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Pre-Course Work
The aim of Medicine for Finals is to cover the essentials in a single day, allowing you to
organise your knowledge and refresh your memory of the common medical conditions
appearing in the final examination.
This pre-course material is designed to help you gain maximum benefit from the course
itself by giving you the opportunity to do some preparatory work on a few of the topics
which previous finalists have found challenging.
Dr R Clarke 1
www.askdoctorclarke.com
Medicine: Questions
Cardiology
1) List the physical signs of mitral stenosis. What would you be looking for when palpating for
the apex beat? What is the explanation for this physical sign?
2) What are the signs of left ventricular failure apart from basal crackles?
3) A 54 year-old man complains of chest pain. Report on his ECG taken in the emergency
department.
Dr R Clarke 2
www.askdoctorclarke.com
Neurology
Diabetes
5) A 50 year old man is referred to the diabetic clinic as a new patient referred for confirmation
of the diagnosis of type 2 diabetes mellitus.
What level of venous plasma glucose two hours after a 75g glucose load would confirm
diabetes?
A diagnosis of type 2 diabetes is confirmed and you assess him for complications. His fundi
are abnormal.
Dr R Clarke 3
www.askdoctorclarke.com
The nurse in charge informs about a recently diagnosed type 1 diabetic who has been brought
in semi-conscious. The BM stix reading is between 22 and 44mmol/l and the urine contains
ketones ++.
Once the patient has been stabilised, your registrar gives you a quick tutorial on acidosis and
then asks you to interpret some data.
Acidosis
pH is tightly controlled between 7.38 and 7.42. pH is a negative logarithmic scale of
hydrogen ion concentration: a fall to pH 7.3 means a doubling of H+
Bicarbonate is the body's chief buffer system- the ratio of bicarbonate to pCO2 is the
main determinant of pH
Acidosis may be caused primarily by: respiratory problems (hypercapnia) or by
metabolic problems (lowering of bicarbonate)
Metabolic acidosis may be due either to loss of bicarbonate from the body (eg severe
diarrhoea, renal tubular acidosis, pancreatic fistula) or to addition of acids (eg
ketoacidosis, lactic acidosis, aspirin poisoning) when bicarbonate "mops up" the acid, is
converted to CO2 and excreted via the lungs
The difference between these is usually obvious clinically, but in cases of doubt the
anion gap can be measured
Normally there is a small difference between the sum of the two main cations (Na+K)
and the two main anions (Cl+HCO3). This is easily calculated from routine analysis of
venous blood. The anion gap of 12-18mmol/l is due to phosphate and some lactate
The gap increases when there is an "added acid" such as the ketone bodies:
acetoacetate and hydroxybutyrate
Dr R Clarke 4
www.askdoctorclarke.com
Acidosis
Low pH
Acidosis
Check pCO2
Low High
Acute Chronic
Data Interpretation
8) Patient A
These are the results from the diabetic patient with ketoacidosis, on admission.
(Normal range)
pH 7.2 (7.38-7.42)
pCO2 2.8 (4.6-6.4 kPa)
HCO3 8.0 (22-28 mmol/l)
PO2 10.8 (>10.6 kPa)
Lactate normal
Anion gap= (Na+K) - (HCO3+Cl) = 150 - 116= 34 (normal range 10-18).
Dr R Clarke 5
www.askdoctorclarke.com
9) Patient B
This is a patient with an exacerbation of COPD.
pH 7.2
pCO2 8.6
HCO3 34.0
PO2 4.8
10) Patient C
This is a young adult patient with acute asthma.
pH 7.2
pCO2 6.6
HCO3 26.0
PO2 8.0
What are the British Thoracic Society's signs of a severe and a life threatening attack?
Dr R Clarke 6
www.askdoctorclarke.com
1) List the physical signs of mitral stenosis. What would you be looking for when palpating for
the apex beat? What is the explanation for this physical sign?
Mitral stenosis
Malar flush
Atrial fibrillation
JVP not raised until late
Apex beat not displaced
Apex beat tapping in quality- due to a loud palpable first heart sound
Mitral stenosis is a left-sided heart lesion and in early uncomplicated cases, the JVP will be
normal. As the valve is narrowed, the pressure in the left atrium will be high and this is
transmitted backwards to the pulmonary veins, leading to pulmonary venous hypertension.
After some time, this may lead to pulmonary arterial hypertension, which after a further period
of time can lead to right ventricular hypertrophy. Only then will right-sided heart failure develop-
with a raised JVP.
The apex beat is not displaced in pure mitral stenosis as the narrow valve effectively protects
the ventricle, reducing the amount of blood that enters it. However the apex beat may be
tapping, which is due to a palpable first heart sound.
The first heart sound is palpable because it is loud and this is due to the high left atrial
pressure. Normally the mitral valve starts to glide shut towards the end of diastole and then, at
the start of ventricular systole, it closes causing the mitral component of the first heart sound. In
mitral stenosis, the high left atrial pressure keeps the valve open until right at the end of
diastole- so there is loss of the normal way in which the valve glides gently shut. Instead when
systole occurs, the valve is slammed shut from a more open position than normal.
Lub De Derrrr
LUB De Derrrr
Dr R Clarke 7
www.askdoctorclarke.com
2) What are the signs of left ventricular failure apart from basal crackles?
Acute LVF
Sinus tachycardia or atrial fibrillation
Systolic hypotension
Signs of cardiomegaly (displaced apex, signs of valve disease)
Third and fourth heart sounds
Right sided or bilateral pleural effusions
Rate: 60/minute
Rhythm: sinus rhythm
Axis: normal
P waves: normal
QRS: ST elevation in 2, 3 and aVF; deep q wave in 3
T waves: inverted in 1 and V2-4 (reciprocal change)
This is likely to represent a myocardial infarct, which is full thickness as there is a q wave. This
is an inferior infarct as the main changes are in 2,3 and aVF.
st elevation
q waves
imply a full thickness
transmural infarct;
without them:
subendocardial
Dr R Clarke 8
www.askdoctorclarke.com
Diabetes
5) A 50 year old man is referred to the diabetic clinic as a new patient referred for confirmation
of the diagnosis of diabetes mellitus. What level of fasting venous plasma glucose confirms the
diagnosis?
7.0 mmol/l
What level of venous plasma glucose two hours after a 75g glucose load would confirm
diabetes?
11.1 mmol/l
48mmol/mol
See also
https://www.diabetes.org.uk/Professionals/Position-statements-reports/Diagnosis-ongoing-
management-monitoring/New_diagnostic_criteria_for_diabetes/
A diagnosis of type 2 diabetes is confirmed and you assess him for complications.
His fundi are abnormal. Outline your classification of fundal abnormalities due to diabetes:
6) Retinopathy: summary
Background- micoraneurysms and hard exudates
Maculopathy- check acuity; reduction in acuity due either to cataracts or maculopathy
Pre-proliferative- cotton wool spots (an infarct of the nerve cell layer on surface of
retina); also venous beeding and looping; intra-retinal microvascular anbnormalities
Proliferative- new vessels
End-stage- scarring with white bands of scar tissue and retinal traction
Dr R Clarke 9
www.askdoctorclarke.com
The nurse in charge informs you about a recently diagnosed type 1 diabetic who has been
brought in semi-conscious. The BM stix reading is between 22 and 44mmol/l and the urine
contains ketones ++.
Dr R Clarke 10
www.askdoctorclarke.com
8) Patient A
These are the results from the diabetic patient with ketoacidosis, on admission.
(Normal range)
pH 7.2 (7.38-7.42)
pCO2 2.8 (4.6-6.4 kPa)
HCO3 8.0 (22-28 mmol/l)
PO2 10.8 (>10.6 kPa)
Lactate normal
Anion gap= (Na+K) - (HCO3+Cl) = 150 - 116= 34 (normal range 10-18).
9) Patient B
This is a patient with an exacerbation of COPD.
pH 7.2
pCO2 8.6
HCO3 34.0
PO2 4.8
Many would start with 24% oxygen as the raised bicarbonate suggests that renal
compensation has occurred: this implies a longstanding problem with an acute
exacerbation. If the patient has chronic hypercapnia, the respiratory drive may
well depend on hypoxia (unlike the normal person where it depends on pCO2).
Giving too much oxygen may "release the hypoxic respiratory drive", slow
respiration and precipitate CO2 narcosis. A simple clinical check is to measure
the respiratory rate before oxygen and 5 minutes after giving oxygen. You will
wish to check the gases again in any case to see if there has been an
improvement and particularly if there is any reduction in respiratory rate. A rising
pCO2 would indicate the need for ventilatory support.
Dr R Clarke 11
www.askdoctorclarke.com
This is a controversial area. Some physicians argue that the danger of hypoxia is
actually greater than the danger of causing respiratory depression and that in a
critically ill patient, higher concentrations of oxygen should be used, with careful
monitoring of ABGs and then downward titration of oxygen concentrations, once
hypoxia has been corrected. The approach actually taken may depend on how ill
the patient is and how easy it will be to monitor ABGs and ventilate the patient if
necessary. The key point in answering the question is to make the examiner
aware that you recognise the risk and understand the mechanism by which
oxygen therapy could lead to deterioration in a patient with chronic hypercapnia.
and at
www.mcht.nhs.uk/documents/policies/Clinical/Oxygen%20Policy.pdf
10) Patient C
This is a patient with acute asthma.
pH 7.2
pCO2 6.6
HCO3 26.0
PO2 8.0
What are the British Thoracic Society's signs of a severe and a life threatening attack?
Dr R Clarke 12
www.askdoctorclarke.com
This patient is very ill with acute respiratory acidosis: the pCO2 should be low;
normal is worrying but high is a very serious sign. Call for senior help.
Consider using IV magnesium sulphate after discussion with senior medial staff.
See SIGN/ BTS guidelines:
http://www.sign.ac.uk/guidelines/fulltext/63/index.html
http://www.sign.ac.uk/guidelines/fulltext/63/annex2.html
Repeat the arterial blood gases to monitor the effects of treatment and if no sign
if improvement, discuss the use of early ventilatory support.
Dr R Clarke 13