mrcpgp question

1. The following milk feeds are lactose free: True / False

A. Formula S

B. Wysoy

C. Pregestemil

D. SMA gold cap

E. Cow and Gate premium

A, B, C are correct. Lactase seems to be the most vulnerable brush disorder enzyme. For this reason activity can be reduced after insults to the mucosal lining of the gastrointestinal tract. This can happen after acute gastroenteritis, coeliac disease in relapse, after hypoxic episodes and in protein energy malnutrition. Recovery is the general rule is such cases after treatment with lactose-free milks. Formula S is a soya-based milk, as is Wysoy. Pregestemil is a whole-protein-free milk and contains medium chain triglycerides for ease of absorption.

Theme: Industrial diseases

A. Asbestosis

B. Asthma

C. Bladder cancer

D. Cardiomopathy

E. Cerebellar ataxia

F. Cerebral tumour

G. Deafness

H. Leukaemia

I. Lung cancer

J. Lung fibrosis

K. Raynaud's phenomenon

L. Scrotal carcinoma

Select the most likely disease from the above list that is associated with the following professions:

2. Coal miners Lung fibrosis

A form of lung fibrosis is typically found in coal workers from S Wales due to the high silicon contentof the dust produced in the mining process - Pneumoconiosis.

3. Workers in the foam manufacturing industry exposed to isocyanates Asthma

Isocyanates have been identified as the culprit for industrial asthma. These are extensively used in foam manufacture.

4. Dye workers exposed to aniline dyes and aromatic amines Bladder cancer

These are risk factors associated with bladder cancer.

Theme: Urgency of referrals

A. Seen Immediately (within a day)

B. Seen Urgently (within 2 weeks)

C. Seen routinely

D. Referral not indicated

For the following scenarios, select the appropriate referral timing as defined by the National Institute of Clinical Excellence

5. An atopic child with an eczematous rash that has become infected with bacteria (manifest as weeping, crusting or the development of pustules) and treatment with oral antibiotic plus a local corticosteroid has failed Seen Urgently (within 2 weeks)

6. A menorrhagic woman who, despite 3/12 of drug treatment, the heavy bleeding persists and is interfering with quality of life. Failure is best based upon the woman’s own assessment Seen routinely

7. A patient with osteoarthritis of the hip who presents with a hot, red and painful joint and fever. Seen Immediately (within a day)

There is evidence of infection.

8. A patient with evidence of generalised pustular or erythrodermic psoriasis Seen Immediately (within a day)

9. A patient who has varicose veins with an active ulcer and progressive skin changes that may benefit from surgery Seen routinely

10. A 14-year-old child who is prone to guttate psoriasis which is exacerbated by recurrent Tonsillitis Seen routinely

The answers to these questions are taken directly from the national institute of clinical excellence and can also be viewed by subscribers to www.eguidelines.co.uk.

11. A child is noticed to have palpable purpura on the elbows. Which one of the following is most compatible with a diagnosis of Henoch-Schonlein syndrome?

A. Haemolytic anaemia

B. Petechiae

C. Splenomegaly

D. Sudden onset of oedema in the hands and scrotum

E. watery diarrhoea

B is Correct. Thrombocytopenia , haemolysis and splenomegaly are not present and clotting is normal. Subcutaneous oedema of the feet, hands, scalp and ears are seen. Scrotal oedema also

may occur. Gastrointestinal bleeding may occur leading to bloody stools. Haematuria and proteinuria also may occur. Abdominal pain, intussusception and arthritis are features. Petechiae, purpura and papules are commonly present in the thighs and buttocks.

12. Infantile stridor may be associated with: True / False

A. Measles

B. Haemophilus influenzae

C. Expiratory accentuation

D. Bradycardia

E. No other symptoms

A, B, E are correct. In children presenting with stridor it is vital to ensure that the child doesn’t have epiglottitis. This is usually of quick onset with an absent prodromal illness. Features to look

for include cyanosis, respiratory distress drooling and agitation. Other causes of acute stridor include croup, bacterial tracheitis, sub glottic stenosis, foreign body inhalation,and retropharyngeal abscess. Smoke inhalation, diphtheria and angioneurotic oedema may also result in stridor. In all cases oxygen should be given to maintain adequate saturations. Severe stridor may require a period of ventilation. All cases of infantile stridor need to be thoroughly assessed. Babies with no other symptoms may have a diagnosis of floppy larynx or laryngomalacia. According to emedicine: "Other causes of croup include adenovirus, respiratory syncytial virus (RSV), measles, some enteroviruses, metapneumovirus, and influenza A and B."

Theme: Foot Problems

A. Avascular necrosis of the Talus

B. Charcot's joint

C. Charcot-Marie-Tooth disease

D. Friedreich's ataxia

E. Hallux valgus

F. Morton's neuroma

G. Peripheral neuropathy

H. Pes Cavus

I. Pes Planus

J. Plantar fasciitis

K. Tendon xanthoma

Select the most likely diagnosis that would explain the following clinical scenarios:

13. A 22-year-old male presents with increasing weakness of his foot. He has increasingly been aware of stumbling. His father has a similar problem. On examination there is a loss of the lower muscle bulk of the lower leg and he has an appearance of early clawing of the toes. Charcot-Marie-Tooth disease

The early clawing of the toes (Pes Cavus) with loss of muscle bulk of the lower leg suggests Charcot-Marie-Tooth disease which is an autosomal dominant condition associated with peroneal muscle atrophy. There is often mild sensory loss and as the condition progresses there is hand muscle wasting too.

14. A 22-year-old male with a diagnosis of Reiter's disease presents with pain on walking. He feels that the pain is like 'walking on pebbles'. Plantar fasciitis

This is a good description of Plantar Fasciitis which is associated with seronegative arthropathies such as Reiter's and Ankylosing spondylitis.

15. A 55-year-old male presents with increasing difficulty walking. He has a 25 year history of type 1 diabetes for which he receives insulin. On examination there is a marked loss of sensation to pain/touch in both legs up to the mid calf and there is marked hard swelling of the ankle joint with crepitation and limitation of range of movement. Charcot's joint

This patient with diabetes is likely to have developed Charcot's joint where there is often a painless destruction of the ankle joint. The aetiology is unknown but often results from a combination of vascular dysfunction and neuropathy as in this case. Although this patient has a neuropathy, this is not the most salient feature as the joint disorganisation must be recognised and corrected urgently.

Theme: Diabetes 2

A. Cotton wool spots

B. Drusen

C. Haemorrhages

D. Hard exudates

E. Laser scarring

F. Microaneurysms

G. Neovascularisation

H. Roth's spot

I. Silver wiring

J. Venous beading

K. Venous looping

This 31-year-old woman with type 2 diabetes attends for annual review. Examination reveals evidence of reduced vibration and proprioception senses. Opthalmoscopy is shown.

Please select the correct option corresponding to feature shown for each coloured arrow:

16. Black arrow Microaneurysms

17. White arrow Haemorrhages

18. Blue arrow Cotton wool spots

The slide shows the right eye. There are microaneurysms (black arrows), haemorrhages (white arrows) and cotton wool spots (blue arrows). Cotton wool spots are retinal nerve fibre layer infarcts and represent ischaemia. Ischaemic retina releases vasoactive substances that stimulate new vessel formation hence the description of pre-proliferative when they are seen. They are less distinct than exudates and not as reflective on fundoscopy, they are frequently closely associated with haemorrhages. There are also a couple of hard exudates present at approximately the 9 and 10 o'clock position near the outer black arrow and just between the outer blue and white arrows of the slide.

19. A 27-year-old male with a 14 year history of type 1 diabetes attends clinic complaining of this rash on the anterior aspect of his shins and is concerned as to its nature. The appearances are as shown, it is non tender. Which of the following is the most likely cause of the rash?

A. Erythema nodosum

B. Eczema

C. Granuloma annulare

D. Necrobiosis lipoidica

E. Psoriasis

D is correct. Granuloma annulare is histologically similar to necrobiosis but tends to be more localized often seen on the hands. Both can be treated with topical steroids but are probably best left alone. Erythema nodosum is painful, psoriasis more widespread and eczema found on flexor surfaces most commonly.

20. A 22-year-old male nurse presents to the accident and emergency department following a fight in a pub. In self defence, during a messy brawl between patients, he punched a patient in the face and sustained a deep laceration to his knuckle from his assailant's tooth. After the wound is cleaned and he has received tetanus immunisation, which of the following antibiotic regimes would be most appropriate for this patient?

A. Co-amoxiclav oral

B. Doxycycline oral

C. Flucloxacillin

D. Penicillin G IM

E. Trimethoprim oral

A is Correct. There is little research into this area but human bites are notorious for causing infection. This type of closed fist injury is very susceptible to deep infection because the tendon can be infected at the point of injury and then, when the hand relaxes, it slips back into its sheath and is impossible to fully clean. Broad spectrum antibiotics, typically co-amoxiclav, are used.

Theme: Clinical features of lower limb nerve damage

A. Common peroneal nerve

B. Deep peroneal nerve

C. Femoral nerve

D. Genitofemoral nerve

E. Ilioinguinal nerve

F. Saphenous nerve

G. Sciatic nerve

H. Superficial peroneal nerve

I. Sural nerve

J. Tibial nerve

For each item below select the most appropriate nerve injured:

21. A 16-year-old male was involved in a gang fight and was stabbed in the popiteal fossa. The patient developed a calcaneovalgus deformity of the foot. He is unable to tip toe or invert his foot. He has loss of sensation over his sole. Tibial nerve

The tibial nerve originates from the sciatic nerve and descends through the popiteal fossa through the posterior compartment of the leg and divides into medial and lateral plantar nerves. It supplies the posterior leg muscles and knee.

22. A 65-year-old female with osteoporosis undergoes a total hip replacement. After the operation she is unable to dorsiflex and plantarflex her foot, she also has loss of sensation over the lateral aspect of her leg. Sciatic nerve

The sciatic nerve originates from the sacral plexus and enters the gluteal region and descends along posterior aspect of thigh. It divides into the tibial and common peroneal nerve. It supplies the hamstrings and supplies the hip and knee.

23. A 28-year-old male suffered a motorcycle accident and dislocated his knee. He is unable to dorsiflex his foot and toes, and has foot-drop and a high stepping gait. There is loss of sensation over dorsum of foot. (Suplies anterior compartment of the leg) Common peroneal nerve

The common peroneal nerve originates from the sciatic nerve and divides into the superficial and deep peroneal nerve. This nerve is the most commonly injured as it winds superficially around the neck of fibula, which can be injured if the neck of fibula fractures.

Theme: Hand Signs on examination

A. Clubbing

B. Heberden’s nodes

C. Hypothenar wasting

D. Janeway lesions

E. Koilonychia

F. Onycholysis

G. Peripheral Cyanosis

H. Raynaud’s phenomenon

I. Thenar wasting

J. Thin skin

K. Wrist drop

From the above list of options select the most likely physical sign you might expect to find in the following cases.

24. A 32-year-old female presents with a six month history of depression, weight gain and has developed diabetes. On examination she has a proximal myopathy and obvious central adiposity. Thin skin

The 32-year-old woman presents with symptoms of Cushing’s syndrome; a common finding in these patients is thin skin particularly noticeable on the back of the hands which is a result in the increased production of steroid. Other features include interscapular fat pad, easy of bruising and abdominal striae.

25. A 56-year-old male presents with a six month history of nocturnal tingling in the right hand. He works on the highways and uses vibrating tool. He has to get up some nights and shake his hand to obtain relief. He has also noticed some weakness of grip. Thenar wasting

The collection of symptoms in the 56-year-old male indicates that this patient is suffering with carpal tunnel syndrome which is the most common entrapment neuropathy resulting from pressure on the median nerve as it passes through the carpal tunnel. It is usually idiopathic but can be associated with hypothyroidism, diabetes mellitus, pregnancy and obesity. As it is the median nerve that supplies the thenar muscles, wasting of these muscles is often a feature.

26. A 56-year-old female presents with a four month of weakness, fatigue and dysphagia. She finds problems swallowing and has soreness on the sides of her mouth. Koilonychia

The symptoms described in the 56-year-old female are a result of anaemia, the sore corner of the mouth is known as angular stomatitis. The dysphagia is the result of a rare complication whereby pharyngeal webs occur known as Paterson-Kelly-Brown syndrome. A typical hand finding in patients with anaemia is koilonychias which are spoon shaped nails.

27. A 42-year-old male has a flare up of plaque psoriasis. Onycholysis

The 42-year-old male has psoriasis which presents as well demarcated, salmon pink silvery scaling lesions on the extensor surfaces of the limbs. Onycholysis is when the nails begin to separate from the underlying vascular bed, and a sign often found in these patients.

Theme: Depressive symptoms

A. Calcium concentration

B. B12 concentration

C. CT headscan

D. Full blood count

E. LH and FSH concentrations

F. Lipid concentrations

G. Liver function tests

H. MSU culture and sensitivity

I. Plasma glucose

J. Pregnancy test

K. Thyroid function tests

L. Urea and electrolytes

Select the single investigation that is most likely to help with the diagnosis in the following patients who present with depressive symptoms.

28. A 42-year-old female presents with a three month history of tiredness, feeling down with irregular and heavy periods. She confesses to consuming more alcohol over the last two months than she ought. Full blood count

The heavy and irregular periods in this woman with the tiredness suggest that the patient is likely to be anaemic. If hypothyroidism were the cause of the heavy periods then weight gain may also be volunteered in the question but even so the first investigation would probably be an FBC.

29. A 55-year-old female presents with feeling down, tingling in the right hand particularly at night and over the last six months she has noticed a weight gain of 6 kg. You discover that her last period was three years ago but that she is unaware of any flushes. Thyroid function tests

This 55-year-old female has weight gain, depression, and has been aware of nocturnal tingling in the right hand (Carpal tunnel syndrome). These features are typical of hypothyroidism and TFTs should be diagnostic.

30. A 15-year-old female presents with a three month history of depression, poor appetite and secondary amenorrhoea and weight gain. Her parents inform you that she has not ventured out over the last two months and she has lost interest in her school work. Pregnancy test

This 15-year-old with marked introspective symptoms, weight gain and amenorrhoea is likely to be pregnant. Pregnancy is always the first on the differentials list in amenorrhoea

31. A 65-year-old male presents with chronic productive cough and dyspnoea. He is a smoker of 10 cigarettes per day and has smoked for 30 years. How many pack years does this equate to?

A. 15

B. 30

C. 100

D. 300

E. 3000

A is correct. Pack year is calculated by smoking the number of packs of cigarettes per day (20 cigarettes in one pack) times the number of years of smoking. In this case the patient has a 15 pack year history (1/2 x 30 = 15). This is a tool to help standardise tobacco exposure and hence estimate risk.

32. This 73-year-old female presented with facial pain and this rash. Which of the following nerves is affected in this case by her rash?

A. Facial Nerve

B. Oculomotor Nerve

C. Ophthalmic Nerve

D. Trigeminal Nerve

E. Vagus Nerve

D is correct. This patient has the typical vesicular rash of shingles and this is in the distribution of the trigeminal nerve. Sequelae of trigeminal nerve herpes zoster include trigeminal neuralgia, corneal ulceration (corneal division of trigeminal nerve) and postherpetic neuralgia.

Theme: Diabetic and hypertensive retinopathy findings at fundoscopy

A. Advanced diabetic retinopathy

B. Background diabetic retinopathy

C. Diabetic maculopathy

D. Hypertensive retinopathy Grade 1

E. Hypertensive retinopathy Grade 2

F. Hypertensive retinopathy Grade 3

G. Hypertensive retinopathy Grade 4

H. Pre-proliferative retinopathy

I. Proliferative retinopathy

Select the most appropriate diagnosis from each of the following fundoscopic examination findings:

33. There is silver wiring of arteries and arteriovenous nipping Hypertensive retinopathy Grade 2

Hypertensive retinopathy is classified according to Keith-Wagener grades. Grade 1 is indicated by tortuosity and silver wiring of the arteries. Grade 2 has 'av' nipping as well as those from grade 1. Grade 3 has features of grade to as well as flame-shaped haemorrhages and cotton wool spots (sometimes called soft exudate). Grade 4 has features of grade 3 as well as papilloedema.

34. There are dot haemorrhages and some new vessels appear at the disc Proliferative retinopathy

Proliferative retinopathy requires urgent referral. It's hallmark is neovasularisation which has been initiated from retinal infarcts. In advanced retinopathy the patients usually have visual loss and have retinal fibrosis and retinal detachment.

35. There are two dot haemorrhages and two hard exudates in the peripheral fundus Background diabetic retinopathy

Virtually all older patients with diabetes will have background diabetic retinopathy at presentation. It is not a threat to vision but does lead to vision threatening retinopathy therefore patients will require yearly follow up. Background retinopathy consists of dot haemorrhages which are in fact microaneurysms, blot haemorrhages and hard exudates.

36. There are dot and blot haemorrhages with hard exudate and cotton wool spots (soft exudate) Pre-proliferative retinopathy

The hallmark of pre-proliferative retinopathy are those of background retinopathy with cotton wool spots which is oedema from retinal infarcts. Patients will require non-urgent referral to ophthalmologist.

37. There is silver wiring of arteries with arteriovenous nipping, with scattered flamed and papilloedema Hypertensive retinopathy Grade 4

Grade 3 and 4 hypertensive retinopathy are diagnostic of malignant hypertension. Patients require immediate admission to hospital with the aim to reduce diastolic pressure to 100 mmHg over 1-2 days, and then normalised over the next 2-3 days. A too rapid decrease in pressure would result to cerebral, renal, retinal or myocardial infarction.

Theme: Clinical features of upper limb nerve damage

A. Inferior brachial plexus injury

B. Median nerve

C. Musculocutaneous nerve

D. Radial nerve

E. Superior brachial plexus injury

F. Ulnar nerve

For each item below select the most appropriate nerve injured:

38. Following injury, a 20-year-old male presents with weakness of elbow flexion and supination. There is loss of sensation over lateral surface of forearm. Musculocutaneous nerve

The musculocutaneous nerve supplies the coracobrachialis, biceps and brachialis muscle. It also supplies sensation to the lateral surface of forearm by the lateral antebrachial cutaneous nerve.

39. A 52-year-old diabetic male presents with weakness of elbow extension and he has an inability to extend wrist resulting in wrist-drop. Radial nerve

The radial nerve supplies the triceps, brachioradialis, supinator and extensor muscles of wrist and digits.

40. A 42-year-old male with polyarteritis nodosa presents with weakness of the thenar muscles and adjacent two lumbricals. He has an inability to oppose the thumb with little finger. You also note a loss of sensation over thumb and index, middle and lateral half of ring finger. Median nerve

The median nerve supplies the lateral two lumbricals, opponens pollicis, abductor pollicis and flexor pollicis brevis.

41. A 42-year-old male presents following injury with a loss of sensation over the medial one and half fingers. You also note weakness of adduction of the thumb as well as small muscles of hand and the hand assumes a claw appearance. Ulnar nerve

The ulnar nerve supplies all small muscles of the hand except for LOAF which are supplies by the median nerve.

42. You see a 16-year-old male who following a birth injury has a right arm weakness with the assumption of a waiter's tip position. Superior brachial plexus injury

The superior brachial plexus may become injured during motorcycle accidents or due to excess stretching on a newborn's arm.

Theme: Specificity

A. 0.4

B. 0.5

C. 4/7

D. 0.6

E. 2/3

F. 0.75

G. 0.8

H. 1

I. 10

J. 20

A new urine test for chlamydia has been developed which allows near patient testing using a urinary dipstick. To evaluate the test, it is compared with laboratory based nucleic acid amplification techniques from vaginal swabs, which is considered the “gold standard”. The following table shows the results of this comparison.

Lab test +ve Lab test -ve

New test +ve 40 30

New test -ve 10 20

43. What is the sensitivity of the new test? 0.8

Sensitivity is a measure of how good the test is at detecting those with the disease. It is calculated by dividing the number of true positives (in this case, 40) by the total number of people with the disease (50). 40/50 = 0.8.

44. Calculate the specificity 0.4

Specificity is a measure of how good a test is at correctly excluding those without the disease. It is calculated by dividing the number of true negatives (in this case, 20) by the total number of people without the disease (50). 20/50 = 0.4.

45. What is the positive predictive value? 4/7

The positive predictive value is a measure of the likelihood of a person testing positive for a disease actually having it. It is calculated by dividing the number of true positives (40) by the total number of people testing positive (70). 40/70 = 4/7.

46. What is the negative predictive value? 2/3

The negative predictive value is a measure of the likelihood of a person testing negative for a condition not actually having it. It is calculated by dividing the number of true negatives (20) by the total number of people testing negative (30). 20/30 = 2/3.

Screening test statistics
It would be unusual for a medical exam not to feature a question based around screening test statistics. The vailable data should be used to construct a contingency table as below:

Disease present
Disease absent
Predictive value

Test positive
TP = (A)
FP = (C)

Test negative
FN = (B)
TN = (D)

Sensitivity (Sn)

TP = true positive; FP = false positive; TN = true negative; FN = false negative

Sn = A / A + B

Sp = D / D + C

PPV = +ve Predictive value = A / A + C

NPV = -ve Predictive value = D / D + B

Odds +ve = C / A — C

Odds –ve = D / B — D

Probability of the disease if the patients have a +ve test result = 1— [Odds+ve / Odds —ve]

LR +ve = Sn / [1—Sp]

LR -ve = [1—Sn] / Sp

RRR = Relative Risk Reduction = [EER — CER]/CER

EER = Experimental event rate

CER = Controlled event rate

ARR = Absolute Risk Reduction = EER — CER

NNT = Number needed to treat = 1 / ARR

47. A 62-year-old male presents with weakness of the right hand. You note global wasting of the small hand muscles, there is also sensory loss over the medial border of the forearm around the elbow. Which nerve root is damaged?

A. C5

B. C6

C. C7

D. C8

E. T1

E is correct. This patient has Klumpkes paralysis due to damage to the T1 nerve root. This root eventually supplies the median and ulnar nerves. The ulnar nerve supplies all of the intrinsic hand muscles except for those of the thenar eminence and the 1st and 2nd lumbricals which are innervated by the median nerve.

48. A 22-year-old man returned from a trip to West Africa 2 days ago. He is complaining of multiple painful ulcers on his penis. He admits to having unprotected sex with a local woman a few days before he left the country. On examination there are multiple ulcers on his penis, they have a purulent base and bleed when they are touched, the edges are undermined. He has left sided inguinal lymphadenopathy. Which of the following is the most likely diagnosis?

A. Chancroid

B. Herpes zoster infection

C. Herpes simplex infection

D. Lymphogranuloma venereum

E. Trauma

A is correct. This is the classical description of chancroid which is caused by the gram negative bacillus Haemophilus ducreyi. Most common in the tropics the incubation period is 3-10 days and the ulcers described in this case are typical although they may also affect the anal region and may be solitary. This patient should be treated with appropriate antibiotics such a ciprofloxacin and screened for other STI’s including HIV. Lymphogranuloma venereum is caused by Chlamydia trichomatis and presents with a small usually solitary ulcer that may be painless and can be associated with urethritis and proctitis. HSV and HZV both present with multiple painful ulcers but the incubation period is typically longer.

49. A 22-year-old man returned from a trip to West Africa 2 days ago. He is complaining of multiple painful ulcers on his penis. He admits to having unprotected sex with a local woman a few days before he left the country. On examination there are multiple ulcers on his penis, they have a purulent base and bleed when they are touched, the edges are undermined. He has left sided inguinal lymphadenopathy. Which of the following is the most likely diagnosis?

A. Chancroid

B. Herpes zoster infection

C. Herpes simplex infection

D. Lymphogranuloma venereum

E. Trauma

A is correct. This is the classical description of chancroid which is caused by the gram negative bacillus Haemophilus ducreyi. Most common in the tropics the incubation period is 3-10 days and

the ulcers described in this case are typical although they may also affect the anal region and may be solitary. This patient should be treated with appropriate antibiotics such a ciprofloxacin and screened for other STI’s including HIV. Lymphogranuloma venereum is caused by Chlamydia trichomatis and presents with a small usually solitary ulcer that may be painless and can be associated with urethritis and proctitis. HSV and HZV both present with multiple painful ulcers but the incubation period is typically longer.

50. A 55-year-old man who has sex with men presents with general malaise, right upper quadrant pain and yellowing of the eyes. He has had multiple casual sexual partners in the preceding months and admits to not always using a condom. He has had no recent foreign travel. On examination he is jaundiced, he is tender in the right upper quadrant and you can just feel a liver edge. Which of these is the most likely infection?

A. Cytomegalovirus

B. Epstein-Barr Virus

C. Hepatitis A

D. Hepatitis B

E. Hepatitis C

D is correct. Although cytomegalovirus (CMV)and Epstein-Barr virus (EBV) can both cause hepatitis these viruses have usually been encountered by the age of 55 making the diagnosis of acute infection unlikely. Hepatitis A is possible but unlikely with no history of travel. Although hepatitis C can be spread sexually the prevalence among men who have sex with men is much lower than the prevalence of hepatitis B. The fact that hepatitis B is more transmissible by the sexual route than hepatitis C also makes hepatitis B the more likely diagnosis. There is a 5-10% chance that he will become a chronic carrier.

51. A 30-year-old woman presents to her GP in London with a week long history of an offensive smelling greenish-yellow vaginal discharge with associated vulval itching. She does not complain of lower abdominal pain. She is unkempt and admits to sleeping on the streets. She refuses your request that she should be seen at the local GUM clinic. Examination reveals a greenish-yellow discharge but is otherwise unremarkable. Treatment of which of the following should be prescribed for this woman?

A. Bacterial vaginosis

B. Chlamydia trachomatis

C. Gonorrhoea

D. Trichomonas vaginalis

E. All of the above

E is correct. When laboratory support is not available the World Health Organization recommends syndromic management based only on signs and symptoms and in this case this suggests treating all of these possibilities. Vaginal discharge is poorly predictive of the presence of an STI and this woman may have any or all of the conditions. Trichomoniasis is the most common worldwide non-viral STI and is commoner in less advantaged women in affluent countries. The possibility of Chlamydia trachomatis and gonorrhoea is dependent on a risk assessment based on local factors.

52. In a study of 26000 females, 1300 subjects were found to have either overt or subclinical hypothyroidism. Within this group, the risk of demonstrating either overt or subclinical hypothyroidism was therefore 5%. What is the best descriptive term of this 5% risk?

A. Absolute risk

B. Incidence

C. Prevalence

D. Relative risk

E. Specificity

C is correct. This is the risk of either subclinical or overt hypothyroidism in a female population at any specific time which is the prevalence. This is defined as the rate of a disorder in a specified population at a specified time. Incidence refers to the number of new cases of a disorder developing over a specific time.

53. A 52-year-old male presents with a two month history of exertional chest pain. You consider a diagnosis of ischaemic heart disease. Which three of the following risk factors are the most important modifiable risk factors in the treatment of ischaemic heart disease?


B. Family history

C. Glycaemic control in diabetes

D. Hypercholesterolaemia

E. Hypertension

F. Hypertriglyceridaemia

G. Smoking

H. Weight

D, E G are correct. Of the modifiable risk factors (family history is not modifiable), the most important three are smoking, hypertension and hypercholesterolaemia. Diabetes is not a modifiable risk factor per se, and glycaemic control is of little impact on cardiovascular risk as demonstrated by UKPDS compared with treating hypercholesterolaemia and blood pressure. Similarly, there is little evidence to link either BMI or weight with increased cardiovascular risk hence no use of these in Framingham risk equations.

54. A 41-year-old male presents with concerns about his penis. Whilst examining himself he noticed that he had a hard nodule in the shaft of his penis and has been concerned. His erectile function is normal but he is aware of some discomfort in his penis during intercourse. On examination you note that he has a firm fibrous nodule in the mid-shaft of his penis with no other abnormalities noted. Which of the following is the most likely diagnosis?

A. Dermatofibroma

B. lipoma

C. Lymphoma

D. Peyronie's disease

E. Sarcoma of penis

D is correct. This otherwise well man has co-incidentally noted a nodule in the mid shaft of his penis with no other abnormalities. This is suggestive of Peyronnie's disease, with initially the patient being unaware of any deviation in his penis. Peyronnie's is quite common ~1-3% of the population is often asymptomatic but can be associated with erectile dysfunction or painful intercourse due to curvature.

55. A father requests access to his 15-year-old son’s medical records. He is in the process of separating from his son’s mother, and they have been married for twenty-five years. What is the most appropriate action in this case?

A. Disclose the complete record with permission of the mother

B. Disclose the complete records to the father

C. Disclose the record, omitting third party information about the mother

D. Seek consent from the son, and if he is competent, disclose the entire record to the son, his mother, and father

E. Seek consent from the son, and if he is competent, disclose only information that is not prejudicial to a third party with his consent.

E is correct. A 15-year-old adolescent should generally be consulted regarding a request for disclosure of their confidential medical record. The maturity of an adolescent may vary, but if they are considered to be ‘Gillick’ competent, then a practitioner can respect their decision to disclose or withhold disclosure of their medical record. It is important that a practitioner consider carefully any third party information contained within the record, and any information which may be considered to cause serious harm to an individual’s physical or mental health. This information may be withheld under the provisions of the Data Protection Act 1998.

Question supplied by the Medical Defence Union.

56. The aunt of a toddler requests that the child be given the MMR vaccination. She says that she is the child’s paternal aunt, and that she knows her brother wants his daughter to receive the vaccine. What is the most appropriate action in this situation?

A. Give the child the MMR vaccine

B. Decline to give the vaccination and ask that the child attend with social services for the MMR vaccine

C. Decline to give the vaccination ask that the aunt request the father to attend with the child

D. Decline to give the vaccination request that the child attend for the MMR vaccine with a person with parental responsibility

E. Decline to give the vaccination without further explanation

D is Correct. Authorisation for administration of a routine medicine may be given by a person who has parental responsibility for a child defined under the Children Act 1989. It is not clear in this scenario whether the father actually has parental responsibility, or whether social services would have parental responsibility. If parents are unmarried, the father has no legal responsibility, for the child (just for maintenance payments!) Parental responsibility Question supplied by the Medical Defence Union.

57. A few years ago, the Royal College of GPs were criticised by a BBC television programme because they had never had an examination question relating to Kawasaki disease. Although this is a rare condition, would you be able to spot it? Which one of the following features is not a feature of Kawasaki disease?

A. Cervical lymphadenopathy

B. Non-exudative bilateral conjunctivitis

C. Raised temperature, which does not respond to antipyretics and lasts > 5 days

D. Small infarctions at the growth plate of long bones

E. Strawberry tongue

D ic correct. Kawasaki disease is a rare acute vasculitic syndrome first described in 1967. The aetiology is unknown but thought to be due to infective cause. There are no specific diagnostic tests and diagnosis is primarily clinical. The acute stage there are 5 of the 6 major CRESTS signs:

C – Cervical lymphadenopathy

R – Widespread polymorphic Rash

E – Eye signs – Non exudative bilateral conjunctivitis

S – Strawberry tongue (red and prominent papules). Other mucocutaneous signs include pharyngitis and fissured lips.

T – Raised temperature which does not respond to antibiotics or antipyretics and persists for >5 days

S – Sausage-like fingers due to oedema of the extremities

There may be raised inflammatory markers and a mild normochromic normocytic anaemia. Cardiac pathology (coronary aneurysms, thrombosis, myocarditis and arrhythmias) follows the subactute phase on days 11 to 21. This is the stage where desquamation of the skin from digital tips may occur. Earlier diagnosis and treatment is associated with lower mortality and morbidity. Acute stage treatment includes aspirin and IV gammaglobulins. Aneurysms <4mm may regress, but some patients may require cardiac catheterisation, CABG or even transplant.

Theme: Head and neck swellings

A. Branchial cyst

B. Carotid body tumour

C. Cystic hygroma

D. Lymphoma

E. Parotid adenolymphoma

F. Parotid pleomorphic adenoma

G. Submandibular tumour

H. Submandibular duct calculus

I. Thoracic outlet syndrome

J. Thyroglossal cyst

Which of the head and neck lesions above best matches with the case scenarios below?

58. A 63-year-old man is referred with a long-standing and slow-growing painless swelling overlying her left mandible. On palpation the lesion is firm and non-tender, and there is no facial nerve damage evident. Parotid pleomorphic adenoma

Pleomorphic adenomas are the commonest parotid tumours (75%) and the vast majority are in the superficial gland. They typically have a smooth edge and irregular surface. They should be excised carefully taking care not to rupture the tumour as it can seed and regrow. Pleomorphic adenomas have a small risk of malignant transformation if left longterm.

59. A 62-year-old woman asylum seeker from Tibet presents with a painless mass on the right side of her neck lying just anterior to the sternocleidomastoid. On examination, a nontender mass is palpated in close relation to the carotid artery. Carotid body tumour

Carotid body tumours usually present as painless masses but occasionally may compress the vagus or hypoglossal nerves causing dysphagia, hoarseness, stridor, or weakness of the tongue. They are more common in people living at high altitude. The majority (90%) are spontaneous of which are 5% bilateral but in familial cases (10%), 30% are bilateral. Treatment is surgical excision.

60. A 76-year-old man is seen with multiple non-tender masses on both sides of his neck. He also reports weight loss, lethargy and night sweats. The lesions have a rubbery consistency and vary between 2 and 4 cm in diameter. Lymphoma

Patients with lymphadenopathy and constitutional symptoms must be regarded as having a lymphoma until proven otherwise. All head and neck lymphadenopathy must undergo FNA to exclude a squamous carcinoma prior to excsion. However, FNA is often inadequate for diagnosis of lymphoma and an excision biopsy is required for characterisation of lymphoma and planning of chemotherapy.

61. A 19-year-old woman is seen in the clinic with a mass on the right side of his neck. It is asymptomatic but the increasing size is of concern to her as a result of its cosmetic effect. On inspection the mass appears to be medial to the sternoclediomastoid muscle and on palpation is soft and non-tender. Branchial cyst

Branchial cysts are congenital defects related to incomplete obliteration of the 2 or 3 branchial clefts. If left, the cyst may become infected form an abscess then discharging leading to a branchial fistula. Cysts should be excised in continuity with their tract taking care not to damage adjacent structures such as the facial nerve.

62. A 32-year-old woman presents with a swelling in the midline of the neck. The lesion has been present for many years and has not changed significantly in size. On examination it is firm to touch and is displaced vertically when the patient protrudes her tongue. Thyroglossal cyst

Thyroglossal cysts develop as a consequence of failure of obliteration of the thyroid tract and cysts may occur anywhere from the foramen cecum to the thyroid isthmus – most are infrahyoid. The cyst should be excised in continuity with the tract and body of hyoid to prevent recurrence.

Theme: The acute abdomen

A. Acute appendicitis

B. Acute cholecystitis

C. Acute pancreatitis

D. Ascending cholangitis

E. Gastroenteritis

F. Peptic ulcer

G. Pyelonephritis

H. Renal colic

I. Ruptured abdominal aortic aneurysm

J. Small bowel obstruction

For each patient described below presenting with acute abdominal pain, choose the single most likely pathology responsible for the symptoms and signs

63. An 8-year-old boy is admitted with a 6 hour history of worsening right lower quadrant. It started around the umbilicus and is now localising to the right iliac fossa. He is anorexic and has vomited on several occasions. On examination he is pyrexial and there is rebound tenderness in the right iliac fossa. Acute appendicitis

Acute appendicitis is a clinical diagnosis and requires an appendicectomy to relieve the symptoms. A FBC to look for a raised WBC and a CRP may be useful. Imaging with USS or CT is limited to atypical presentations. In children, mesenteric adenitis needs to be excluded – history of viral illness and cervical lymphadenopathy. The diagnosis may be difficult to establish in young woman due to a plethora of gynaecological conditions with similar symptoms.

64. A 7-year-old girl is referred by her GP with diffuse colicky abdominal pain, offensive diarrhoea and vomiting. Her mother tells you that 3 of her daughters’ friends have been off school with similar symptoms. Gastroenteritis

In children with gastroenteritis there are often a number of friends or family affected by the illness. In adults, there is frequency an index meal preceding the symptoms. All cases require stool culture to exclude a bacterial cause which may require antibiotic therapy. Most cases settle spontaneously and simply require advice on supportive hydration.

65. A 72-year-old man is rushed into A&E having collapsed complaining of acute onset severe back pain whilst out shopping. On examination he is hypotensive and there is pulsatile central abdominal mass. Ruptured abdominal aortic aneurysm

The presentation of ruptured aneurysms is often with severe back pain such as described but may be atypical with iliac fossa pain. In the past, presentation with rupture was common but the development of screening programs is changing the presentation, and patients are now younger and fitter and undergo planned operations with much better outcome.

66. A 64-year-old woman is seen in clinic with epigastric pain which is exacerbated by eating. The pain lasts for an hour after meals and then settles. She gains some relief from antacids. Examination is unremarkable. Peptic ulcer

Peptic ulcers are seen less commonly in the acute setting due to widespread use of proton pump inhibitors. When suspected, patients should undergo a confirmatory OGD with biopsy of suspicious ulcers (usually gastric) and a biopsy taken for Helicobacter pylori status. Those who are H. pylori positive should receive eradication therapy and other patients should be treated with a proton pump inhibitor. A repeat OGD is indicated to ensure healing.

67. A 38-year-old woman who had previously undergone an emergency appendicectomy for perforated appendicitis is admitted as an emergency with colicky central abdominal pain, distension and obstipation of 12 hours duration. On examination there is mild tenderness and bowel sounds are high pitched. Small bowel obstruction

The commonest causes of SBO are adhesions, hernias and malignancy. Most cases of SBO may be managed non-operatively initially, by ‘drip and suck’ which entrails and NG tube and IV rehydration. If there are no previous operations – a ‘virgin abdomen’ then this should be limited to 24 hours. If there are signs of peritonism at any time, a laparotomy is indicated urgently.

Theme: Hernias

A. Direct inguinal

B. Epigastric

C. Femoral

D. Hiatal

E. Incisional

F. Indirect inguinal

G. Parastomal

H. Paraumbilical

I. Spigelian

J. Umbilical

Which of the above hernias best fits the clinical cases presented below?

68. A 2 month baby girl presents with a bulging of her umbilicus. She does not appear to be distressed by the swelling which becomes more prominent as she plays. On examination there is a soft reducible swelling. Umbilical

True umbilical hernias occur mainly in childhood and represent a failure of full closure of the umbilical cicatrix. In infants, the majority close spontaneously if left and so the management in the absence of symptoms is watch and wait. In adults umbilical hernias may occur as a result of increasing abdominal pressure and weakening of the cicatrix e.g. malignancies, ascites, multiple pregnancies or peritoneal dialysis.

69. A 48-year-old heavy manual worker attends the clinic with a bulge in his right groin. The swelling appeared acutely after trying to lift a heavy weight. On examination he is obese and has nicotine-stained fingers. He has a reducible, non-tender swelling with a positive cough impulse. Direct inguinal

The history is classical for a direct hernia – others include COPD and appendicectomy (this may damage the ilioinguinal nerve). The hernia arises as a result of weakness of the transversalis fascia in and area known as Hasselbach’s triangle. They may be difficult to distinguish from indirect hernias. All symptomatic hernias should be repaired.

70. An 8-year-old boy is seen in the clinic complaining of intermittent swelling and aching in his upper abdominal. On examination he points to an area midway between the xiphoid process and the umbilicus. No mass is present but there is an area of weakness and a positive cough impulse. Epigastric

Epigastric hernias usually occur in children and young adults and represent a defect in the linea alba. They have narrow necks and are prone to obstruction and as such should be electively repaired.

71. A 28-year-old woman presents to the clinic with a non-tender swelling in her lower abdomen. Her only past history is of a Caesarean section 2 years previously. On examination she has a non-tender swelling closely related to her incision. Incisional

Incisional hernias are common and there are numerous predisposing factors including:

Malnutrition (Protein, Vitamin C, Zinc); Jaundice; Uraemia; COPD; Smoking; Obesity; Steroids; Post-Operative (Distension, Wound Infection, Haematoma); Poor Technique (Suture Type; Suture Placement). Most Incisional Hernias Should Be Repaired To Prevent incarceration and obstruction.

Theme: Skin and subcutaneous lesions

A. Ganglion

B. Hidradenitis suppurativa

C. Hypertrophic scar

D. Keloid scar

E. Lipoma

F. Onychogryphosis

G. Onychocryptosis

H. Pyogenic granuloma

I. Sebaceous cyst

J. von Recklinghausen’s disease

For each of the cases described below select the most appropriate condition from the list above.

72. A 21-year-old man attends his GP with a condition affecting his left 1st toe which he describes as a ‘rams horn’. It has been progressively getting worse and is rubbing on his shoe but it is not tender. Onychogryphosis

Onychogryphosis is a benign condition characterised by over-proliferation of the germinal matrix leading to excessive growth of the nail plate. Treatment is by means of a Zadik’s procedure – avulsion of the nail and ablation of the nail bed.

73. A 19-year-old woman attends the clinic for follow-up 6 weeks after an emergency appendicectomy. Her recovery was unremarkable but she is concerned about a prominent but flat scar. Hypertrophic scar

A hypertrophic scar is a response to healing in which there is prominent scarring which is painless and remains confined to the scar. Hypertrophic scars appear soon after surgery and often regress spontaneously without any treatment.

74. A 62-year-old woman attends the clinic with a tense, painless swelling over the flexor tendon of the 2nd finger of her left hand. It has been present for many years and has been growing slowly but is now catching on the handle of her tea cup. Ganglion

A ganglion is a benign lesion although it remains uncertain as to whether it is a tumour of the joint capsule/tendon sheath or a degenerative process of these structures. Ganglia are also seen over the dorsum of the wrist and foot, and peroneal tendons. They can be excised under LA but up to 1/3 recur.

75. A 9-year-old boy is seen in the clinic with a 1cm pedunculated lesion on his forearm. It has been catching on his clothes and bleeding frequently. Pyogenic granuloma

Pyogenic granulomas are usually seen is in children and young adults on the hands and face and pregnant women develop lesions on their lips and gums. The name is a misnomer (initially believed to be a granulation response to infection) and they are in fact benign capillary haemangiomas. The lesion should be treated by curettage and diathermy of the base.

76. A 35-year-old man is referred with a soft fleshy lesion around his ankle which is rubbing on his shoe. When seen in the clinic it is observed that he has dozens of similar lesions over his body and he also has numerous pigmented lesions over his torso. von Recklinghausen’s disease

The combination of fleshy lumps which are neurofibromas and café au lait spots (> 6 patches) is typical of von Recklinghausen’s disease or neurofibromatosis Type II (Type I = acoustic neuromas and sparse skin lesions). Other findings include multiple freckles over the torso and axillae and areas of depigmentation. May be associated with: multiple endocrine neoplasia IIb (medullary carcinoma of thyroid & phaeochromocytoma); glioma; and meningioma. It is autosomally dominantly inherited. Symptomatic lesions can be excised. There is a 10% risk of malignant change.

Theme: Head and neck swellings - 1

A. Branchial cyst

B. Carotid body tumour

C. Cystic hygroma

D. Lymphoma

E. Parotid adenolymphoma

F. Parotid pleomorphic adenoma

G. Submandibular tumour

H. Submandibular duct calculus

I. Thoracic outlet syndrome

J. Thyroglossal cyst

Which of the head and neck lesions above best matches with the case scenarios below.

77. A 14-year-old boy is seen in clinic with a swelling on the left side of his neck. On inspection it is seen to lie medial to the sternoclediomastoid muscle and is soft to palpation. Branchial cyst

Branchial cysts are congenital defects related to incomplete obliteration of the 2 or 3 branchial clefts. If left, the cyst may become infected form an abscess then discharging to form a branchial fistula. Cysts should be excised in continuity with its tract taking care not to damage adjacent structures such as the facial nerve.

78. A 23-year-old woman is seen with a swelling in the midline of the neck. The lesion is firm to touch and is displaced vertically when the patients protrudes her tongue. Thyroglossal cyst

Thyroglossal cysts develop as a consequence of failure of obliteration of the thyroid tract and cysts may occur anywhere from the foramen cecum to the thyroid isthmus – most are infrahyoid. The cyst should be excised in continuity with the tract and body of hyoid to prevent recurrence.

79. A 16-year-old boy presents with a swelling on the left side of the neck. The swelling has been present since birth but is now causing social ridicule. On examination the swelling is soft, fluctuant swelling which is compressible and which transilluminates brilliantly. Cystic hygroma

Cystic hygromas represent hamartomas of the jugular lymphatics. They may enlarge quickly because of haemorrhage and then develop secondary infection or compress local structures e.g. oesophagus causing dysphagia or trachea leading to dyspnoea. Treatment is by excision although this is often difficult due to their location.

80. A 76-year-old woman is referred with a slow-growing painless swelling overlying her left mandible. On palpation the lesion is firm and there is no nerve damage evident. Parotid pleomorphic adenoma

Pleomorphic adenomas are the commonest parotid tumours (75%) and the vast majority are in the superficial gland. They typically have a smooth edge and irregular surface. They should be excised carefully taking care not to rupture the tumour as it can seed and regrow. Pleomorphic adenomas have a small risk of malignant transformation if left longterm.

81. A 60-year-old woman presents with bilateral cervical masses. She reports lethargy and night sweats. The lumps measure between 2 and 4 cm in diameter and have a rubbery consistency. Lymphoma

Patients with lymphadenopathy and constitutional symptoms must be regarded as having a lymphoma. All head and neck lymphadenopathy must undergo FNA to exclude a squamous carcinoma. However, FNA is often inadequate for diagnosis of lymphoma and an excision biopsy is required for characterisation of lymphoma and planning of chemotherapy.

Theme: Lower Limb 1

A. Abdominal aortic aneurysm

B. Aorto-iliac occlusive disease

C. Arterial ulceration

D. Critical ischaemia

E. Femoral embolus

F. Femoral pseudoaneurysm

G. Intermittent claudication

H. Popliteal artery aneurysm

I. Varicose veins

J. Venous ulceration

Match the case histories below to the vascular conditions indicated above.

82. A 84-year-old man is seen in clinic with severe calf pain which is limiting his mobility to 10 yards. The pain is also occurring at rest and disturbing his sleep. On examination there are areas of skin breakdown over the tips of his 1st and 2nd toes and over his heel. Critical ischaemia

Critical ischaemia such as described in this case is defined by one or more of: persistent rest pain for a minimum of 2 weeks; ulceration; or gangrene in conjunction with an ankle systolic blood pressure less than 50 mm Hg. The ABPI in critical ischaemia varies from 0.3- 0.6 if there is rest pain only, down to < 0.3 by the time ulceration has developed. The acute issue is pain control following which the patient must be imaged to see if they are a candidate for reconstruction. If not an amputation may be appropriate.

83. A 60-year-old man is seen following investigation in the urology clinic where an ultrasound for haematuria had revealed an incidental vascular pathology. On examination he has a prominent aortic pulsation. Abdominal aortic aneurysm

Abdominal aortic aneurysms (AAA) are common, with a prevalence of 7.5% in men aged over 65 years. With increased use of ultrasound and with the development of screening, smaller asymptomatic AAAs are now being identified allowing planned elective surgery. Risk factors for AAAs are the same as for atherosclerosis namely: male gender; hypertension, elevated lipids; smoking. Patients with AAAs should be offered repair when the AAA is > 6cm.

84. A 64-year-old man is seen with abrupt onset pain in his left lower limb below the level of the knee. He has previously had no problems with claudication. On examination his left pedal pulses were absent but the popliteal pulse was prominent. Popliteal artery aneurysm

Popliteal artery aneurysms share the same aetiology as AAAs. They may be incidental findings or present with thrombosis and distal embolisation such as this case. Rupture is less common than with AAA. 85% of patients will have a AAA and 50% are bilateral. Symptomatic popliteal aneurysms should be repaired but the treatment if incidental ones is less certain.

85. A 57-year-old woman is seen as an emergency with pain and parasthesiae of the right lower limb. She suffers from AF but has never reported any claudication. On examination the limb is cold and pale, there is no spontaneous movement and pulses are absent. Femoral embolus

The presentation of acute vascular ischaemia is with the 6 Ps pain, pallor pulselessness, parasthesiae, paralysis and perishing cold. This may be due to an embolus or acute thrombosis on the background of arterial disease. The common sources of emboli are: AF; mural thrombus; aorta; and peripheral aneurysms. It is important to diagnose promptly and to perform an emergency embolectomy.

86. A 33-year-old woman is seen in clinic complaining of an aching sensation in her right leg. The aching commenced during her first pregnancy and is worse at the end of the day when she finishes her shift at the supermarket. Varicose veins

Varicose veins affect up to 20% of men and 30% of women. The common sites of valvular incompetence are: saphenofemoral junction; saphenopopliteal junction and perforator veins. Predisposing factors include raised pelvic pressure (pregnancy; obesity; gynaecological malignancies) and prolonged standing (occupational e.g. checkout assistants). Most patients want surgery for cosmetic reasons, other indications are pain (after standing all day); ulceration, bleeding, eczema and thrombophlenitis. Surgery involves ligation at the level of the incompetent vein +/- stripping of a vein segment in the case of saphenofemoral incompetence.

87. Where else might you find these lesions in this patient who presents with these appearances of the hands?

A. Eyes

B. Angles of Mouth

C. Patellae

D. Penis

E. Shoulder's

D is correct. This patient has Dupuytrens contractures of both hands. This is a disorder associated with fibrosis of the palmar aponeurosis and begins with fibrotic nodules in the palms of the hands and gradual contraction of the little and ring fingers. The disorder is associated with trauma and has a familial predisposition. It is also associated with fibrosis of the penis - Peyronnie's Disease.

88. This young woman presents at an insurance medical and this appearance is noted. She is otherwise well. Which of the following is most likely to account for this appearance?

A. Argyl-Robertson pupil

B. Holmes-Adie pupil

C. Horner's syndrome

D. Neurofibromatosis

E. Wilson's disease

B is correct. This is Holmes-Adie pupil; she has a large irregular left pupil which only slowly responds to light. A clue here is the bright light, resulting in normal constriction of the right pupil but a left pupil which remains dilated. This is typical of Holmes-Adie often discovered coincidentally, with the majority being young females, and 80% have only one pupil affected. In the syndrome, it is associated with absent/depressed reflexes.

89. Gynaecomastia may be caused by True / False

A. Cimetidine

B. Digoxin

C. Anabolic steroids

D. Tetracycline

E. Spironolactone

D is incorrect. There are several drug classes associated with gynaecomastia : 1. Oestrogens or drugs with oestrogen like activity - digoxin, diethylstilbestrol, phytoestrogens, oestrogencontaminated food and oestrogen-containing cosmetics, 2. Drugs that enhance oestrogen synthesis: gonadotropins, clomiphene, phenytoin, and exogenous testosterone 3. Drugs that inhibit testosterone synthesis or action: ketoconazole, metronidazole, alkylating agents, cisplatin, spironolactone, cimetidine, flutamide, finasteride, and etomidate 4. Drugs that act by unknown mechanisms: isonicotinic acid hydrazide, methyldopa, busulfan, tricyclic antidepressants, diazepam, penicillamine, omeprazole, phenothiazines, calcium channel blockers, ACE inhibitors, alcohol, marijuana, and heroin

90. This result returns on a 76-year-old male presenting with troublesome diarrhoea. Which of the following is the most appropriate treatment for this?

A. Ampicillin

B. Cefuroxime

C. Metronidazole

D. No treatment required as condition self limiting

E. Trimethoprim

C is correct. This result reveals the presence of Clostridium Difficile Toxin and supports the diagnosis of Pseudomembranous Colitis. This condition is typically related to prior treatment with broad spectrum antibiotics and left untreated can cause serious problems such as dehydration, perforation and obstruction. Treatment is oral metronidazole or oral vancomycin.

91. A 55-year-old male presents with abdominal swelling, nausea and mild jaundice. He admits to a long history of alcohol abuse, drinking 2 pints of lager per day as well as 2 bottles of wine per week. How many units of alcohol per week does this equate to?

A. 20 units

B. 28 units

C. 36 units

D. 46 units

E. 56 units

D is correct. There are 2 units of alcohol in each pint of lager and there are approximately 9 units in a bottle of wine. This person therefore drinks approximately 28 units of alcohol in the lager and 18 units in the wine = 46 units/wk. The recommendation is no more than 21 units per week for a man and 14 for a woman.

92. This result returns on a 76-year-old male presenting with troublesome diarrhoea. Which of

the following is likely to have been responsible for this result?

A. Consumption of a re-heated chinese meal

B. Contact with a young child with vomiting and diarrhoea

C. Recent treatment of bronchitis with cefuroxime

D. Recent return from holiday to Kenya

E. Treatment with antimalarials

C is correct. This result reveals the presence of Clostridium Difficile Toxin and supports the diagnosis of Pseudomembranous Colitis. This condition is typically related to treatment with broad spectrum antibiotics as these kill the normal flora in the bowel allowing C Dificile the opportunity of colonising the colon. Left untreated it can cause serious problems such as dehydration, perforation and obstruction. Treatment is oral metronidazole or oral

Theme: Medical conditions presenting with psychiatric symptoms

A. Cerebrovascular accident

B. Cushing's disease

C. Epilepsy

D. Hypoglycaemia

E. Hypothyroidism

F. Multiple sclerosis

G. Normal pressure hydrocephalus

H. Paracetamol overdose

I. Sub-dural haematoma

J. Thyrotoxicosis

K. Wolf-Parkinson White syndrome

For each presentation below, choose the SINGLE most likely underlying medical condition from the above list of options. Each option may be used once, more than once, or not at all.

93. An 18-year-old woman presents with paroxysmal anxiety and palpitations with associated dizziness. Her weight is stable. Wolf-Parkinson White syndrome

This syndrome presents with paroxysmal tachycardia and syncope. Palpitations may cause anxiety leading to a mis-diagnosis of panic disorder. Syncope suggests a non-psychological cause for the episodes, and should prompt further investigation. The syndrome is caused by an additional conduction pathway between atrial and ventricular myocardium. ECG shows a short PR interval and a widened QRS complex due to the presence of a delta wave.

94. A 65-year-old woman presents with depressed mood, weight gain and sensitivity to the cold. Hypothyroidism

These symptoms are consistent with a diagnosis of hypothyroidism. Other classical symptoms of hypothyroidism include lethargy, tiredness, hair loss, dry skin and bradycardia. Psychiatric symptoms include depression and psychosis. Patients presenting with suggestive symptoms should have their thyroid function investigated. Thyroid function tests will show decreased serum T3 and T4 and elevated TSH due to negative feedback effect. Correction of the hypothyroidism with thyroxine will generally lead to the resolution of psychiatric symptoms without need for additional psychiatric treatment.

95. A 14-year-old boy with learning disability has episodes of visual hallucinations. Epilepsy

Symptoms such as illusions, hallucinations changes in emotions or cognition are common features of complex partial fits of temporal lobe origin. There may be progression to automatic behaviour (repeated stereotyped movements) and generalised convulsions during an ictal episode. Psychiatric symptoms occurring in an ictal episode are characterised by a sudden onset, transient duration and relatively rapid resolution. Attacks are often stereotyped in quality and associated with some alteration in consciousness. Visual hallucinations are a relatively uncommon symptom in functional psychotic illness, and should give rise to consideration of an organic cause.

96. A 76-year-old woman is admitted poor balance and falls. Her husband has noticed a deterioration in her memory. She has also been incontinent of late. Normal pressure hydrocephalus

Normal pressure hydrocephalus is classically associated with dementia, urinary incontinence and gait disturbance (apraxia: "glued-to-the-floor" sign). CT scan shows enlarged ventricles disproportionate to the degree of cortical atrophy. CSF pressure is characteristically normal.

97. A 35-year-old psychiatric in-patient with schizophrenia and insulin dependant diabetes suddenly becomes confused and aggressive for no apparent reason whilst waiting for his lunch. Hypoglycaemia

Hypoglycaemia is a likely cause for this patient's sudden change in mental state and must be excluded before his symptoms are attributed to his psychiatric disorder.

Theme: Neuropsychiatry

A. Acute intermittent porphyria

B. Epilepsy

C. Huntington’s disease

D. Multiple sclerosis

E. Parkinson’s disease

F. Prion disease

G. Syphilis

H. Systemic lupus erythematosus

I. Vitamin B12 deficiency

J. Wilson’s disease

Select the most likely explanation from the above list explaining the following presentations:

98. A 28-year old man with mild learning disabilities presents to his GP with a six-month history of worsening dysarthria. He also states that his limbs sometimes jerk uncontrollably. The GP notices a greenish-brown pigment at the periphery of the cornea. Wilson’s disease

This man has Wilson’s disease, characterised by an accumulation of copper in the liver, brain, kidney, cornea (Kayser-Fleischer rings) and bone. The most common psychiatric symptom clusters are affective and behavioural changes.

99. A 27-year-old man presents to his GP with a six-month history of feeling depressed. He also states that recently he has experienced jerky movements flitting from one part of the body to another. His father experienced similar symptoms aged 30 and committed suicide. Huntington’s disease

This man has Huntington’s disease. He is experiencing choreiform movements. It is autosomal dominant and his father had the condition and committed suicide.

100. A 19-year old woman is admitted to a psychiatric hospital thinking that everyone wants to kill her. Four days later she develops severe abdominal pain, pyrexia, vomiting and starts to fit. She is referred to A&E, where the nurses notice that her urine turns red / brown on standing. Acute intermittent porphyria

This lady has acute intermittent porphyria . Psychiatric disturbances include delirium, depression, emotional lability, schizophreniform psychoses and hysteria.

Theme: Neuropsychiatry

A. Acute intermittent porphyria

B. Epilepsy

C. Huntington's disease

D. Multiple sclerosis

E. Parkinson's disease

F. Prion disease

G. Syphilis

H. Systemic lupus erythematosus

I. Vitamin B12 deficiency

J. Wilson's disease

Select the most likely explanation from the above list explaining the following presentations:

101. A 60-year old lady has become increasingly forgetful over the last year and her husband states she easily becomes confused. Her GP examines her and notes exaggerated knee reflexes and distal sensory loss. Blood tests show a macrocytic anaemia. Vitamin B12 def iciency

This lady's psychiatric symptoms are due to vitamin B12 deficiency. She also has focal neurological signs suggestive of this. Treatment is with hydroxycobalamin.

102. A 30-year old lady presents to her GP after her partner expresses concern about her fluctuating mood and recent personality change. Two weeks later she is referred to hospital after developing sudden onset blindness in the left eye. Fundoscopy is normal. Multiple sclerosis

This lady has multiple sclerosis. Psychiatric manifestations include elation/euphoria, cognitive impairment (early on) and progressive dementia (late stages). The blindness is due to retro-orbital neuritis.

Theme: Chest symptoms

A. Asthma

B. Bronchial carcinoma

C. Chronic obstructive pulmonary disease

D. Pneumothorax

E. Pneumonia

F. Pulmonary fibrosis

G. Pulmonary embolism

H. Pulmonary oedema

Select the most likely diagnosis for the following cases:

103. A 62-year-old female presents with acute breathlessness of one hour duration. She smokes occasionally. On examination, she is sweaty and needs to sit up, has oxygensaturations of 89% on air, a temperature of 37.5°C and has a respiratory rate of 30/min.Auscultation of the chest reveals widespread expiratory wheezes and extensive basal crackles Pulmonary oedema

This woman presents with severe acute breathlessness and the most salient finding is the extensive bibasal crackles - this would suggest pulmonary oedema. Wheeze/bronchospasm is a frequent feature of pulmonary oedema. Asthma and pneumonia are less likely scenarios - the former as there are no other features and the latter as the temperature and acute nature would argue against this.

104. A 68-year-old male presents with long-standing breathlessness and cough. He is a smoker of 20 cigarettes daily. On examination, he appears to have a bluish discolouration of the lips is obese and has nicotine stained fingers. He has a temperature of 36.7°C, a respiratory rate of 20/min and oxygen saturations of 92% on air. Chest examination reveals reduced expansion of a generally expanded chest, widespread scattered wheezes and occasional crackles.Chronic obstructive pulmonary disease

The history is most suggestive of chronic obstructive pulmonary disease - long standing productive cough with a blue bloater appearance. There is nothing else in the history to suggest underlying bronchial carcinoma.

105. A 55-year-old female presents with an acute history of left sided chest pain and breathlessness. She is a smoker of 10 cigarettes per day, takes hormone replacement therapy and three days ago returned from holiday in Spain. On examination, she is tanned, has some nicotine staining of the hair, she has a temperature of 37°C, a respiratory rate of 25/min and oxygen saturations of 93% on air. Chest examination reveals no specific abnormalities on the chest. Pulmonary embolism

The most salient features here are the acute breathlessness, reduced oxygen saturations and increased respiratory rate. In a patient who has had a recent flight and in the absence of any overt chest signs one must consider a pulmonary embolism. ECG may show S1Q3, T3 and gases may reveal hypoxia with hypocapnia. A ventilation perfusion scan or CTPA should be requested. There are no features to suggest pneumonia - one may think of legionnaire's disease due to Spain but signs of infection are notably absent.

106. A 15-year-old female comes to you requesting a termination of pregnancy. She tells you that her boyfriend is 17 years old. Having asked a number of questions about the relationship you do not have reason to suspect that it is abusive. The patient seems to be mature for her age, understands what you are telling her about her options and appears capable of deciding for herself what she wants to do. You cannot persuade her to inform her parents that she is pregnant. The girls mother makes an appointment the following day and tells you that she knows her daughter has been to see you. She says that she is worried about her daughter, and asks you to tell her whether you have given her daughter any family planning advice. Which of the following is the most appropriate action under these circumstances?

A. Inform the police because underage sex is against the law. Do not tell the patient or her mother that you are doing so.

B. Reassure her mother that you have provided her daughter with family planning advice but do not tell her that the daughter is pregnant.

C. Tell the mother that the daughter is pregnant on the basis that you believe that doing so is in the girl’s best interests.

D. Tell the social services.

E. Do not give information to any of the above.

E is correct. At 15, your patient is not yet legally an adult but if you judge that she has the capacity to make a decision about disclosure of information she is entitled to confidentiality in her own right. Capacity of a person under the age of 16 to give or withhold consent is known as Gillick (Fraser) competence after the case of Gillick vs West Norfolk and Wisbech AHA that was considered by the Law Lords. Their lordships held that in certain circumstances a child under 16 can give valid consent without parental knowledge or agreement. There is no duty to report a crime. However, if you feel that disclosure is necessary to protect a patient from risk of serious harm, for example if you suspect that she has been abused, you should take action. It would be helpful to discuss matters with a suitably experienced colleague, for example your child protection lead. It would also be advisable to discuss difficult cases with your medical defence organisation. Doctors may be called upon to justify having disclosed or withheld information, and it is important to keep a clear record of the reasons behind your decision. Question supplied by the Medical Defence Union.

Theme: Eponymous signs

A. Charcot

B. Courvoisier

C. Cullen

D. Goodsall

E. Grey-Turner

F. Mc Burney

G. Murphy

H. Rovsing

I. Troisier

J. Trouseau

For each scenario chose the eponym which describes the acute clinical presentation

107. A 75-year-old patient with painless jaundice and a palpable right upper quadrant mass. Courvoisier

Courvoisier’s law states that if in the presence of painless obstructive jaundice there is a palpable gallbladder then the cause is unlikely to be gallstones. In practice this means that anyone presenting in such a way should be presumed to have a carcinoma of the head of the pancreas until proven otherwise.

108. A 42-year-old lady with right upper quadrant pain, pyrexia and tenderness is noted to be tender on palpation over the tip of the right 9th rib when asked to breath in. Murphy

Murphy’s sign indicates local peritonism over the gallbladder and is classical of acute cholecystitis although empyema is another possibility. Classically, it is performed by asking the patient to breathe out and then palpating below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) the test is considered positive.

109. A 23-year-old girl with right iliac fossa pain in who the pain is exacerbated by pressing in the left iliac fossa. Rovsing

Rovsing’s sign is exacerbation of RIF pain by applying pressure in the LIF and occurs as a result of bowel being pushed onto an inflamed appendix and is regarded as one of the diagnostic signs of acute appendicitis.

110. A 55-year-old man admitted with severe acute pancreatitis who develops bruising of the flanks. Grey-Turner

Grey-Turner’s sign is indicative of retroperitoneal haemorrhage and is commonly seen in acute pancreatitis and ruptured aneurysms. Cullen’s sign is periumbilical bruising due to the same causes and may be seen long with Grey Turner’s sign or independent of it.

111. A 9-year-old boy who exhibits maximal tenderness on pressing on a point 2/3 of the way between the umbilicus and the anterior superior iliac spine. Mc Burney

Mc Burney’s point is the name given to the point of maximal tenderness 2/3 of the way between the umbilicus and the ASIS. This is said to be the location of the appendix in its most frequent anatomical setting

Theme: The acute abdomen

A. Acute appendicitis

B. Acute cholecystitis

C. Acute pancreatitis

D. Ascending cholangitis

E. Biliary colic

F. Gastroenteritis

G. Pyelonephritis

H. Renal colic

I. Ruptured abdominal aortic aneurysm

J. Small bowel obstruction

For each patient described below presenting with acute abdominal pain, choose the single most likely pathology responsible for the symptoms and signs.

112. A 12-year-old girl presents with dysuria, left loin pain and rigors. Her mother reports that she suffered recurrent urinary infections as an infant. Her temperature is 38.5°C and she is tender upon baloting the kidney. Blood, protein and nitrites are noted on a urine dipstick. Pyelonephritis

113. A 66-year-old woman who had previously undergone an abdominal hysterectomy is admitted as an emergency with colicky central abdominal pain, distension and obstipation. On examination there is mild tenderness and bowel sounds were high pitched. Small bowel obstruction

114. 50-year-old lady with a past medical history of gallstones is referred with pain, a change in stool and urine colour, and rigors. On examination she is jaundiced and tender in the right upper quadrant. Ascending cholangitis

115. A 23-year-old man attends A&E with diffuse colicky abdominal pain, offensive diarrhea and persistent vomiting. His symptoms started 2 hours after he ate a re-heated Chinese takeaway. Gastroenteritis

116. A 40-year-old lady is referred with severe colicky right upper quadrant pain. The pain commenced after eating fish and chips for lunch. By the time she is seen an hour later the pain has settled and she is otherwise asymptomatic and examination is unremarkable. Biliary colic

The commonest casuses of SBO are adhesions, hernias and malignancy. Most cases of SBO may be managed non-operatively initially by ‘drip and suck’ which entrails and NG tube and IV rehydration. If there are no previous operations – a ‘virgin abdomen’ then this should be limited to 24 hours. If there are signs of peritonism at any time a laparotomy is indicated urgently. Cholangitis carries a significant mortality risk and so it is important to distinguish it from other manifestations of gallstones. If diagnosed, it requires broad spectrum antibiotic coverage and urgent ERCP and drainage of pus from the bile duct. In cases of gastroenteritis there is frequency an index meal preceding the symptoms. In children, there are often a number of friends or family affected by the illness. All cases require stool culture to exclude a bacterial cause which may require antibiotic therapy. Most cases settle spontaneously and simply require advice on supportive hydration. Biliary colic is a common diagnosis and is typified by a short duration colicky pain exacerbated by ingestion of fatty food. Most patients may be managed in the community but if there are signs of inflammation – elevated WBC, pyrexia, peritonism then may require admission. An ultrasound is required for confirmation of the diagnosis. Pyelonephrits requires broad spectrum antibiotic coverage whilst urine cultures are sent to determine sensitivities. It is important to ensure normal renal function and also perform an ultrasound to examine for a dilated draining system as this would require urgent nephrostomy tube insertion for decompression.

Theme: Groin swelling

A. Direct inguinal hernia

B. Femoral artery aneurysm

C. Femoral hernia

D. Hydrocele of the cord

E. Indirect inguinal hernia

F. Lipoma

G. Lymphadenopathy

H. Psoas bursa

I. Saphena Varix

J. Undescended retractile testes

Each of the following patients present with a swelling in the groin from the options select the most likely diagnosis in each case.

117. A 55-year-old man presents with a right sided, non tender groin swelling that is only present on standing. On examination the mass is compressible and on release it can be seen to refill. Saphena Varix

Saphena Varix this is a condition which results from abnormal dilatation of the terminal portion of the long saphenous vein at its confluence with the femoral vein. As it is venous in origin it has cough impulse on examination and may have a bluish tinge, it wall also disappear on lying down. It is sometimes described as a ‘bag of worms’. No treatment is necessary unless symptomatic.

118. A 42-year-old woman presents with a tender swelling in her left groin. On examination the position of the lump is noted to be below and lateral to the pubic tubercle and has a cough impulse. Femoral hernia

The answer here is femoral hernia. Femoral hernias are more common in women although they are the least common hernia originating from the groin. They are quite likely to strangulate and the fact that the lump in this case is tender suggests that there may be a degree of strangulation. Femoral hernias are diagnosed by their position which is typically below and lateral to the pubic tubercle, however as they enlarge they do so in an ascending manner which is why they are often difficult to differentiate from the other hernias. Due to their high risk of strangulation surgery is nearly always required.

119. A 64-year-old man known to suffer with chronic obstructive airways disease presents with a swelling in his left groin that he says on bad days moves down to his scrotum. It is painless but has been gradually increasing in size over a period of 6 months. Examination reveals a lump that is difficult to reduce but when it is reduced pressure on the mid inguinal point seems to control it. It does not transilluminate. Indirect inguinal hernia

This is a classical presentation of an indirect inguinal hernia which is the commonest type of inguinal hernia. The relevance of this patients COAD is the likelihood of a chronic cough making a hernia the likely diagnosis from the start. Inguinal hernias can be differentiated from direct inguinal hernias in several ways: indirect hernias can descend into the scrotum, direct ones don’t; indirect hernias are renowned to be difficult to reduce, direct hernias tend to reduce spontaneously on lying down; indirect hernias are controlled by applying pressure to the deep inguinal ring (which like below the mid inguinal point), direct hernias are not.

Theme: Causes of amenorrhoea

A. Drug induced

B. Kallmann’s syndrome

C. Menopause

D. Microprolactinoma

E. Non-classical congenital adrenal hyperplasia

F. Pituitary tumour

G. Polycystic ovarian syndrome

H. Pregnancy

I. Primary ovarian failure

J. Turner’s syndrome

K. Weight related

Select the most likely cause for the amenorrhoea in the following cases:

120. A 22-year-old female presents with a six month history of secondary amenorrhoea associated with flushes and vaginal dryness. She is taking thyroxine 100 micrograms daily. There are no abnormalities on examination. Primary ovarian failure

The 22-year-old female has secondary amenorrhoea and together with a history of hypothyroidism and the symptoms of ovarian failure (flushes etc) would suggest a diagnosis of primary ovarian failure. The exact aetiology is unknown although autoimmunity is a typical cause.

121. An 18-year-old female presents with primary amenorrhoea. She is not taking any medication currently. She has short stature, poor pubertal development and has a soft systolic murmur. Turner’s syndrome

The 18-year-old female has short stature, poor pubertal development and a soft systolic murmur (bicuspid aortic valve possibly) suggestive of Turner’s syndrome. Turner’s XO is associated with other features including webbed neck, wide carrying angle and streak gonads.

122. A 33-year-old woman presents with a six month history of secondary amenorrhoea. She has recently been diagnosed with schizophrenia for which she is taking Haloperidol. She also reports that she is aware of breast milk production. On examination, she has some galactorrhoea to expression from both breasts. Drug induced

The 33-year-old female has drug induced hyperprolactinaemia associated with antipsychotic therapy. This would be a far more likely cause than a microprolactinoma.

Theme: Deranged liver function tests

A. Alcoholic cirrhosis

B. Autoimmune chronic hepatitis

C. Drug-induced

D. Gilbert’s syndrome

E. Haemolytic anaemia

F. Hepatic metastases

G. Pancreatic carcinoma

H. Primary biliary cirrhosis

I. Sclerosing cholangitis

Select the most likely diagnosis from the above list that is responsible for the presentation of the following patients Normal ranges: Bilirubin 0-18, AST 5-45, ALT 5-40, alkaline phosphatase 30-110, gammaGT 10-50.

123. A 42-year-old female presents with a two month history fatigue and weight loss. She admits to drinking approximately two cans of lager nightly since her divorce 1 year ago. On examination she has a few spider naevi and palpable hepatomegaly. Investigations show Bilirubin 28 micromol/l, AST 550 iu/l, ALT 476 iu/l, Alkaline Phosphatase 210 iu/l and gammaGT 200 iu/l. Autoimmune chronic hepatitis

124. A 55-year-old male attends with a three day history of flu-like symptoms and nausea. On examination he has a stuffy nose but is otherwise well. Investigations show Bilirubin 28 micromol/l, AST 22 iu/l, ALT 30 iu/l, Alkaline phosphatase 75 iu/l and gamma GT 45 iu/l. Gilbert’s syndrome

125. A 54-year-old male presents with acute vomiting and upper abdominal pain. He drinks approximately 7 units of alcohol daily. On examination he has a few spider naevi and appears slightly jaundiced. He has two finger breadth hepatomegaly. Results show Bilirubin 72 micromol/l, AST 98 iu/l, ALT 120 iu/l, Alkaline Phosphatase 358 iu/l and gammaGT 450 iu/l. Alcoholic cirrhosis

Liver Function tests (LFTs) are among the most commonly used investigations in clinical medicine. A sound understanding of why they become abnormal and a rational, cost effective approach to their investigation is essential. Marked elevations of AST and ALT with only modest rises of alkaline phosphatase and gamma GT suggest hepatitis whereas markedly raised alkaline phosphatase and gamma GT reflect a cholestatic picture. Gilbert’s syndrome is an autosomal dominant disorder associated with benign, mildly symptomatic, nonhaemolytic, unconjugated hyperbilirubinaemia. No treatment is required and the typical feature is the isolated elevation of bilirubin often found found completely co-incidentally. The bilirubin may rise in illness or starvation. The greater than 10 fold elevation of transaminases in the middle aged female suggests a hepatitis and does not appear to be related to alcohol where elevation of alkaline phosphatase and gamma GT would be more pronounced. The middle aged male with heavy alcohol use has examination and biochemical features which suggest an acute alcoholic hepatitis associated with cirrhosis.

126. A 70-year-old man presents with 'dizziness'. He describes a feeling as though he was about to faint. He has not blacked out and there has been no history of chest pain. He is otherwise well but does complain of shortness of breath when walking up hills. He has a history of hypertension for which he is treated with bendroflumethiazide 2.5 mg, atenolol 50 mg and aspirin 75mg. He is noted to have a slow pulse. His blood pressure is 130/90. His ECG is shown. What is the diagnosis?

A. Atrial fibrillation

B. Complete heart block

C. Mobitz Type 2 AV block

D. Sick sinus syndrome

E. Sinus bradycardia

B is correct. The ECG shows a marked bradycardia of about 40 bpm. There are P waves easily visible in the rhythm strip but they have no relation to the QRS complexes - this is called AV dissociation. The QRS complexes are wide and this represents a ventricular escape rhythm. This is a typical ECG of third degree (or complete) heart block. The first step is to admit him for monitoring and stop his betablocker.

127. You are asked to provide the first part of a cremation form. Which of the following would need to be removed prior to cremation?

A. Breast implants

B. Hip replacement

C. Pacemaker

D. Cochlear implant

E. Ventricular shunt

C is correct. Any radioactive devices or pacemakers need to be removed prior to cremation. The latter has been asociated with minor explosion during cremation.

128. You are called to the death of a 90-year-old male on the care of the elderly unit. He has a long history of breathlessness associated with heart failure and the nurses state that he suddenly collapsed and died. He was not resuscitated. Which of the following is an accepted cause of death that you may place on a death certificate?

A. Heart failure

B. Cardiac arrest

C. Ischaemic heart disease

D. Old age

E. Respiratory arrest

C is correct. Cardiac arrest, syncope, apnoea, respiratory arrest, heart, liver or kidney failure are all modes of death and not acceptable for a death certificate. Generally, a cause of death is the pathological condition responsible for death eg ischaemic heart disease or myocardial infarction. Old age should be avoided.

129. A 30-year-old male is unconscious on admission following a road traffic accident. He was the driver of the car and there is the suspicion that he was responsible for the accident in which a passenger of another car died. In attendance with the patient is his wife who was uninjured in the accident. The police are keen to obtain a blood sample for alcohol measurement but the patient is incapable of giving consent for this procedure.What is the most appropriate action in these circumstances?

A. Inform the police that you may only take blood samples on medical grounds.

B. Draw a blood sample for later analysis when the patient is competent to consent.

C. Draw a blood sample which can be analysed immediately.

D. Obtain consent from his wife, as next of kin, to draw the blood sample.

E. Refuse to obtain a blood sample until the patient is competent to provide consent.

B is correct. There is clear guidance published on such a situation by the BMA. Following the Police Reform Act, it is no longer necessary to obtain consent from unconscious or incapacitated drivers. However, the sample is not tested until the person regains competence and gives valid consent to it being tested. A competent person who refuses to allow his or her sample to be tested might be liable to prosecution. Similarly, the new law recognizes the duty to justice.

130. A 55-year-old man presents having recently noticed a lump in his right groin which disappears when he is recumbent. It is accompanied by some discomfort. He has a chronic cough due to smoking. He has had an appendicectomy previously. What is the SINGLE most likely diagnosis?

A. Epigastric hernia

B. Femoral hernia

C. Incisional hernia

D. Inguinal hernia

E. Spigelian hernia

D is correct. Inguinal hernia is the most likely cause of a lump in the right groin in a patient of this age. The hernia protrudes through the external inguinal ring and may go unnoticed for quite some time, may cause an ache and may resolve on lying flat. Femoral hernias are more common in females, the anatomical site is inconsistent with epigastric and an incisional hernia following appendicectomy would be very unusual. This patient is at increased risk of hernias as he has a persistent cough due to his smoking.

131. A 36-year-old woman attends her GP’s surgery. She has been diagnosed with hypothyroidism recently and takes thyroxine 100 microgrammes daily. The GP has the benefit of thyroid function and other tests from the previous week. Which test is the best for monitoring progress and treatment?

A. Free thyroxine levels

B. Protein bound iodine levels

C. Thyroid stimulating hormone levels

D. Thyroid peroxidase antibody levels

E. Triiodothyronine levels

C is correct. Thyroxine suppresses the high TSH levels noted in hypothyroidism. TSH is the best

monitoring test and one should aim to get the TSH into the normal range.

132. A 26-year-old man presents to his GP with a urethral discharge. Laboratory investigation of the discharge shows numerous neutrophils, some of which contain Gram-negative intracellular diplococci. He received Ceftriaxone, 250 mg intramuscularly. The symptoms initially resolved but the patient returned five days later with the same complaint. Which of the following is the most likely cause of this discharge?

A. Chlamydia trachomatis

B. Ureaplasma urealyticum

C. Penicillin-resistant Neisseria gonorrhoeae

D. Re-infection with Neisseria gonorrhoeae

E. Urethral stricture

A is correct. This patient has had gonorrhoea which has been successfully treated with IM ceftriaxone. But, co-infection with Chlamydia is common. Chlamydia is a very common sexually transmitted disease worldwide. The majority of the cases are asymptomatic. In fact 75% of women and 25% of men with Chlamydia show no symptoms, and this disease also plays an important role in infertility. The main symptoms in men are clear, white, or yellow discharge from the urethra, dysurea, and tingling or itching sensations. Doxycycline is the treatment of choice and azithromycin is an alternative as are chloramphenicol, rifampicin, and fluroquinones. Read more about

Theme: Pathology of the nervous system

A. Cerebral Tumour

B. Charcot Marie Tooth disease

C. Diabetic neuropathy

D. Viral meningitis

E. Guillain Barre Syndrome

F. Bacterial Meningitis

G. Motor neurone disease

H. Multiple sclerosis

I. Myasthenia Gravis

J. Parkinsons disease

Choose the most likely diagnosis for each of the following.

133. A 67-year-old male presents with weakness and loss of sensation in his feet and legs. His history includes a flu-like illness 2 weeks prior to the start of these symptoms. Guillain Barre Syndrome

Guillain-Barre syndrome is an acute, inflammatory, postinfectious polyneuropathy.

134. A 32-year-old female presents with unilateral subacute visual loss, associated with a central scotoma and pain on ocular movement. A year ago she experienced a transient clumsiness of the right hand which improved over a fortnight. Multiple sclerosis

Multiple sclerosis is a disease which affects the nervous system and is relapsing and remitting in nature.

135. A 69-year-old man has a history of resting tremor, bradykinesia and rigidity. On examination the symptoms are bilateral and the patient walks with a shuffling gait. Parkinsons disease

Bradykinesia, rigidity and shuffling gait are all classic symptoms of Parkinsons disease.

136. A 45-year-old women presents with ptosis and diplopia. She also has proximal limb weakness which worsens after exercise. Sensory function is normal. Myasthenia Gravis

Myasthenia Gravis is an acquired autoimmune disease characterised by by weakness, typically of the periocular, facial, bulbar, and girdle muscles. It is associated with serum IgG antibodies to acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction. Classically, the muscles are easily fatigued.

137. An 8-year-old female presents with headache, photophobia and neck stiffness which has rapidly progressed over the last two days. Her mother is worried about a rash which has developed on her daughters leg. Bacterial Meningitis

Headache, neck stiffness, photophobia and rash are red flags for meningitis which must be acted upon immediately.

Theme: Urological Clinical Scenarios

A. Acute Cystitis

B. Acute Bacterial Prostatitis

C. Acute Pyelonephritis

D. Benign Prostatic Hypertrophy

E. Bladder Calculi

F. Bladder Cancer

G. Chronic Bacterial Prostatitis

H. Prostate Cancer

I. Renal Calculi

J. Renal Carcinoma

Please select the most likely diagnosis for the scenarios below. You may use each option once, more than once, or not at all.

138. A 62-year-old man has a 5 month history of fatigue, perineal discomfort, lower back and loin pain. He experiences pain on micturation, and has recently lost 1 stone in weight. Chronic Bacterial Prostatitis

139. A 21-year-old woman complains of an 18 hour history of urgency of micturition, dyspareunia and malaise. Acute Cystitis

140. A 60-year-old man complains of painful haematuria and urgency. There is no abnormality on

141. examination of the abdomen. Bladder Calculi

142. A 72-year-old man presents to A&E with acute back pain and leg weakness. He also mentions that he has been experiencing hesitancy and dribbling of urine for the last 12 months. On examination he has a spastic paraparesis and palpable bladder. Prostate Cancer

143. A 52-year-old women presents to A&E with severe colicky pain radiating from her right loin to the groin. Analysis of her urine reveals +++ blood. Renal Calculi

One main difference between prostate cancer and chronic bacterial prostatitis is that cancer does not usually present with perineal pain. In cystitis, dyspareunia (pain during sexual intercourse) is common. Painful haematuria suggests calculi, where painless haematuria suggests a possible occult malignancy. The 72-yearold man is showing signs of collapsed vertebrae. This is a not uncommon presentation of metastatic prostate cancer and is a neurosurgical emergency. Colicky pain that radiates from the loin to the groin always suggests renal colic. With haematuria, this is a common presentation of renal calculi.

Theme: Alimentary: Components of food.

A. Copper

B. Niacin

C. Oleic Acid

D. Riboflavin

E. Strearic Acid

F. Thiamine

G. Vitamin A

H. Vitamin E

I. Vitamin K

J. Zinc


Please select the most likely vitamin/mineral excess/deficiency involved in the following diseases. You may use each option once, more than once, or not at all.

145. In excess in Wilson’s Disease. Copper

Wilson’s disease is an inherited diseased caused by the excess of copper.

146. Deficient in night blindness. Vitamin A

Night blindness and beriberi are diseases that usually affect people of the third world; they are caused by vitamin A and thiamine deficiency respectively.

147. Deficient in beriberi. Thiamine

Night blindness and beriberi are diseases that usually affect people of the third world; they are caused by vitamin A and thiamine deficiency respectively.

148. Deficient in acrodermatitis enteropathica. Zinc

Acrodermatitis enteropathica is a rare disease caused by the deficiency of zinc.

149. Deficiency of this component leads to coagulation defects. Vitamin K

A diet deficient of vitamin K would cause coagulation defects, as vitamin K is an important cofactor in the coagulation cascade.

150. With which of the following is a lower motor neuron lesion associated?

A. Flaccid paralysis

B. Exaggerated stretch reflex

C. Muscular inco-ordination

D. Spasticity

A is correct. Lower motor neuron lesions are associated with flaccid paralysis, reflex contractions can no longer be elicited, the muscle slowly atrophies, downward plantar response and fasciculations.

151. You look up a drug in the BNF and see this symbol associated with the drug: What does this symbol signify?

A. Prescribing can be optional and medication can be obtained over the counter

B. Medication only available as prescription by licenced practitioner

C. Intense monitoring required for any adverse events

D. Pharmacist prescribable drug

E. Controlled drug

B is correct. Prescription Only Medicine - POM and can be prescribed only by licensed medical or dental practioners.

Theme: Managing childhood asthma

A. Antibiotics

B. Antihistamines

C. Inhaled steroid 800 mcg/day equivalent

D. Inhaled steroid 400mcg/day equivalent

E. Leukotriene receptor antagonist

F. Long acting beta-2 agonist

G. Nebulised steroid

H. Non steroidal anti inflammatory

I. Oral steroids

J. Short acting beta-2 agonist

Which of the above would be the next step in the management of the following children with asthma?

152. A 3-year-old boy who uses salbutamol twice a night to control cough and wheeze. Inhaled steroid 400mcg/day equivalent

153. A 6-year-old girl on fluticasone 100 mcg twice daily and using salbutamol at least once a day. Long acting beta-2 agonist

154. A 15-year-old boy, usually well controlled on budesonide 200 mcg/day and salbutamol with a 3 day history of cough, wheeze and coryza. He continues to deteriorate despite his usual medication and PEFR is 40% best Oral steroids

The new British Thoracic Society (BTS) asthma guidelines (2003) are a stepwise guide to management., and are divided according to patients age.

In children age 5-12

1.Step 1 Inhaled short acting b2 agonist as required

2.Step 2 Add inhaled steroid 200-400 mcg/day

3.Step 3 Add long acting b2 agonist (LABA)then assess control. If good response to LABA, continue. If benefit from LABA but control still iadequate, continue LABA and increase steroid up to 400 mcg/day if not already on this dose. If no response to LABA, stop and try other therapieseg. Leukotriene receptor antagonist or SR theophylline.

4.Step 4 Persistent poor control- increase steroid up to 800 mcg/day

5.Step 5 Daily oral steroid

In children under 5

1.Step 1 b2 agonist

2.Step 2 Inhaled steroid 200-400mcg/day

3.Step 3 In children age 2-5, try leukotriene receptor antagonist, in children under 2, go to

4.step 4

5.Step 4 Refer to respiratory paediatrician

Theme: Vaginal discharge.

A. Allergic

B. Bacterial vaginosis

C. Child sex abuse

D. Foreign body

E. Pinworms

F. Rectovaginal fistula

G. Tumour

H. Vulvovaginitis, infectious

I. Vulvovaginitis, non-specific

For each scenario choose the most likely diagnosis:

155. A 4-year-old girl presents with persistent scratching of her anus. Perineal examination is unremarkable. Pin worms

Perianal itching is usually due to pinworms (threadworms). This can be confirmed by a sellotape test, where a strip of sellotape is placed at the anal margin on waking and examined for worms.

156. A 4-year-old girl presents with vaginal irritation and scanty discharge. On examination she has minimal perineal redness. Vulvovaginitis, non-specific

Vaginal irritation with redness is common as girls learn to wipe themselves after defaecation and as the skin is thin and sensitive at this age. Avoidance of occlusion (eg plastic pants), irritants (eg bubble bath) and keeping the perineum dry usually results in rapid resolution.

157. A 9-year-old girl presents with vaginal irritation and offensive discharge. On examination a mucopurulent discharge is seen. Vulvovaginitis, infectious

Offensive mucopurulent discharge suggests a significant infection, such as chlamydia or gonorrhoea. Swabs should be taken, including for these organisms. If positive then child sex abuse has been confirmed.

Theme: Ear pain in children.

A. Acquired cholesteatoma

B. Acute mastoiditis

C. Acute otitis media

D. Dental problems

E. Foreign body

F. Furuncle

G. Herpes zoster

H. Temporo-mandibular joint disease

I. Tonsillitis

For each scenario choose the most likely diagnosis:

158. A 3-year-old boy presents with fever and ear pain. He was treated last week with antibiotics for acute otitis media, and initially improved. On examination he has swelling and tenderness behind the ear. Acute mastoiditis

The 3-year-old child had symptoms of acute otitis media, and now has mastoid inflammation, mastoiditis.

159. A 14-year-old presents with a history of chronic ear pain and discharge. On examination he has a right perforated eardrum with whitish protrusion through it. Acquired cholesteatoma

In the 14-year-old, there are chronic middle ear problems and a visible cholesteatoma.

160. A 6-year-old girl presents with left ear pain. On examination there are vesicles in the left ear canal and left facial weakness. Herpes zoster

In the 6-year-old there are vesicles in the ear canal and facial weakness. This is likely to be Herpes zoster (Ramsay-Hunt syndrome). Ear pain can be associated with abnormal external ear findings, abnormal middle ear findings or neither.

Theme: Eating disorders.

A. Anorexia nervosa

B. Anorexia nervosa with bulimic symptoms

C. Bulimia nervosa

D. Chronic liver failure

E. Constitutional delay in growth and puberty

F. Hypothyroidism

G. Inflammatory bowel disease

H. Renal insufficiency

I. Turner’s syndrome

For each scenario choose the most likely diagnosis:

161. A 15-year-old girl is referred with poor weight gain. She weighs 35kg, and keeps to a strict diet. Her mother thinks she makes herself sick but she denies this. Anorexia nervosa with bulimic symptoms

162. A 13-year-old girl presents with primary amenorrhoea. She weighs 33kg which she feels is about right. She exercises for an hour a day. On examination she has a heart rate of 50/min and cool mottled peripheries. Anorexia nervosa

163. A 14-year-old girl is referred because she is worried about her weight, which is on the 25 centile. She restricts her intake, then binges, then makes herself sick. Bulimia nervosa

Anorexia is associated with a morbid fear of gaining weight and distorted body image. Eventually the body may 'go into hibernation', with cool peripheries, slow pulse and hormonal alterations (the 13-year-old girl). Bulimia is associated with bingeing, then self-loathing followed by purging/induced vomiting (the 14-year-old girl). Overlap conditions exist (the 15-year-old girl).

More here

Anorexia features

· Most things low

· G's and C's raised:

1. Growth hormone,

2. Glucose,

3. Salivary Glands,

4. Cortisol,

5. Cholesterol,

6. Carotinaemia


Anorexia nervosa is associated with a number of characteristic clinical signs and physiological abnormalities which are summarised below


1.Loss of axillary and pubic hair



4.Enlarged salivary glands

Physiological abnormalities

1. Hypokalaemia

2. Low fsh, lh, oestrogens and testosterone

3. Raised cortisol and growth hormone

4. Impaired glucose tolerance

5. Hypercholesterolaemia

6. Hypercarotinaemia

7. Low T3
Bulimia nervosa

· Referral to secondary care

· High-dose fluoxetine

Clinical Knowledge Summaries recommend referring all people with an eating disorder to secondary care. This is most important for patients with anorexia nervosa where there is a significant associated morbidity and mortality. However, services across the UK are sometimes patchy and treatment within primary care may be appropriate

Bulimia nervosa

Bulimia nervosa is a type of eating disorder characterised by episodes of binge eating followed by intentional vomiting


· Referral for specialist care is appropriate in all cases

· Cognitive behaviour therapy (cbt) is currently consider first-line treatment

· Interpersonal psychotherapy is also used but takes much longer than cbt

· Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking

Main points

· Useful in the management of depression and anxiety disorders

· Usually consists of one to two hour sessions once per week

· Should be completed within 6 months

· Patients usually get around 16-20 hours in total

Top of Form

164. Which ONE of the following plasma glucose levels is diagnostic of diabetes mellitus?

A. Fasting plasma glucose 5.4 mmol/L

B. Fasting plasma glucose 6.5 mmol/L

C. Fasting plasma glucose 7.1 mmol/L

D. Random plasma glucose 10.1 mmol/L

E. Random plasma glucose 9.5 mmol/L

A popular exam question as the diagnosis of diabetes is based on interpreting plasma glucose concentrations. A fasting plasma glucose above 7 mmol/l or a random glucose above 11.1 mmol/l are diagnostic of diabetes melltius.

165. A community hospital implements a locally derived set of infection management practice guidelines. Adherence to the guidelines by the medical staff will most likely result in which of the following outcomes?

A. Accelerated emergence of antibiotic resistant strains

B. Increase in the use of inadequate antimicrobial treatment regimens

C. Increase in drug adverse events

D. No change in overall use of antibiotics

E. Stable antibiotic susceptibility patterns for bacteria

E is correct. Guideline use has been associated with stable antibiotic susceptibility patterns for both

gram-positive and gram-negative bacteria, possibly as the result of promoting antimicrobial heterogeneity. Guideline use has also been associated with a reduction in the overall use of antibiotics and reduction in the use of inadequate antimicrobial treatment regimens, both of which could affect the development of antibiotic resistance. The use of automated guidelines has been associated with a decrease in adverse drug effects and improved antibiotic selection.

166. Dupuytrens contracture is fibrosis of the:

A. Palmar fascia

B. Forearm muscles

C. Sartorius fascia

D. None

E. Any of above

A is correct. Dupuytren's contracture is an abnormal thickening of tough tissue in the palm and fingers that can cause the fingers to curl. It is more common in men than in women and becomes

more common as we grow older

167. Breath-holding attacks: True / False

A. Are most common over the age of 4 years old

B. May be confused with generalised seizures

C. May be precipitated by a minor injury

D. May precipitate anoxic convulsions

E. Respond well to treatment with sustained release theophylline

B, C, D are correct. Breath holding attacks are also sometimes known as cyanotic breath holding spells. They are more common in the pre school child with a peak incidence occurring at 2 years of

age. The child may be upset as a result of being told off or scolded. The attack may also follow a minor injury or fall. The child starts to scream and after a period of forced expiration becomes apnoeic and loses consciousness. The episode lasts seconds following which the child is back to normal. The breath holding may be confused with a seizure and may even precipitate a fit resulting in generalised tonic clonic jerking or opisthotonus. No treatment is required.

168. In the UK the following are seen more frequently in Asian and West Indian children: True / False

A. Cystic fibrosis

B. Glucose-6-phosphate dehydrogenase deficiency

C. Rickets

D. Haemoglobin S disease

E. Rhesus incompatibility

A is incorrect. Cystic fibrosis is most prevalent in populations of Northern and Central European origin with an incidence as high as 1/625 live births. Incidence varies in other populations, being much less common among blacks and Asians. G6PD is highly prevalent in individuals originating from most parts of Africa, Asia and from Southern Europe. It can rarely be found in other individuals. Rickets is a disease of childhood .It occurs due to a mineral deficiency which prevents the normal process of bone mineralisation. The metabolism involves the skin as well as liver, kidneys and intestine. It is more common in the asian populations. Hbs or sickle haemoglobinopathy occurs more frequently in regions where Plasmodium falciparum (malarial parasites) occur endemically.

169. A 7-year-old girl complains of a sore throat. She has experienced this symptom on 2 previous occasions over the past 3 years. Her tonsils are large and congested. Also found is a benign heart murmur: True / False

A. An ENT opinion should be sought to advise whether to recommend tonsillectomy

B. White exudates on the tonsils indicate a bacterial infection

C. If antibiotics are given, Tetracycline is the drug of choice

D. Further sore throats should be treated aggressively with antibiotics to lessen the risks of sub-acute bacterial endocarditis

E. Petechiae on the palate suggest infectious mononucleosis

E is correct. This question describes a child with an upper respiratory tract infection.This is extremely common and in most cases the cause is viral and treatment is conservative only. Tonsillectomy is considered in children with a history of recurrent tonsillitis causing them to miss significant time at school. If antibiotics are required to treat a bacterial infection penicillin is the drug of choice. Tetracycline is contraindicated in children due to the side effects affecting bones and teeth. Palatal petechiae are often seen in patients with Glandular fever.

170. Fever in a child True / False

A. Is not always found in neonates with sepsis

B. Is best treated by cold water sponging

C. Is more effectively treated by oral Acetylsalicylate than Paracetamol in recommended dosage

D. Due to heat stroke is best treated by an anti-pyretic

E. In Kawasaki disease is usually best treated with oral Paracetamol

A is correct. Due to an immature immunological system neonates with sepsis may not present with

fever. Clinical manifestations are highly variable, ranging from asymptomatic to severe fulminant presentations, acute to chronic, and one or multiple organs being affected. Symptoms and signs are so non-specific that a neonate usually requires a full septic screen. The presence of fever requires the source of infection to be identified. In most cases in children fever is the result of a viral infection. Antipyretics such as paracetamol are effective . Cold sponging is not. Option c. is incorrect. Children are NOT usually treated with aspirin due to the serious complications and side effects including Reyes syndrome. The febrile phase of Kawasaki disease is treated intravenously with gamma globulin as well as aspirin (with careful monitoring) to minimise the risk of coronary artery aneurysms.

171. Functional recurrent abdominal pain: True / False

A. Affects at least 10% of children over the age of 5

B. Is characteristically localised away from the umbilical area

C. May be accompanied by vomiting

D. Can only be diagnosed after radiological demonstration of normal kidneys

E. Is well recognised to cause poor weight gain

A , C are correct. Recurrent abdominal pain is encountered in approximately 10% of over 5-year-olds. It is vital to ascertain the nature of the pain, the degree of disruption the pain causes and how the child and his or her family deal with the pain. Organic causes need to be excluded and these include GI, urological,and haematological causes as well as miscellaneous causes. Peri-umbilical pain suggests non-organic pain. Vomiting may be a feature of non organic abdominal pain, although children rarely lose weight. Other key questions to ask include timing of pain, associated features, family history and social history. Examination is often unrewarding and when the diagnosis is suspected, investigations will most likely be of no diagnostic value.

172. Recurrent abdominal pain in children is a recognised feature of: True / False

A. Constipation

B. Emotional stress

C. Migraine

D. Urinary tract infection

E. Cystic fibrosis

All are correct. All of the above conditions may present with recurrent abdominal pain. It is therefore vital to take a thorough history and carry out a detailed examination. With constipation there may be an associated history of toilet refusal or associated soiling. There may also be faecal loading palpable on palpation. Emotional problems may present with abdominal pain and clues may be obtained when focusing on the childs social history including school progress. Migraine often is familial and the child may also be experiencing associated features of headache, and visual problems. There is often a precipitating factor. Urinary infections may present with dysuria, fever, and abdominal pain. An infection is easily confirmed on bacteriological analysis. A child with cystic fibrosis may develop abdominal pain for a number of reasons including liver involvement, intussusception. Other cause of intestinal obstruction(meconium ileus) as well as non organic functional pain.

173. Breath-holding attacks: True / False

A. Are a type of epileptic seizure

B. Usually follow a noxious stimulus

C. Are associated with cyanosis and stiffness

D. Remit spontaneously with increasing age

E. Occur most frequently in the first year of life

B, C, D are correct. Breath holding attacks are common. They typically affect children between the ages of approximately 2 years and 5 years. They are rare before the age of 6 months.The peak age is 2 years. They are frightening for the parents because the child appears limp and unresponsiveness. They usually follow a noxious stimulus such as the child being hurt or upset. The episode is heralded by a shrill cry.,following which there is forced expiration and apnoea.There is often associated cyanosis and this may result in repeated clonic jerks ,opisthotonus and bradycardia. The parents need reassurance regarding the diagnosis and no specific treatment is indicated as there is spontaneous resolution.Most abate by the age of 5 years.

174. Groin swelling in a 5-year-old child may be due to: True / False

A. Acute leukaemia

B. Transient synovitis of the hip

C. Rheumatoid arthritis

D. Osgood-Schlatter’s disease

E. Factor VIII deficiency

D is incorrect. Acute leukaemia often presents with lymphadenopathy. Transient synovitis often occurs secondary to an URTI and lymphadenopathy. Rheumatoid arthritis is a condition characterised by inflammation of the joints as well as rheumatoid nodules. Osgood Schlatters is an apophysitis of the tibial tubercle and often presents with pain, tenderness and a swelling at the insertion of the patellar tendon. Factor 8 deficiency is also known as haemophilia. The hallmark of this condition is haemarthroses or spontaneous bleeding into the joints resulting in swelling.

175. A seven month old baby presents with a short history of cough and dyspnoea. On examination, the pulse is 180 per minute and there are generalised crepitations present throughout the chest. There are no heart murmurs present. The liver is palpable 2cm. The differential diagnosis includes: True / False

A. Congestive cardiac failure

B. Acute broncholitis

C. Cystic fibrosis

D. Meningococcal septicaemia

E. Laryngotracheo bronchitis

A, B, C are correct. This presentation would fit with cardiac failure, Cystic Fibrosis, and bronchiolitis. It is important to take a detailed history and carry out a thorough examination in order to reach a differential diagnosis. For example the child may have a cardiac murmur suggesting cardiac disease. There may be a history of failure to thrive and recurrent chest infections suggesting the possibility of C.F. Acute bronchiolitis may be preceded by a coryzal illness. Investigations will include a CXR . A nasopharyngeal swab may reveal RSV in the case of bronchiolitis and a sweat test is important to exclude the possibility of cystic fibrosis. The latter two options would not present in this way. Meningococcal septicaemia would present with the child becoming acutely unwell with a fever, a non-blanching rash and septicaemia. Laryngotracheomalacia is another term for croup. This illness is characterised by a prodromal viral illness leading to a barking cough and stridor.

176. A three-year-old girl presents with increasing dyspnoea and cyanosis. On examination, finger clubbing is present, she has moderate pectus carinatum (pigeon chest), and widespread crepitations throughout the lung fields. There are no cardiac murmurs: True / False

A. She has lobar pneumonia

B. A sweat test would provide valuable information

C. Staphylococcus aureus is likely to be isolated from her sputum

D. This condition may present with rectal prolapse in the newborn period

E. Generally speaking, 50% of children in the UK with this condition die before the age of 14 years

B, C, D are corret. This child needs to be investigated for Cystic Fibrosis. Cystic Fibrosis is the leading cause of severe chronic lung disease in children. It has an autosomal inheritance It may present with failure to thrive,rectal prolapse or with intestinal obstruction. It may also present with recurrent respiratory infections. In most centres screening for Cystic fibrosis is carried out with the Guthrie test in the first week or two of life. Examination findings supporting this diagnosis include the chest signs and the clubbing, although bronchiectasis secondary to previous infections may also have similar findings. A diagnosis of lobar pneumonia is unlikely due to the crepitations being bilateral and the absence of a fever. A chest x-ray would be useful. The sweat test remains the standard approach to diagnosis with the chloride concentration being elevated. The most common causative organism in children is Staphylococcus aureus,Haemophilus influenza may also be present .Pseudomonas aeruginosa uncommonly colonises the young child but may be a significant problem in older children.

177. A child of 18 months, who has been unwell for several months, presents with a firm mass in the right side of the abdomen. The differential diagnosis includes: True / False

A. Cystic kidneys

B. Spina bifida

C. Nephroblastoma

D. Splenomegaly secondary to chronic myeloid leukaemia

E. Hydronephrosis

A, C, E correct. This abdominal mass could be renal in origin and therefore a), c) and e) are possible.Children with polycystic kidneys may be diagnosed antenatally although this is not always the case.Other features at presentation may include haematuria, and hypertension as well as flank pain. Children may also present in chronic renal failure. Nephroblastoma is also known as Wilms tumour.Typically the children present with an asymptomatic firm tumour. There may be a history of recurrent abdominal pain and vomiting. If there is renal artery involvement there may be hypertension and in severe cases cardiac failure. Depending on the staging at presentation there may also be symptoms due to more extensive spread. Renal obstruction may also present as described in the question. Obstructive lesions may be asymptomatic although often presents with abdominal pain, a mass and a history of urinary tract infections. Splenomegaly will originate on the left side rather than a right sided mass. Spina Bifida does not present like this.It is neurological condition which may result in a neurogenic bladder and therefore functional loss, urinary tract infections and reflux.

178. Neck stiffness in a two-year-old may occur secondary to: True / False

A. Tonsillitis

B. Idiosyncratic response to metoclopramide (Maxolon)

C. Meningitis

D. Subarachnoid haemorrhage

E. Meningeal leukaemia

All are correct. Neck stiffness is a common feature of tonsillitis due to the discomfort and lymphadenopathy. Meningitis and meningeal leukaemia may also present with neck stiffness. Metoclopramide is an effecive anti emetic.It can be responsible for acute dystonic reactions involving the face and neck as well as an oculogyric crisis.The dystonia may result in nuchal rigidity.

179. A 10-year-old boy presents with pain in the upper tibia. There is tenderness on palpation of the bone but no limitation of movement at the knee. The differential diagnosis includes: True / False

A. Acute lymphoblastic leukaemia

B. Rheumatoid arthritis

C. Osteomyelitis

D. Osteosarcoma

E. Osgood-Schlatter disease (osteochondritis of the tibial tubercule)

C, D, E are correct. This scenario describes a boy with localised pain in his upper tibia. This does not sound typical for ALL which would manifest with more diffuse bone pain as well as joint pain. Neither does it describe a patient with Stills disease which would involve inflammatory changes of the joints. The latter three options are possible and therefore careful history and appropriate radiological investigations need to be organised. In the case of osteomyelitis patients may show raised inflammatory markers, a possible fever and characteristic radiological features on x ray and bone scan. In the case of an osteosarcoma there may be features of more extensive involvement, weight loss, chest spread etc. The x ray may show a sclerotic lesion with signs of new bone formation. Osgood Schlatters disease is an osteochondritis of the tibial tubercle.X rays may be normal and therefore are useful to rule out other conditions.

180. Organic disease is frequently found in a child presenting with: True / False

A. Recurrent abdominal pain

B. Faecal soiling

C. Nocturnal enuresis

D. Constant dribbling of urine in a 5-year-old girl

E. Headaches

D is correct. Recurrent abdominal pain occurs in approx 10% of over 5-year-olds and in less than 10% an organic cause can be found. Faecal soiling is mostly due to constipation with secondary overflow. Nocturnal enuresis is not usually associated with underlying organic pathology however daytime enuresis and constant dribbling of urine in a child is abnormal and an ultrasound scan of thhe renal tract including bladder studies are required. Children often present with headaches. Clearly it is important to take a thorough history and carry out a detailed examination in order to exclude space occupying lesions as well as excluding migraine etc. However most children presenting with headaches do not have demonstratable organic causes.

181. Harry Foreman is an 82yr old retired school teacher who has been increasingly forgetful and confused over recent months. He lives with his wife and has plenty of local family support enabling them to currently cope with his declining memory, motor skills and perception. During a home visit, you suggest to the family that you would like to refer Harry for further assessment because you suspect that he may be suffering from Alzheimer’s disease. They have read in the paper that there are drugs available that may help with this. NICE have updated their guidance in January 2006. In light of this, which TWO of the following statements is correct?

A. Diagnosis of Alzheimer’s disease can be made by the GP either in surgery or at the patient’s own home

B. Assessments must be done before initiating treatment

C. Treatment should only be initiated by the patient’s own General Practitioner, an old age psychiatrist, neurologist or care of the elderly physician

D. If GPs are involved in prescribing, a shared care protocol should be in place

E. Stable patients should be reviewed on an annual basis.

B, D are correct. Alzheimer’s disease (AD) is the most common cause of dementia in older people with an estimated 500,000 people affected in the UK. There is currently no known cure and the disorder is usually terminal within three to seven years. The World Health Organisation international classification of disease criteria require a duration of more than six months. The cholinesterase inhibitors donepezil, rivastigmine and galantamine have good evidence base in patients with mild to moderate AD. The proposal to limit cholinesterase inhibitors only to patients with AD of moderate severity is inconsistent with evidence base ; BMJ 2005; 331 (7512):321-7.

Patients should be reviewed six monthly under current guidance, which is due to be reviewed in 2009. Diagnosis is made in a specialist clinic and cannot be made by a GP.

182. Concerning lactation True / False

A. Lactation is successfully suppressed by demand feeding to empty the engorged breast

B. Colostrum is secreted for seven days after birth

C. Bromocryptine promotes milk production

D. Problems are often associated with an incorrect position of the baby’s mouth on the breast

E. The staphylococcus organism is associated with puerperal mastitis

D, E are correct. Staphylococci are the commonest cause of mastitis in lactating women. Bromocripline, a dopamine agonist, can be used to prevent milk production through inhibiting prolactin secretion. A full breast should be emptied to prevent engorgement and inflammation which may inhibit milk production. Colostrum is produced for the first few days only after birth. Feeding promotes milk production. Demand feeding would increase milk production.

The advantages to the infant of breast feeding include: True / False

A. The production of active immunity to common childhood infections

B. The development of an improved mother-child relationship

C. The promotion of protective intestinal flora

D. A reduction of allergic disorders in childhood

E. A reduction in the incidence of gastroenteritis

A is incorrect. Breast feeding provides passive immunity. Breast milk contains lactoferrin, lysozyme and IgA which influence the infants bowel flora. Macrophages assist in the defence of the intestinal tract.

Theme: Anaemia

A. Aplastic anaemia

B. Caecal carcinoma

C. Chronic lymphocytic leukaemia

D. Chronic renal failure

E. Folic acid deficiency

F. Multiple Myelomatosis

G. Myelofibrosis

H. Nutritional iron deficiency

I. Peptic ulceration

J. Pernicious anaemia

K. Rheumatoid arthritis

L. Vitamin B12 deficiency

M. Vitamin K deficiency

For each of the following patients, select the most likely cause of their anaemia:- NR - Haemoglobin 12-16; Urea 3-8, Creatinine 50-100.

183. An otherwise well 70-year-old man complains of fatigue. Investigations show that he has a haemoglobin of 8g/dl with an MCV of 80fl and a low MCHC. His urea is 20 mmol/l and creatinine is 190mols/l. Chronic renal failure

This patient has chronic renal failure and appears to have anaemia of chronic disease. Renal failure is associated with erythropoietin deficiency. Although his MCV is low and he may well have an iron deficiency anaemia due to any associated GI loss, there is no reason to assume that he has a 'nutritional' iron deficiency anaemia.

184. A 70-year-old woman who has pain and swelling of her wrists and knees also complains of fatigue and bruising easily. She has a haemoglobin of 9g/dl with a normal mean corpuscular volume and mean corpuscular haemoglobin contentration. Her ESR is 120mm/hr. Rheumatoid arthritis

This lady has joint pains and swelling as well as chronic anaemia. The high ESR reflects this chronic inflammatory condition. Haematological manifestations of RA...

185. A 40-year-old woman who had a resection of her terminal ileum for Crohn's Disease 5 years ago, presents with breathlessness and malaise. She has a megaloblastic anaemia with a haemoglobin concentration of 6g/dl. Vitamin B12 deficiency

This patient has Crohn’s disease and terminal ileitis resulting in resection. It is within this region that vitamin B12 complex is absorbed and hence vitamin B12 deficiency is the likely cause explaning the megaloblastic anaemia.

186. The following are indications for surgical treatment of hiatus hernia with gastrooesophageal reflux in children: True / False

A. Vomiting

B. Anaemia

C. Persistent oesophagitis

D. Recurrent chest infection

E. Hiatus hernia still present after the age of 2 years

C, D are correct. Indications for surgical operation in children with hiatus hernia include persistent symptoms such as oesophagitis and recurrent chest infection. Vomiting is not in itself an indication for surgery as it is not an unusual symptom which may settle with appropriate treatment.

187. A six month old infant has paroxysmal cough and vomiting: True / False

A. The absence of an inspiratory whoop makes the diagnosis of pertussis unlikely

B. A total white cell count of 80 x10^9/l with lymphocyte count of 75 x10^9/l excludes a diagnosis of pertussis

C. Sub-conjunctival haemorrhages indicate the presence of thrombocytopenia

D. Bordetella pertussis, if present, is more likely to be recovered from a nasopharangeal swab than a throat swab

E. If the infant has whooping cough, the disease is likely to be milder than it would be in an older child

D is correct. This scenario describes a baby with whooping cough.This illness tends to be more severe in younger infants. The organism responsible being Bordetella pertussis. This is more likely

to be isolated from a nasopharyngeal swab than a throat swab. Clinical manifestations include a paroxysmal cough (100%),whoops (60%) dyspnoea, apnoea, emesis, leucocytosis with an absolute lymphocytosis (>10 x10^9/l) is characteristic. Complications include pneumonia, bronchiectasis, emphysema and pneumothorax.The forcefulness of the paroxysms often result in subconjunctival haemorrhages.

188. The following are indications for circumcision in children: True / False

A. Non-retractile prepuce

B. Phimosis

C. Soreness of prepuce

D. Acute balantitis

E. Urinary infection

B is correct. The one absolute indication for circumcision is scarring of the opening of the foreskin making it non-retractable (pathological phimosis). This is unusual before the age of 5. A non-retractile prepuce without inflammation is, of course, a normal variant in the first few years of life. Recurrent troublesome episodes of infection beneath the foreskin (balanoposthitis) are an occasional indication for circumcision. Occasionally paediatric circumcisions are required for rare conditions.

189. A mother is concerned because she cannot retract the prepuce of her two-year-old son: True / False

A. Circumcision is indicated

B. He is likely to get recurrent balantitis

C. Urethral valves are well known association

D. Regular retraction of the prepuce during bathing should be recommended

E. This is a completely normal condition at this age

E is correct. This question relates to the natural history of the foreskin . The foreskin is still developing at birth and hence is often non retractable up to the age of 3 years, The process of separation is spontaneous and does not require manipulation. By the age of 3 years ,(90% of boys will have a retractable foreskin.In a small proportion of boys this natural process of separation continues well into childhood.

190. Appendicitis in children: True / False

A. Occurs usually under the age of 3 years

B. Is the commonest abdominal emergency in childhood requiring surgery

C. Is always associated with pyrexia

D. White blood count is an important part of the diagnosis

E. Antibiotics should be given postoperatively in all cases

Acute appendicitis is the most common cause of abdominal surgery in childhood. The disease typically is caused by some obstruction of the lumen of the appendix. It is uncommon in the under 5 age group. Clinical manifestations include abdominal pain that begins as central pain and then localises to the right iliac fossa. Associated symptoms include fever, tachycardia, vomiting and anorexia. Diagnosis is suspected by clinical examination. Associated laboratory findings include a raised white cell count and occasionally pyuria in cases where the inflamed appendix overlies the ureter. Treatment involves surgical removal of the inflamed appendix. Preoperative antibiotics are

controversial, but may reduce the risk of postop wound infection. Perioperative antibiotics are also prescribed as well as a post operative course if there has been peritonitis.

191. Indications for circumcision include: True / False

A. Phimosis

B. Severe ammonia dermatitis

C. Non-retractile prepuce in a 3 month old baby

D. Scrotal thrush

E. Enuresis

A is correct. The one absolute indication for circumcision is scarring of the opening of the foreskin making it non-retractable (pathological phimosis). This is unusual before the age of 5. Recurrent troublesome episodes of infection beneath the foreskin (balanoposthitis) are an occasional indication for circumcision. Occasionally paediatric circumcisions are required for rare conditions.

192. The diagnosis of non-accidental injury in a child is more likely if: True / False

A. The presentation of a child with significant injuries to a health professional is delayed

B. The history of injury given by the father is consistent with that given by the mother

C. The child is 3 years old and has bruising to the shin

D. There is extensive bruising and thrombocytopenia

E. He/she is 6 months old and has a torn labial frenulum

A, E are correct. Abused children may present in many different ways and recognition is very rarely straight forward .As always, it is very important to document the injuries clearly and accurately. It is also essential to take a detailed history of how the injuries were sustained, preferably from more than one person. Social background and family circumstances are important factors to ask about in the history. Other relevant details which may point to a diagnosis of non-accidental injury include the following:

1. A delay in seeking advice from health professionals

2. An inadequate,inconsistent or unrealistic explanation.

3. Indifferent,or inappropriate concern of the carer.

4. Parent unwilling for the child to be examined.

5. Child or siblings on the child protection register.

A child of 3 is very likely to have bruising to the shins as a result of accidental minor injury. If a child with extensive bruising is found to have a thrombocytopaenia, the child will need further haematological investigations. It is, however important to emphasise that children with other medical conditions may also be the victims of child abuse and therefore it is important to take all factors into account. The final stem relates to a baby of 6 months presenting with a torn frenulum. This scenario should raise serious suspicion of the baby either being force fed or having other objects thrust into his/her mouth. A mobile child can tear the labial frenulum as a result of an accidental fall however this is not the case in non ambulatory children.

193. Diseases determined by autosomal dominant genes: True / False

A. Are more common in consanguineous marriages

B. Usually appear in every second generation

C. Are seen more commonly in women than men

D. May only become apparent after the individual has reached the age of 30 years

E. Have a chance of occurring of one in two among the siblings of an affected individual

A is correct. Consanguinity increases the risk of all kinds of genetically determined disease. There is no 'skipping a generation', the disease has a clear pedigree. The sex ratio for autosomal dominant conditions is usually 1:1. Typical conditions include Huntingdon's, achondroplasia and MEN type 1. These conditions may only become apparent after 30 years of age. There is a 50% chance of the offspring of an affected individual acquiring the condition.

194. Which of the following are true regarding squamous cell carcinoma: True / False

A. It is a commoner malignant skin tumour than basal cell carcinoma

B. It only occurs in the skin

C. It is the most common skin tumour seen in transplant patient

D. Metastasis is usually to the regional lymph nodes

E. The tumour typically has everted edges

C, D, E are correct. The commonest dermatological malignancy is a basal cell carcinoma with squamous being next commonest, but this tumour is commonest in immunocompromised transplant subjects. Squamous carcinomas can also occur in the lung, cervix and oesophagus. SCC metastasises to regional lymph nodes and characteristically have an everted edge.

195. The plantar reflex is extensor: True / False

A. Following sciatic nerve trauma

B. In the newborn infant

C. During hypoglycaemic coma

D. In lesions of the corticospinal tract

E. During sleep

B, C, D are correct. Extensor plantar responses occur as a consequence of upper motor neurone damge (sciatic nerve = lower motor neurone). It is a normal sign in a newborn. It may also be present associated with encephalopathy such as hepatic, hyponatraemic and hypoglycaemic coma.

196. The following are true about malignant melanoma: True / False

A. It is commoner in males than females

B. The amelanotic type is more aggressive than the pigmented type

C. Malignant transformation in common moles is about 1:10,000

D. Staging is according to the size of the tumour

E. It is found exclusively in the skin

B is correct. Malignant melanoma may be subungual, buccal, anal, and present on any mucosal surface, not merely in the dermis/epidermis. The incidence of malignant melanoma of the skin has been rising rapidly in the white populations around the world for several decades. Incidence rates in Great Britain increased from around 2 per 100,000 population for males and 3 per 100,000 population for females in 1971 to 7 and 9 per 100,000 population for men and women respectively in 1996, a threefold increase. Amelanotic malignant melanoma most commonly occurs in the setting of melanoma metastasis to the skin, presumably because of the inability of these poorly differentiated cancer cells to synthesize melanin pigment. More than 50% of cases are believed to arise de novo without a preexisting pigmented lesion. Tumour size is only one of the criteria used in the AJCC 2002 Revised Melanoma Staging.

197. Which of the following statements are true regarding keratoacanthoma? True / False

A. It is also called molluscum sebaceum

B. It usually remits spontaneously without leaving scar

C. It is caused by a pox virus

D. Central necrosis is uncommon

E. Histologically is difficult to distinguish from squamous cell carcinoma

A, E are correct. Keratoacanthoma usually remits spontaneously, but often leaves a scar. It is not of infective origin, indeed it may be difficult to differentiate from squamous cell carcinoma under the microscope. Central necrosis with ulceration is a common feature.

198. Animals may be the source of the following disease: True / False

A. Listeriosis

B. Cholera

C. Brucellosis

D. Pertussis

E. Tuberculosis

A, C, E are correct. Zoonoses include Anthrax (cattle, goats), Listeriosis (pets), leptospirosis (rats), toxocara (cats), toxoplasmosis (dogs), tapeworms (dogs), brucella (sheep) and TB (cattle) is implicated.

Theme: Pelvic pain

A. Adenomyosis

B. Adnexal torsion

C. Complete abortion

D. Degenerating fibroid

E. Ectopic pregnancy

F. Endometriosis

G. Incomplete abortion

H. Irritable bowel syndrome

I. Missed abortion

J. Pelvic inflammatory disease (PID)

K. Rupture of an ovarian cyst

L. Threatened abortion

Select the most likely diagnosis for the following cases presenting with pelvic pain:

199. A 24-year old lady presents to her GP complaining of a two-day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in three months complaining of pelvic pain and dyspareunia. Pelvic inf lammatory disease (PID)

This lady has PID due to Neisseria gonorrhoeae/chlamydia infection which is responsible for the vaginal discharge. The RUQ pain is due to perihepatitic adhesions, which is a complication of PID (Fitz-Hugh-Curtis syndrome).

200. A 17-year old girl presents to A&E with sudden onset sharp, tearing pelvic pain associated with vaginal bleeding. She also complains of shoulder tip pain. On examination she is hypotensive, tachycardic and cervical motion tenderness is elicited. Ectopic pregnancy

This history is highly suggestive of an ectopic pregnancy . She has shoulder tip pain due to

diaphragmatic irritation (referred) from intraperitoneal blood.

201. A 52-year-old female asks you for copies of her medical records. Within the records are several letters from hospital specialists, one of which refers to the patient in very unflattering terms. There is also a note in the records of a call that was made to the surgery by a neighbour of the patient who reported hearing noises through the wall and expressed concern that the patient may be suffering domestic violence.

A. Under the Data Protection Act 1998 you are allowed to withhold the note of the telephone call from the neighbor.

B. Under the Data Protection Act 1998 you are obliged to disclose the record in its entirety

C. You may withhold access to any references to third parties, including hospital specialists.

D. You must seek the consent of the hospital specialists before disclosing their letters

E. You must withhold access to any references to third parties, including hospital specialists Incorrect answer selected

B is correct. Under data protection etc. The legislative framework for the disclosure of medical records is the Data Protection Act 1998. Under the Act, you may withhold access to any part of the record if you consider that disclosure would cause serious mental or physical harm to the patient or another person. You may also withhold access to part of the record that in effect discloses information about an identifiable third party, unless you have the consent of the third party to make the disclosure or it is reasonable in all the circumstances to make the disclosure without seeking consent. Information in a health record made by a healthcare professional involved in the care of the patients does not count as third party information for this purpose; where, as in this case, disclosure of a hospital letter is likely to generate a complaint, you may choose to inform the author that the disclosure has been made but are not obliged to do so. If information is likely to cause serious harm to the physical or

mental health or condition of the data subject or any other person, then it can be withheld regardless of the author. Question supplied by the Medical Defence Union.

Theme: The red eye

A. Acute angle closure glaucoma

B. Amblyopia

C. Blepharitis

D. Keratitis

E. Scleritis

F. Uveitis

G. Vernal angiitis

A patient walks into the surgery with eye symptoms and signs. For the following clinical scenarios, select the most appropriate diagnosis:

202. Patient presents with severe ocular pain and decreased vision with coloured halos around lights. Examination shows a fixed, mid-dilated pupil and cloudy cornea. Acute angle closure glaucoma

Alternative presentation could be with little ocular pain but severe headache and nausea or vomiting. Tonometry shows raised intraocular pressure.

203. Patient has been wearing contact lenses for a prolonged period of time and presents with ocular pain, redness and decreased vision. Keratitis

Examination may show a white lesion (ulcer), although slit lamp examination and fluorescein staining would be needed to show herpetic ulcers.

204. A patient with rheumatoid arthritis presents with severe pain and tenderness. Examination shows a bluish red discolouration. Scleritis

205. A patient presents with a sudden onset of pain, photophobia and blurred vision. Examination shows circum-corneal injection, tenderness on palpation and a meiotic pupil. Uveitis

Tonometry will often show decreased pressure. A slit lamp would be needed to show flare. All of the above correct options would require referral to an opthalmologist. Other conditions requiring referral include orbital cellulitis, hyphema, scleritis, iritis or uveitis. Symptoms of blepharitis, particularly if staphylococcal, would be crusting and matting of eye lashes. There is no such thing as vernal angiitis.

206. In a clinical trial of a new drug treatment for Irritable Bowel syndrome, the following results are obtained:

Drug Placebo

Improved 46 patients 34 patients

Not Improved 14 patients 26 patients

True / False

A. The superiority of the drug over placebo is so obvious that formal statistical testing is unnecessary.

B. Data can be evaluated by computing a chi-squared test

C. Data can be evaluated using a students t-test

D. If the statistical probability that the difference between drug and placebo is 0.1 then the drug can be introduced into clinical practice

E. Pearson's coefficient of linear correlation could be used to test significance

Chi-squared test is most appropriate to assess significance of the results.

207. A 90-year-old man with chronic leukaemia presents with gout which his general practitioner treats with Allopurinol. How does Allopurinol prevent the accumulation of uric acid?

A. By competing for its transporter to the kidney

B. By enhancing its solubility

C. By inhibiting xanthine oxidase

D. By inhibiting pyrimidine synthesis

E. By inhibiting the inflammatory response it causes

C is correct. Allopurinol is a xanthine oxidase inhibitor and is converted by this enzyme to alloxanthine in this form it inhibits the conversion of hypoxanthine to xanthine, and the conversion of xanthine to uric acid. Therefore inhibiting the formation of uric acid. Article about allopurinol

208. Which of the following is true concerning Scaphoid fractures?

A. Rarely occur in young adults

B. When complicated by avascular necrosis the proximal pole is usually affected

C. Should be treated by bone grafting and internal fixation even if undisplaced

D. Wrist fractures are uncommon Incorrect answer selected

E. Anteroposterior and lateral radiographs reveal most fractures

B is Correct. Scaphoid fractures are common in young adult males and occur as a result of a fall on an outstretched hand. If complicated by avascular necrosis the proximal pole is usually affected due to the distal to proximal direction of the scaphoid blood supply. Un-displaced fractures can be treated in a plaster. Wrist fractures are common. Initial radiographs usually involve four views of the scaphoid due to difficulties in visualising fractures.

209. A 53yr old baker comes to see you in surgery following an MI 3 months previously. He has made a full recovery but wants to ask about his diet. Which 2 of of the following foods should he avoid?

A. Frozen Vegetables

B. Margarine containing sitostanol esters

C. Olive oil

D. Organic butter

E. Pork

F. Tinned vegetables

D, E are correct. People should be advised to adopt a healthier overall diet following an MI, as up to 30% of all deaths from coronary heart disease (CHD) have been attributed to unhealthy diets. The

focus should not just be on reducing fat intake - exercise also plays a very important role. Tinned and frozen fruit and vegetables are as good as fresh vegetables and should be encouraged A Mediterranean diet contains many of the dietary elements that are thought to be protective in CHD

ø Replace butter with olive oil and mono-unsaturated margarine (e.g. based on rape-seed or olive oil). Organic butter is no better for you than non-organic from a CHD point of view

ø Eat less red meat (replace beef, lamb, and pork with poultry).

ø Margarine containing sitostanol ester may help some people reduce the cholesterol intake from their diet. It has been shown to reduce total cholesterol by about 10% when substituted for part of the daily fat intake.

Adding 2g of plant sterol to an average daily portion of margarine reduces serum low-density lipoprotein cholesterol by an average of 0.54 mmol/l in people aged 50-59, 0.43 mmol/l in people aged 40-49, and 0.33 mmol/l in those aged 30-39

ø Eat more fish, including at least one portion of oily fish per week (e.g. mackerel, herring, kipper, pilchard, sardine, salmon, or trout).

ø Eat more bread (especially whole-grain bread).

ø Eat more root vegetables and green vegetables.

ø Eat fruit every day.

210. A 30-year-old woman with hepatitis C comes to your surgery because she is planning to have a baby. She asks whether her baby could get hepatitis C. What are the chances that the virus will be transmitted from mother to child?

A. <10%

B. 10-30%

C. 30-50%

D. 50-75%

E. 75-100%

F. 100%

A is correct. The transmission rate from mother to child is about 6%. You should explain this to the patient in layperson's terms and give her time to absorb the information before she decides what to do.

211. Complications of childhood obesity includes: True / False

A. Diabetes Mellitus

B. Perthe's disease

C. Schizophrenia

D. School truancy

E. Slipped femoral epiphysis

A, D, E are correct. Complications include increasing risk of T2DM, slipped femoral epiphysis, behavioural problems (including truancy) and depression (not schizophrenia). Management of obesity in children Avoiding childhood obesity Hip conditions in children

212. A 33-year-old school teacher with diabetes attends surgery with 8 weeks amenorrhoea and a positive pregnancy test. She last had a child when she was aged 21 and her current pregnancy is the result of failure of progesterone only pill. Her body mass index is 31 kg/m2 and this is her third pregnancy. Her antenatal booking diastolic blood pressure is 82 mmHg and her urine has shown + protein today and when tested 2 weeks earlier with the practice nurse. Which 4 factors in the history are predisposing factors for pre-eclampsia?

A. 12 years since her last pregnancy

B. Aged 33 years

C. Body mass index 31

D. Diastolic blood pressure at booking of 82 mmHg

E. Pre-existing diabetes

F. Third pregnancy

G. Urine + on two occasions

A, D, E, G are correct.

Factors which predispose women to pre-eclampsia are:

ø First pregnancy

ø Previous pre-eclampsia

ø >10yrs since last baby

ø Age >40yrs

ø Body mass index >35

ø Family history

ø Booking diastolic BP >80mmHg

ø Proteinuria at booking (> + on more than one occasion or >300mg/24h)

ø Multiple pregnancy

ø Underlying medical conditions (Hypertension, renal disease, diabetes, anti phospholipids antibodies)

Ref BMJ 2005; 330; 359:1877-90

213. A general practitioner is likely to have, in his practice of 2500, at least one individual with: True / False

A. Severe mental handicap

B. Spina bifida

C. Cystic fibrosis

D. Muscular dystrophy

E. A chromosomal anomaly

D is incorrect. This question basically assesses the knowledge of incidence of disorders in a typical population. 1:2500 is the figure for CF (gene frequency 1:25, therefore chances of two heterozygotes meeting 1 in 625 and the chances of having an affected child is 1 in 4, giving the incidence of 1 in 2500. Similar incidences occur for spina bifida (1 in every 1000 live births) and accumulated chromosomal abnormalities. http://www.patient.co.uk/showdoc/40001372/

Theme: Differential Diagnosis of Dementia.

A. Alzheimer's disease

B. Creutzfeldt-Jacob disease

C. Lewy body dementia

D. Huntington's disease

E. Hypothyroidism

F. Post-ictal confusion

G. Pseudodementia

H. Wernicke's encephalopathy

For each patient below, choose from the list above the single most relevant diagnosis. Each option may be chosen once, more than once or not at all.

214. A 43-year-old unmarried woman has had poor memory and sleep disturbance for the last three weeks. She has been living alone for the first time, after recently relocating to an address 250 miles from her previous one. Neurological examination is normal. Pseudodementia

Pseudodementia due to affective disorder may be difficult, to distinguish from Alzheimer’s disease. In depression the cognitive deficit (if present) is typically acute and recent. Whereas that associated with Alzheimer's disease is typically insidious. The depressed patient will often communicate a sense of distress and agitation, and the depression will be associated with typical features e.g. positive diurnal mood variation and early morning waking. Other clinic features favouring a diagnosis of depression include family history, previous episodes and precipitating life events.

215. A 36-year-old woman is brought to hospital having being found unconscious at home after falling down the stairs. She cannot remember anything about the episode. She is mildly disoriented and has bitten her tongue. Neurologic examination is otherwise unremarkable and MRI brain scan shows no abnormality Post-ictal confusion

Postictal confusion may produce memory loss, but the onset is acute and associated with symptoms and signs strongly suggestive of a seizure

216. A 32-year-old homeless woman is brought to hospital complaining of memory loss. She is disoriented in space and time has gait ataxia and a right sixth nerve palsy.Wernicke's encephalopathy

Wernicke’s encephalopathy represents an acute neuropsychiatric reaction to severe thiamine deficiency. Characteristically patients are globally confused with gait ataxia and ophthalmoplegia (nystagmus, abducens palsy or conjugate gaze disorder all typical). All three elements of this triad need not be present in order to make diagnosis Thiamine deficiency may be secondary to alcoholism, vomiting during pregnancy, dietary insufficiency or gastric carcinoma. Treatment is with urgent intravenous thiamine, but the majority will develop a chronic Korsakoff syndrome

217. A 56-year-old man complains of low mood and sleep disturbance for the last two months. In the last two weeks he reports difficulty remembering the names of familiar objects and difficulty writing. Myoclonus in the upper limbs is noted on examination Creutzfeldt-Jacob disease

Creutzfeldt-Jacob disease is characterised by a rapidly progressive dementia, myoclonus and distinctive electroencephalographic and neuropathologic findings. The infectious agent casing CJD is unique in being a conformationally abnormal prion protein i.e. contains no genetic material. The dementia can be accompanied by signs of involvement of any part of the central nervous system, but myoclonus is particularly common. Although typically occurring sporadically in middle-aged adults, a family history may be present in 8-1%. More recently, variant CJD in young adults has been linked with exposure to beef infected with the bovine spongiform encephalopathy agent. This ‘new variant’ form often presents with an extended neuropsychiatric prodrome with mood disturbance or other psychiatric symptomatology.

218. A 65-year-old man presents with a six-month history of forgetfulness. His wife reports he occasionally gets lost when out walking around their neighbourhood, has been misplacing items in the home and on a number of occasions left the front door ajar when he had gone out for his walk. Neurological examination is otherwise unremarkable. Alzheimer's disease

Dementia is a term that describes a progressive and pervasive loss of a number of different cognitive capabilities. Alzheimer’s dementia patients show deficits of visual-spatial skill, memory and cognitive capabilities e.g. problem solving, word finding and speech, navigation, arithmetic, writing or reading. Alzheimer's disease is caused by a progressive neuronal damage, accumulation β-amyloid peptide, senile plaques and neurofibrillary tangles.

219. Sulphonylurea therapy: True / False

A. May increase weight

B. Is useful in all type II diabetics

C. Enhances glucose stimulated insulin release from the pancreas

D. Stimulates peripheral glucose utilization

E. Has hyponatraemia as a side effect

A, E are correct. Sulphonylurea therapy such as glibenclamide etc stimulates insulin secretion from the beta cells by potassium channel inhibition. Metformin causes increased glucose utilisation. These agents may cause SIADH.The meglitinides promote glucose stimulated insulin release, traditionally it has been thought that the sulphonylureas are less effective at this, an effect which gives rise to hypoglycaemia, particularly in the elderly.

Theme: General Practice forms

A. DS1500

B. D4

C. FP10


E. FP92A

F. FW8

G. GOS18



J. RM7

For each of the following situations, choose the correct form.

220. A standard prescription form FP10

221. A request for an ophthalmology opinion from an optician to the GP GOS18

222. To access maximum benefits for terminally ill patients likely to die within 6 months DS1500

223. A standard sickness certificate MED3

224. A termination of pregnancy form HSA1

General practice is sadly awash with paperwork. Other important GP forms include: D4 - application and medical report for group 2 driving licence FP10MDA - prescription for prescribing in the treatment of addiction FP92A - application for medical exemption from prescription charges FW8 - application for maternity exemption from prescription charges MED4 - a sickness certificate to be completed with details of a patient's illness prior to a Personal Capability Assessment in a patient claiming incapacity benefit. MED5 - a special statement of incapacity to work, which may be issued on the basis of a written report from another doctor or backdated by the GP when you have previously examined the patient during the course of their current illness. RM7 - when the GP doubts the true nature of the patient's incapacity and wishes for a Personal Capability Assessment to be carried out. Questions that relate to administrative issues and forms are popular in the exam. Make sure that you are familiar with the various forms used in day to day general practice and know the circumstances in which they can be used appropriately.

225. A paper describes a new diagnostic test for myocardial infarction. You want to know what proportion of patients who are classified as not having had a myocardial infarction by the test will actually not have had a myocardial infarction. Which one of the following measurements would indicate this?

A. Accuracy

B. Negative predictive value

C. Positive predictive value

D. Sensitivity

E. Specificity

B is correct. The proportion of 'true negatives' not having had a MI correctly identified by this test is called the Negative predictive value and refers to the number accurately identified to not have MI by the new test over the number without MI identified by the test + those wrongly identified as not having had an MI. specificity is the number without MI accurately predicted. Sensitivity refers to the number correctly identified with MI by the new test. A positive predictive value refers to the number accurately identified with MI by the test over the number accurately identified with MI + those wrongly identified with MI.

226. Recognised associations exist between pruritus ani and: True / False

A. ascaris lumbricoides infestation

B. diverticulitis coli

C. threadworm infection

D. coeliac disease

E. candidiasis

A, C, E are correct. There are many causes of pruritus ani including typically threadworm infestation, candidiasis, haemorrhoids and anal fissure. Rarer causes include ascaris and carcinoma.

227. Personal medical services (PMS) for GPs. Which single statement regarding PMS arrangements is correct?

A. PMS contracts are negotiated at a national level

B. GPs and nurses can be PMS providers, but not NHS foundation trusts

C. If a PMS provider becomes a health service body, it cannot enter into other NHS contracts with any other health service body

D. The recommended period of notice to terminate the contract between PMS provider and PCT is 6 months

E. The 6 direct enhanced services include diabetes, asthma, coronary heart disease and epilepsy

D is correct. PMS is a local contract so, while all PCTs and contractors have to comply with the provisions of the National Health Service (Personal Medical Services Agreements) Regulations 2004, local variations that do not change the mandatory provisions can be agreed. GPs, nurses, dentists, staff employed by the practice or NHS and NHS foundation trusts can all be providers. The period of notice to terminate is to be agreed mutually between PMS provider and the PCT and should be specified in the local contract. The recommended period is 6 months. The 6 direct enhanced services include childhood immunisations, influenza immunisations, minor surgery, access, violent patients and quality information preparation. Based on the revised guidance issued March 2004. See www.bma.org for further details.

Theme: Chest pain

A. Acute myocardial infarction

B. Aortic dissection

C. Cholecystitis

D. Costochrondritis

E. Heartburn

F. Hiatus hernia

G. Hyperventilation

H. Oesophageal spasm

I. Pericarditis

J. Pleurisy

K. Stable angina

L. Unstable angina

For each patient, select the most likely diagnosis of his/her chest pain:

228. A 71-year-old man reports chest tightness and pain in his throat when walking his dog after his evening meal. He has had no previous symptoms. These symptoms have not changed since they started 2 months ago. The resting electrocardiogram is normal. Stable angina

These symptoms are classical of angina. There is typical exertional chest pain suggestive of stable angina. This may be exacerbated after eating a meal due to the parasympathetic diversion of blood to the GI tract, hence making angina more likely.

229. A 41-year-old woman with a family history of coronary artery disease, complains of pain under her left breast followed by central upper chest tightness, associated with exercise. During symptoms, she is also breathless and dizzy. The routine electrocardiogram shows a sinus tachycardia. Hyperventilation

This case has anxiety related to thoughts that she may have coronary disease as suggested by the resting tachycardia but nil else. Coronary artery disease would be rather unusual in a woman of this age.

230. A 37-year-old man has had fever and malaise for 5 days. For the past 12 hours he has had severe left-sided chest pain which is exacerbated by movement or respiration. The 12-lead ECG shows T-wave inversion in aVR. Pleurisy

This case has pleurisy rather than any heart disease as suggested by the 5 day history of malaise and the chest pain on movement or respiration. T wave in aVR is non-specific.

231. A 64-year-old man has developed sudden severe pain between his shoulder blades while digging in his garden. There is no past medical history. Clinical examination is normal except that he is overweight, sweaty and distressed. Transthoracic echocardiography demonstrates left ventricular hypertrophy. Aortic dissection

The history of severe chest pain radiating through to the back during exertion should prompt the diagnosis of aortic dissection. The presence of hypertension (LVH) would be a risk factor and a transthoracic echo may not adequately show the aorta.

232. A 58-year-old woman has a three-week history of episodes of central chest pain while lying flat, which is relieved when she sits up. Similar symptoms can occur if she gets upset. The resting electrocardiogram shows T-wave inversion in leads, aVL and V3-6. Unstable angina

This case has a history suggestive of unstable angina with angina decubitus (ie chest pain provoked by lying flat) and is further supported by the ECG changes, which suggest inferolateral ischaemia. Although pericarditis may be considered, the ECG changes associated with this condition are ST segment elevation (convex upwards) in incongruous leads.

Theme: Breast Disease

A. Abscess

B. Carcinoma

C. Cyst

D. Fat Necrosis

E. Fibroadenoma

F. Lipoma

G. Mammary duct ectasia

H. Pagets disease of the nipple

I. Papilloma

J. Phylloids tumour

Match each of the following stems to one of the conditions above.

233. Occurs in middle aged women and develops in the lactiferous ducts just below the nipple. Form a lumpy mass and associated with a bloody discharge. Papilloma

Papillomas develop in the lactiferous ducts and are associated with a worrying bloody discharge.

234. Red scaly eczematous nipple which may be associated with underlying carcinoma. Pagets disease of the nipple

- Pagets disease of the nipple Pagets disease is a skin cancer associated with long standing eczematous disease of the nipple/areolar region.

235. Usually found in women below 35 years old. Present as firm rubbery non tender masses which may slip away during palpation. Fibroadenoma

Most are smooth or slightly lobulated and are usually 2-3 cm in diameter. They usually present between 16 and 24 yrs of age and decrease in incidence approaching the menopause. They may present has 'hard' calcified masses in the elderly. Approximately 10% of fibroadenomas are multiple. They are diagnosed by triple assessment: 1. Clinical examination 2. Mammography or ultrasound 3. Fine needle aspiration cytology or core biopsy

236. Rare condition caused by trauma to the breast. Form firm irregular mass Fat Necrosis

Fat Necrosis Fat necrosis often follows trauma and is associated with a hard mass. The [receding history of trauma should help secure the diagnosis.

237. Usually found in climacteric women, present with chronic inflammation of the breast with a creamy protein rich (green) discharge. Mammary duct ectasia

Mammary duct ectasia This is a benign breast condition in which the milk ducts beneath the nipple become dilated and sometimes inflamed. It occurs most often in women during or after menopause. History taking in breast disease

Theme: Hearing loss

A. Acoustic neuroma

B. Acute suppurative otitis media

C. Alport’s syndrome

D. Barotrauma

E. Chronic suppurative otitis media

F. Glue ear

G. Meniere’s disease

H. Presbyacusis

I. Otosclerosis

J. Vestibular neuronitis

Select the most appropriate diagnosis from the above list that explains the presentation of the following cases:

238. A 30-year old man presents to his GP with a six-month history of progressive deafness and tinnitus in his left ear. His wife states that recently he has been unsteady on his feet and that his voice is becoming hoarse. Acoustic neuroma

This patient has an acoustic neuroma. He has a hoarse voice and is unsteady on his feet because the neuroma is extending into the cerebellopontine angle compressing cranial nerve 10 and the cerebellum.

239. A 65-year old lady presents to her GP complaining of recurrent bouts of deafness. A typical attack starts with a full feeling in the ear with tinnitus, which gradually increases in volume to be followed by nausea, vomiting, and rotational vertigo. Meniere’s disease

This lady has Meniere’s disease. The symptoms are due to a gradual increase in fluid in the endolymphatic compartment in the inner ear.

240. A 35-year old man presents to his GP complaining of progressive bilateral hearing loss over the last year. Rinne’s test is negative and on examination the tympanic membrane is normal. His father lost his hearing at a similar age and required a hearing aid. Otosclerosis

This man has otosclerosis. He has a progressive conductive deafness due to fixation of the stapes in the oval window. It is inherited as a Mendelian dominant and is cured by an operation called stapedectomy. Hearing loss classification and assessment...

Theme: Nerve injury syndromes

A. Carpal tunnel syndrome

B. Common peroneal compression

C. Meralgia paraesthetica

D. Sciatic nerve palsy

E. Radial nerve palsy

F. Tarsal tunnel syndrome

G. Ulnar nerve palsy

Select the most likely nerve injury with which the following present:

241. A 40-year old man has been lying unconsciously on his left side for 14-hours. When he recovers he notices that he cannot dorsiflex his left foot. On examination there is reduced sensation over the dorsum of the foot. Common peroneal compression

This patient has a common peroneal nerve palsy due to nerve compression against the head of the fibula when lying unconscious. Spontaneous recovery may be expected but surgical decompression may be required.

242. A 65-year-old former carpenter notices a problem with his left hand. His grip has weakened over a period of some months. He notices that when washing his face, his ring and little fingers seem to get in the way. On examination. in the position of rest, his ring and little finger are flexed at both interphalangeal joints and extended at the MCP joints. Grip is exacted by the remaining fingers and thumb. Ulnar nerve palsy

Ulnar nerve compression, usually at the elbow, is common in manual workers, especially with a history of using impact tools. The claw hand deformity is characteristic, caused by paralysis of the interossei. Although the interossei to the other fingers are affected, the deformity is not so apparent due to the integrity of the radial innervated lumbricals.

243. A 35-year-old pregnant lady presents to her GP complaining of pain and paraesthesiae over the upper outer thigh. On examination there is reduced sensation in this area. Meralgia paraesthetica

This lady has meralgia paraesthetica due to compression of the lateral cutaneous nerve of the thigh on leaving the pelvis just medial to the ASIS. It is common in pregnancy and obesity.

244. Seborrhoeic keratoses: True / False

A. Is commonly seen in young adults

B. Are benign lesions

C. Caused by proliferation of melanocytes

D. May be associated with an internal malignancy

E. Surgical excision and skin grafting is the treatment of choice

B, D are correct. Seborrhoeic keratoses (basal cell papilloma, seborrhoeic wart) is a common lesion often seen in large numbers on the trunk, face, and arms of middle-aged and older individuals. They are benign tumours caused by the overgrowth of epidermal keratinocytes. They are frequently pigmented and often develop as single or multiple, round or oval shaped slightly greasy lesions with a 'stuck on' appearance. Sometimes they occur in crops in sunexposed areas and is often characterised by a network of crypts. Multiple seborrhoeic keratosis may be associated with an internal malignancy (Leser-Trelat sign). Treatment options include shave excision curettage, superficial electrodessication and freezing with liquid nitrogen.

Theme: Acute colorectal disease

1. Caecal volvulus

2. Colonic carcinoma

3. Crohn's disease

4. Diverticular abscess

5. Diverticulitis

6. Infective colitis

7. Ischemic colitis

8. Sigmoid volvulus

9. Toxic megacolon

10. Ulcerative colitis

For each of the following clinical scenarios, select the most likely colorectal pathology.

245. A 34-year-old woman with a family history of IBD is admitted with severe generalized abdominal pain, bloody diarrhoea and a pyrexia. Her abdomen is distended and diffusely tender with peritonism. An abdominal radiograph reveals a transverse colon measuring 10cm in diameter. Toxic megacolon

Toxic megacolon is most frequently associated with ulcerative colitis although it may be seen with Crohn's or infective colitis. The diameter of 10 cm indicates a high risk of perforation and surgical intervention should be considered.

246. A 78-year-old lady is admitted with a sudden onset severe central abdominal pain and rectal bleeding which she describes as being like redcurrant jelly. She has a history of ischaemic heart disease and atrial fibrillation. She is shocked and diffusely tender on palpation of her abdomen. Ischemic colitis

Any patient with AF who presents with acute abdominal pain, especially if there is new onset bleeding must be considered to have acute intestinal ischaemia unless proven otherwise. The condition has a high mortality and must be treated urgently.

247. A 68-year-old woman with a past medical history of diverticular disease attends with severe left iliac fossa pain. On examination she has a swinging pyrexia and is tender with evidence of peritonism. Diverticular abscess

Pain in the left iliac fossa in a patient with known diverticular disease is often due to faecal impaction in a divertculum and the development of diverticulitis. If the diverticulum then perforates there is local peritonitis and an abscess develops and the features of peritonism and swinging pyrexia are seen. Alternatively there may be free perforation and faecal peritonitis.

248. An anorexic looking 70-year-old man is admitted with distension and constipation. He has noticed a gradual weight loss of 2 stone and fresh rectal bleeding over a period of 6 months prior to presentation. Examination reveals a distended abdomen with a suspicion of a mass in the left iliac fossa. Colonic carcinoma

Colorectal cancer affecting the left colon often presents with fresh rectal bleeding and constipation. The fact that there is weight loss and a palpable tumour suggest that the tumour has been ignored by the patient for some time. Right-sided tumours typically present with anaemia.

249. A 28-year-old male presents with right lower quadrant pain, weight loss and bloody diarrhoea. He has been experiencing frequency of mucous stool for 2 months and has also been suffering from recurrent oral ulcers. Crohn's disease

Crohn's disease often presents with this combination of symptoms. Initial management is medical with surgical intervention limited to complicated disease such as bleeding, fistulation, obstruction or perforation. The aphthous ulcers are part of the disease and indicate the widespread distribution of the disease.

250. Which of the following drugs increase the risk of myotoxicity associated with statin therapy? True / False

A. Erythromycin

B. Fibrates

C. Ketoconazole

D. Alcohol

E. Amiodarone

All are correct. All the above are associated with an increased risk of myotoxicity when co-prescribed with statin therapy. Although the risk of myotoxicity with statin therapy is small <10% this risk is dose related and associated with mechanisms such as effects on cytochrome p450 enzymes and hypothyroidism.

251. A 57-year-old male diabetic requests Sildenafil for erectile dysfunction. Which of the following are contraindicated with Sildenafil?

A. Carbamazepine

B. Carvedilol

C. Indomethacin

D. Nicorandil

E. Valsartan

D is correct. Sildenafil is contraindicated if the patient is taking nitrates, or nitrate derivatives (nicorandil). We are informed on the prescribing information that if the patient takes nitrates then they should be stopped for the period during which Sildenafil is used.

252. Regarding diabetic ketoacidosis: True / False

A. It occurs more often in type 2 or non-insulin dependent diabetes patients

B. The acidosis is due to renal dysfunction

C. Glucose and ketones cause an osmotic diuresis

D. Kussmaul respiration is a feature

E. The breath may smell of acetone (nail polish)

C, D, E are correct. In diabetic ketoacidosis (DKA) the lack of insulin leads to a breakdown of fat and the production of ketone bodies. The ketone bodies produce an acidosis which leads to deep, rapid breathing (kussmaul respiration). Both the ketones and glucose produce an osmotic diuresis causing severe dehydration. The ketones smell of acetone or nail polish. Diabetic ketoacidosis is more common in type 1 diabetes.

253. The following are true of vascular dementia: True / False

A. It has the same age distribution as senile dementia

B. The condition may run a steadily progressive course

C. Emotional lability is common

D. Insight tends to be retained

E. Depression is uncommon

B, C, D are correct. Vascular dementia includes multi-infarct dementia and other forms of intellectual deterioration in individuals at high risk of artherosclerosis. It is distinguished from Alzheimers by the stepwise progression (although it MAY present as a steadily progressive dementia), this history of risk factors (TIAs, stroke, hypertension, smoking, hypercholesterolaemia etc.), and the lack of uniformity of the intellectual impairment - there may be prominent language / spatial problems. Insight is preserved more than in Alzheimers and depression is common. Further information in these PDFs: www.medicine.manchester.ac.uk www.alzscot.org

Theme: Skin and subcutaneous lesions

A. Basal cell carcinoma

B. Dermatofibroma

C. Ganglion

D. Keratoacanthoma

E. Lipoma

F. Malignant melanoma

G. Pyogenic granuloma

H. Sebaceous cyst

I. Squamous cell carcinoma

J. von Recklinghausen’s disease

Which of the lesions listed above best matches the case scenarios described below.

254. A 64-year-old park attendant is referred with a slow growing ulcerated lesion on the dorsum of his hand. On closer inspection it has a raised everted edge. Squamous cell carcinoma

An ulcerated lesion with an everted edge is typical of an SCC, a malignant skin lesion that typically arises on sun-exposed areas of the body. The lesions grow slowly and locally destroy tissue but may also metastasise to lymph nodes. Other predisposing factors include: radiation exposure; pre-malignant conditions (Bowens, senile keratosis, lupus vulgaris, pagets disease); inherited (xeroderma pigmentosum, albinism); chronic irritation (Marjolins ulcer, leukoplakia, varicose veins, osteomyelitis sinus); infection (HPV 5 & 8).

255. A 43-year-old woman is seen with multiple fleshy lesions over her torso and several are catching on her clothing and irritating her. In addition to these lesions she also has numerous brown spots on her trunk. von Recklinghausen’s disease

The combination of fleshy lumps which are neurofibromas and caf au lait spots (> 6 patches) is typical of von Recklinghausens disease or neurofibromatosis Type I (Type II = acoustic neuromas and sparse skin lesions). Other findings include multiple freckles over the torso and axillae and areas of depigmentation. May be associated with: multiple endocrine neoplasia IIb (medullary carcinoma of thyroid & phaeochromocytoma); glioma; and meningioma. It is autosomally dominantly inherited. Symptomatic lesions can be excised. There is a 10% risk of malignant change.

256. A 60-year-old man presents with a non-tender swelling on the dorsum of his left wrist. It has been slowly growing over many years and on examination is tense and does not empty. Ganglion

A ganglion is a benign lesion although it remains uncertain as to whether it is a tumour of the joint capsule/tendon sheath or a degenerative process of these structures. Ganglia are also seen over the dorsum of the foot, flexor aspects of the fingers and peroneal tendons. They can be excised under local anaesthetic but up to 1/3 recur.

257. A 13-year-old boy is seen in the clinic with a 1cm bright red pedunculated lesion on his hand which is encrusted following a recent bleed. Pyogenic granuloma

Pyogenic granulomas are usually seen is in children and young adults on the hands and face and pregnant women develop lesions on their lips and gums. The name is a misnomer (initially believed to be a granulation response to infection) and they are in fact benign capillary haemangiomas. The lesion should be treated by curettage and diathermy of the base.

258. A 23-year-old woman is seen with a 1 x 2 cm brown-purple lesion on the back of her calf. On closer inspection it is uniform in colour, has a smooth surface and edges and is slightly elevated from the surrounding skin. Dermatofibroma

A dermatofibroma is a benign skin lesion. No treatment is required but there is often patient anxiety over the presence of a pigmented lesion and many request their removal which can be done under local anaesthetic.

259. Short stature is a feature of: True / False

A. Coeliac disease

B. XO karyotype

C. XXY karyotype

D. XYY karyotype

E. Vitamin D resistant hypophosphataemic rickets

A, B, E are correct. Coeliac disease and Turner's syndrome (XO) are well established causes of short stature. XXY is Klinefelter's syndrome and the phenotype is of tall stature, gynaecomastia and small, firm testes. XYY karyotype has a tall, thin phenotype,with normal fertility and no increased risk of mental retardation. Vitamin D resistant rickets is tubular phosphate wasting with normal serum calcium and no secondary hyperparathyroidism. Children present with short stature and bowing of the legs.

Theme: Clinical audit 2

A. Data analysis

B. Data collection

C. Identify standards

D. Implement change

E. Needs assessment

F. Re-audit

Select the most appropriate next step from the list above for the following teams who are undertaking audits:

260. A vascular team assessing the mortality of patients in ITU/HDU following surgery for abdominal aortic aneurysm have retrospectively collected data over the last five years on 133 patients. Data analysis

261. At a recent directorate meeting an ENT consultant has been nominated to select the next clinical audit. Needs assessment

262. A team presented their audit of post-operative analgesia for GI surgery approximately one year ago from which a number of recommendations were made and changes implemented. Re-audit

The audit cycle comprises an initial needs assessment where the requirements of the department/section/individual are determined and the actual audit itself determined. Then when what is to be audited is decided upon, it is important to identify the standards against which the audit will be compared. These can be national standards or clinical guidelines determined by the national bodies or even comparisons can be made within the department. Once the standards are set, data collection is undertaken with selection of retrospective or prospective data followed by data analysis. The results can then be presented, compared with the standards and from this recommendations for improvements/implementation of change are/is made. Finally, to assess how effectively these recommendations have been implemented, a re-audit is suggested for some stage in the future. In the case of the ENT team nominated to take on an audit, they have to decide what needs to be audited. The vascular team having collected data on AAA procedures needs to analyse and then present their data. Finally, having presented their data, the a re-audit of post-operative pain control is now required to see if the recommendations have been implemented.

Theme: Statistical interpretation

A. Blinding

B. Confidence interval

C. Confounding factor

D. Double blinding

E. Meta-analysis

F. Observer bias

G. Odds ratio

H. Placebo effect

I. Relative risk

J. Selection bias

K. Single blind study

Select the most appropriate statistical term for the following descriptions.

263. A study looks at the effects of Alzheimer's drugs on cognitive decline in 1000 patients with Alzheimer's disease. Patients are randomised to receive either the active treatment or placebo. At the conclusion of the study, patients who experienced side effects were not included in final analysis. Observer bias

In this scenario, the patients who did not complete the study due to side effects are excluded. It may well be that the conclusions of the study are going to be influenced by this conclusion, as more patients on active treatment are likely to be excluded and hence the ones most tolerant with possibly the best results included - observer bias.

264. A study of a new anti-rheumatic agent is conducted amongst a group of 500 patients. The patients are randomised to either placebo or the active drug by the drug company although neither the patients nor investigators know which treatment they are receiving. Double blinding

Double blind refers to a type of research study. In a double blind study, neither the study participants nor the person giving the treatment knows which treatment any particular subject is receiving. In this way, both the researchers and the study participants are 'blind' to who is receiving which treatment during the study. This method helps researchers get more accurate results from their research. Double blinding allows researchers to 'control' a study for the psychological effects that sometimes help people feel better, simply because they expect to feel better when they receive a medication. In other words, double blinding helps researchers separate the 'power of suggestion' from the real effects of a medication or therapy.

265. A study is undertaken assessing the effects of a cholesterol-lowering agent on cardiovascular disease. Patients are randomised by the investigators to receive either the drug or placebo, although the patients do not know which they will receive. Single blind study

This is a single blind study where the patient does not know which arm of therapy they are receiving, yet the investigator does.

266. A study attempts to establish whether there is a relationship between COX-2 inhibitors and vascular risk. They analyse the side effects reported in all published data relating to COX-2s. Meta-analysis

This is typical of a meta-analysis, where the data from many studies are accumulated and assessed to establish any relevant link to a specific outcome.

267. Post-menopausal females from a variety of health clubs are selected to participate in a study of hormone replacement therapy. Selection bias

In this case there would be selection bias as the group from the health clubs are very unlikely to be representative of the population.

268. The stroke mortality rates of areas X and Y are the same. The SMR (Standard Mortality Rate) for stroke in X is 110 and the SMR for stroke in Y is 90. Which of the following can be deduced? True / False

A. The numbers of deaths coded as due to stroke are the same in the two areas.

B. The population in area X is, on average, younger than in Y

C. incidence of stroke is higher in X than in Y

D. The age-specific mortality rates for stroke are higher in X than in Y

E. The case-fatality for stroke is higher in X than in Y

B, D are correct. This epidemiological study finds the stroke mortality the same for both areas but this is not the entire picture as, if the stroke mortality rates are the same (say 4%) for the population yet the SMR for X is 20 points higher than that of Y then the population of X is younger (strokes occuring at a younger age group hence higher SMR). The incidence is the number of strokes occuring in the population which is the same for both areas. The case fatality rate is calculated as the number that have the condition die from that condition. This cannot be determined from the figures provided, as for whatever reason the mortality rate could be lower (or higher) in X despite the mortality rates being the same.

269. A 55-year-old woman who has a history of atrial fibrillation and is receiving warfarin and digoxin, informs you that she has been feeling down of late and has been self medicating with St John's Wort that she obtained from a health shop. Which of the following interactions may be expected between St John's Wort and her current medication?

A. INR is likely to be increased

B. INR is likely to be reduced

C. INR is likely to be unaffected

D. There is an increased risk of digoxin toxicity

E. Digoxin concentrations are unlikely to be affected

B is correct. St John's Wort is now commonly taken for depressive symptoms, yet it is a liver enzyme inducer and therefore has interactions with medications typically reducing the efficacy. In

this regard, St John's Wort may reduce the efficacy of Warfarin, requiring increased dose to maintain the INR and it may also reduce the efficacy of Digoxin.

270. Koplik's spots appear: True / False

A. Two days before the rash of measles

B. Opposite incisor teeth

C. Only when fever is over 39°C

D. As red papules on the dorsum of the hands

E. Fluorescent under Wood's light

A is correct. Classically Koplik's spots are pathognomonic of measles being found opposite the premolars two days prior to the development of the rash.

271. Clinical manifestations of a pulmonary embolus (PE) in childhood include: True / False

A. Reduced central venous pressure

B. Fever

C. Bradycardia

D. Haemoptysis

E. Chest pain

The clinical manifestations of a pulmonary embolus (PE) include: dyspnoea, tachypnoea, tachycardia (not bradycardia), chest pain, cough, haemoptysis and fever. The central venous pressure is usually elevated. Usually occurs in adolescents, so this ref should help: emedicine PE. Back pressure from raised right-sided pressures causes elevated JVP.

272. Regarding immunisation: True / False

A. In premature babies timing of the first course should be postponed until 3 months from expected date of delivery

B. Immunisation is contraindicated in a baby with Down syndrome and congenital heart disease

C. Oral polio vaccine is contraindicated in a baby with diarrhoea and vomiting

D. Oral polio vaccine may be given to siblings of immunosuppressed children

E. MMR vaccine may be given within 3 weeks of oral poliomyelitis

C is correct. The immunisation schedule should proceed normally. Immunisation is not contraindicated in cases of congenital heart disease. Oral polio vaccine is contraindicated if vomiting is present. Oral polio vaccine consists of live virus, some of which may be excreted in the faeces and hence spread to immunosuppressed children. "Avoid administration of live vaccines (except MMR and BCG) to siblings of immunocompromised patients." RCPCH Best Practice Statement. MMR is given at 12 months, which is 8 months after the last dose of oral polio. MMR is the best example of simultaneous administration of multiple live attenuated viral vaccines. Here, the combination is known not to reduce the protective effect of each component, as the combined vaccine is as effective as spaced injections of individual components. The main objection to administering live vaccines close together is the risk of systemic symptoms, and the possibility of reduced immune response.

Theme: Examination of the pulse

A. Bradycardia

B. Collapsing pulse

C. Irregularly irregular pulse

D. Pulsus alternans

E. Pulsus bisferiens

F. Pulsus paradoxus

G. Radio-femoral delay

H. Regularly irregular pulse

I. Slow rising pulse

Select the most likely abnormality that would be found on examination of the pulse in the following cases:

273. A 72-year-old male presents with breathlessness and chest pain. On examination he has a blood pressure of 118/70 mmHg, has an audible third heart sound, elevated JVP and bibasal crackles on auscultation of the chest. Pulsus alternans

274. A 72-year-old female with a past history of rheumatic fever presents with a year history of worsening breathlessness. On auscultation of the praecordium she has a low pitched diastolic rumbling murmur preceded by a click. Irregularly irregular pulse

Heart failure is associated with pulse waves of differing amplitude/intensity and hence Pulsus alternans. The features indicating heart failure in this case include the acute presentation, elevated JVP, third heart sound and bibasal crackles. The past history of rheumatic fever and the presence of a rumbling mid diastolic murmur suggests a diagnosis of mitral stenosis. This is associated with a low volume pulse, atrial fibrillation (irregularly irregular), mitral facies, mid diastolic murmur preceded by an opening snap and tapping apex beat.

275. Which one of the following statements is true for aortic stenosis?

A. Angina suggests co existing CHD

B. Characteristically has a collapsing pulse

C. Effort syncope is a common but innocent feature

D. May be associated with reverse splitting of the second heart sound

E. Usually associated with disease of other valves

F. Usually caused by rheumatic fever

D is correct. Angina is caused by poor perfusion of the coronary arteries which may well be normal. The pulse is characteristically anacrotic or slow rising. Effort syncope is a sinister symptom indicating severe if not critical stenosis. Normal A2, P2 splitting can be reversed due to delayed valve closure. Diseases of other valves, usually mitral, was the norm when rheumatic fever was common. These days it is usually congenital in the young and sclerotic (calcified) in the older age group. Ref: http://circ.ahajournals.org/cgi/content/full/95/4/892

276. Raised FSH levels are found in: True / False

A. Postmenopausal females

B. Turner's syndrome

C. Prepubertal girls

D. Gonadal dysgenesis

E. Women taking the combined oral contraceptive pill

A, B, C are correct.

ø In the menopause there is an increased secretion of FSH and LH from the pituitary in an attempt to stimulate ovulation.

ø LH and FSH may be normal in childhood but are significantly elevated by 10-11 years in Turner syndrome.

ø During childhood GnRH production by the hypothalamus is totally quiescent but as late childhood ensues, so gradually the pulses of GnRH begin to be produced, initially only at night. These infrequent pulses of low amplitude and low frequency increase during the subsequent years and eventually are found during the daytime hours as well as at night, and as the pulse frequency and amplitude increase, so the ovarian response is seen to occur. So FSH is low in response to low GnRH.

ø Causes of hypergonadotropic hypogonadism (high FSH, low estradiol)

N Gonadal dysgenesis 45 XO (Turner's syndrome)

N Gonadal dysgenesis 46 XY (Swyer syndrome)

N Gonadal dysgenesis 46 XX

N Familial gonadal dysgenesis 17-hydroxylase deficiency

N Galactosaemia

N Ataxia telangiectasia

N Myotonia dystrophica

N Autoimmune disorders

N Chemotherapy/radiation therapy (ovarian cytotoxicity)

N Resistant ovary syndrome

N Menopause, premature ovarian failure

ø In the case of women who are taking the combined oral contraceptive pill, because of inhibition of the pituitary by raising concentrations of oestrogen the secretion of FSH is inhibited

277. Practical considerations when using a syringe driver. Which 3 drugs should be administered with a separate syringe driver when the patient is receiving diamorphine?

A. Cyclizine

B. Dexamethasone

C. Haloperidol

D. Ketamine

E. Octreotide

F. Phenobarbital

B, D, F are correct. When using a syringe driver, the following drugs are compatible with diamorphine: Cyclizine, Haloperidol, Hyoscine, Metoclopromide, Octreotide, Midazolam and ondansetron. The following drugs should be administered with a separate syringe driver: Dexamethasone, Phenobarbital, Diclofenac and Ketamine. The following drugs are not suitable for subcutaneous useage: Diazepam, Chlorpromazine and phrochlorperazine

Theme: Shortness of Breath

A. Acute Left Ventricular Failure

B. Aortic stenosis

C. Asthma

D. Bronchiectasis

E. Chronic obstructive pulmonary disease

F. Congestive Cardiac Failure

G. Pleural effusion

H. Pneumonia

I. Pneumothorax

J. Pulmonary embolism

Choose the most likely diagnosis for each of the following.

278. A 72-year-old male presents with a 6 month history of gradually progressing shortness of breath and a productive cough. He is a heavy smoker of 50 years. Chronic obstructive pulmonary disease

COPD is a chronic, slowly progressive disorder characterised by airways obstruction (FEV1 < 80% predicted and FEV1/FVC ratio < 70%) which does not change markedly over several months. The impairment of lung function is largely fixed but is partially reversible by bronchodilator or other therapy.

279. A 76-year-old female presents with shortness of breath on exertion, orthopnoea and paroxysmal nocturnal dyspnoea. She describes a persistent cough and brings up what she describes as pink froth. On examination she is tachycardic and has basal crackles and a smooth, enlarged liver. Congestive Cardiac Failure

Orthopnoea, paroxysmal nocturnal dyspnoea, basal crackles and a cough productive of pink froth all indicate pulmonary oedema which is often secondary to ischaemic heart disease.

280. A 64-year-old female presents with shortness of breath and a dull right sided chest pain. On examination her trachea is displaced to the left side, and there is an area over her right lung which is dull to percussion and where breath sounds are reduced. Pleural effusion

Shortness of breath, dull right sided chest pain with left sided displacement of the trachea suggest right sided respiratory pathology. Dull percussion over the effected area suggest an area of fluid collection. maybe either transudates – heart/renal/liver failure or exudates (protein >30g/l) – pneumonia, neoplasia, PE etc.

281. A 14-year-old male presents with a history of attacks of shortness of breath triggered during exercise. He has a night time cough and a tight chest in the morning. Asthma

Has common age of onset between 5-30 years of age. Symptoms such as night time cough and chest tightness are characteristic of asthma.

282. A 45-year-old Female presents with gradually worsening shortness of breath with chest pain for 1 week. Her other symptoms include cough, haemoptysis and a fever. Pneumonia

Fever with cough and haemoptysis suggests a chest infection, most probably. Aetiology of shortness of breath...

Uterine leiomyomata may undergo the following changes: True / False

A. Hyaline degeneration

B. Squamous metaplasia

C. Atrophy

D. Calcification

E. Sarcomatous change

B is incorrect.

Changes in fibromyomata include: -------------------------------------------------------------------------------

ø Hyaline change

ø Cystic change

ø Infarction (red degeneration)

ø Fatty change

ø Calcification

ø Atrophy

ø Torsion of the pedicle

ø Infection

ø Malignant change.

Theme: Breast disease

A. Breast abscess

B. Cystic breast disease

C. Ductal carcinoma

D. Ductal carcinoma in situ

E. Duct ectasia

F. Fibroadenoma

G. Gynaecomastia

H. Lobular carcinoma

I. Paget’s disease

J. Phyllodes tumour

Match the case histories of breast disease below to the pathologies listed above.

283. A 23-year-old lady attends the breast clinic anxious that she has breast cancer. On examination you identify a 2 cm mobile lesion, which on ultrasound, demonstrates a welldefined hypoechoic lesion. Fibroadenoma

The clinical and ultrasound features are classical for a fibroadenoma, the most common lesion in the <35 age group. If the history and ultrasound are convincing nothing else need be done. However, in the case of uncertainty an FNS/core may be performed or if the patient is very anxious the lesion may be excised. The risk of malignant transformation is very small and usually only in very large tumours.

284. A 55-year-old woman attends the clinic having had an area of microcalcification identified on screening mammography. No masses are palpable and there is no lymphadenopathy. Ductal carcinoma in situ

The history suggests ductal carcinoma in situ (DCIS), the most common finding on screening mammography. The prevalence of this condition has increased from 5 to 30% as screening now detects previously undiagnosed DCIS. Patients with DCIS require surgical excision of the disease and unless there is widespread disease a wide local excision will usually suffice. If left untreated 25% will progress to invasive cancer.

285. A 60-year-old lady attends her GPs clinic with an erythematous rash around her left nipple. On examination there is an additional finding, a small mass in the upper outer quadrant of the breast.

Paget’s disease

Paget’s disease represents invasion of the nipple by malignant cells from an underlying neoplasm although the cancer may not be clinically palpable in up to 50%. Patients will require full work-up as per a cancer with cytology of the Paget’s mammography and biopsy of any suspicious lesions.

286. A 27 year mother attends the A&E department with her 6 week old baby. She reports a painful swelling in the breast. On examination there is a 3 x 3 cm tender, fluctuant swelling lateral to the nipple. Breast abscess

The patient has a lactational breast abscess. 80% of breast abscesses are seen in breastfeeding women. The organism is usually Staphylococcus aureus, but other bacteria include streptococci, enterococci and anaerobes. Unless there is substantial skin destruction, the abscess should be treated with USS-guided aspiration and antibiotic therapy. If the abscess recurs then formal incision and drainage is required.

287. A 61-year-old woman is referred urgently by her GP with a 3 cm mass in her right breast. The mass is firm and appears to be tethered to both overlying skin and underlying muscle. There are also palpable axillary lymph nodes. Ductal carcinoma

In this case a carcinoma must be assumed by the clinical history. The patient will require radiological assessment by mammography (USS is better in younger patients due to fibrous changes) and histology by means of a targeted core biopsy. Breast carcinoma is common affecting 1 in 12 women (F:M = 100:1). Management will depend on the grade and stage of the tumour, patient age and presence of co-morbidities. In most cases a wide local excision or mastectomy with adjuvant therapy will be indicated.

288. When immunising a child in the United Kingdom: True / False

A. The first diphtheria, pertussis and tetanus inoculation should be given at two months

B. BCG is never performed in the neonatal period

C. Immunity to polio after the three initial doses is lifelong

D. Polio vaccine is given orally as part of primary immunisation

E. HIV positive children should receive the measles/mumps/rubella and IM polio vaccines

From cBNF "For primary immunisation of children aged between 2 months and 10 years vaccination is recommended usually in the form of 3 doses (separated by 1-month intervals) of diphtheria, tetanus, pertussis (acellular, component), poliomyelitis (inactivated) and haemophilus type b conjugate vaccine (adsorbed) (see schedule, section 14.1). In unimmunised children aged over 10 years the primary course comprises of 3 doses of adsorbed diphtheria [low dose], tetanus and inactivated poliomyelitis vaccine. A booster dose should be given 3 years after the primary course. Children under 10 years should receive either adsorbed diphtheria, tetanus, pertussis (acellular, component) and inactivated poliomyelitis vaccine or adsorbed diphtheria [low dose], tetanus, pertussis (acellular, component) and inactivated poliomyelitis vaccine. Children aged over 10 years should receive adsorbed diphtheria [low dose], tetanus, and inactivated poliomyelitis vaccine. A second booster dose of adsorbed diphtheria [low dose], tetanus and inactivated poliomyelitis vaccine should be given 10 years after the previous booster dose." And "VACCINES AND HIV INFECTION HIV-positive children with or without symptoms can receive the following live vaccines: MMR (but not whilst severely immunosuppressed), varicella-zoster (but avoid if immunity significantly impaired - consult product literature);(2)(3) and the following inactivated vaccines: cholera (oral), diphtheria, Haemophilus influenzae type b, hepatitis A, hepatitis B, influenza, meningococcal, pertussis, pneumococcal, poliomyelitis(4), rabies, tetanus, typhoid (injection). HIV-positive individuals should not receive: BCG, yellow fever(5) Note The above advice differs from that for other immunocompromised patients."

289. Tricyclic antidepressants: True / False

A. Relieve depression more quickly than electroconvulsive therapy

B. Are associated with an increased incidence of cerebrovascular accidents

C. May cause acute dystonias

D. May cause postural hypotension

E. May cause paralytic ileus in the elderly

B, D, E are correct. TCA effects on depression are much much slower than ECT. Like antipsychotics such as respiridone they are associated with an increased risk of CVAs. They have little effect on dopamine receptors and so do not cause dystonias (metoclopramide is typical for this). The postural hypotension, tachycardia, dry mouth, blurred vision, urinary retention, constipation etc., may ensue from anticholinergic effects.

290. A 33-year-old Type 1 diabetic male presents with a two day history of pain, swelling and redness in his left middle finger. This began after he pricked his finger in the garden whilst pruning a bush. His diabetic control has been quite reasonable with a HbA1c of 7.1% (3.8- 6.4) on basal bolus insulin consisting of Lispro tds and Humulin I in the evenings. On examination he has a painful, red and swollen middle finger with the redness extending to the metacarpophalangeal joint. He is diagnosed with cellulitis. What is the most appropriate treatment for this patient?

A. Admit to hospital for IV antibiotics

B. Oral flucloxacillin only

C. Oral metronidazole only

D. Oral penicillin V only

E. Oral penicillin V and flucloxacillin

E is correct. The patient has digital cellulitis and the most likely organisms responsible are Strep pyogenes or Staphylococcus aureus. The most appropriate treatment is penicillin V and Flucloxacillin which should result in a rapid improvement. If there is a deterioration then admission for IV antibiotics may be required, but this should be unnecessary with appropriate antibiotic selection.

291. With regard to abortion: True / False

A. An abortion cannot be obtained beyond 24 weeks of pregnancy

B. An abortion can only be obtained with parental consent in a 16-year-old

C. Parental consent must be obtained for an abortion in a patient below 16 years of age

D. A doctor or another healthcare professional can decide that an abortion is appropriate for the patient

E. A doctor has the right to refuse to be involved in arranging an abortion

E is correct. Abortion can be obtained up to 24 weeks of pregnancy. However, in certain circumstances, abortion can be obtained beyond 24 weeks. Parental consent is not required for individuals below 18 years of age. Consent of a minor is regarded in the law as valid. Two doctors are required to agree that abortion is appropriate for the procedure to be performed. All healthcare professionals have the right to refuse to be involved with an abortion but must refer the patient on to another who would.

292. This patient presents with painful, raised, erythematous macules on the anterior lower limb. Which drug was she recently prescribed?

A. Ciprofloxacin

B. Co-trimoxazole

C. Metronidazole

D. Ketoconazole

E. Trimethoprim

B is correct. The clinical picture depicts erythema nodosum. The causes of erythema nodosum are:

1. Acute sarcoidosis

2. Streptococcal infection

3. Rheumatic fever

4. Primary tuberculosis

5. Drugs e.g. sulphonamides, penicillin, OCP, codeine, salicylates, barbiturates

6. Others- pregnancy, UC, Crohn’s Disease, malignancy, Behcet’s Syndrome.

Co-trimoxazole is the combination of trimethoprim and the sulphonamide, sulphamethoxazole.

Ciprofloxacin can be associated with erythema nodosum and often with examination questions, there may be distractors which are correct. In this instance, the association of sulphonamides (Co-trimoxazole) with EN is well recognised and Cipro less so, as it is far less likely to cause EN. So, the former would be the best answer.

Theme: Visual field defects

A. Bitemporal hemianopia

B. Central scotoma

C. Cortical blindness

D. Enlarged blind spot

E. Left Homonymous hemianopia

F. Inferior homonymous quadrantanopia

G. Superior homonymous quadrantanopia

H. Tunnel vision

I. Uniocular blindness

Select the most appropriate visual field defect that would be expected in association with the following conditions:

293. Retinitis pigmentosa Tunnel vision

Retinitis pigmentosa, a hereditary condition associated with destruction of the retina, often begins as poor night vision. Fundoscopy reveals a trabeculated, pigmented appearance of the retina usually beginning at the periphery. This is associated with the typical tunnel vision seen in this disorder.

294. Right internal capsular infarction Left Homonymous hemianopia

Internal capsular infarct is the commonest cerebral infarct associated with contralateral hemiparesis and homonymous hemianopia where there is optic radiation damage causing loss of the ipsilateral nasal field and contralateral temporal field.

295. Acromegaly Bitemporal hemianopia

Compression of the nasal retinal fibres in the optic chiasm by the pituitary tumour produces this.

296. A 23-year-old patient with complex partial seizures controlled with carbamazepine is 32 weeks pregnant. She has not had a seizure throughout pregnancy. She expresses a wish to breast feed, but is concerned that the carbamazepine may affect her child. Which of the following statements would be the correct advice to give her?

A. Breast feeding should be encouraged

B. Carbamazepine is not present in breast milk

C. Folic acid should be continued whilst breatfeeding

D. Serum Carbamazepine levels should be monitored whilst breastfeeding

E. She should be advised not to breast feed

A is correct. Answer 1 encourage breast feeding Carbamazepine is found in breast milk, but only in small amounts. Mothers should be encouraged to breastfeed, as the levels of CBZ in breast milk are too low to cause problems in baby. Folic acid should be commenced prior to conception at a dose of 5mg daily. It is not recommended for breastfeeding mothers - its use is to prevent neural tube defects in the foetus. In patients well controlled with treatment in epilepsy there is no increased frequency of seizures during pregnancy nor in the post-partum period. There is no indication to routinely monitor serum antiepileptic concentrations though the NICE guidelines suggest monitoring levels in certain circumstances, e.g. adjusting phenytoin dose, poor concordance, suspected toxicity etc. Here is a link to the NICE epilepsy guidelines.

297. A 16-year-old girl is seen in clinic as she is concerned due to areas of hair loss on the scalp. Past medical history includes atopic eczema and she has a number of depigmented areas on her hands. What is the most likely diagnosis?

A. Alopecia areata

B. Hypothyroidism

C. Seborrhoeic dermatitis

D. Systemic lupus erythematosus

E. Trichotillomania

A is correct. This girl has a combination of vitiligo and alopecia areata which can co-exist and have

similar autoimmune aetiology. Discrete areas of hair loss and normal texture on the scalp are highly suggestive of alopecia areata.

Theme: Treatment of drug and alcohol abuse

A. Alcoholics Anonymous

B. Antipsychotic medication

C. Aversion treatment

D. Controlled drinking

E. Disulfiram

F. Inpatient detoxification with chlordiazepoxide

G. Methadone maintenance treatment

H. Motivational interviewing

I. Simple advice

J. Token economy

K. Treatment under Section 3, Mental Health Act 1984

For each case below, choose the SINGLE most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

298. A 32-year-old man with a ten-year history of heroin addiction has a string of convictions for theft. He is at risk of HIV and other transmissible diseases due to needle sharing. He wants to stabilise his lifestyle, but does not feel ready to give up opiates. Methadone maintenance treatment

Methadone maintenance involves the prescription of the oral opiate, methadone. Consumption is often supervised on a daily basis. The aim is of harm reduction- allowing the user to cease illicit drug use (with its associated risks of injecting and criminal behaviour) and to stabilise their life style. This may lead in time to a position where the addict is ready to withdraw from opiate use.

299. A 43-year-old businessman, who has a history of alcohol dependence, has managed to stop drinking. He is afraid of relapsing during a forthcoming business trip and wants help to remain abstinent from alcohol. Disulfiram

This deterrent drug (trade name antabuse) may help our businessman remain abstinent from alcohol during his business trip. Disulfiram blocks the breakdown of acetaldehyde, causing a transient acetaldehyde poisoning if alcohol is taken. This causes a range of unpleasant symptoms with flushing, palpitations headache and nausea. The knowledge that even a small amount of alcohol will cause an immediate unpleasant reaction helps the patient resist temptations to drink.

300. A 25-year-old male student drinks about 4 pints of beer a day every day. He has no symptoms of alcohol dependency or physical problems. He is concerned his level of drinking may be harmful. Simple advice

This man is drinking 56 units of alcohol a week, a level which is potentially harmful, although he does not yet appear to have any alcohol related problems. Randomised controlled trials have shown that simple advice from a GP or nurse can have a beneficial effect in changing drinking habits in such patients. The advice given focuses on safe drinking levels and ways of reducing consumption.

301. A 33-year-old homeless man drinks a bottle of whisky per day. He has begun to have episodes of amnesia. He wants to stop drinking. When he last tried to give up drinking, he suffered a grand mal convulsion. Inpatient detoxification with chlordiazepoxide

This man with severe alcohol dependency will need inpatient admission during alcohol withdrawal. He is at risk of delirium tremens and further fits. A 5-7 day reducing course of a benzodiazepine such as Chlordiazepoxide will reduce withdrawal symptoms and lessen the risk of fits. High doses of Chlordiazepoxide may be needed due to its cross-tolerance with alcohol. Parenteral multivitamins (e.g. parentrovite should also be given. Patients with lesser degrees of alcohol dependency and good social support may not need admission, and detoxification can be completed successfully at home.

302. A 45-year-old man would like to have support to give up drinking. Alcoholics Anonymous

The AA offers long-term supportive group therapy at evening meetings and also run groups for spouses (Alanon) and children of alcoholics (Alateen). Inpatient alcoholic units usually offer intensive group psychotherapy over a few weeks or months. Aversion therapy eg electric shock with alcohol, is less favoured nowadays because of ethical reasons. What is the management of alcohol abuse?...

303. A 43-year-old male is diagnosed with diabetic nephropathy. If this patient had type 1 diabetes his chances of progressing to End Stage Renal Disease (ESRD) would be approximately 50%. What percentage of type 2 diabetics with diabetic nephropathy would be expected to progress to ESRD?

A. 15%

B. 30%

C. 45%

D. 50%

E. 55%

A is correct. Although the incidence of diabetic nephropathy is less in type 2 diabetics as approximately 90-95% of all diabetics are type 2s, the majority of patients with diabetic nephropathy are type 2 diabetics. There are a number of stages in the development of nephropathy with glomerular hyperfiltration being an early feature. Nephropathy itself is signalled by the excretion of trace amounts of protein in the urine microalbuminuria. The progression of the disease may be attenuated by stringent blood pressure control (with an ACEi) and strict glycaemic control.

Theme: Thyroid swelling.

A. Anaplastic cancer

B. Hashimoto thyroiditis

C. Drug induced thyrotoxicosis

D. Follicular cancer

E. Papillary cancer

F. Reidels thyroiditis

G. Simple goitre

H. Subacute thyroiditis

I. Thyroid adenoma

J. Thyrotoxic goitre

For each patient below choose from the list above the single most likely diagnosis. Each option may be chosen more than once or not at all.

304. A 50-year-old man with a history of heart disease complains of night glare and tinge while driving. His FT3 and FT4 levels are raised and TSH is decreased. Drug induced thyrotoxicosis

The drug in question is amiodarone which can cause almost any type of thyroid hormone abnormality. The visual symptoms are the result of corneal deposits.

305. A 25-year-old woman presents with sweating, palpitation and heat intolerance. On examination, a soft thyroid swelling and a bruit is revealed. Thyrotoxic goitre

Thyrotoxicosis with a bruit is most certainly Graves' disease.

306. A 40-year-old woman gives a history of sore throat, a painful neck swelling and fever. Her thyroid hormone levels are elevated and ESR is markedly raised. Subacute thyroiditis

Subacute thyroiditis is associated with viral infections. It is characterized by transient hyperthyroidism and high ESR.

307. A 40-year-old woman complains of a rapidly growing hard swelling. She also has a history of dysphagia and hoarseness. Anaplastic cancer

A very tricky question. The diagnosis probably lies with the very rapid growth. Anaplastic tumours constitute only ~10% of all thyroid cancer in women below 40 years of age.

308. A woman presents with goitre, constipation and bradycardia. She also has megaloblastic anaemia.

Hashimoto thyroiditis

Typical hypothyroid symptoms and the most likely cause is Hashimoto's hyroiditis, an autoimmune condition with Thyroid autoantibodies. Associated with other autoimmune conditions like pernicious anaemia - hence the megaloblastic anaemia as described here. Read about the aetiology, presentation, investigations and management of thyroid goitres...

309. The following diseases only occur in males. One or more may be correct.

A. Duchenne muscular dystrophy

B. Haemophilia A

C. Huntingdon's chorea

D. Sydenham's chorea

E. Von Rechlinhausen's neurofibromatosis

F. Von Willebrand's disease

A is correct. C, E and F are inherited autosomally and occur in both sexes. Sydenham's chorea is not inherited. Haemophilia A is X linked and is recessive, so the usual scenario is that all females can only be carriers, whereas boys are affected or not (50% incidence from haemophiliac man and normal female). In the rare situation where a haemophiliac man marries a carrier female, then it is possible for female offspring to have the disease. Theoretically you could argue this for Duchenne's but as they mostly become disabled well before puberty, procreation is unlikely, whereas in the case of haemophilia, even affected males can be well for many years.

310. When talking to patients, the following are good interview skills True / False

A. maintaining continuous eye contact

B. the use of non verbal methods of communication

C. asking direct questions during the interview

D. being empathetic rather than sympathetic

E. premature assurances are helpful

Good interview skills include appropriate not continuous eye contact which can be threatening for the patient. Again verbal communication stating the specific points with empathy is regarded as appropriate rather than using non verbal queues. Premature assurances are negative and will be perceived as inappropriate by the patient.

311. In X-linked recessive disease True / False

A. Mothers will always carry the affected gene

B. Fathers never transmit to their sons

C. There is variable expression in females due to random inactivation

D. 50% of daughters of carrier females will be carriers

E. Incidence increases with maternal age

E is incorrect. If they are homozygous then they will be affected. If they are heterozygous (the usual case) then they are termed 'carriers'. There is variable expression of the gene in females associated with X-linked inactivation, that is, the Barr body. Karyotype disorders. (Dr Vajira H. W. Dissanayake)

312. Regarding language impairment: True / False

A. It is 4 times more common in girls

B. It is commoner in large families

C. It is commonly associated with middle ear disease

D. It may be associated with motor impairment

E. It is highly associated with socio-economic deprivation

B, C, D are correct.

The following are associated with language impairment:

ø Sex: 4 times commoner in males

ø Family history

ø Motor/developmental problems

ø Social: large family size, and socio-economic deprivation.

There is seldom any abnormality in perinatal history, and though middle ear disease may be important for individual children, it is not responsible for the majority of cases of language impairment.

Theme: Non-thyroid endocrine disease

A. Addison’s disease

B. Carcinoid syndrome

C. Conn’s Syndrome

D. Cushing’s disease

E. Cushing’s syndrome

F. Phaeochromocytoma

G. Primary hyperparathyroidism

H. Secondary hyperparathyroidism

I. Tertiary hyperparathyroidism

J. Zollinger-Ellison Syndrome

Which of the above endocrine disorders best matches the case histories provided below?

313. A 50-year-old man undergoing haemodialysis for chronic renal failure is noted to have an elevated parathyroid hormone level together with high phosphate and low calcium levels.Secondary hyperparathyroidism

The biochemistry results are typical of secondary hyperparathyroidisim developing as a result of chronic renal failure. In many cases it may be adequately managed by calcium/vitamin D supplementation and phosphate binders. The pathology is usually hyperplasia and so if medical therapy fails on some patients, they should undergo subtotal parathyroidectomy.

314. A 40-year-old man is seen in the endoscopy unit for assessment of recurrent epigastric pain. He has had 3 peptic ulcers diagnosed at different locations during the past 2 years which have not responded to proton pump inhibitors. Zollinger-Ellison Syndrome

Zollinger-Ellison syndrome occurs as a result of a gastrin secreting tumour. The diagnosis should be considered in patients with recurrent ulceration despite optimal medical therapy and can be formed by measuring fasting gastrin levels. Tumours are often located in the pancreas and duodenum and must be localised prior to resection.

315. 35-year-old man presents with weight loss, sweats and palpitations. On examination he is found to have a blood pressure of 168/100 mmHg and a pulse of 106 bpm. Phaeochromocytoma

Phaeochromocytoma is a tumour arising in the adrenal medulla and represents one of the surgically correctable causes of hypertension. It classically shows elevated urinary levels of catecholamines, metanephrines, and VMA. Patients with phaeochromocytomas should undergo resection but require preoperative alpha and beta blockade to prevent intraoperative catecholamine release.The symptoms, tachycardia and hypertension suggest a phaeochromocytoma.

316. A 43-year-old transplant recipient is noted to have developed truncal obesity since his operation and is complaining of generalised weakness. Routine U&Es indicate hypokalaemia and hypochloraemia. Cushing’s syndrome

The clinical picture is of Cushings syndrome and occurs as a result of corticosteroid immunosuppression. The condition is less common than previously as new regimens are steroid-sparing. The syndrome differs from Cushings disease which is due to a pituitary adenoma. Tumours should be removed and in many cases this can now be done laparoscopically.

317. A 30-year-old man is seen as an emergency with renal colic. Systematic review identifies that he also has generalised bone pain and upper abdominal discomfort and indeed was recently admitted with acute pancreatitis. On examination he has ablood pressure of 160/88 mmHg. Primary hyperparathyroidism

Primary hyperparathyroidism can also cause hypertension. Primary hyperparathyroidism usually occurs as a result of a parathyroid adenoma and is typified by the symptoms ‘bones, stones, abdominal moans and psychic groans’. The diagnosis can be confirmed by measurement of PTH and the adenoma localised by USS or MRI of the neck. Treatment is by means of parathyroidectomy.

Theme: Lumps and Bumps

A. Bartholin's cyst

B. Berry aneurysm

C. Branchial cyst

D. Epididymo-orchitis

E. Erythema nodosum

F. Femoral hernia

G. Ganglion

H. Germ cell tumour

I. Heberden's node

J. Hiatus hernia

K. Hydrocoele

L. Inguinal hernia

M. Lipoma

N. Lymphadenopathy

O. Neurofibroma

P. Palpable gall bladder

Q. Papillary carcinoma of thyroid

R. Parathyroid adenoma

S. Paraumbilical hernia

T. Pleomorphic adenoma of parotid

U. Rheumatoid nodule

V. Sebaceous cyst

W. Thyroglossal duct cyst

Each of the following patients presents with a swelling on clinical examination. Select the most likely diagnosis from the list above.

318. A woman aged 73 years presents with a painful swelling in the right groin, measuring 3 cm in diameter. It lies below the inguinal ligament, and medial to the femoral artery. A plain x ray examination of the abdomen reveals dilated loops of small bowel. Femoral hernia

Femoral herniae account for 4% of all herniae. They are most common in elderly women. They may strangulate, and the dilated bowel loops in this case may suggest bowel obstruction.

319. A man aged 25 years presents with an enlarging painless swelling in the left side of the scrotum. It does not transilluminate. Ultrasound scan of the lower abdomen reveals lymphadenopathy along the external iliac artery; a chest x ray is normal. Germ cell tumour

This unfortunate gentleman has a testicular tumour until proven otherwise, given the intra-abdominal lymphadenopathy, and a germ cell tumour is the likely candidate in this age group. Neither Epididymo-orchitis nor hydrocele cause intra-abdominal lymphadenopathy.

320. A woman aged 24 years presents with a smooth painless swelling, 2 cm in diameter, in the midline of the neck just below the hyoid bone. An ultrasound scan shows that the lesion is cystic. Thyroglossal duct cyst

A cystic midline swelling of the neck which is painless in a young person suggests thyroglossal cyst. They may occur on the chest wall and axilla and rarely elsewhere. Its cystic nature differentiates it from lipoma and neurofibroma.

321. A man aged 40 years develops a recurrence of a painless swelling on the wrist; it is not tethered to the skin. x Ray of the wrist reveals no bony abnormality. Ganglion

A ganglion is a small cyst filled with synovial fluid, most commonly found on the dorsal aspect of the wrist. It is not tethered to the skin and does not rapidly change in size.

322. A man aged 51 years notices a painless swelling, 1.5 cm in diameter, on the back of the neck; it is tethered to the skin. An x ray of the cervical spine is normal. Sebaceous cyst

Sebaceous cysts are normally found on the scalp, nape of the neck, face, ears and genitals. Cysts form when the release of sebum from sebaceous glands in these regions is blocked. On examination of lumps...

Theme: The combined oral contraceptive pill

A. WHO Category 1 – Unrestricted use (No contraindication to OCP use)

B. WHO Category 2 – Benefits outweigh risks (Relative contraindication)

C. WHO Category 3 – Risks outweigh benefits (Strong relative contraindication)

D. WHO Category 4 – Unacceptable risk (Absolute contraindication)

The WHO have categorised scenarios for the eligibility of combined oral contraceptive use into the groups above. For the following clinical scenarios, choose the appropriate WHO category that applies.

323. A 39-year-old factory worker with a body mass index of 24. She is divorced with 3 children and is about to consummate a new relationship. She smokes 20 a day. She has had a cholecystectomy and bouts of depression in the past and is allergic to latex. BP is 130/60. Her partner refuses vasectomy and after reading a leaflet on contraception (given by the practice nurse when she attended with her child), she has decided that she wants to go back on the pill. She is not taking any current medication and is currently abstinent (LMP 1 week ago) WHO Category 4 – Unacceptable risk (Absolute contraindication)

The important points here are her age and smoking status. Women aged over 35 and smoke more than 15 cigarettes a day are categorised WHO 4.

324. A 36-year old school teacher with a body mass index of 27. She is single with 2 children. She is a non smoker who suffers from thallassemia. Her second pregnancy was complicated by trophoblastic disease and she had a benign ovarian tumour removed 2 years previously. She has been using condoms with her new boyfriend. She would like to start the pill, having read a leaflet on contraception, but is concerned because of her previous trophoblastic disease. WHO Category 1 – Unrestricted use (No contraindication to OCP use)

The following points place this lady in WHO category 1: Her age is 'menarche to below 40', she is a non smoker. Thallassemia, benign ovarian tumours (or ovarian cancer) and trophoblastic disease (benign or malignant) are not contraindications to the use of COCP.

325. A 28-year-old accountant with a body mass index of 28. She is married with no children. She is a non smoker. Her past medical history includes varicose veins and endometriosis. She attended the practice minor surgery clinic 5 weeks previously to have a sebaceous cyst excised from her left axilla. Her current visit actually relates to a diagnosis of pelvic inflammatory disease which you have just made. When you asked her about her contraceptive history, she said that she would like to stop using the contraceptive diaphragm (with spermicidal gel) and start the OCP. A pregnancy test taken 2 days earlier is negative and she has not had sexual intercourse for the past 7 days.

WHO Category 1 – Unrestricted use (No contraindication to OCP use)

Minor surgery without immobilisation, varicose veins and PID (current or within past 3 months) are not contraindications

326. A 32-year-old shop assistant with a body mass index of 26. She is a non smoker who is married with 2 children. She had an ectopic pregnancy aged 21 and suffers from non migrainous headaches. Her only medication is paracetamol prn for the headaches. There is a family history of breast cancer (her mother's aunt - now deceased). Her BP is 145/95 WHO Category 3 – Risks outweigh benefits (Strong relative contraindication)

Her age, BMI, smoking status, past medical and family history would all place her in WHO 1 (no contraindication). The deciding factor is her blood pressure. Blood pressure indices pertaining to WHO 3 include a history of hypertension when BP cannot be managed, adequately controlled BP where it can be measured, elevated BP 140-159 systolic and 90- 99 diastolic.

327. An otherwise healthy woman of 30 has a second attack of renal colic in two years and passes a stone. Blood urea is normal. The following investigations are indicated: True / False

A. x Ray of the hands

B. Serum calcium concentration

C. Culture of the urine

D. Renal biopsy

E. Urinary amino-acid chromatography

B, C, E are correct. Further investigation of young patients with a second episode of renal colic is recommended. Clearly a plasma calcium is important and assessment for cystinuria/renal ubular acidosis again is required. x Ray of hands is really not required nor is renal biopsy. Clearly urine culture is an important investigation to exclude concurrent infection and infection is associated with stone formation.

328. In the following scenario, choose the single most likely diagnosis: A 30-year-old woman has suffered from heavy periods, but has come to see her GP because she has been very tired recently. She has lost a little weight, is off her food and gets occasional diarrhoea and abdominal pain. On examination her skin is pale but her mucous membranes look normal colour. Her nipples have become darker and her blood pressure is normal on the couch but drops significantly on standing.

A. Acute anxiety

B. Addison's disease

A. Hypothyroidism

B. Iron deficiency anaemia

C. Pregancy

D. Underlying malignancy

E. Vaso vagal syncope

B is correct. Although a rare disease, primary adrenal failure fits the bill here on symptomatology and examination findings. The postural drop in BP is the key finding.

329. A 59-year-old lifelong smoker presents to her GP complaining of increasing shortness of breath and ptosis and constriction of her pupil. She is referred by her GP for a chest x ray that is reported as showing an apical mass. What is the name given to the origin of this lady's condition?

A. Horner's syndrome

B. Pancoast tumour

C. Peyronie's disease

D. Pott's cancer

E. Wilms' tumour

B is correct. This lady has almost certainly got a Pancoast tumour: a neoplasm of the apex of the lung that typically invades the chest wall and brachial plexus and is causing a Horner's syndrome. The ptosis and constriction of her pupil is suggestive of a Horner's syndrome but this is a consequence of her Pancoast tumour. Peyronie's disease is hardening of the corpora cavernosa of the penis caused by scar tissue. Pott's cancer is a scrotal cancer caused by coal tar exposure. A Wilms' tumour is a malignant tumour of the kidney that usually occurs in childhood.

330. You would be likely to observe the lowest heritability score in:

A. Cystic fibrosis

B. Spina bifida

C. Cleft lip/palate

D. Mumps

E. Congenital heart disease

D is correct. Mumps is due to an infective agent and hence has the lowest heritability score. Al the other disorders have a genetic aetiological component eg CF autosomal recessive.

Theme: Practice management

A. Cost rent

B. Notional rent

C. Actual rent

D. Private finance initiative

E. Superannuation

F. Sale of goodwill

G. National Insurance

H. Limited Company

I. GMS contract

J. National enhanced service

For each management issue listed below choose the SINGLE most likely answer from the above list of options. Each option may be used once, more than once, or not at all

331. A sum received by a practice that owns its own premises based on the market rent value of that building. Notional rent

The notional rent is agreed between the practice the district valuer and the PCO.

332. A sum that would have been deemed to have been paid if a newly appointed partner was asked to pay over the odds for a share of the practice based on profit not property. Sale of goodw ill

Sale of goodwill used to be illegal. The new GMS contract allows some of practice profits in relation to enhanced services to be set against any sum a new partner would need to invest for a share in the business.

333. A sum paid to a practice based on calculations made when a premises was developed on a new building site and the interest rates available on a year on year basis Cost rent

Cost rent is a sum paid to cover the interest accrued on an investment in a newly built premises. It is fixed once the building is completed but will go up or down depending on the interest rates available (re set annually).

334. Regarding emphysema occurring without chronic bronchitis. Which one of the following statements is correct?

A. Cannot be familial

B. May be caused by smoking

C. More likely to cause cor pulmonale

D. More likely to have barrel chest

E. More likely to have clubbing as a feature than when a consequence of chronic bronchitis

Usually referred to as 'blue bloaters' When continuous oxygen is needed is dealt with the same as Chronic bronchitis Emphysema can be familial (alpha 1 antitrypsin deficiency). Primary emphysema can be triggered by smoking. These patients are no more likely to get right sided heart failure or hyperinflation than with combined disease. The descriptive phrase usually associated with emphysema is 'pink puffers'. When at end stage domiciliary oxygen is required, due to often normal arterial CO2 pressure, a higher percentage mask can be used.

335. A 58-year-old lady whose mother has osteoporosis but no fractures attended your surgery asking for advice. She is a lifelong non-smoker, does not take steroids, has no major health problems and has never had a fracture. Her menopause occurred age 51 years. She has no other risk factors for osteoporosis. She is adamant that she will not take drug therapy but would like guidance on lifestyle changes to reduce her risk of developing osteoporosis. Which one of the following statements is the most appropriate management plan?

A. Her daily calcium intake is 800 mg per day so you would prescribe a

B. calcium supplement to reduce her risk of fracture

C. She should be encouraged to have a DXA scan and to take preventive drug therapy e.g. bisphosphonates if her T score is less than -2

D. She should be encouraged to undertake weight-bearing aerobic exercise and resistance exercise which have been shown to increase spine bone density in post-menopausal women

E. She should be offered a DXA scan even though she will not consider drug therapy

D is correct. There is no evidence that lifestyle changes will influence her risk so you would provide guidance on falls avoidance and ensure she has treatment in future if she suffers a fracture Cochrane review (Bonaiuti et al 2005) concluded that aerobics, weight-bearing and resistance exercises are all effective in increasing the BMD of the spine in postmenopausal women. This lady would not qualify for a DXA scan under the 1999 RCP guidance, and it would be inappropriate to arrange a scan if the result would not change her management. She would not meet the NICE criteria for bisphosphonate use. 800 mg is an acceptable dietary calcium intake for someone who is not known to have osteoporosis and there is no evidence that calcium supplementation either alone or with vitamin D can reduce fractures in a lady of this age who is free-living.

Theme: Antibiotics

A. Cefuroxime

B. Chloramphenicol

C. Ciprofloxacin

D. Clarithromycin

E. Co-amoxiclav

F. Co-trimoxazole

G. Gentamicin

H. Nitrofurantoin

I. Pyrazinamide

J. Rifampicin

K. Tetracycline

Select the antibiotic from the above list that would be associated with the following side effects.

336. Aplastic anaemia Chloramphenicol

Chloramphenicol is associated with aplastic anaemia in approx 1 in 1000 users, which consequently limits its use.

337. Peripheral neuropathy Nitrofurantoin

Nitrofurantoin may cause a peripheral neuropathy.

338. Red discolouration of the urine Rifampicin

Rifampicin typically causes red discolouration of bodily fluids.

339. Sensorineural deafness Gentamicin

Gentamicin is associated with both ototoxicity and nephrotoxicity.

340. Dental staining of the fetus if administered to the mother Tetracycline

Dental staining in the fetus is typically associated with tetracycline.

Theme: Care of the terminally ill

A. Decrease dose of opioids

B. Escalate opioid therapy

C. Methylcellulose

D. No treatment required

E. Palliative radiotherapy

F. Pamidronate IV

G. Start oxygen therapy

H. Start syringe driver with diamorphine

Select the most appropriate treatment for the following cases who present in distress.

341. A 70-year-old male receiving treatment for metastatic bronchial carcinoma complains of deteriorating dyspnoea. He is noted to have compromised respiratory function. Start oxygen therapy

342. A 72-year-old male diagnosed with metastatic bowel carcinoma is being treated for bone pain with high doses of oral Morphine Sulphate. Recently he has become aware of increasing constipation and lower abdominal pain. Methylcellulose

343. A 75-year-old patient treated with tramadol for control of pain related to metastatic malignant melanoma. The patient still feels that the pain is unbearable. Escalate opioid therapy

344. A 66-year-old female with carcinoma of the breast associated with multiple metastases is receiving palliative care. She develops severe nausea and vomiting and bone pains. Investigations reveal a serum calcium concentration of 3.5 mmol/l. Pamidronate IV

345. An 80-year-old male receiving treatment for prostate carcinoma complains of pelvic pain and is noted to have pelvic metastases on radiological investigation. Palliative radiotherapy

The patient with bronchial carcinoma and dyspnoea would most appropriately be treated with oxygen. The patient with metastatic bowel carcinoma has typical opioid side effects of constipation.

The most appropriate treatment is methylcellulose in the first instance. The patient with the metastatic malignant melanoma has pain despite tramadol. Consequently escalation of opioid analgesia is required with the introduction of Oramorph as the next appropriate step. The patient with breast carcinoma has symptoms of symptomatic hypercalcaemia and the most appropriate therapy is IV rehydration and Pamidronate therapy. Pamidronate, a bisphosphonate may also be associated with the relief of bone pain. The patient with prostate carcinoma may well respond to palliative radiotherapy which should be considered in this case.

Theme: Diets

A. Atkins

B. Cabbage Soup

C. Gluten free

D. Low GI (glycaemic index)

E. Lactose free

F. Scarsdale

G. Weight watchers

Match the following descriptions with the appropriate diet.

346. A seven day diet which allows regular snacking on a vegetable broth, and includes one day of eating only bananas and skimmed milk. Cabbage Soup

Patients often present asking for opinions of different “celebrity diets”. It is useful to have an idea what they involve.

347. A seven day diet which involves drinking at least 4 cups of water a day, and includes eating half a grapefruit each morning for breakfast. Scarsdale

The Scarsdale diet suggests at least 4 cups of water a day, and has a set menu each day, including tea or coffee and grapefruit each breakfast.

348. A diet whereby cheese and bacon are allowed, but grains, pasta and rice are discouraged. Atkins

The Atkins diet involves eating less than 20 grams of carbohydrate each day.

349. A diet which involves comparing foods with plain sugar for their ability to lift blood glucose levels. Low GI (glycaemic index)

A low GI diet is based on the principle that some foods satisfy hunger for longer than others (i.e. have a low glycaemic index). Peanuts and low fat yoghurt are examples of low GI foods, whereas white rice and parsnips have a high GI.

Theme: Thyroid disease

A. Anaplastic carcinoma

B. Follicular carcinoma

C. Grave’s disease

D. Hashimoto’s disease

E. Lymphoma

F. Medullary carcinoma

G. Multinodular goitre

H. Papillary carcinoma

I. Pendred’s syndrome

J. Riedel’s thyroiditis

Chose the best match between the case histories below and the thyroid pathologies listed above.

350. A 40-year-old woman is seen in the clinic having been advised to seek advice from her optician. She has sweaty palms, a tachycardia, exophthalmos and a diffuse goitre. Grave’s disease

These features are classical of hyperthyroidism or Graves disease. These patients will have elevated T3/T4 and reduced TSH as well as high levels of thyroid autoantibodies. Treatment options include: anti-thyroid drugs; radio-iodine; and surgery. The treatment choice will depend on the patient age and status as well as their choice.

351. A 77-year-old woman is rushed to A&E with acute dyspnoea. On examination she is exhibiting stridor and has a large woody hard goitre. Anaplastic carcinoma

A rapidly growing woody hard thyroid is typical of an anaplastic tumour (5-10%) which eventually compresses the trachea leading to acute dyspnoea. The tumour has an abysmal prognosis but may respond to a course of emergency radiotherapy or excision of the thyroid isthmus with tracheostomy. There are no 5 years survivors.

352. A 40-year-old man attends the endocrine surgery clinic with a firm mass on the left side of his neck. His father and brother had previously undergone surgery for thyroid tumours. Medullary carcinoma

Medullary thyroid carcinoma (5-10%) arise from the c cells of the thyroid and may be familial and/or associated with multiple endocrine neoplasia type II (presence of ret protooncogene). Families may now be screened for the presence of gene mutations and offered prophylactic surgery. The tumour should be treated by total thyroidectomy and lymph node dissection. 5-year survival is 85% for node –ve and 45% for node +ve cases. In this case the suggestion of an autosomal dominant inheritance pattern would promote the selection of medullary thyroid cancer as the answer –Pendred’s is associated with deafness.

353. A 60-year-old woman from Derbyshire is seen with a a progressively enlarging mass on the right side of the neck. It had been present for 10 years and now causing dyspnoea on exertion. Multinodular goitre

Multinodular goitres may be asymptomatic or present with pressure symptoms such as dysphagia, dyspnoea or hoarseness. MNGs were previously endemic in areas of iodine deficiency such as Derbyshire/Pennines. They usually grow slowly and gradually become symptomatic but may develop acute symptoms due to haemorrhage into a nodule.

354. A 42-year-old woman is referred by her GP who noticed a single nodule in her left thyroid and several lymph nodes on the ipsilateral side of the neck. Papillary carcinoma

Papillary tumours are the commonest thyroid neoplasms (60-65%). They effect the young and middle-aged and are more common in women: F:M = 4:1. They are frequently multifocal and spread to lymph nodes. Treatment is resection followed by thyroxine suppression. Follicular carcinoma has a similar female preponderance but typically effects slightly older patients – mean of 50 years. Follicular carcinoma is distinguished in that it spreads haematogenously. Treatment is total thyroidectomy with radioiodine for metastases. Survival is excellent for localised papillary tumours and is still 85% at 5-years with extra-thyroidal disease. Follicular carcinoma survival is 97% falling to 50% in the presence of frankly invasive disease.

355. A 33-year-old female presents with pain at the elbow which she has been aware of for the last 2 weeks. Which of the following would be consistent with a diagnosis of tennis elbow?

A. Pain on pressure over the medial epicondyle

B. Pain on wrist extension against resistance

C. Pain on pronation of the forearm

D. Pain on flexion of the fingers against resistance

E. Pain on extension of the elbow

B is correct. Tennis elbow is due to lateral epicondylitis and is due to overuse/strain of the extensor

muscles of the forearm. Golfer's elbow is pain at the medial epicondyle. Consequently, there is pain over the lateral epicondyle and the pain is exacerbated by wrist extension.

356. Panic attacks are associated with: True / False

A. Bradycardia

B. Distal paraesthesia

C. Blurred vision

D. Expiratory wheeze

E. Hyperventilation

B, C, E are correct. Panic attacks result in tachycardia, hyperventilation (tetanic spasms and paraesthesiae due to rise in pH and reduced ionised calcium) and a feeling of foreboding. An expiratory wheeze would suggest asthma rather than panic.(Dr Siobhan Jackson)

Theme: Head and neck swellings – 2

A. Branchial cyst

B. Carotid body tumour

C. Cystic hygroma

D. Lymphadenopathy

E. Parotid adenolymphoma

F. Parotid pleomorphic adenoma

G. Submandibular tumour

H. Submandibular duct calculus

I. Thoracic outlet syndrome

J. Thyroglossal cyst

Which of the head and neck lesions above best matches with the case scenarios below?

357. A 60-year-old woman is seen in clinic with a mass underneath her mandible. It has increased significantly in size over the past 2 months and is non-tender. Submandibular tumour

Submandibular gland tumours are more frequently malignant than those of the parotid (50% vs. 20%) although not as common as the minor glands where 80% of tumours are cancer. Adenoid cystic tumours, the commonest variety, are aggressive compressing and invading along nerves (lingual, hypoglossal and mandibular branch of the facial). Patients should have an FNA and a CT scan followed by surgery with node dissection if operable of radiotherapy.

358. A 58-year-Tibetan man is seen in the clinic with a painless mass on the left side of his neck lying just anterior to the sternocleidomastoid. He is asymptomatic and no other masses are palpable. Carotid body tumour

Carotid body tumours usually present as painless masses but occasionally may compress the vagus or hypoglossal nerves causing dysphagia, hoarseness, stridor, or weakness of the tongue. They are more common in people living at high altitude. The majority (90%) are spontaneous of which 5% bilateral but in familial cases (10%), 30% are bilateral. Treatment is surgical excision.

359. A 43-year-old woman is seen in the Emergency Department with a 4 x 3 cm painful swelling beneath her left mandible. It has been rapidly increasing in size over the previous week and the pain has increased as the lesion has enlarged. Submandibular duct calculus

The submandibular gland is the commonest site for calculi (85%), this being due to the higher calcium content in its saliva compared to the other glands. Calculi are seen equally in men and women and can be seen at any age. Some stones can be removed by opening Warthin's duct and milking the stone along but many require excision of the gland.

360. A 70-year-old male smoker is seen in the clinic with a 3 x 3 cm soft mass on his right cheek anterior to his earlobe. It has been present for 5 years and is asymptomatic, the patient being referred by the GP for a confirmatory diagnosis. Parotid adenolymphoma

Adenolympha or Warthin's tumour is the second commonest parotid tumour (15%) and a strong association with smoking. It is softer, slower growing and is commoner beyond middle age in men with a 5:1 male:female ratio. Up to 10% are bilateral. They are easier to excise, do not seed in the wound, and there is no malignant potential.

361. A 53-year-old woman is seen in the clinic reporting pain in her left hand on exertion, such as when she brushes her hair. At rest her pulses are palpable but they disappear after repeatedly elevating her arm. An x ray is performed that confirms the diagnosis. Thoracic outlet syndrome

Thoracic outlet syndrome includes compression or thrombosis of the subclavian artery and vein and compression of the brachial plexus as they pass over the first rib. Cervical ribs, abnormalities arising from the 7th cervical vertebra, are amongst the commonest causes. Patients complain of upper limb claudication when asked to perform repeated movements such as in brushing the hair. Some complain of pain, numbness and tingling (C8 and T1) and autonomic features such as pale, cold hands may be present. Adson's test is the definitive test. Cervical ribs may be identified on chest x rays or thoracic inlet views, but fibrous ribs will not show. A Doppler scan will accurately define vascular compression and MRI will demonstrate nerve injury. Treatment is by means of excising the cervical rib or releasing scalene muscles if these are compressing.

362. You are called to see a 78-year-old lady, who has been previously reasonably well. She was diagnosed with mild CCF two years ago, but had been better on furosemide 40 mgms and ramipril 5 mgms. She has become more breathless in the last few days and is confined to a recliner chair. About 2 weeks previously she slipped while gardening, bruised her knee and her right lower ribs. She had some chest pain the previous night. She feels very unwell and she is breathless on exertion and at rest. However, she does find her breathing easier when she puts the recliner back. O/ E she has a tachycardia, 110, thready pulse, with the 4:1 expected increase in resp rate. Her JVP is raised to pulsating ear lobe level, and her legs are both oedematous. Her BP is 110/60 lying down and she feels too unwell to have it checked standing. The likely diagnosis is:

A. Exacerbation of CCF

B. Large tension pneumothorax

C. Libman-Sachs endocarditis

D. Massive pulmonary embolism

E. Ruptured chordae tendini

D is correct. The story has some blind alleys, but the sentinel symptom here is the fact that dyspnoea is improved by lying flat. This is pathonemonic of massive pulmonary embolism. Combined with clinical signs of right-sided heart failure, it clinches the diagnosis.

363. Identify the 2 most effective treatments, based on current evidence, for Restless Legs Syndrome (RLS)

A. Clonazepam

B. Bromocriptine

C. Iron

D. Ropinirole

E. Pergolide

F. Carbamazepine

G. Gabapentin

D, E are correct. Dopamine agonests. The term Restless Leg Syndrome was coined by Professor Karl-Axel Ekbom in 1944 and is therefore also known as 'Ekbom's disease'. Restless legs syndrome (RLS) is a neurological disorder with unpleasant sensations in the legs and an uncontrollable urge to move when at rest to try to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs, and a wide variety of descriptions is included in diagnostic criteria. Most cases of RLS are of unknown cause. There is little clinical trial information on drugs for RLS. Several drugs have been tested in only a single trial, and only 2 drugs have been tested on more than 100 patients, L-Dopa (142) and ropinirole (233). The best information in terms of overall results and numbers exists for ropinirole and pergolide. Comparisons must be tempered by the relative paucity of evidence for most treatments. For further information, see http://www.jr2.ox.ac.uk/bandolier/booth/booths/RLS.html

364. Giant 'A' waves in the JVP occur in: True / False

A. Pulmonary hypertension

B. Aortic regurgitation

C. Thyrotoxicosis

D. Constrictive pericarditis

E. Tricuspid stenosis

A, E are correct. A Giant 'A' waves occur when there is a poorly compliant right ventricle (or tricuspid stenosis) increasing the impedence against which the right atrium has to eject blood. D In constrictive pericarditis the JVP is high with an abrupt fall in systole (x descent) and may rise with inspiration (Kussmaul's sign).

365. In a primary prevention study of stroke comparing a new antihypertensive with conventional antihypertensive therapy, the number of patients who had a stroke over the study period was 200 in group 1 with the new therapy (n=5200) versus 250 with conventional therapy (n=4750). Which of the following is the approximate odds ratio for the new therapy?

A. 0.25

B. 0.5

C. 0.75

D. 1

E. 1.5

C is correct. An odds ratio is calculated by dividing the odds in the treated or exposed group by the

odds in the control group. Studies generally try to identify factors that cause harm – those with odds ratios greater than one. The new therapy odds of an event is 200/5000 (patients without an event 5200- 200)=0.04. Group 2's odds event rate if 250/4500 (4750-250)=0.055. The odds ratio is therefore: 0.04/0.055=0.73 This odds ratio is less than 1, indicating an overall benefit of therapy. For calculations on Odds ratio see this article.

366. Pertussis immunisation is contraindicated if the child: True / False

A. Has had an anaphylactic reaction to a previous dose

B. Has an uncle who has epilepsy

C. Is being treated with antibiotics

D. Was delivered at less than 32 weeks gestation

E. Is 3-years-old when the immunisation programme commences

Pertussis immunisation is contraindicated in this circumstance, but not if there is a family history of epilepsy or the child is on antibiotics. It is given to infants with a history of prematurity and the initial immunisation occurs at 2 months. Further reading

367. A random selection of 1200 adults agree to participate in a study of the possible effects of drug X. They are followed prospectively for a period of five years to see if there is an association between the incidence of cataract and the use of drug X. This type of study is a:

A. Case-control study

B. Randomised controlled clinical trial

C. Cross-sectional study

D. Cohort study

E. Cross-over study

D is correct. Cohort studies or longitudinal studies involve the follow-up of individuals. A cohort study may be prospective in which individuals who are exposed and non-exposed to a putative risk factor are followed up over a defined period of time and the disease experience of the exposed group at the end of follow-up is compared with that of the non-exposed group. A cohort study may also be historical (retrospective or non-concurrent). A cohort is identified, for whom records of exposure status are available from the past, and whose disease experience can now be measured, a substantial period of time having already elapsed since exposure.

368. A patient of yours suffers a myocardial infarction and dies in Spain. His relatives arrange for his body to be repatriated and plan for him to be cremated. You last saw him alive 7 days before his death. Which of the following is true with respect to completion of cremation forms?

A. A colleague should complete form 4

B. A cremation may only take place if a coroner rules that no inquest or postmortem is needed

C. The Spanish doctor who originally treated him should complete form 4

D. You are allowed to complete form 5

E. You are allowed to complete forms 4 and 5

B is correct. Where deaths abroad are concerned, a cremation may only take place if the coroner is

satisfied that a post mortem or inquest is not necessary. It is highly unlikely that you will be in a position to complete forms 4 and 5, and it is not appropriate for form 4 to be completed by the Spanish doctor who originally treated the patient. Ministry of Justice cremation guidelines 2009

369. One of the nurses working on the Care of the Elderly ward sustains a needlestick injury while taking blood from a patient. What is the most appropriate immediate management?

A. Administer prophylactic hepatitis B immunoglobulin regardless of vaccine status

B. Exclude the nurse from performing exposure-prone procedures for three months until a negative HIV antibody test has been obtained

C. Immediately take the nurse’s blood to test for antibodies to hepatitis B, hepatitis C and human immunodeficiency viruses

D. Promptly administration of antiretroviral therapy

E. Wash the wound with soap under running water

E is correct. The first line of management of needlestick injuries includes immediate washing under running water. All incidents should be reported to occupational health department and have a careful risk assessment. HBIG is given only if donor is known Hepatitis B positive and victim is non-immune. Antiretroviral therapy is given, after counseling, if donor is known HIV positive and the exposure is deemed high risk.

370. The following are indications for tonsillectomy

A. Five acute attacks,with time off school, in 1 year

B. Obstructive sleep apnoea

C. Parental pressure

D. Quinsy

E. Recurrent tonsillitis with complications

F. Three attacks, with time off school, in 2 yrs

G. Tonsillar lymphoma

A, B, D, E, G are correct. Two acute attacks accompanied by systemic upset in 3 months Weight loss The SIGN guidelines quote five acute attacks of proven tonsillitis. Some sources quote 3-4 in 1year, or 5 attacks in 2 yrs. F&H are too short a period. Weight loss per se is not an indication, although children post tonsillectomy often have an improvement in general health. Complications such as nephritis, Rheumatic fever, are indications as is peritonsillar abcess. Benefit has been shown in children with obstructive sleep apnoea, and malignancy is an absolute indication.


371. A 62-year-old male presented to the urologists with symptoms of urinary hesitancy and dribbling. They diagnose benign prostatic hyperplasia and he is commenced on Finasteride. Through which of the following mechanisms does Finasteride function?

A. 5-alpha-reductase inhibitor

B. Alpha receptor antagonist

C. LHRH analogue

D. LHRH antagonist

E. Testosterone receptor antagonist

A is correct. Finasteride is a 5 alpha reductase inhibitor preventing the conversion of testosterone to the actve dihydrotestosterone (DHT). Consequently, the effects of this agent are to oppose testosterone and hence gynaecomastia, reduced libido are typical. It is also used topically as the agent propecia used in the treatment of male pattern hair loss!

Theme: Side effects of drugs and the kidneys

A. Ace inhibitors

B. Atenolol

C. Bendroflumethiazide

D. Furosemide

E. Gentamicin

F. Ibuprofen

G. Methysergide

H. Penicillamine

I. Rifampicin

Please select the most likely drug responsible for the side effects as indicated. You may use each option once, more than once, or not at all.

372. Associated with red staining of the urine. Rifampicin

A common complaint of rifampicin is red staining of urine, as well as staining of sweat and tears.

373. Acute tubular necrosis. Gentamicin

Gentamicin is nephrotoxic, causing acute tubular necrosis. It is also associated with ototoxicity.

374. Urate stones. Bendrof lumethiazide

Bendroflumethiazide, a thiazide diuretic is associated with hypokalaemia, hyponatraemia, hyperglycaemia and hyperuricaemia. Thiazide diuretics may, however, be beneficial in calcium stone formation due to reduced urinary calcium in normocalcaemic patients.

375. Deteriorating renal function in renal artery stenosis. Ace inhibitors

Ace inhibitors should not be prescribed to patients with renal artery stenosis as deteriorating renal function is seen. Alternative blood pressure lowering agents should be used instead.

376. Ureteric obstruction with retroperitoneal fibrosis. Methysergide

Methysergide is well known to cause retroperitoneal fibrosis. Its pathology is unknown.

377. You are completing a cremation form 5 for a patient registered with a neighbouring practice. You examine the form and one of the doctors has completed the cause of death as stroke, but the patient appears to have fallen at home. The husband wants to arrange cremation as soon as possible. Apparently the doctor involved has gone home and will not be back for a few days, so you can't easily get hold of him to question him further. Which of the following is true with respect to completion of the form?

A. Completion of form 5 to show that examination of the case has been "adequate" would be acceptable

B. It is acceptable in this case not to question the doctor

C. Medical referees will not mind if you haven't contacted the doctor

D. When completing form 5 you must only be reasonably sure that the patient suffered a stroke

E. You should wait to complete the form until the doctor is available to answer questions

E is correct. Doctors are now instructed that form 5 should always be completed after questioning the doctor who completed form 4 except under exceptional circumstances, i.e. only if the doctor is seriously ill. Unavailability of the doctor is not an appropriate excuse, so quite clearly in this case you should wait to complete the form. The other major principle with respect to completion of form 5 is that you must be absolutely sure that the cause of death is correct. Ministry of Justice cremation guidelines 2009

378. A 23-year-old female attends clinic for a routine appointment regarding a six month history of occasional fits. She has seen the neurologists who have diagnosed idiopathic epilepsy and have prescribed lamotrigine. She informs you that she is doing well with this medication and has not had a fit for two months. She has been told that she must stop driving but you have seen that she drove to attend the clinic. You discuss this with her and insist that she stops driving to which she informs you that she had stopped driving but since she is fit free she must continue to drive because of her employment. Which of the following is the most appropriate action to take in these circumstances?

A. Inform patient that you will notify the DVLA

B. Inform patient that you will notify the police

C. Inform the epilepsy clinic that she is still driving and allow them to deal with this issue.

D. Your only action is to write in the notes that the patient has been repeatedly warned but chose to ignore advice as she presents no serious risk in view of her epilepsy control.

E. You cannot inform any external body due to patient confidentiality.

A is correct. The law is quite clear on such issues regarding epilepsy and the ability to drive. If the

diagnosis is confirmed the patient must stop driving and inform the DVLA regarding the diagnosis. If the patient continues to drive despite advice to the contrary then the doctor has a duty of care to society overriding confidentiality to the patient and may inform the DVLA.

Theme: Male infertility

A. Varicocele

B. History of Hodgkin's Lymphoma

C. Peripheral vascular disease

D. Multiple sclerosis

E. Auto-antibodies

F. Retrograde ejaculation

G. Beta blocker medication

H. Depression

For each case of male infertility choose the SINGLE most likely diagnosis from the list of options.

379. Normal sexual function but persistent azoospermic sample in a man who suffers from recurrent urinary tract infections. Retrograde ejaculation

380. Azo-spermia in a 58-year-old businessman 3 years after prostate surgery. Retrograde ejaculation

381. Oligospermia and scrotal swelling in a 24-year-old. Varicocele

382. Erectile failure in a smoker of 40 cigarettes per day. Peripheral vascular disease

383. Erectile dysfunction in a 44-year-old hypertensive. Beta blocker medication

Retrograde ejaculation leds to azoospermia and may follow lower urinary tract surgery or scarring.

Varicocoele can usually be detected by palpating a soft scrotal swelling. Peripheral vascular disease associated with buttock claudication and impotence (Leriche Syndrome) is commonest in heavy smokers.Drugs such as beta-blockers (and alcohol) may lead to erectile failure.

Theme: Testiclular pain

A. Epididymal cyst

B. Epididymitis

C. Hydrocoele

D. Lymphoma

E. Melanoma

F. Testicular cancer

G. Testicular torsion

H. Torted appendix testis

I. Ureteric colic

J. Varcicocoele

Select the most appropriate diagnosis for the following cases:

384. A 13-year-old boy presents with a 3 hour history of right testicular pain. Urinalysis does not reveal any abnormality. On clinical examination he is tender over the superior pole of the right testis and a black spot is visible through the scrotal skin. Torted appendix testis

The appendix testis may undergo torsion and mimic the presentation of testicular torsion. It usually presents in boys under the age of 16 but can occur in adults. There is acute testicular pain, confined to the upper pole of the testis. There may be a black spot visible through the scrotal skin which suggests this diagnosis. Where there is any doubt the testicle should be explored, if a firm diagnosis can be made the patient can be treated with rest and analgesia and the pain will subside in 5-7 days.

385. A 22-year-old man presents with a 2 day history of left testicular pain and swelling. Urinalysis reveals leucocytes, blood and nitrites. On examination he has a swollen erythematous scrotum, the testis is non tender, the epididymis is swollen and exquisitely tender. Epididymitis

Epididymitis usually occurs in young and middle aged men. There is often a history of lower urinary tract symptoms preceding the testicular pain, urinalysis may show pyuria / nitrites, the scrotal skin may be oedematous and red, there may be a secondary hydrocoele and careful examination of the affected side may reveal tenderness confined to a swollen epididymis.

386. A 21-year-old man presents with a 1 day history of severe right testicular pain and swelling. Urinalysis does not reveal any abnormality. On examination his scrotum is swollen and erythematous, his testis is high in the scrotum and exquisitely tender. Testicular torsion

Testicular torsion most commonly affects adolescent males presenting with severe testicular pain. The overlying skin may be red and oedematous as in epididymitis. The testis is high in the scrotum and the testis and cord cannot be identified a separate structures. Immediate exploration is indicated in all acute presentations with testicular pain where torsion cannot confidently be excluded.

387. An 82-year-old man visits you to discuss blood pressure management. He has been seen by the nurse some 3 times in the past 6 months and she has noted his BP to be above 160/95 each time he has visited. He has no significant past medical history apart from a hernia repair some 8 years previously. On examination today his BP is 155/92, pulse is 70 and regular, and he has a BMI of 27. Investigations:

Hb 12.3 g/dl (13.5 - 18) WCC 5.1 x 109/l (4 - 10) PLT 190 x 109/l (150 - 400)

Na 141 mmol/l (134 - 143) K 4.5 mmol/l (3.5 - 5.0) Cr 145 ]mol/l (60 - 120)

Which of the following is true with respect to blood pressure management in this man?

A. A higher target BP of 150/95 is permitted as he is above 70 years

B. Atenolol 50mg would be an appropriate first management step

C. Calcium channel antagonists are not recommended because of the risk of ankle swelling

D. If BP target isn't reached on 2 or more agents then addition of more drugs is of no value

E. Indapamide 2.5mg is an appropriate therapy choice

E is correct. Learning point: Patients should be treated to target, irrespective of age.

Guidelines recommend the same target BP of 140/90, irrespective of patient age. Studies show not unexpectedly that older patients get a greater absolute benefit from the same level of BP reduction versus younger counterparts with the same BP. The guidelines also suggest that calcium channel antagonists or diuretics are the most appropriate first line therapies to use. Indapamide is a thiazide diuretic, which is perhaps associated with less hyponatraemia compared to bendroflumethiazide, and as such is an appropriate choice for first line therapy in this patient. Even if the target BP isn't reached on 2 or more agents, it is of course important to continue therapy.

388. A 42-year-old male is currently being looked after in a care home after being diagnosed with Wernickes encephalopathy. He has had a long history of alcohol abuse. Which of the following vitamin deificiencies is responsible for Wernickes encephalopathy?

A. Nicotinamide

B. Thiamine

C. Vitamin C

D. Vitamin D

E. Vitamin K

B is correct. Wernickes encephalopathy is associated with haemorrhage into the areas of the brain called the mamillary bodies and this occurs in patients with Thiamine deficiency. It is a particular problem in patients chronically abusing alcohol as these subjects depend heavily on the alcohol for their calorific intake.

389. A 27-year-old female presents with a 3 hour history of vaginal bleeding, abdominal pain and right shoulder tip pain. Her past history includes pelvic inflammatory disease (PID), a miscarriage and two terminations. A urine pregnancy test is positive. From the following which is the most appropriate next step of management?

A. Admit as an emergency under the gynaecologists.

B. Prescribe analgesics and review in 24 hours.

C. Refer to a routine ante-natal clinic.

D. Treat for a possible sexually transmitted disease with clarithromycin and ciprofloxacin.

E. Take high vaginal swabs and review the patient in light of results in 48 hours.

A is correct. This history should alert you to a possible diagnosis of an ectopic pregnancy. Risk factors are the PID, previous terminations and the positive pregnancy test. This is a gynaecological emergency and requires emergency admission.

390. In normal puberty: True / False

A. Levels of luteinising hormone (LH) rise before follicle stimulating hormone (FSH) in girls)

B. Development of pubic hair is the first sign of puberty in girls

C. An increase in testicular size occurs before increased penile size in boys

D. Menarche over the age of 15 years occurs in 20% of girls

E. Menarche usually coincides with the peak of the height velocity curve seen during the puberty-associated growth spurt

C is correct. Levels of oestriol increase with advancing sexual menstruation along with levels of FSH. LH levels do not increase until secondary sexual characteristics are well developed. In girls the first sign of puberty is breast bud development. Testicular enlargement is the first sign of puberty in boys. Age range for menarche is 11.0 - 15.0 years. Less than 3% will have menarche after 15 years. Menarche is associated with the deceleration phase of the height velocity curve seen in puberty.

391. A 17-year-old man presented to casualty complaining of difficulty breathing. He had been brought to hospital by ambulance, having collapsed shortly after being stung on the hand by a bee. On examination, his blood pressure was 80/40 mmHg, and facial swelling was noted. Which one of the following investigations is most likely to confirm the nature of the reaction?

A. Haemolytic complement (CH50) level

B. Plasma tryptase activity

C. Serum complement C3 level

D. Serum total IgE level

E. Serum venom-specific IgE level

B is correct. Type I hypersensitivity, also known as immediate or anaphylactic hypersensitivity, usually takes 15 - 30 minutes from the time of exposure to the antigen. The reaction may cause a range of symptoms from minor inconvenience to death. The reaction involves preferential production of IgE, in response to certain antigens, which in turn initiates a sequence of events leading to the release various pharmacologically active substances that are responsible for the clinical features. Diagnostic tests include skin tests, measurement of total IgE and specific IgE antibodies against the suspected allergens. However, this question asks which of the following tests would provide confirmatory information and that would be Tryptase. Tryptase is a neutral protease stored in mast cell secretory granules that is secreted by human mast cells. Levels in normal blood are undetectable (< 1 ng/ml). Elevated serum levels demonstrate that mast cell activation with mediator release has occurred whether triggered by IgE-mediated anaphylaxis or non-IgE-mediated anaphylactoid reactions. The greater the severity of anaphylaxis, the more likely that serum -tryptase levels will be elevated.

392. A female patient of yours unfortunately goes into premature labour at 23 weeks; the fetus is not viable. She wishes to have the fetal remains cremated. Which of the following is true with respect to legal aspects of this case?

A. Cremation of the remains is not subject to the Cremation Act

B. Only a pathologist is allowed to complete form 4

C. Only form 4 need be completed

D. Only form 5 need be completed

E. The case must be discussed with the coroner

A is correct. Cremation of fetal remains under 24 weeks is not subject to the Cremation Act. As such forms 4 and 5 should not be completed. In spite of this, most crematoria are happy to make arrangements to cremate fetal remains. Where body parts are removed at post mortem, arrangements for cremation of these are normally made by the pathology service. Ministry of Justice cremation guidelines 2009

Theme: Treatment for diabetes

A. Acarbose

B. Diet and exercise

C. Glibenclamide

D. Insulin

E. Metformin

F. Rosiglitazone

Select the most appropriate treatment for the following patients with diabetes:

393. A 54-year-old male is newly diagnosed with diabetes mellitus. He has a BMI of 32.3 kg/m2 and a blood pressure of 145/85 mmHg. Fundal examination reveals two Microaneurysms in each eye. His fasting glucose is 8.3 mmol/l and he has a HbA1c of 8.2% Diet and exercise

394. A 72-year-old man presents with weight loss, thirst and polyuria. On examination he has a BMI of 21.3 Kg/m2, a blood pressure of 122/74 mmHg and examination is otherwise normal. His fasting plasma glucose is 25.5 mmol/l and his HbA1c is 10%. Insulin

Initially 3 months of diet and exercise would be appropriate for this obese newly diagnosed Type 2 patient prior to the introduction of any oral hypoglycaemic agent. If this measure fails to improve glycaemic control then probably metformin would be the best choice. This elderly man presents with Type 1 diabetes as reflected by the osmotic symptoms of weight loss, thirst and polyuria. No amount of diet and exercise would control his plasma glucose which is excessive and so insulin would be the most appropriate therapy. Ref:NICE (May 2008). Type 2 diabetes The management of Type 2 diabetes.

395. Fine basal lung crackles are characteristic of which one of the following:

A. Bronchiectasis

B. Cystic fibrosis

C. Fibrosing alveolitis

D. Lobar pneumonia

E. Lung abcess

F. Pneumocystis carinii pneumonia

C is correct. Bronchiectasis is the outcome of cystic fibrosis and crackles are usually medium to coarse in A and B. In lobar pneumonia before full consolidation, crackles are medium in type. Lung abcess can occur in any lobe and the crackles are again medium to coarse. Pneumocystis often presents with just tachypnoea and lung signs are rare. Any cause of pulmonary fibrosis can give fine crackles at the bases, but is particularly seen in cryptogenic fibrosing alveolitis and is described as a "shower" of crackles. Oxford Textbook of Medicine (Respiratory Diseases)


1 comment:

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