1
Q
A 32-year-old male attends the Emergency department complaining of severe chest pain of one hour.
On examination he is 6’4” tall and of slim build.
His blood pressure is 135/80 mmHg and he has an early diastolic murmur.
Electrocardiogram shows 1 mm ST elevation in II, III, and aVF.
What is the likely diagnosis?
What is the most appropriate action?
A
In a suspected presentation of an atypical (an inferior) myocardial infarction and a diagnosis of aortic artery dissection must be excluded.
These features are consistent with Marfan’s syndrome and aortic dissection.
2
Q
What is the rule of nines?
A
The ‘rule of nines’ is used to approximate the body surface area (BSA) burnt.
For adults
- The head is 9%
- Upper limbs 9% each
- Lower limbs 18% each
- Trunk 18% front
- Back 18% back and finally
- The perineum 1%.
3
Q
What is the half-life of carboxyhemoglobin?
What is the half-life of carboxyhemoglobin on 100% oxygen?
A
The half-life of carboxyhemoglobin is four hours but this falls to 30 minutes when breathing 100% oxygen.
4
Q
What is the mount Vernon formula?
A
The Mount Vernon formula uses colloid at 0.5 ml per Kg x %BSA of burn every four hours for the first 12 hours following injury, then every six hours for the next 12 hours.
5
Q
At what point are IV fluids required in burn victims?
A
- Adults can compensate with oral fluids for up to a 15% burn
- but children can only compensate for a burn <10%.
6
Q
A 27-year-old asthmatic who has been unwell for 24 hours with a productive cough, fever and episodic wheeze.
He initially managed it at home with his regular salbutamol inhaler but was having worsening shortness of breath so presented to the hospital.
Your colleague has clerked him and thus far prescribed four sets of back to back salbutamol nebulisers, one set of ipratropium nebulisers and intravenous hydrocortisone.
The patient is now tiring and speaking in words only, with a silent chest.
His respiratory rate is climbing and his saturations are 90% on 10 litres of oxygen.
What therapeutic intervention should be given next?
A
Magnesium sulphate 2 g
Oxygen
- if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
- if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.
Bronchodilation with short-acting beta₂-agonists (SABA)
- high-dose inhaled SABA e.g. salbutamol, terbutaline
- in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
- in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended
Corticosteroid
- all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
- during this time, patients should continue their normal medication routine including inhaled corticosteroids.
ipratropium bromide
- in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist
IV magnesium sulphate
- the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma
IV aminophylline
- may be considered following consultation with senior medical staff
7
Q
Management stages of acute asthma attack in ER
(6)
A
Oxygen
- if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
- if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.
Bronchodilation with short-acting beta₂-agonists (SABA)
- high-dose inhaled SABA e.g. salbutamol, terbutaline
- in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
- in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended
Corticosteroid
- all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
- during this time, patients should continue their normal medication routine including inhaled corticosteroids.
ipratropium bromide
- in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist
IV magnesium sulphate
- the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma
IV aminophylline
- may be considered following consultation with senior medical staff
8
Q
Mechanism of action of ipratropium
A
Ipratropium exhibits broncholytic action by reducing cholinergic influence on the bronchial musculature.
It blocks muscarinic acetylcholine receptors, without specificity for subtypes, and therefore promotes the degradation of cyclic guanosine monophosphate (cGMP), resulting in a decreased intracellular concentration of cGMP.
Most likely due to actions of cGMP on intracellular calcium, this results in decreased contractility of smooth muscle in the lung, inhibiting bronchoconstriction and mucus secretion. It is a nonselective muscarinic antagonist,
9
Q
A 54-year-old female is admitted after suddenly collapsing in the street whilst out shopping with her friend. On examination she appears drowsy, has a pulse of 110 beats per minute and a temperature of 37.1°C.
She has nuchal rigidity which elicits a moan.
There is no eye opening to pressure over the sternum, but pressure over the nail bed elicits this withdrawal of the limb.
She is generally hyper-reflexic with bilateral extensor plantar responses.
What is her GCS?
What diagnosis do you suspect?
A
The 54-year-old female who collapses in the street sounds as if she may have had a subarachnoid haemorrhage.
Her GCS is E1, V2, M4 = 7.
10
Q
A 19-year-old female is brought to the Emergency department following a car accident.
On examination she has a head wound, has a pulse of 110 beats per minute, smells of alcohol, is confused.
She shouts for her boyfriend while thrashing around on the couch and only partially co-operates with examination.
Her eyes are fully open, pupils appear slightly dilated and reflexes appear brisk with down going plantar responses.
Calculate her GCS
A
E4
V4 (as confused)
M6 (obeys commands) = 14
11
Q
An 80-year-old male is admitted after being found collapsed at home.
No history is obtainable.
On examination he has a pulse of 45 beats per minute, a temperature of 34°C, no eye opening to pressure over the eyebrows and he makes no audible sounds.
No movements can be elicited and he has generally brisk reflexes with bilateral extensor plantar responses.
What is his GCS?
A
The 80-year-old male with what sounds like raised intracranial pressure has E1, V1, M1 = 3, suggesting a grave prognosis.
12
Q
Which virus is associated with hepatocellular carcinoma?
A
Approximately 2% of those with cirrhosis from hepatitis C develop hepatocellular carcinoma.
13
Q
A 10-year-old boy attends the Emergency department with a scalp laceration he sustained playing football.
Examination confirms a superficial clean incised wound approximately 2 cm in length.
Which would be the best way of managing this wound?
A
Tissue adhesive glue is very useful for scalp wounds particularly in children.
Wounds must be clean and less than about 3 cm in length. Glue should not be used to close wounds around the eyes or over joints.
14
Q
A 58-year-old dairy farmer attends the Emergency department following a fall at work. He slipped in the cowshed cutting his leg on some metal fencing.
On examination he has a severely contaminated deep wound on the lateral aspect of his thigh.
After completing the examination and obtaining an x ray to exclude a foreign body you would like to clean the wound.
Which cleaning agent is the best to use?
A
- Sterile 0.9% saline
- Hydrogen peroxide is generally not recommended and carries a risk of oxygen embolism.
15
Q
On examination he has abdominal swelling, guarding and numerous audible bowel sounds.
What is the diagnosis?
A
Sigmoid volvulus
16
Q
A 3-year-old boy is brought to the Emergency department with onset of stridor in the last few hours.
Over the past three days he has been unwell with coryzal symptoms and ear temperature of 38.2°C.
What is the diagnosis?
What is the infective agent?
A
Croup may be caused by different viruses although most commonly as a result of infection with parainfluenza.
Typically it occurs in young children a few days after a coryzal illness with symptoms of a barking cough, a low grade fever and an inspiratory stridor.
Symptoms are worse at night.
17
Q
A 9-month-old boy is referred to ENT as he has been noted to have stridor.
He sometimes chokes when drinking or feeding.
His head circumference has risen from the 50% at birth to the 98% and he has short limbs.
What is the diagnosis?
A
This child has achondroplasia, which is often associated with hydrocephalus (Arnold-Chiari malformation).
This in turn can be associated with vocal cord palsy.
18
Q
A 22-year-old male is admitted wheezing with a respiratory rate of 35/min, a pulse of 120 beats per min, blood pressure 110/70 mmHg, peak expiratory flow rate <50% predicted.
He has been given back-to-back nebulisers of salbutamol 5 mg and ipratroprium 0.5 mg for the last 45minutes and is on face mask oxygen. He has been given hydrocortisone 100 mg IV.
The intensive care team are aware of the patient.
What is the next stage in this patient’s treatment?
A
- oxygen
- Salbutamol
- steroids
- ipratropium
- magnesium sulphate
- amenophyleline
19
Q
Which criteria must be met for asthma to be life threatening?
(6)
A
- PEFR < 33% best or predicted
- Oxygen sats < 92%
- ‘Normal’ pC02 (4.6-6.0 kPa)
- Silent chest, cyanosis or feeble respiratory effort
- Bradycardia, dysrhythmia or hypotension
- Exhaustion, confusion or coma
20
Q
A 62-year-old male presented with an eight hour history of double vision.
He has generally been well but has a history of hypertension for which he takes amlodipine and atenolol.
He also has a four year history of diet controlled type 2 diabetes.
On examination he has some watering of the right eye, there is a slight droop of the eyelid and the eye is displaced to the right.
Pupil size is the same as on the left and the left eye appears to have a full range of movements.
What is the likely cause of his symptoms?
Which cranial nerve is being affected?
A
Diabetes
- third nerve palsy
- This man has a painless partial third nerve palsy which affects his eye but there is pupil sparing.
- The most likely cause is diabetes mononeuropathy and is thought to be due to a microangiopathy with occlusion of the vasa nervorum.
- Aneurysm of the posterior communicating artery is associated with an often painful third nerve palsy with pupillary dilatation being typical.
21
Q
Features of toxicity to lithium
(6)
A
Features of toxicity
- coarse tremor (a fine tremor is seen in therapeutic levels)
- hyperreflexia
- acute confusion
- polyuria
- seizure
- coma
22
Q
A 56-year-old fit and well man presented to the hand trauma clinic with a one week history of pain and swelling to his right ring finger. He recalls lifting a garden pot and feeling a sudden pain in his finger.
A photograph of his hand is shown below; radiographs were normal.
What is the deformity and what is the diagnosis?
A
Boutonniere deformity due to central slip rupture
23
Q
Which anti-depressant class overdose presents with prolonged QRS complex?
A
Prolonged QRS complex is consistent with TCA overdose.
24
Q
On examination she has a temperature of 39°C, has neck stiffness and is drowsy.
What is the most likely diagnosis?
A
The patient’s symptoms are important here in establishing the diagnosis as she has a temperature and signs of meningeal irritation suggesting infection.
The CT head scan shows a frontal space occupying lesion with rim enhancement suggesting tumour/metastasis or abscess.
Thus with her presentation the likely diagnosis is abscess.
25
**Which abnormals result of CSF analysis would confirm bacterial meningitis?**
**(4)**
Raised neutrophil count
raised WBC
turbid appearance
Gram stain
26
During lumbar puncture, the needle can be inserted between which two vertebrae?
(3)
L4 & L5
L3 & L4
L5 & S1
27
What are the most important **contraindications** to performing a lumbar puncture?
(4)
1. Increased intracranial pressure
2. bleeding diathesis
3. cardiorespiratory compromise
4. infection at site of needle insertion
28
List four specific complications of a lumbar puncture.
(4)
Post-LP/post-spinal tap headache
nerve root trauma
CSF infection
intraspinal haematoma
"coning" (herniation)
29
A 24-year-old man with a past medical history of asthma is admitted to hospital with a left lower lobe pneumonia. He is treated with amoxicillin.
Within two minutes of the antibiotic being administered, the patient complains of feeling unwell. There is a rapidly developing, erythematous, macular rash over his trunk and limbs and there are large wheals on his torso. He is noted to have lip and tongue swelling. Harsh wheeze is heard on auscultating the chest.
Observations show a blood pressure of 84/39 mmHg and a heart rate of 167 bpm, shown to be a sinus tachycardia when connected to cardiac monitoring. Oxygen saturations are 90% on air so he is put onto high flow oxygen.
**Which drug would be the next most appropriate to administer?**
Adrenaline 1:1000 0.5 ml (500 mcg equivalent) intramuscular
30
A 62-year-old man presents to the rural medical clinic in India with a non-healing wound on the volar aspect of the right arm four weeks after incision and drainage of an abscess.
He now has restricted movement of the right arm and shoulder.
**What is the diagnosis?**
Upper limb ischaemia is rare, and age, alone, is not a risk factor in wound healing.
## Footnote
**This patient has chronic tuberculous osteomyelitis**
31
A 2-year-old boy is seen in the Emergency department 30 minutes after ingesting 150 ml of amitriptyline syrup.
He is fully conscious.
**Which clinical signs might you anticipate? (5)**
**How would this child be managed? (3)**
**Which clinical signs might you anticipate?**
* Pupil constriction
* Coma
* Myoclonic twitches
* Choreoathetosis, and
* Pyramidal tract signs
**How would this child be managed?**
* ABC resuscitation as necessary
* Gastric lavage followed by activated charcoal in severe poisoning, and
* Treatment of the arrhythmias and seizures as necessary.
32
A 72-year-old woman is admitted unconscious with a core temperature of 35.6°C. She has a heart rate of 42 beats per minute and slowly relaxing reflexes.
Which test should be ordered?
TFT
## Footnote
Drowsiness, bradycardia and slowly relaxing reflexes would suggest the diagnosis of hypothyroid coma.
Urgent thyroid function tests will confirm the diagnosis.
33
A healthy female is scheduled for laparoscopic sterilization.
## Footnote
**Suitable muscle relaxation will be provided by which drug? (1)**
**Which alternatives wouldn't be used? (2)**
Muscle relaxation is required during the creation of a pneumoperitoneum, which provides a clear view and access to the fallopian tubes.
The anticipated duration of surgery is 20 to 30 minutes, thus **atracurium** is the best choice.
**Suxamethonium** is too short acting and pancuronium lasts too long.
34
A 21-year-old-male presents for dental extractions under general anaesthesia.
He has epilepsy but has been seizure free for nine months on his current medication.
**Select an appropriate intravenous induction agent.**
**Which agents would be contra-indiciated?**
**Thiopentone is a barbiturate and has anticonvulsant properties thus it the correct answer.**
Diazepam is an anticonvulsant but it is not used to induce anaesthesia.
**Propofol** and **etomidate** have both been known to cause movement resembling convulsions thus are best avoided.
35
A young male is due to have a large lipoma excised from his forearm.
## Footnote
**Which agent would be a suitable intravenous induction agent to allow placement of an LMA?**
Propofol is the best induction agent when planning to use an LMA.
It inhibits the pharyngeal and laryngeal reflexes faster than thiopentone or etomidate, providing optimal conditions for inserting the device.
36
A 64-year-old male presents for a cystoscopy.
A hiatus hernia was diagnosed six months ago.
His current medication is Gaviscon and he has been nil by mouth since midnight.
Select a suitable muscle relaxant to allow placement of the endotracheal tube.
Patients with a hiatus hernia must have their airway protected as quickly as possible following induction of anaesthesia.
Failure to protect the airway with a cuffed endotracheal tube may lead to soiling of the trachea from regurgitation of residual gastric fluid.
Thus a rapid sequence induction should be considered.
**Suxamethonium is the correct choice as it provides optimum intubating conditions in 30 to 45 seconds.**
37
24-year-old female non-smoker; pleuritic chest pain and hemoptysis; a normal chest radiograph
## Footnote
**What is the next investigation?**
CTPA
These clinical features suggest pulmonary embolism and CTPA is regarded as the best test to diagnose this condition.
38
4-day-old male; convulsions and bulging fontanelles
## Footnote
**What is the most appropriate next investigation?**
Transcranial ultrasound is an useful tool in the assessment of brain injury in the newborn.
39
65-year-old male hypertensive; acute central chest pain; a widened superior mediastinum on his chest radiograph
## Footnote
**What is the next most appropriate investigation?**
The presumed diagnosis here must be aortic dissection, and this will be revealed using a CT of the thorax and aorta.
In the past, aortic arch angiography was considered the optimal diagnostic tool but this has been superseded by imaging with CT or MRI.
40
22-year-old female, unable to conceive; history of pelvic inflammatory disease
## Footnote
**What is the most appropriate next investiation?**
The hysterosalpingogram will investigate the anatomy of the uterus and fallopian tubes. Pelvic inflammatory disease is associated with infertility, due to scarring in the fallopian tubes secondary to salpingitis.
41
A 68-year-old man is referred with a four month history of back pain.
On examination of his abdomen an epigastric pulsatile mass is palpable.
A CT scan is performed as shown.
**What does the CT scan show? (3)**
**List two indications for surgical intervention. (3)**
**Name three potentially treatable risk factors for this condition. (3)**
**What does the CT scan show?**
* Abdominal aortic aneurysm (2 marks)
* Aortic aneurysm (1 mark)
* NOT dissection
**List two indications for surgical intervention.**
* Aneurysm \>5.5 cm in diameter
* Dissection/rupture
**Name three potentially treatable risk factors for this condition.**
* Hypertension
* Smoking
* Atherosclerosis
42
You are the foundation year doctor in general surgery and have been asked to review a patient who has acutely become unresponsive at 4 am. She is a 40-year-old female who has been an elective admission for a cholecystectomy and is due surgery at 8 am.
On examination the patient looks sweaty and clammy and is hypoventilating. She is responsive only to a painful stimulus.
Her observations are: HR115, BP 110/70 mmHg, RR 8 O2 99%, BM 1.1.
**What is drug therapy would you next initiate?**
Dextrose 20% 100 ml IV
**Hypoglycaemia is defined as a blood sugar \<3.0 and Whipple's triad states the diagnosis should be made with:**
* Evidence of plasma hypoglycaemia
* Associated symptomology, and
* Resolution of sequalae with correction of the hypoglycaemia.
43
A 34-year-old man presents with a frank haematemesis.
## Footnote
**List clinical signs that may be associated with a poor prognosis in this patient. (4)**
**What investigation is urgently required?**
**List possible diagnoses.**
**List clinical signs that may be associated with a poor prognosis in this patient.**
* Hypotension
* Tachycardia
* Signs of chronic liver disease
* Further haematemesis.
**What investigation is urgently required?**
* OGD
* Oesophagogastroduodenoscopy
**List possible diagnoses.**
* Gastric/ duodenal/ peptic ulcer
* NSAID-induced
* Oesophageal/ gastric varices
* Mallory-Weiss tear/ syndrome/ oesophageal tear
* Reflux oesophagitis
* Gastric erosions
* Gastric carcinoma.
44
A 50-year-old man has an appointment for a routine blood pressure check. He is sitting in the waiting room when he becomes very breathless with stridor.
He had mentioned to another person in the room that he had been stung by an insect on his way to the clinic. You diagnose an anaphylactic reaction to the sting.
**What dose and route of administration would you use for adrenaline in this situation?**
Intramuscular 1:1000 (500 micrograms
45
You are asked to assess a 56-year-old woman in the emergency department using the Glasgow coma scale.
When you pinch the patient's arm she opens her eyes and withdraws the limb by normal flexion. She does not open her eyes to any stimulus other than pain and she is unable to speak or provide any verbal response.
**List the patient’s scores for eye opening, best motor response and verbal response.**
**What is the patient’s total score?**
**Using the Glasgow coma sale definition, is the patient in a coma?**
**List the patient’s scores for eye opening, best motor response and verbal response.**
E2V1M4
**What is the patient’s total score?**
7
**Using the Glasgow coma sale definition, is the patient in a coma?**
Yes
46
A 76-year-old lady attends the Emergency department after knocking her shin on some furniture at home. She takes prednisolone for polymyalgia rheumatica.
You examine her leg and find a pre-tibial laceration with a large skin flap.
**What is the best way to manage this?**
**Clean then steristrip the laceration**
* In young patients with good skin, pre-tibial lacerations may be sutured, usually with non-absorbable sutures that are removed after seven to 10 days.
* In elderly patients with thin skin, or those on warfarin or steroids the skin is frequently too fragile to suture.
47
A 49-year-old female is referred to the medical team after collapsing at home.
She has had two episodes of haematemesis in the emergency department but without any melaena.
There is no history of alcohol excess from the family and she has otherwise been reasonably well.
On examination, she is pale, sweaty, has a pulse of 110 bpm and a lying blood pressure of 95/60 mmHg falling by 30 mmHg systolic on standing.
A note is also made of palmar erythema, purpura and spider naevi.
There is no hepatomegaly, but fullness is noted in the left hypochondrium.
**What is the appropriate action for this patient?**
**What is the likely diagnosis?**
**What is the appropriate action for this patient?**
endoscopy
**What is the likely diagnosis?**
This patient has evidence of upper gastrointestinal bleeding with significant haemodynamic compromise suggested by her hypotension and postural drop.
The likely cause is due to variceal bleeding as there is evidence of chronic liver disease and portal hypertension.
This is an indication for urgent endoscopy as over half of patients will have a variceal bleed which will need intervention (banding/sclerotherapy) and it is associated with a high mortality.
The aetiology of the portal hypertension here is unknown and therefore there is no need for vitamins unless alcohol excess were suspected.
48
Are the following true or false of a 2½-year-old boy who is rushed into the Emergency department having ingested 30 of his mother's iron tablets?
## Footnote
**Which organ will be most affected?**
**Which drug treatment should he be given?**
**Which treatment is contra-indicated?**
**Which organ will be most affected?**
* Severe hepatic necrosis results in jaundice, deranged liver function and clotting abnormalities.
* Perforation of the bowel is expected.
* Severe hypotension may occur.
**Which drug treatment should he be given?**
* desferrioxamine
**Which treatment is contra-indicated?**
* lavage
49
Which EEG pattern is seen in a patient with hepatic encephalopathy?
Delta waves
50
A 65-year-old with a ten year history of constipation and of left-sided lower abdominal pain which is partially releived by defecation. Her weight is steady and she has normal micturition, She has had no periods for 15 years.
## Footnote
**What is the most likely diagnosis?**
In a patient of this age, diverticular disease is common and would present in this fashion. The fact that weight loss is not present suggests that malignancy is not present.
51
A 24-year-old woman presents with a four month history of right-sided lower abdominal pain, watery diarrhoea and a loss of weight of 6 kg. Her periods are regular taking the oral contraceptive pill.
What is the most likely diagnosis?
The most likely answer in this case is chronic inflammatory bowel disease given the weight loss, abdominal pain and diarrhoea. Addison's disease would present insidiously, and typically without bowel symptoms.
52
List two accessory, or groups of muscles, of respiration. (4)
List organisms typically responsible for community acquired pneumonia. (4)
The patient is intubated and has assisted ventilation. Name one possible complication that may arise from this. (6)
**List two accessory, or groups of muscles, of respiration.**
* Sternocleidomastoid
* platysma
* strap muscles of neck
* abdominal muscles
**List organisms typically responsible for community acquired pneumonia.**
* Pneumococcus/Strep pneumoniae
* Haemophilus influenza
* Mycoplasma
* Legionella
**The patient is intubated and has assisted ventilation. Name one possible complication that may arise from this.**
* barotrauma,
* lung overdistention,
* alveolar rupture,
* pneumothorax,
* surgical emphysema,
* reduced cardiac output.
53
A 26-year-old teacher attends the Emergency department complaining of a sudden onset of severe headache six hours previously.
She reports associated nausea and has vomited three times.
On examination she is afebrile with a GCS of 15 and there is neck stiffness and photophobia.
What is the most likey diagnosis?
Subarachnoid haemorrhage
## Footnote
The differential diagnosis includes bacterial meningitis, although other features of sepsis such as pyrexia would be expected.
54
Mangement of aspirin overdose
| (4)
1. gastric lavage
2. sodium bicarbonate
3. vitamin k supplementation
4. encourage fluid intake
55
The features of Ecstasy overdose include: (4)
* Hyperthermia
* Hypertension
* **Hyponatraemia** due to polydipsia associated with syndrome of inappropriate antidiuretic hormone (SIADH) and
* Respiratory alkalosis.
56
A 56-year-old female presents with a five day history of fever, cough and malaise.
She returned from a holiday in southern Spain one week ago and has since developed a non-productive cough with chills which have deteriorated.
She has no previous medical history but is a smoker of 10 cigarettes per day.
Examination reveals a temperature of 40°C, with a blood pressure of 118/72 mmHg with a pulse of 106 bpm.
Chest examination reveals some inspiratory crackles at the left base only, with a respiratory rate of 28/min. She has oxygen saturations of 94% on air.
Baseline investigations reveal:
**What is the most likely diagnosis?**
**What is the causative organism?**
**What is the treatment?**
This history together with symptoms suggest a community-acquired pneumonia.
The investigations show a relatively normal white cell count, despite the obvious infection and would therefore suggest an atypical pneumonia.
**The travel to Spain and the hyponatraemia would suggest a diagnosis of Legionnaire's disease.**
This is due to infection with the organism Legionella pneumophila.
**The disease is spread through infected water supplies, usually air conditioning systems.**
It is most readily diagnosed through the detection of urinary antigen prior to any rise in serum antibody titres.
The organism is sensitive to macrolides and ciprofloxacin.
57
A 60-year-old man presents with an episode of memory loss.
Three days earlier he had become confused.
His wife led him into the house where he apparently sat down at her request and had a cup of tea.
He then wandered around the house confused, but remained conscious and able to have some conversation with his wife, though continuing to ask similar questions repeatedly.
After three hours, he abruptly returned to normal and had no recollection of the events.
**What is the most likely diagnosis?**
**Transient global amnesia** lasts less than 24 hours and normal cognition and an awareness of personal identity is retained
58
A 16-year-old African male presents with a two day old penetrating wound to his calf. His main complaint is pain. Pulse and blood pressure are normal and a full blood count reveals a haemoglobin of 85 g/L. He is booked for exploration and debridement of the wound.
Which investigation should be performed?
* haemoglobin electrophoeresis
* This needs to be investigated as a sickling crisis can be precipitated by surgery.
59
A 59-year-old previously healthy male, presented 12 hours ago with bowel obstruction and has become increasingly confused. He is receiving oxygen by mask. The pulse oximeter reads 100%, pulse is 110/min and blood pressure 135/85 mmHg. Intravenous fluid resuscitation is with 5% dextrose, infusing at a rate of 150 ml/hour.
What is the next appropriate investigation?
This patient's confusion in the context of his obstruction suggests marked dehydration with sepsis and probable renal impairment.
* U&E
60
A 28-year-old Zimbabwean man presents with severe constant abdominal pain. He has not opened his bowels for three days and is not passing flatus. He has had two previous similar episodes but has never seen a doctor before. The pain is now much worse.
On examination, he is pale and sweaty. He is dehydrated, his pulse is 100 beats per minute, blood pressure 100/70 mmHg and temperature is 38°C. The abdomen is distended and diffusely tender.
You begin to resuscitate the patient and arrange an urgent supine abdominal x ray.
There is small and large bowel distension on this x ray but the appearance is of the classic 'coffee bean' of sigmoid volvulus.
Sigmoid volvulus as a cause of large bowel obstruction is not uncommon in sub-Saharan Africa and if not decompressed urgently, may result in ischaemia and perforation of the colon.
This patient has constant, severe pain and is likely to have ischaemia resulting in peritonitis.
He needs resuscitation, urgent laparotomy, and sigmoid colectomy.
61
A 33-year-old female presents with acute dyspnoea and left sided chest pain.
She has just returned from a trip to Spain with her friends. There is no medical history of note and she takes the oral contraceptive pill.
On examination, she has a pulse of 100 bpm, a temperature of 37°C, oxygen saturations are 95%, she has a respiratory rate of 28/min, a blood pressure of 116/76 mmHg but there are no abnormalities on chest examination.
Chest x ray is clear.
Which investigation is most likely to confirm the diagnosis?
CTPA
62
A 55-year-old male has a history of paroxysmal atrial fibrillation.
Despite treatment with digoxin and bisoprolol, he continues to experience episodes of uncontrolled tachycardia precipitating acute left ventricular dysfunction. He has therefore been commenced on amiodarone.
**Which investigation is mandatory before starting amiodarone?**
**Amiodarone can cause disorders of thyroid function, both hypothyroidism and hyperthyroidism.**
* **TFT**
Thyroxine (T4) can be elevated in the absence of hyperthyroidism due to inhibition of the conversion of T4 to triiodothyronine (T3); therefore thyroid-stimulating hormone (TSH) and T3 should always be tested.
* Amiodarone can be hepatotoxic therefore treatment should be discontinued if evidence of liver dysfunction develops.
63
Neuroleptic malignant syndrome
What is the tetrad? (4)
What is the typical cause?
What is the treatment?
A potentially life-threatening complication of treatment with antipsychotic drugs, or abrupt withdrawal of dopamine agonists.
**Characterised by a tetrad of**
* altered mental status
* muscle rigidity
* autonomic instability
* hyperthermia
A diagnosis of exclusion. Common differential diagnoses are sepsis and drug reactions.
**NMS is a medical emergency. Treatment consists of immediate cessation of the offending medication and provision of supportive measures (hydration and cooling).**
A delay of at least 2 weeks in restarting **antipsychotic** treatment is advised following full resolution of an NMS episode.
64
Organophosphate poinsoning
## Footnote
**What is the pathophysiology? (1)**
**What are the features? (5)**
**What is the mangement? (3)**
**What is the pathophysiology?**
Organophosphates (and 'nerve gas' chemical weapons) bind to cholinesterase thereby preventing the breakdown of acetylcholine at synapses.
**What are the features?**
* vomiting
* muscle fasciculation
* paralysis
* diarrhoea
* convulsions
**What is the management?**
* Treatment consists of atropine to antagonise the cholinergic effects,
* and oxime (pralidoxime) to limit the inhibition of cholinesterase
* and diazepam to prevent fits.
65
**_Hepatitis B questions_**
* **A 25-year-old woman with confirmed chronic hepatitis B is planning to become pregnant next year. What is the best treatment option?**
* **A previously fit and well 31-year-old man is incidentally diagnosed with cytomegalovirus. What is the most appropriate treatment?**
* **A 56-year-old man receiving chemotherapy for diffuse large B cell lymphoma has intranuclear 'owl's eye' inclusion bodies on histological tissue. What treatment should he be offered?**
* **A 62-year-old woman who is currently being treated for hepatitis B complains of regular falls as she cannot feel her feet on the floor properly. What medication might she be receiving?**
* **A 32-year-old woman is admitted with acute renal failure. She is HBV positive and recently started a new treatment as her virus was found to be lamivudine-resistant. What is the most appropriate treatment?**
**_Hepatitis B questions_**
**A 25-year-old woman with confirmed chronic hepatitis B is planning to become pregnant next year. What is the best treatment option?**
* **Interferon** is the most appropriate choice if the patient is young, uncomplicated and/or planning pregnancy.
**A previously fit and well 31-year-old man is incidentally diagnosed with cytomegalovirus. What is the most appropriate treatment?**
* This man is young and well. Unlike CMV in the immunocompromised, a previously fit and well patient with an incidental finding of CMV should be advised to **rest only.**
**A 56-year-old man receiving chemotherapy for diffuse large B cell lymphoma has intranuclear 'owl's eye' inclusion bodies on histological tissue. What treatment should he be offered?**
* 'Owl's eye' appearance on inclusion bodies is highly specific for cytomegalovirus (CMV). CMV is more likely to be found in immunocompromised patients, for example, receiving chemotherapy or HIV positive. **Ganciclovir** is the most appropriate treatment for CMV in such patients. NB. Owl's eye appearance of the entire nucleus (also known as Reed-Sternberg cells) is found in patients with Hodgkin's lymphoma.
**A 62-year-old woman who is currently being treated for hepatitis B complains of regular falls as she cannot feel her feet on the floor properly. What medication might she be receiving?**
* A common side effect of **telbivudine** is peripheral neuropathy.
**A 32-year-old woman is admitted with acute renal failure. She is HBV positive and recently started a new treatment as her virus was found to be lamivudine-resistant. What is the most appropriate treatment?**
* Adefovir is the best alternative treatment for a patient with chronic hepatitis B resistant to lamivudine. **Adefovir** is associated with nephrotoxicity.
66
A 77-year-old man presents with his fourth episode of acute rectal bleeding.
The blood is a mixture of fresh blood and clots.
On this occasion the bleeding has been severe enough to require a 4 unit blood transfusion.
A barium enema is undertaken and is normal.
The differential diagnosis is diverticular disease or angiodysplasia.
Both can produce a significant gastrointestinal blood loss which is painless.
In contrast a sigmoid carcinoma would not usually bleed enough to require a transfusion but would be associated with chronic blood loss causing anaemia.
Angiodysplasia is only diagnosed by colonoscopy. Diverticulae would be seen on a barium enema.
67
What does each herpes virus cause?
## Footnote
**Human herpes virus 1**
**Human herpes virus 2**
**Human herpes virus 3**
**Human herpes virus 4**
**Human herpes virus 5**
**Human herpes virus 6**
**Human herpes virus 7**
**Human herpes virus 8**
**Human herpes virus 1**
* the cause of cold sores around the mouth
**Human herpes virus 2**
* causes genital herpes
**Human herpes virus 3**
* causes chickenpox
**Human herpes virus 4**
* Human herpes virus 4 (HHV4) is also known as the Epstein-Barr virus. It is the major cause of infectious mononucleosis, or "mono" - the "kissing disease."
**Human herpes virus 5**
* Human herpes virus 5 (HHV5) is the official name of cytomegalovirus (CMV)
**Human herpes virus 6**
* It causes roseola (a viral disease causing high fever and a skin rash in small children)
**Human herpes virus 7**
* It causes roseola (a viral disease causing high fever and a skin rash in small children)
**Human herpes virus 8**
* Human herpes virus 8 (HHV8) was recently discovered in the tumours called Kaposi's Sarcoma (KS). These tumours are found in people with AIDS and are otherwise very rare
68
A 33-year-old male injures his hand whilst playing rugby. He attends the Emergency department but leaves after waiting two hours without obtaining medical advice. He represents three months later with pain at the base of the thumb and painful movements of the thumb.
## Footnote
**What is the likely diagnosis?**
The patient has fractured his scaphoid and has developed avascular necrosis of the scaphoid.
69
A 40-year-old male receives a compound fracture of his left tibia after falling from a ladder. He undergoes internal fixation.
However, several months after discharge from hospital, the patient is aware of a breakdown of skin overlying the tibia and a persistent discharge.
What is the likely diagnosis?
Osteomyelitis
## Footnote
This case has a discharging sinus months after a compound fracture. This would suggest an underlying osteomyelitis.
70
"A picornavirus with a single stranded RNA genome.
Transmission is usually faecal-oral and there are no chronic sequelae from this virus."
**Which virus is this?**
**Hepatitis A** is a picornavirus and is responsible for about 40% of hepatitis worldwide.
It is the only hepatitis virus to have a single stranded RNA genome
71
**What is the name given to this physical sign?**
**What is the most likely diagnosis?**
**Name four initial investigations that you would request?**
**List one long term complication of this condition.**
**What is the name given to this physical sign?**
* Cullen's sign
* Ecchymoses
**What is the most likely diagnosis?**
* Acute pancreatitis
* Bleeding aortic aneurysm
**Name four initial investigations that you would request?**
* Serum amylase
* Abdominal ultrasound
* Arterial blood gas analysis
* Full blood count
* Urea and electrolytes
* Calcium
* Glucose
**List one long term complication of this condition.**
* Psuedocyst of pancreas
* Diabetes mellitus
* Pancreatic insufficiency/malabsorption
72
**What is this sign?**
**What does it represent?**
Grey Turner sign
Classically it correlates with severe acute necrotizing pancreatitis
73
Causes of anion gap (8)
**A useful mnemonic is MUDPILES:**
1. Methanol
2. Uraemia
3. DKA
4. Paraldehyde
5. Infection
6. Lactic acidosis
7. Ethylene glycol/ethanol
8. Salicylates.
74
A 24-year-old woman is brought to the Emergency department after being stabbed once in the neck with a 6 cm blade. She is complaining of odynophagia.
She is fully conscious, haemodynamically normal and initial examination of the chest is unremarkable other than some surgical emphysema bilaterally (more so on the left side of the neck).
**What is the best choice of investigation?**
**Gastrografin swallow and upper GI endoscopy**
## Footnote
The chest x ray shows a small left apical pneumothorax (1) and pneumomediastinum (2) most likely caused by a left pleural injury and oesophageal injury.
The pneumothorax is due to a left pleural injury and pneumomediastinum may be due to pharyngeal, laryngeal, tracheal or oesophageal injury. Odynophagia is suggestive of oesophageal injury.
Investigation of oesophageal perforation is with spiral multislice CT or with a combination of contrast study and endoscopy which increases sensitivity to 95%.
**Although barium is more effective at demonstrating small perforations, it causes mediastinitis. Water soluble gastrografin is, therefore, preferable.**
75
Which drugs are contraindicated in asthmatics?
(4)
NSAIDs
adenosine
beta-blockers
Morphine can release histamine that may make bronchospasm worse
76
ASPIRIN POISONING
**Features at presentation may include (4)**
**There are four main derangements (4)**
**Treatments (3)**
**Features at presentation may include:**
* Fever and sweating
* Hyperventilation and tachycardia
* Nausea and vomiting
* Dehydration
**There are four main derangements:**
* Raised intracranial pressure
* Hypoglycaemia
* Coagulopathy
* Hyperammonaemia.
**Treatment**
* general (ABC, charcoal)
* urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine
* haemodialysis
77
A 76-year-old woman presented with an acute myocardial infarction.
The ECG showed ST segment elevation in **leads II, III, and a VF.**
**Which coronary artery is most likely to be occluded?**
**Which area of the heart is affected?**
78
A 76-year-old woman presented with an acute myocardial infarction.
The ECG showed ST segment elevation in leads **V1-V2**
**Which area of the heart is affected?**
**Which coronary artery is most likely to be occluded?**
79
A 76-year-old woman presented with an acute myocardial infarction.
The ECG showed ST segment elevation in leads **V3-V4**
**Which area of the heart is affected?**
**Which coronary artery is most likely to be occluded?**
80
A 76-year-old woman presented with an acute myocardial infarction.
The ECG showed ST segment elevation in leads **V5-V6**
**Which area of the heart is affected?**
**Which coronary artery is most likely to be occluded?**
81
A 76-year-old woman presented with an acute myocardial infarction.
The ECG showed ST segment elevation in leads **I, aVL**
**Which area of the heart is affected?**
**Which coronary artery is most likely to be occluded?**
82
A 76-year-old woman presented with an acute myocardial infarction.
The ECG showed ST segment elevation in **V7, 8, 9**
**Which area of the heart is affected?**
**Which coronary artery is most likely to be occluded?**
83
# **_Define each term_**
**HbSAg**
**Anti-HBs**
**IgM anti-HBc**
**IgG anti-HBc**
**HBeAg**
**Anti-HBe**
**HbSAg**
* HBsAg (Hepatitis B surface antigen) - A "positive" or "reactive" HBsAg test result means that the person is infected with hepatitis B
**Anti-HBs**
* A "positive" or "reactive" anti-HBs (or HBsAb) test result indicates that a person is protected against the hepatitis B virus.
**IgM anti-HBc**
* Anti-HBc (IgG and IgM) antibodies are the body's first response to a hepatitis B virus (HBV) infection.
**IgG anti-HBc**
* Anti-HBc (IgG and IgM) antibodies are the body's first response to a hepatitis B virus (HBV) infection.
**HBeAg**
* HBeAg stands for hepatitis B e-antigen. This antigen is a protein from the hepatitis B virus that circulates in infected blood when the virus is actively reproducing
**Anti-HBe**
* Positive anti-HBe results usually indicate inactivity of the virus and low infectivity.
84
A 62-year-old man presents to the Emergency department after collapsing at home.
He has had several episodes of syncope and severe shortness of breath over the past three months which usually occur on exertion.
In his drug history he is being treated for chronic stable angina.
On examination he has a pulse of 80 beats per minute, a blood pressure of 112/92 mmHg and a **systolic murmur over the praecordium.**
**Based on his history and examination what is the most likely diagnosis?**
**List two causes of this condition.**
**List two appropriate investigations you would request for this patient.**
**Based on his history and examination what is the most likely diagnosis?**
* Aortic stenosis
**List two causes of this condition.**
* Rheumatic heart disease
* Calcification of a congenital bicuspid valve
* Calcification of a normal valve
**List two appropriate investigations you would request for this patient.**
* Echocardiography
* ECG
* Chest x ray
85
The classic triad of symptoms in aortic stenosis are
Angina
Exertional syncope
Exertional shortness of breath.
86
A 38-year-old female attends the Emergency department after falling onto a muddy path in the park whilst out running.
She has grazes over both knees and a very dirty deep wound to her left thenar eminence. An x ray of her hand confirms the presence of a foreign body.
The patient says that she is fully immunised against tetanus (last vaccination 7 years ago).
**Which of the following steps should be taken?**
Both a reinforcing dose of vaccine and tetanus immunoglobulin should be given immediately
87
A 16-year-old girl is brought to the Emergency department by her parents.
She has a two day history of general malaise, vomiting and vague abdominal discomfort. Over the past twelve hours she has become increasingly drowsy.
On examination she was unresponsive to verbal commands.
Her temperature 36.5°C, BP 74/48 mmHg.
**After giving emergency treatment?**
**What single investigation would be of most value in confirming the diagnosis?**
The patient has presented with an Addisonian crisis.
A definitive diagnosis is made with a Synacthen test.
88
A 54-year-old man presents with a haematemesis, ascites and disorientation.
On examination he has a mild pyrexia, has signs of chronic liver disease with ascites and is confused.
The man's neighbour reports that the patient drinks up to two bottles of whisky.
**List three potential causes of this patient's haematemesis. (3)**
**What is the cause of the patient's confusion? (1)**
**List other clinical signs of chronic liver disease. (6)**
**List three potential causes of this patient's haematemesis.**
* Oesophageal varices
* Gastric/ duodenal/ peptic ulcer
* Mallory-Weiss tear/ syndrome/ oesophageal tear
**What is the cause of the patient's confusion?**
* Wernicke's
**List other clinical signs of chronic liver disease.**
* Clubbing
* Spider naevi
* Gynaecomastia
* Pruritic scratches
* Jaundice
* Leuconychia.
89
Which condition is "globular heart" associated with?
cardiac tamponade
90
Which pattern is often seen on PE patient's ECG?
The S-I Q-III T-III ECG pattern
91
You are the foundation year doctor on the medical admissions unit and have been asked to review a 65-year-old male who has been referred to the unit for palpitations.
The venous gas has been performed by the nurse and has revealed a potassium of 7.0 mmol/L. The patient's ECG shows tented T waves.
What is the most important first drug intervention?
Calcium gluconate 10% 10 ml
92
A 30-year-old woman develops a right sided facial weakness very quickly over 24 hours. You think that the most likely diagnosis is Bell's palsy and you carry out an examination to confirm this.
Which findings are in keeping with a diagnosis of Bell's palsy?
Right sided facial paralysis
with weakness of right-side (occipito-)frontalis
93
A 14-year-old boy is referred by his GP to the hospital's Emergency department.
The boy complains of headache, neck stiffness and photophobia.
**What does the picture show?**
**What is the most likely diagnosis?**
**Which organism is the most likely cause for this patient’s presentation?**
**What haematological abnormality may underlie this rash?**
**What does the picture show?**
* Petechiae
* purpura
* septicaemic rash
**What is the most likely diagnosis?**
* Meningococcal meningitis
* meningococcal septicaemia
**Which organism is the most likely cause for this patient’s presentation?**
* Meningococcus/Neisseria meningitidis
**What haematological abnormality may underlie this rash?**
* Disseminated intravascular coagulation (DIC)
94
**Which of the following agents is the most appropriate to treat this lesion?**
**What is the causative agent?**
**What is the lesion called?**
**Which of the following agents is the most appropriate to treat this lesion?**
* acyclovir
**What is the causative agent?**
* Herpes simplex
**What is the lesion called?**
* Dendritic Ulcer
95
You are the foundation year doctor on ward cover and have been asked to review a 70-year-old male who has been admitted to the cardiac care unit with chest pain five hours ago.
He has been treated with morphine, aspirin, clopidogrel, enoxaparin and metoprolol. He has just developed a further worsening of chest pain and his heart rate has suddenly dropped to 30 beats per minute. His other observations are: BP 140/85 mmHg, O2 98%, RR 18.
An ECG is performed and demonstrates complete heart block.
**What is the most likely precipitating factor?**
**Which artery has most likely been affected?**
**Which leads in an ECG would they represent?**
**Inferior myocardial infarction**
Patients presenting with myocardial infarctions are at higher risks of associated arrhythmias.
Inferior MIs in particular can have associated transient complete heart block, due to the right **coronary artery supplying the AV node**.
96
A 21-year-old student is referred to the medical team on call with fever, neck stiffness and altered Glasgow coma scale. Acute bacterial meningitis is suspected.
## Footnote
**Which of the following would be the most appropriate antibiotic choice for this patient?**
For infants over 3 months old up to adults of 50 years old the most appropriate empirical antibiotic choice is cefotaxime (a third generation cephalosporin) alone.
If the patient has been outside the UK recently or has had multiple courses of antibiotics in the last 3 months then vancomycin may be added, given the worldwide increase in penicillin resistant pneumococci.
97
A 70-year-old man is taken to theatre with a massive upper gastrointestinal (GI) bleed. At laparotomy he is found to have a large mass in the gastric body which is rubbery in nature and is bleeding profusely.
What is the diagnosis?
The rubbery large mass suggests leiomyoma. These are prone to haemorrhage.
98
A 62-year-old presents with massive haematemesis. He has a midline laparotomy scar from an aortic aneurysm repair and is vomiting large quantities of fresh blood.
What is the likely diagnosis?
Explanation
The midline laparotomy and massive haematemesis after AAA repair are highly suggestive of **aorto-enteric fistula.**
A possibility is peptic ulceration/stress ulcer but, in the circumstances, the examiner is probably seeking the former answer.
99
A 45-year-old man with HIV and a CD4 count of 46 has 'owl's eye' inclusion bodies on histological tissue staining.
Of which of the listed viruses is this suggestive?
CMV is an opportunistic virus affecting patients whose immune system is compromised.
Although CD4 of less than 400 is the usual cut off, CMV disease in HIV seropositive patients is uncommon unless they have a CD4 count of less than 50.
A diagnosis of CMV can be made following a positive PCR result and should be treated with ganciclovir.
Owl's eye appearance of the entire nucleus (also known as Reed-Sternberg cells) is found in patients with Hodgkin's lymphoma.
100
A 47-year-old man who is a former intravenous drug user has blood results as follows:
Hep B surface antigen +ve
IgG Anti-HBc Ab +ve
IgM Anti -HBc Ab -ve
Anti-HepBs Ag Ab -ve
Chronically infected with hepatitis B
101
A 19-year-old medical student is admitted as an emergency case to a university hospital, as he was found semi-conscious at home.
On examination he has a Glasgow coma scale of 12, is febrile at 39.5°C, has a pulse of 120/min, has a blood pressure of 105/60 mmHg, is photophobic and has meningism.
The patient has been cannulated and blood cultures have been sent.
What are the most appropriate next steps?
IV antibiotics followed by CT head and subsequent lumbar puncture
102
A 70-year-old widower is brought to the Emergency department having been found collapsed at home. His wife recently passed away and he has been very depressed. He has a history of stable angina for which he is prescribed atenolol.
On examination he is bradycardic with a blood pressure of 80/35 mmHg, first and second heart sounds are audible, his oxygen saturations are 95%, and his chest is clear. The cardiac monitor shows a heart rate of 20 beats per minute, and the ECG shows a junctional escape rhythm without changes of ischaemia.
What is the most appropriate initial intervention?
Emergency Medicine
In beta blocker overdose, the initial intervention is **intravenous atropine**
YEAR 4 ACC
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