1
Q
A
- Macrocytic anaemia: Diagnosis
This patient has macrocytic anaemia and neurological symptoms (symmetrical neuropathy affecting
the legs more than the arms), which are both associated with vitamin B12 deficiency. Deficiency in
vitamin B12 can cause sub-acute combined cord degeneration (SACD), typically after developing
anaemia. SACD can cause loss of proprioception and vibration, absent ankle jerk reflexes and
peripheral neuropathy, all of which are present in this case. None of the other options would help
confirm this diagnosis.
Source: https://cks.nice.org.uk/topics/anaemia-b12-folate-deficiency/diagnosis/signs-symptoms/
https://radiopaedia.org/articles/subacute-combined-degeneration-of-the-cord-1?lang=gb
2
Q
NOTE: This condition causes drooping of the whole of one side, no forehead sparing! Think like the guy in my year!
A
- Bell’s Palsy: Management
Bell’s palsy presents with unilateral facial muscle weakness, involving both the upper and lower
parts of the face, often presenting with reduced power and a drooping eyebrow on the affected
side. NICE CKS recommend prescribing high dose (50-60 mg) prednisolone for Bell’s palsy, when the
patient presents within 72 hours of the onset of symptoms. In addition, patients should be reassured
that the prognosis is usually good and given eye care advice.
Source: https://cks.nice.org.uk/topics/bells-palsy/background-information/
3
Q
A
- Gout: Diagnosis
This patient has the symptoms and signs of gout (swollen first metatarsophalangeal joint and pain
reaching intensity at 24 hours), on a background of risk factors (male and alcohol use). The raised
CRP and negative birefringent crystals seen in the synovial fluid confirm the diagnosis. In
pseudogout, the symptoms are usually milder than in gout, and weakly positive birefringent crystals
are seen in the synovial fluid. Osteoarthritis and rheumatoid arthritis would not present like this, and
the lack of systemic symptoms (fever) and no organisms seen on microscopy make septic arthritis
unlikely.
Source: https://cks.nice.org.uk/topics/gout/diagnosis/assessment/
4
Q
A
- Appendicitis: Diagnosis
Right iliac fossa pain with rebound tenderness and guarding is highly suggestive of acute
appendicitis. The raised inflammatory markers help to confirm the diagnosis. Diverticulitis would
usually present in an older patient as left iliac fossa pain. An ectopic pregnancy is unlikely given the
negative βhCG and ureteric colic typically presents as severe loin to groin pain. Volvulus is more
common in the elderly and is associated with abdominal distention.
Source: https://cks.nice.org.uk/topics/appendicitis/diagnosis/diagnosis/
5
Q
A
- Bowel obstruction: Diagnosis
Abdominal pain with constipation and absence of flatus in an elderly patient is in-keeping with
bowel obstruction. Given this patient’s background of previous surgery and dilated small bowel
loops on abdominal X-ray, the most likely diagnosis is small bowel obstruction secondary to
adhesions.
Source: https://radiopaedia.org/articles/small-bowel-obstruction?lang=gb
6
Q
A
- Hypoglycaemia: Medical and laboratory sciences (Aetiology)
Hypoglycaemia is a common/ very common side effect of sulfonylureas (such as Glimepiride), which
is why they should be used with caution in those with renal impairment and elderly people. The risk
of hypoglycaemia should be discussed with the patient.
Source: https://bnf.nice.org.uk/drug/glimepiride.html
7
Q
A
- Polycystic ovarian syndrome (PCOS): Diagnosis
This patient has symptoms of hyperandrogenism (acne, hirsutism) and oligomenorrhoea, making
PCOS a likely diagnosis. Her blood results showing raised testosterone supports the diagnosis. LH
may be raised and FSH may be normal or low, both of which occur in this case. For this patient a
diagnosis of PCOS could be made without arranging an USS as she has 2 of the 3 diagnostic criteria.
Premature ovarian failure is very rare in this age group and the other answer options would not
present with this combination of symptoms and investigation results.
Source: https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/
8
Q
A
- Cushing’s syndrome: Diagnosis (Investigations)
Cushing’s syndrome classically presents with weight gain, facial fullness, proximal muscle wasting,
hypertension, easy bruising, hirsutism and skin pigmentation, several of which are present in this
case. The first line diagnostic test for Cushing’s syndrome is low dose dexamethasone suppression
test, where 1 mg of dexamethasone is ingested late at night and cortisol levels are checked the next
morning. High dose dexamethasone suppression test is used to help identify the cause of Cushing’s
syndrome, rather than diagnose the syndrome itself. Imaging may also be done to look for an
underlying cause, but these would not be the next most appropriate investigation.
Source: https://patient.info/doctor/cushings-syndrome-pro#nav-4
9
Q
A
- Stroke: (Diagnosis
Persistent, sudden onset left-sided weakness and left homonymous hemianopia are consistent with
the diagnosis of an ischemic stroke, specifically a right sided cerebral infarct. This patient’s age and
risk factors (atrial fibrillation, hypertension and hyperlipidaemia) all support this diagnosis. In a TIA
the symptoms would fully resolve within 24 hours. A subdural haemorrhage would typically occur on
a background of head trauma and present with reduced GCS and pupillary abnormalities. Hemiplegic
migraines can mimic strokes; however the effects would be temporary.
Source: https://cks.nice.org.uk/topics/stroke-tia/diagnosis/clinical-features/
10
Q
A
- BPPV: Management
Vertigo brought on by moving the head and reproduced by the Dix-Hallpike manoeuvre is diagnostic
for Benign paroxysmal positional vertigo (BPPV), which is an inner ear disorder and the most
common cause of vertigo. NICE CKS recommend either watchful waiting (as it can often resolve
without treatment) or the Epley manoeuvre to manage BPPV. The Epley manoeuvre is done in
several stages and aims to relocate crystals to the correct part of the ear. Medication is not usually
helpful in BPPV.
Source: https://cks.nice.org.uk/topics/benign-paroxysmal-positional-vertigo/
11
Q
A
- Mastitis/breast abscesses: Diagnosis
Mastitis is a painful inflammatory condition of the breast. It is more common in lactating women as
seen in this case, where milk stasis causes an inflammatory response which may lead to infection.
Symptoms include fever, a painful breast, or a red swollen area, and complications include the
formation of a breast abscess.
Source: Definition | Background information | Mastitis and breast abscess | CKS | NICE
12
Q
A
- Deep vein thrombosis (DVT): Medical and laboratory sciences
Deep vein thrombosis is most likely to occur in patients with intrinsic risk factors, or factors that
temporarily increase risk such as recent prolonged immobility/bed rest. In this scenario the patient
has had recent hand surgery, however this does not require a period of subsequent prolonged
immobility. Smoking and obesity both have weak associations with DVT risk, but the patient’s BMI
here is not in the obese range, so smoking status is the correct answer.
Source: Deep vein thrombosis - History and exam | BMJ Best Practice
13
Q
A
- Peripheral vascular disease: Diagnosis
This patient has features of critical limb ischaemia on a background of intermittent claudication,
which is a vascular emergency. His foot is pale, pulseless, painful and perishingly cold. An ABPI of <
0.4 indicates severe peripheral artery disease. Arteriography of the affected leg enables stenoses or
occlusions to be seen in anatomical detail.
Source: Peripheral arterial disease - History and exam | BMJ Best Practice
14
Q
A
- Hydrocele: Diagnosis
A hydrocele is a collection of serous fluid that surrounds the testes. It presents as a painless, swollen
scrotum, which feels like a water-filled balloon. Transillumination of the mass is a key diagnostic
feature on examination. Diagnosis is usually clinical, however if the testes cannot be palpated
ultrasonography can be performed to exclude underlying pathology.
Source: Hydrocele - Symptoms, diagnosis and treatment | BMJ Best Practice
15
Q
A
- Urinary tract calculi: Management
The renal stone in this instance is a staghorn, so is unlikely to pass without surgical treatment.
Percutaneous nephrolithotomy is the preferred modality of treatment for large stones and staghorn
calculi. It has a lower morbidity rate than transurethral surgery with rates of successful elimination
of stones. Extracorporeal shock wave lithotripsy has a lower rate of stone elimination and is reserved
for patients with high surgical risk.
Source: Urolithiasis (Urinary Tract Stones and Bladder Stones) | Patient
16
Q
A
- Renal cell carcinoma: Diagnosis
The patient has macroscopic haematuria and systemic features (weight loss and night sweats), as
well as an episode of flank pain. These are all indicative of renal cell carcinoma, which does not
always present with the triad of haematuria, flank pain and a palpable abdominal mass.
Source: Renal cell carcinoma - History and exam | BMJ Best Practice
17
Q
A
- Testicular cancer Diagnosis
A painless irregular testicular mass is suspicious for testicular cancer, the most common type of
which is a seminoma. Tumour markers can be used to differentiate between the types of testicular
cancer. Seminomas may produce βhCG but do not produce AFP, which can be seen in patients with
yolk sac tumours and teratomas.
Source: Testicular seminoma | Radiology Reference Article | Radiopaedia.org
18
Q
A
- Cholecystitis: Medical and Laboratory Sciences
The patient has obstructive gallstones, and her ultrasound indicates the common bile duct is dilated.
Obstruction due to gallstones occurs when either the cystic duct or common bile duct are affected.
Patients commonly present with intermittent RUQ pain that is exacerbated by eating fatty foods.
Here we are told that the CBD is dilated, thus the obstruction is distal to the cystic duct and the
correct answer is the common bile duct.
Source: Common bile duct | Radiology Reference Article | Radiopaedia.org
19
Q
A
- Haemorrhoids: Diagnosis
Painless bright red PR bleeding is the most common symptom of haemorrhoids, and proctoscopy is
the investigation of choice to confirm the diagnosis/exclude sinister pathology. The patient has no
red flag symptoms, and thus would not need referral for CT scanning of his abdomen.
Source: Diagnosis | Diagnosis | Haemorrhoids | CKS | NICE
20
Q
A
- Colorectal carcinoma: Diagnosis
This patient meets the criteria for a 2 week wait referral for lower GI malignancy. She is over the age
of 60, and has a change in bowel habit, plus an iron deficient anaemia. Either of these findings in this
patient should trigger a 2ww referral, and the modality of investigation is via a colonoscopy.
Source: Symptoms suggestive of gastrointestinal tract (lower) cancers | Diagnosis | Gastrointestinal
tract (lower) cancers - recognition and referral | CKS | NICE
21
Q
A
- Liver abscess: Diagnosis
Amoebic liver abscesses are rare in the UK, but the patient in this case has travelled from an
endemic area. Symptoms include fever, right upper quadrant pain, and patients may also have
hepatomegaly as seen in this case. An abdominal CT is the preferred imaging, and blood cultures
should be taken (plus stool cultures if diarrhoea also present). Aspiration confirms the diagnosis and
directs the choice of antibiotic therapy.
Source: Liver abscess - Diagnosis Approach | BMJ Best Practice
22
Q
A
- Respiratory alkalosis: Management
The ABG in this scenario shows an elevated pH with a low pCO2 and normal bicarbonate, which is in
keeping with a respiratory alkalosis. This is iatrogenic in nature because the patient is on artificial
ventilation. By reducing the ventilation rate, the excretion rate of CO2 will be reduced, and the pH
should normalise.
Source: Assessment of respiratory alkalosis - Differential diagnosis of symptoms | BMJ Best Practice
23
Q
A
- Pneumonia: Management
This case concerns a patient with pneumonia, where there is high suspicion of an atypical organism
(bilateral changes on CXR, dry cough, recent international travel). For suspected atypical
pneumonias, use of a macrolide antibiotic or doxycycline is preferred as first line versus the use of
amoxicillin, which is the first line treatment for community acquired pneumonia otherwise.
Source: Respiratory system infections, antibacterial therapy | Treatment summary | BNF content
published by NICE
24
Q
A
- Cellulitis: Diagnosis
A swollen, erythematous and painful lower leg in conjunction with fever makes cellulitis the most
likely diagnosis. There is no history of insect bite, and no suggested risk factor for DVT formation,
whilst a fever also makes this less likely. Thrombophlebitis causes tenderness along the site of a vein
rather than the entire leg. Skin involvement in gout is usually closely related to a joint, classically the
first MTPJ or the knee.
Source: Cellulitis and erysipelas - Symptoms, diagnosis and treatment | BMJ Best Practice
25
25. Blood product transfusion: Diagnosis
This patient is suffering from an acute haemolytic transfusion reaction, as evidenced by his fever,
hypotension, chest pain, timing of blood product delivery and change in urine colour. There is no
drop in oxygenation or change in respiratory rate to suggest PE or fluid overload, and further blood
loss should not lead to a fever. The most common cause of acute haemolytic reaction is clerical
error, and so it is very important to note that a second patient may also be given the wrong blood at
the same time.
Source: Transfusion reaction - Symptoms, diagnosis and treatment | BMJ Best Practice
26
26. Systemic sclerosis: Diagnosis
The patient in this vignette is experiencing Raynaud’s phenomenon – reversible vasospasm of the
peripheral arteries. In 80-90% of cases it is not associated with underlying disease (Primary
Raynaud’s), however it can be a sign of an underlying cause such as a connective tissue disease. This
patient also has sclerodactyly and pulmonary hypertension, making the underlying diagnosis
systemic sclerosis.
Source: Systemic sclerosis (scleroderma) - Symptoms, diagnosis and treatment | BMJ Best Practice
27
27. Urinary tract infection: Management
No treatment is routinely needed for patients with asymptomatic bacteriuria (the exception being in
pregnant women). Indwelling catheters can become colonised with microbes, however in this
vignette the patient clearly has no symptoms and thus no treatment is necessary. If he was
symptomatic, changing his catheter would be necessary to remove the source of infection.
Source: Urinary-tract infections | Treatment summary | BNF content published by NICE
28
28. Head injury: Diagnosis
GCS is used to determine the level of consciousness in all patients who have received a head injury.
Patients are scored on eye, verbal and motor responses. This patient has a GCS of 7. His eyes open to
pain (2/4), he is not verbalising (1/5), and he withdraws to painful stimuli (4/6).
Source: Scenario: Head injury | Management | Head injury | CKS | NICE
29
29. Goitre: Diagnosis
The blood tests in this case indicate hyperthyroidism in the context of a patient with an
asymmetrical goitre. The isotope scan of the neck in this instance demonstrates multiple ‘hot’
nodules, which indicates a diagnosis of toxic multinodular goitre. In Grave’s disease the uptake
would be diffuse rather than nodular.
Source: Toxic multinodular goitre - Symptoms, diagnosis and treatment | BMJ Best Practice
30
30. Diabetes mellitus: Medical and Laboratory Sciences
Ulcers in diabetes may be venous, arterial or neuropathic. Neuropathic ulcers typically develop over
callouses or pressure points. Impalpable pulses or cold extremities indicate arterial compromise
rather than neuropathic.
Source: Differential diagnosis | Diagnosis | Leg ulcer - venous | CKS | NICE
31
31. Acromegaly: Diagnosis
Acromegaly is a rare disorder caused by excess GH secretion (or ectopic production). It tends to have
an insidious onset and slow progression, hence diagnosis is often delayed. Headache and active
sweating are common presenting symptoms, but in this case the diagnosis is inferred from the blood
results. GH stimulates the production of IGF-1, which is recommended as the initial screening test
for suspected acromegaly (and is elevated in this vignette). An oral glucose tolerance test is used to
confirm a raised IGF-1, as a glucose load should suppress GH. In this case, damage caused by the
pituitary tumour has led to hyperprolactinaemia.
Source: Acromegaly | Doctor's Guide | Patient
32
32. Coeliac disease: Diagnosis
The patient has T1DM and a family history of autoimmune disease, with blood tests suggestive of
malabsorption (iron, folate and B12 deficiency). All these factors point to a likely diagnosis of coeliac
disease, and the patient presents with typical symptoms of this (bloating, abdominal pain, loose
stools).
Source: Coeliac Disease free medical information. Patient | Patient
33
33. Pancreatitis: Medical and Laboratory Sciences
This case illustrates symptoms of pancreatitis and pancreatic exocrine dysfunction (steatorrhoea and
diarrhoea), likely secondary to chronic alcohol abuse. X-ray calcification in the epigastric region likely
illustrates calcification secondary to inflammation from chronic pancreatitis.
Source: Assessment | Diagnosis | Pancreatitis - chronic | CKS | NICE
34
34. Barrett’s oesophagus: Medical and Laboratory Sciences
Barrett’s oesophagus is the replacement of the normal squamous epithelial lining of the oesophagus
with metaplastic columnar epithelium, extending >1cm above the gastro-oesophageal junction. It
results from chronic gastro-oesophageal reflux, and infers a higher risk of dysplasia into invasive
adenocarcinoma of the oesophagus.
Source: Barrett's Oesophagus. Information about Barrett's Oesophagus | Patient
35
35. Acute confusion: Diagnosis
Alcohol dependence is very common and if untreated, patients can develop withdrawal symptoms
and delirium tremens. Withdrawal symptoms include tremor, sweating and headache, and minor
withdrawal symptoms can appear within 6-12 hours after alcohol has stopped. Symptoms may
progress, and delirium tremens can begin 24-72 hours after alcohol consumption has been reduced
or stopped. The difference versus usual withdrawal symptoms is that there is an altered mental state
(hallucinations/confusion/delusions/seizures). In Wernicke-Korsakoff’s you would expect mental
alertness with social habits maintained, but patients may exhibit confabulation, memory loss and
cerebellar/oculomotor abnormalities.
Source: Acute Alcohol Withdrawal and Delirium Tremens | Patient
36
36. Oesophageal cancer: Diagnosis
Progressive dysphagia (initially to solids and subsequently to liquids) is a red-flag symptom for
oesophageal malignancy. The patient also has weight loss, and a strong risk factor for oesophageal
cancer in her smoking history. An urgent OGD should be performed to investigate this under the 2
week wait pathway.
Source: Assessment of dysphagia - Differentials | BMJ Best Practice
37
37. Gastrectomy: Medical and Laboratory Sciences
The patient’s symptoms of fatigue and lethargy suggest anaemia. Vitamin B12 deficiency causes a
macrocytic anaemia, and is most commonly due to pernicious anaemia. However, gastric surgery
such as gastrectomy/gastric resection may affect B12 absorption, which is what has occurred in this
case, leading to a macrocytic anaemia.
Source: Pernicious Anaemia and B12 Deficiency | Doctor | Patient
38
38. Tuberculosis: Diagnosis
Pulmonary TB is an infectious disease caused by Mycobacterium tuberculosis. Risk factors include
exposure to infection, such as visiting an endemic country (as seen in this case). Symptoms include
coughing, haemoptysis, fever and weight loss. X-ray findings typically are upper lobe abnormalities
such as fibronodular opacities.
Source: Pulmonary tuberculosis - Symptoms, diagnosis and treatment | BMJ Best Practice
39
39. Aspergillus lung disease: Diagnosis
ABPA is a hypersensitivity reaction to bronchial colonisation by Aspergillus fumigatus mould. It
typically affects patients with asthma or cystic fibrosis. The presentation is usually in keeping with
asthma complicated by fever, malaise, mucus expectoration and haemoptysis, in a patient with a
peripheral blood eosinophilia.
Source: Allergic bronchopulmonary aspergillosis - Symptoms, diagnosis and treatment | BMJ Best
Practice
40
40. Bronchiectasis: Diagnosis
Bronchiectasis should be suspected in any patient with persistent or recurrent coughing with sputum
production. Patients may have daily expectorations of large volumes of sputum. The gold standard
investigation for establishing a diagnosis is the HRCT. Following this, further tests will be performed
to determine the underlying cause of bronchiectasis, such as screening for cystic fibrosis.
Source: Diagnosis | Diagnosis | Bronchiectasis | CKS | NICE
41
41. Lung cancer: Diagnosis
Most often, lobar collapse on CXR indicates bronchial obstruction. This patient has an extensive
pack-year smoking history, which is an important risk factor for malignancy. Finger clubbing,
shortness of breath and chronic cough all indicate a likely diagnosis of lung cancer.
Source: Lobar lung collapse | Radiology Reference Article | Radiopaedia.org
42
42. Pneumothorax: Management
Management of a pneumothorax depends on the type (primary or secondary), size, and clinical
status of the patient. Spontaneous pneumothoraxes can be classified as either primary (in the
absence of underlying lung disease) or secondary (in the presence of underlying lung disease). The
first line management for a large (>2cm) primary pneumothorax is to attempt aspiration.
Source: Pneumothorax - Management recommendations | BMJ Best Practice
43
43. Idiopathic pulmonary fibrosis: Diagnosis
Progressive chronic breathlessness, with clubbing and fine crackles at lung bases are indicative of
pulmonary fibrosis. This is supported by the pulmonary function test findings which show a
restrictive deficit (reduced forced vital capacity and reduced total lung capacity).
Source: Idiopathic pulmonary fibrosis - Investigations | BMJ Best Practice
44
44. Chronic obstructive pulmonary disease (COPD): Diagnosis
This question here asks what the most likely diagnosis is. Progressive breathlessness with an
extensive smoking history, a hyperinflated chest, and flattened diaphragms all point towards COPD.
Asbestosis is diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres.
The patient has a history of asbestos exposure with scattered pleural plaques on CXR, however there
is no evidence of fibrosis.
Source: Chronic obstructive pulmonary disease (COPD) - Symptoms, diagnosis and treatment | BMJ
Best Practice Asbestosis - Symptoms, diagnosis and treatment | BMJ Best Practice
45
45. Cardiomyopathy: Medical and Laboratory Sciences
Hypertrophy describes an increase in the size of cells, and often occurs in response to an invoking
stimulus or stress, which in turn will increase the size of the organ. Physiological cardiac hypertrophy
can occur in athletes.
Source: Athlete's heart or hypertrophic cardiomyopathy? - PubMed (nih.gov)
46
46. Aortic stenosis: Diagnosis
The murmur of aortic stenosis is an ejection systolic murmur loudest at the right upper sternal
border, which radiates to the carotids. Symptoms include chest pain, shortness of breath and
syncope. Diagnosis is performed via echocardiography to assess valve area, gradient and jet velocity.
Source: Aortic stenosis - History and exam | BMJ Best Practice
47
47. Cardiac arrest: Management
VF is the most commonly identified rhythm in cardiac arrest patients. It is most often associated with
coronary artery disease, and may be due to acute myocardial infarction or ischaemia, or due to a
chronic infarction scar. Defibrillation is the most appropriate management step for patients with
shockable rhythms.
Source: Adult Cardiopulmonary Arrest. Cardiac Arrest information. Patient | Patient
48
48. Ethics & Law: Capacity
The patient can understand, retain and weigh up the relevant information and communicate their
decision, therefore they have capacity irrespective of whether their reasoning is rational or
irrational.
Source: Assessment of capacity | The BMJ
49
49. Ethics & Law: Confidentiality
Doctors owe a duty of confidentiality to their patients, but they also have a wider duty to protect
and promote the health of patients and the public. A driver is legally responsible for telling the DVLA
or DVA about any condition or treatment that might affect their ability to drive. Doctors may,
however, need to make a decision about whether to disclose relevant information without consent
to the DVLA in the public interest if a patient is unfit to drive but continues to do so. The doctor
should tell the patient about their intention to disclose personal information in this setting.
Source: Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA (gmcuk.org)
50
50. Ethics & Law: End of life care
An advance decision is a statement of a patient’s wish to refuse a particular type of medical
treatment or care if they become unable to make or communicate decisions for themselves. If a
patient has made an advance decision or directive refusing a particular treatment, the doctor must
make a judgement about its validity and its applicability to the current circumstances. If the doctor
concludes that the decision or directive is legally binding, it must be followed in relation to that
treatment.
Source: Treatment and care towards the end of life: good practice in decision making (gmc-uk.org)
Year 3 mocks
flashcards
Decks in class (3)
# Cards
