes of abdo pain DKA Given the most likely diagnosis,which is the most appropriate immediate management. A. IV hydrocortisone+ IV ciclosporin+ IV fluids - Mx for acute UC B. Keep nil by mouth and prescribe adequate analgesia with antibiotics- Mx for acute appendicitis (does not explain weight loss) C. IV insulin - Risk of dehydration/shockis immediate priority D. Calcium gluconate + insulin + glucose - Mx for hyperkalaemia E. IV fluids + potassium replacement IV fluids for severe dehydration. Potassiumgiven if blood potassium is low or even normal (as subsequent administrationof insulin will drive K into cells  hypokalaemia)42. A 76yo male present to his GP with alternating diarrhoea and constipation this past month. On further questioning he mentions that “Yes, Indeed my favorite jeans feel looser”. On examination he has a BMI of 30, the GP also feels a mass in the left iliac fossa. Which of the following will best aid the diagnosis of this patient? Change in bowel habit/weight loss red flags for colorectal cancer A) OGD - not indicated for suspected lower GI cancer B) FBC C) CT Chest / Abdo / Pelvis colonoscopy is the diagnostic testia D) Colonoscopy and Biopsy E) Double contrast barium enema 43. foot and hand tingling. Her symptoms rapidly progress over 4 days to include lower extremityweaknessral to the point that she is unable to mobiliseher lower extremities.She reports coryzal symptoms 2 weeks ago. Which of the followingis NOT consistent with a diagnosis of Guillain-Barré syndrome? (lymphoma).demyelinating polyneuropathy.Post- infection (e.g, C Jejuni, HIV, herpes), malignancy Affects peripheral nerves whereas multiple sclerosisaffects CNS. A. Low nerve conduction velocity - due to loss of myelin on peripheral nerves B. Low CSF protein - HIGH CSF protein is actually observed,due to inflammation C. Albuminocytological dissociation-just means high CSF protein, but normal cell count (no infection) D. Reduced vital capacity on spirometry- is the dangerous complicationof GBS, watch out for this in SBAs! E. Detectionof C. jejuni in stool culture- GBS may follow C Jejuni infection 44. A 62-year-old-man presents to A+E with severe abdominal pain which radiates to his back. The pain started about 45 minutes ago and is a 9/10. On examination he looks systemically unwell and has cool peripheries totouch. Observations: What is the most likely diagnosis? HR = 140bpm BP = 80/56. A. Pancreatitis- very possible diagnosis, perhaps slightly slower onset B. Ruptured abdominal aortic aneurysm - Patients with ruptured aneurysm present with the triad of abdominal and/or back pain, pulsatile abdominal mass, and hypotension C. Aortic dissection - typically substernal / interscapular pain. D. Myocardial infarction- usually chest pain (but can be epigastric) E. Splanchnic artery occlusion- can occur due to aortic dissection if it occludes aorta45. A 58-year-old man presents to A&E late at night with an acutely painful right eye, poor vision, and extreme nausea. He reports that the pain came on suddenly whilst he was reading his Kindle in bed. On examination, the right cornea is injected, and the pupil appears semi-dilated andfixed. What is the most likely diagnosis? A - Anterior Uveitis -Constricted pupil. Ass w HLA B27 B - Corneal Abrasion- Mechanical trauma. Foreign body sensation, photophobia, and copious tearing. C - Angle ClosureGlaucoma - Blockage of Canal of Schlemm impaired aqueous humour drainage. Raised intraocular pressure then causes symptoms. Halos around lights, aching eye, headache, N&V, eye redness, blurred vision. D - Herpes simplex Keratitis- watering, photophobia, tearing and scratchy sensation and “dendritic ulcer” E – Cataract- more chronic presentation with clouding of lens46. An 80-year-old male attends a routine GP appointment and complains that he has been feeling tired all the time. His FBC reveals a high WCC, and some remnants of cells are visible on the blood film. What is the most likely diagnosis? A. Acute Myeloid Leukaemia- Q does not have acute presentation, no mention of Auer rods B. Hodgkin’s Lymphoma- No mention of lumps, no Reed-Sternberg cells/bi-nucleate lymphocytes C. Burkitt Lymphoma- No EBV infection or immunosuppression, no mention of “starry sky appearance” under microscopy D. Chronic Lymphocytic Leukaemia- Mainly asymptomatic presentation, remnants of cells = smudge cells E. Polycythaemia Vera- question has raised WCC rather than RBC 47. An 34-year-old gentleman presents with red, sore eyes, photosensitivity, mouth ulcers and a 3-month history of symmetrical arthralgias. Which of the following featureswould be consistentwith a diagnosis of SLE? A. Psoriasis SOAP BRAIN MD B. Back ache S- serositis (pericarditis, pleuritis) O- oral ulcers C. Pericarditis A- arthritis D. Lupus pernio - be careful, this is a misnomer P- photosensitivity B- Bloods (anaemia, leukopenia, thrombocytopenia) (not associated with lupus, it is purplish rash often R- Renal (glomerulonephritis) A- ANA seen on the face in sarcoid) I- Immuno (anti-dsDNA) E. Type 1 Diabetes N- Neuro (seizures) M- malar rash D- discoid rash48. A 30 year old woman presents to A&E complaining of severe muscle weakness for the past 3 days. On examination, there are purple marks all over her back and her face is very swollen. Cushing’s syndrome What would be the first line investigationto confirm the diagnosis? A. High dose dexamethasone suppression test B. Plasma aldosterone:renin ratio C. Morning cortisol level D. Short Synacthen test E. Low dose dexamethasone test - any cause of Cushing’s will fail to suppress cortisol production following dex administration49. A 57 year old woman has presented to A&E with a chronic cough, productive of thick, yellowsputum, that sometimes becomes blood- tinged. Her PMHx includes recurrent chest infections. A diagnosis of bronchiectasis is suspected. What would be the best investigationto confirm the diagnosis? Other common bronchiectasis presentation is child with CF A Chest X-ray - nonspecific/non-diagnostic B Sputum culture - may identify pathogen, not diagnostic C ABG - maybe in an acutely breathless pt, not here though D High resolution CT - shows dilation of bronchi E Spirometry - FEV1/FVC for asthma/COPD diagnosis50. V TOUGHSBA A 64-year-old man who is recovering from an ischaemic stroke on the stroke ward was found to have a low sodium of 118 mMol/L (135-145).He shows no signs of fluid overload syndrome of inappropriate ADH secretion.ts are ordered which are normal. You suspect Which of the followingtests would confirm this diagnosis? Euvolaemic hyponatraemia.To achieve diagnosis of SIADH, must rule out hypothyroidism (TFTs) and Addison’s(with a short synACTHen test) A. Short synACTHen test - normal short synACTHen test  SIADH diagnosis B. Dexamethasone suppression test - Cushings C. 9am cortisol - cannot exclude adrenal failure in unwell pt. D. CT brain E. Fluid restriction and monitor sodium - appropriate Mx not Ix General advicefor theexam • PACE YOURSELF- 50 Qs per hour for 3 hours •subscription)uestions, questions (USE OSMOSIS- Imperial • Prepare to be unsure of the answer- not clear cut (follow the evidence) • Have a quick glance at the actual Q, do you really need to read (all of) the stem?THANK YOU AND GOOD LUCK PLEASE FILL IN THE FEEDBACK!!!!