MRCP 1 On examination ITU 2015

1.A 64-year-old man is admitted with severe epigastric pain. He has had the pain for 36 hours. An
abdominal x ray shows a central, dilated small bowel loop.

His temperature is 37.0°C, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min,
SpO2 85% on air.

His full blood count reveals:

Haemoglobin 130 g/L (130-180)

9
White cell count 3.2 ×10 /L (4-11)
Platelets 108 ×109/L (150-400)
MCV 105 fL (80-96)

Which of the following is the most appropriate initial treatment of this patient?

(Please select 1 option)

1 Administer high-flow oxygen Correct

2 Insert 2 × 14 gauge venflons and give 2 litres Hartmann's solution
3 Intensive care
4 Intubation and ventilation
5 Invasive monitoring

This patient has systemic inflammatory response syndrome, possibly caused by acute pancreatitis
given the finding of an isolated dilated loop of small bowel on abdominal radiograph. However, the
initial treatment is the same independent of the underlying cause.

All of the above answers are reasonable, however resuscitation of the sick patient still follows the
ABC algorithm:

Airway
Breathing
Circulation.

Airway control and oxygen to maintain normal saturations is the first part of that algorithm.
Subsequent fluid resuscitation and treatment of the underlying cause can then be initiated. The need
for invasive monitoring and intensive care is then assessed, depending on the response to initial
treatment.

2.A 64-year-old man is admitted with central epigastric pain.

Abdominal x ray shows a central dilated bowel loop. His temperature is 37.0°C, pulse 130 beats per
min, blood pressure 80/50 mmHg, respiratory rate 29/min and SpO2 90 on air.

His full blood count reveals:

Haemoglobin 130 g/L (130-180)

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White cell count 3.2 ×10 9/L (4-11)

Platelets 108 ×109/L (150-400)
MCV 105 fL (80-96)

Which of the following is the most likely diagnosis?

(Please select 1 option)

1 Gall stone ileus

2 Ischaemic bowel
3 Pancreatitis CORRECT
4 Perforated duodenal ulcer
5 Small bowel obstruction

Ischaemic bowel and perforated duodenal ulcer would be high in the differential list. However the
history and raised mean corpuscular volume (MCV) suggests alcohol use and the severity of his
observations would suggest a systemic inflammatory response which is more common with
pancreatitis.

Acute pancreatitis has a mortality of 7-10%, often due to sepsis or multi-organ failure. There are a
number of scoring systems which can be used to guide prognosis, but they are unreliable within the
first 48 hours o f the illness. Gallstones account for 50% of cases, with the majority of the rest being
associated with alcohol.

Patients typically present with severe epigastric pain which radiates to the back and vomiting. As
seen in this example, there is often a systemic inflammatory response. Amylase is markedly raised,
often in excess of four times the normal value. Early complications include ARDS (adult respiratory
distress syndrome), acute kidney injury and disseminated intravascular coagulation (DIC).

Treatment is essentially supportive, and high levels of monitoring are usually required (often in the
intensive care unit). Those patients who are found to have gallstones should be considered for
emergency ERCP, and all should have a cholecystectomy during the same admission.

3. 75-year-old man post-oversew of a duodenal ulcer. He is confused.

His SpO2 is 97 on oxygen. Pulse 110 beats per min, blood pressure 100/50 mmHg, respiratory rate
32/min and his urine output is 10 ml in the last hour.

Which of the following is the most appropriate treatment for this man?

(Please select 1 option)

1 100% oxygen via face mask

2 Central line and arterial line
3 Normal saline 500 ml stat CORRECT
4 Haloperidol 2.5 mg intravenously

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5 Noradrenaline via central line

Postoperative confusion is common in the elderly. However this can be caused by a low perfusion
state.

His observations are indicative of underfilling/dehydration. (He could also have atelectais or have
developed a chest infection. Post-operative problems are often multifactorial.)

Of the options given a fluid bolus is appropriate. This is what you would expect your FY1 to do
while waiting for the blood test results and before calling you.

Some would argue that 100% oxygen comes before fluids but with an SpO2 of 97 it is unlikely that
hypoxia is contributing to his problems. (nonetheless oxygen therapy would be recommended).

The other options would come further down the line if initial interventions were unsuccessful and he
deteriorated.

4.A 67-year-old man who is three days post-operation for a sigmoid colectomy. He has insulin
dependent diabetes mellitus. He complains of dizziness, upper abdominal discomfort and faintness.

His blood pressure is 110/75 mmHg, his pulse is 95 bpm, he has a respiratory rate 24/min, and he has
SpO2 99% on air. His blood glucose is 18 mmol/l.

His electrocardiogram shows ST depression of 2 mm in leads II, III and AVF.

Which of the following is the initial drug therapy for this patient?

(Please select 1 option)

1 Aspirin 300 mg Correct

2 Clexane 1 mg/kg subcutaneously
3 Clopidogrel 75 mg
4 Diamorphine 2.5 mg
5 Glycerol trinitrate 800 mcg sublingually

Initial treatment of an acute coronary syndrome is aspirin 300 mg. This should be safe in the post-
surgical patient with no signs of bleeding at three days post operation. Clexane would have also been
given pre- and post-op.

The dose of clopidogrel is 300 mg in an acute coronary syndrome.

Diamorphine is used to treat anxiety and pain, neither of which is commented upon.

GTN would be reasonable to try, however the blood pressure is low.

Remember that in the diabetic chest pain may not be a feature of acute coronary syndrome due to
autonomic dysfunction, and in most post surgical patients myocardial infarct is silent

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5.The pulmonary vascular system is different from the systemic circulation in that the pulmonary
system demonstrates which of the following?

(Please select 1 option)

1 High pressures, high flow rates,

highly compliant vessels
2 High pressures, high flow rates,
low compliance vessels
3 Low pressures, high flow rates,
high compliance vessels
4 Low pressures, low flow rates,
high compliance vessels CORRECT
5 Low pressures, low flow rates,
low compliance vessels

The normal pulmonary circulation is characterised by low pressures, low flow rates, high compliance
vessel

6.Which of the following is not a feature of cannabinoids?

(Please select 1 option)

1 9-tetrahydrocannabinol is the active

constituent of the resin
2 Bioavailability after oral administration
is about 80% CORRECT
3 Inhibits eicosanoid synthesis
4 Lowers intraocular pressure
5 Naloxone blocks the antinociceptive actions of cannabinoids

Cannabinoids are derived from the resin of cannabis sativa, and 9-tetrahydrocannabinol (9-THC) is
its most important pharmacologically active constituent.

Oral bioavailability of THC, whether given in the pure form or as THC in marijuana, is low and
extremely variable, ranging between 5% and 20%, with effects occurring 0.5-3 hours later.
Bioavailability of THC in a marijuana cigarette or pipe also rarely exceeds 10-20%.

Naloxone and other opioid receptor antagonists block the analgesic actions of cannabinoids.

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Synthetic cannabinoids reduce arachidonic acid-induced inflammation by inhibiting eicosanoid
producti

7.A 56-year-old man is admitted with epigastric pain after drinking heavily.

He has a temperature of 36.9°C, a pulse of 95/min, a blood pressure of 85/60 mmHg, and a
respiratory rate of 32/min.

Investigations reveal:

Haemoglobin 126 g/L (130-180)

9
Platelets 169 ×10 /L (150-400)
White cell count 3.9 ×10 9/L (4-11)

Which of the following is the diagnosis?

(Please select 1 option)

1 Leaking aortic aneurysm

2 Multi-organ dysfunction syndrome (MODS)
3 Severe sepsis
4 Septic shock
5 Systemic inflammatory response syndrome (SIRS) CORRECT

This patient has features of pancreatitis. He also has hypotension, and leucopenia. He therefore
fulfils the criteria for systemic inflammatory response syndrome. This is equivalent to sepsis, but
occurs in the absence of infection (e.g. in pancreatitis).

SIRS is defined as two or more of the following:

Temperature more than 38°C or less than 36°C.

Heart rate more than 90 beats/min.
Respiratory rate more than 20 breaths/min or PaCO2 less than 4.3 kPa.
WBC count 12,000/mm3, less than 4000/mm3 , or more than 10% immature (bands) form.

A leaking aortic aneurysm is still a possibility, however a decreased white cell count would not be
expected.

We do not have enough information to diagnose multi-organ dysfunction. There is no evidence of

infection to make a diagnosis of septic shock or severe sepsis. For information, sepsis is defined as
the association of systemic inflammatory responses with evidence of microbial origin. Severe sepsis
also has hypoperfusion or dysfunction of at least one organ system, and septic shock is this plus
hypotension refractory to fluid resuscitation

8.A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary to
pancreatitis is admitted to the High Dependency Unit.

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He has a pulse of 109 beats/min and a blood pressure of 89/74 mmHg despite receiving IV fluids and
urine output of 25 ml/hour after catheterisation.

Which of the following is the most appropriate course of action for this patient?

(Please select 1 option)

1 A central line Correct

2 A CT abdomen
3 A surgical referral
4 An arterial line
5 Broad spectrum antibiotics

Early goal-directed therapy (EGDT) in cases of SIRS or septic shock is becoming increasingly
recognised as potentially beneficial. If fluids are not achieving haemodynamic stability, and there is
indication of hypoperfusion as indicated by oliguria or lactataemia, then vigorous resuscitation is
indicated.

EGDT aims to increase organ perfusion through restoration of mean arterial pressure using inotropes
if necessary, maintaining central venous pressure (CVP), maintaining oxygenation, and using SjVO2
(jugular venous oxygen saturation) as a guide to oxygen utilisation at the tissue level. SjVO2 higher
than 70% is indicative of organ hypoperfusion, as oxygen is not being extracted.

Insertion of a central line above allows measurement of CVP, SjVO2 and the use of inotropes.

9.A 64-year-old man is admitted with severe epigastric pain. He has had the pain for 36 hours. An
abdominal x ray shows a central, dilated small bowel loop.

His temperature is 37.0°C, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min,
SpO2 85% on air.

His full blood count reveals:

Haemoglobin 130 g/L (130-180)

9
White cell count 3.2 ×10 /L (4-11)
Platelets 108 ×109/L (150-400)
MCV 105 fL (80-96)

Which of the following is the most appropriate initial treatment of this patient?

(Please select 1 option)

1 Administer high-flow oxygen Correct

2 Insert 2 × 14 gauge venflons and give 2 litres Hartmann's solution
3 Intensive care
4 Intubation and ventilation

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MRCP 1 On examination ITU 2015
5 Invasive monitoring

This patient has systemic inflammatory response syndrome, possibly caused by acute pancreatitis
given the finding of an isolated dilated loop of small bowel on abdominal radiograph. However, the
initial treatment is the same independent of the underlying cause.

All of the above answers are reasonable, however resuscitation of the sick patient still follows the
ABC algorithm:

Airway
Breathing
Circulation.

Airway control and oxygen to maintain normal saturations is the first part of that algorithm.
Subsequent fluid resuscitation and treatment of the underlying cause can then be initiated. The need
for invasive monitoring and intensive care is then assessed, depending on the response to initial
treatment

10.A 64-year-old man is admitted with central epigastric pain.

Abdominal x ray shows a central dilated bowel loop. His temperature is 37.0°C, pulse 130 beats per
min, blood pressure 80/50 mmHg, respiratory rate 29/min and SpO2 90 on air.

His full blood count reveals:

Haemoglobin 130 g/L (130-180)

9
White cell count 3.2 ×10 /L (4-11)
Platelets 108 ×109/L (150-400)
MCV 105 fL (80-96)

Which of the following is the most likely diagnosis?

(Please select 1 option)

Acute pancreatitis has a mortality of 7-10%, often due to sepsis or multi-organ failure. There are a
number of scoring systems which can be used to guid

Gall stone ileus

Ischaemic bowel
Pancreatitis CORRECT
Perforated duodenal ulcer
Small bowel obstruction

e prognosis, but they are unreliable within the first 48 hours o f the illness. Gallstones account for
50% of cases, with the majority of the rest being associated with alcohol.

Patients typically present with severe epigastric pain which radiates to the back and vomiting. As
seen in this example, there is often a systemic inflammatory response. Amylase is markedly raised,
often in excess of four times the normal value. Early complications include ARDS (adult respiratory
distress syndrome), acute kidney injury and disseminated intravascular coagulation (DIC).
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MRCP 1 On examination ITU 2015
Treatment is essentially supportive, and high levels of monitoring are usually required (often in the
intensive care unit). Those patients who are found to have gallstones should be considered for
emergency ERCP, and all should have a cholecystectomy during the same admission

11. A 74-year-old man with ischaemic heart disease is in the surgical high dependency unit following
a Hartmann's procedure completed 12 hours previously.

He is in pain. He has drained 100/200/300 mls of blood into his drains in each of the last three hours.
His blood pressure is 110/80 mmHg, his pulse 105/min. He has a respiratory rate 32/min, SpO2
100% on oxygen by face mask.

Crossmatched blood is available.

Haemoglobin 81 g/L (130-180)

9
White cell count 4.5 ×10 /L (4-11)
Platelets 132 ×109/L (150-400)

Which of the following actions would be undertake as your initial priority?

(Please select 1 option)

1 Give 1000 ml of colloid stat

2 Give 1000 ml of crystalloid stat
3 Morphine 5 mg intravenously
4 Return to theatre
5 Transfuse 2 units of packed red blood cells stat CORRECT

He is still actively bleeding and haemodilution will not have been achieved so his Hb will be lower
than the result given. It will take at least 30-60 minutes before he is back in theatre and anaesthetized
(CEPOD lists/emergency sections/crash calls/no porter etc). With IHD he is at at high risk of a
perioperative MI. He should have the blood first as crossmatched blood is available.

His observations could be caused by pain. However in the face of a fallinghaemoglobin, a rising
pulse rate and an increasing loss into his drains this patient needs to return to theatre.

His blood pressure is not critically low and although many would give crystalloid or colloid it is
reasonable in an elderly man with ischaemic heart disease to give blood if it is easily available.
Overload with non-oxygen carrying fluid should be avoided (although the red cells are not functional
for a while

12. A 67-year-old man who is three days post-operation for a sigmoid colectomy. He has insulin
dependent diabetes mellitus. He complains of dizziness, upper abdominal discomfort and faintness.

His blood pressure is 110/75 mmHg, his pulse is 95 bpm, he has a respiratory rate 24/min, and he has
SpO2 99% on air. His blood glucose is 18 mmol/l.

His electrocardiogram shows ST depression of 2 mm in leads II, III and AVF.

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MRCP 1 On examination ITU 2015
Which of the following is the initial drug therapy for this patient?

(Please select 1 option)

1 Aspirin 300 mg Correct

2 Clexane 1 mg/kg subcutaneously
3 Clopidogrel 75 mg
4 Diamorphine 2.5 mg
5 Glycerol trinitrate 800 mcg sublingually

Initial treatment of an acute coronary syndrome is aspirin 300 mg. This should be safe in the post-
surgical patient with no signs of bleeding at three days post operation. Clexane would have also been
given pre- and post-op.

The dose of clopidogrel is 300 mg in an acute coronary syndrome.

Diamorphine is used to treat anxiety and pain, neither of which is commented upon.

GTN would be reasonable to try, however the blood pressure is low.

Remember that in the diabetic chest pain may not be a feature of acute coronary syndrome due to
autonomic dysfunction, and in most post surgical patients myocardial infarct is silent.

13. A 56-year-old man with severe brain damage is apnoeic, unsedated, and temperature 36.9°C.

He is intubated and ventilated. His biochemistry is normal.

The combination of which of the following specialists would be able to confirm brain stem death?

(Please select 1 option)

1 Consultant/specialist trainee with

one years experience
2 Consultant/specialist trainee with three years experience
3 Consultant/specialist trainee with four years experience
4 Consultant/specialist trainee with five years experience CORRECT
5 Consultant/specialist trainee with two years experience

The conventional criteria previously established for clinical death were based upon lack of
cardiorespiratory function.

The development of organ transplantation highlighted patients who had conditions incompatible with
life, but who continued to have some form of cardiorespiratory function with artificial support. This
led to a code of practice for the diagnosis of brainstem death.

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This is based on the knowledge that when the brainstem is damaged to such a degree that its
functions are irreversibly destroyed, the heart will inevitably stop beating shortly afterwards. When
this occurs, therefore, the patient is dead even though respiration and circulation can be artificially
maintained. Brain stem function is checked through set criteria, and the findings must be agreed by at
least two senior doctors. One should be a consultant, and the other must have at least five years post
registration who has experience in the testing of brain stem death.

'Life-support' should be withdrawn at this point, but consideration should be taken as to whether the
person would be a suitable organ donor.

14. An 18-year-old male is admitted with a history of diarrhoea and vomiting associated with
weakness and lethargy.

His motor power in the distal arms and legs is decreased and he describes difficulty swallowing. His
forced vital capacity (FVC) is 1.5 litres.

Which of the following is the most appropriate immediate treatment for this condition?

(Please select 1 option)

1 Cyclophosphamide
2 Intravenous immunoglobulin therapy (IgG) 0.5 g/kg CORRECT
3 Intubation and ventilation
4 Plasmapheresis
5 Prednisolone 60 mg

This scenario is suggestive of Guillain-Barré syndrome (GBS).

Dysphagia is a dangerous symptom suggestive of bulbar involvement. However a FVC of 1.5 litres
is not an indication for immediate ventilation (a FVC of less than 1 litre would be an indication).

First line therapy is intravenous IgG. Plasmapheresis can also be used but requires specialist
equipment.

Steroids are of no benefit.

Cyclophosphamide, although an immune suppressant, is a red herring.

15.A 27-year-old female with adult respiratory distress syndrome (ARDS) is ventilated on intensive
care.

Her inspired oxygen is 100%, positive end expiratory pressure is 15 cmH2O and peak airway
pressure is 40 cmH2O.

Her arterial blood gas shows:

PaO2 6 kPa (11.3-12.6)

PaCO2 6.9 kPa (4.7-6.0)

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SpO2 88% (>92%)

What treatment has been shown to decrease mortality in this patient group?

(Please select 1 option)

1 High frequency oscillatory ventilation

(HFOV)
2 Increasing tidal volume and respiratory rate
on the ventilator
3 Inhaled nitric oxide therapy
4 Prone position
5 Extracorporeal membrane oxygenation (ECMO) CORRECT

This lady is on maximal ventilatory therapy but is still hypoxic. Her high CO2 is a reflection of
permissive hypercapnia to prevent overdistension of the lungs with high tidal volumes.

Treatment of these patients used to be extremely difficult, with no significant improvement in

prognosis seen will any technique. However, in 2010 the CESAR trial demonstrated a significant
increase in survival without significant disability with the use of extracorporeal membrane
oxygenation (ECMO).

ECMO involves connecting a patient's circulation to an external oxygenator and pump, via a catheter
placed in the right side of the heart. It requires the continuous infusion of anticoagulant, and as such
bleeding is the most commonly associated complication. Infection and haemolysis are also a risk.

A recent study1 published in the NEJM concluded that prone positioning improved outcome in
severe ARDS. However, it is only one study in a controversial area. There are a number of studies,
including one by the same group, which have not shown a mortality benefit (and others which show
a detrimental effect on mortality). Prone positioning is therefore not yet widely accepted in clinical
practice, although this may change in the future.

For the purpose of this exam (where there are single best answers), ECMO remains the correct
answer

16.A 21-year-old male is admitted with acute onset headache and is drowsy.

He is opening his eyes spontaneously, is disoriented but is localising to painful stimuli.

Which of the following is the investigation of choice for this man?

(Please select 1 option)

1 Computed tomography (CT) Correct

2 Lumbar puncture (LP)
3 Magnetic resonance angiography (MRA)

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4 Magnetic resonance imaging (MRI)
5 Positron emission tomography (PET)

Urgent CT will confirm diagnosis in 95% of patients with subarachnoid haemorrhage.

Lumbar puncture is not usually required unless the history is suggestive and the CT is normal.

Blood will be present in the cerebro-spinal fluid (if a bloody tap is suspected the number of red blood
cells should fall with each successive sample).

If the LP is performed six hours after onset of symptoms the supernatant fluid should be examined
for xanthochromia after centrifugation

17.A 21-year-old male is admitted with acute onset headache and is drowsy.

He is opening his eyes spontaneously, is disoriented and is localising painful stimuli. He has a
normal computed tomography (CT) scan.

Which of the following is the most appropriate next investigation for this patient?

(Please select 1 option)

1 Cerebral angiography
2 Lumbar puncture CORRECT
3 Magnetic resonance angiography
4 Magnetic resonance imaging
5 No further investigations necessary

Lumbar puncture (LP) is not usually required unless the history is suggestive and the CT is normal as
in this case.

Blood will be present in the CSF (if a bloody tap is suspected the number of red blood cells should
fall with each successive sample).

If the LP is performed six hours after onset of symptoms the supernatant fluid should be examined
for xanthochromia after centrifugation

18.A 67-year-old male is admitted with central chest pain of sudden onset which radiates through to
his back.

His blood pressure is 160/70 mmHg in his right arm and 140/60 mmHg in his left arm. He has
electrocardiographic (ECG) changes in leads II, III and AVF showing ST elevation of 2 mm.

What is the most likely diagnosis?

(Please select 1 option)

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1 Coarctation of the aorta
2 Dissecting thoracic aortic aneurysm CORRECT
3 Inferior myocardial infarct
4 Pancreatitis
5 Perforated duodenal ulcer

This history is suggestive of a dissecting thoracic aortic aneurysm.

The ECG changes of inferior myocardial infarct suggest that the aneurysm has dissected the right
coronary artery at its ascending aortic ostium. An ascending aortic dissection needs immediate
surgery. Whilst en route to surgery, beta-blockade to control hypertension is appropriate.

An inferior myocardial infarct is high in the differential - however thrombolysis will kill a patient
with an aortic dissection.

Coarctation can give different blood pressures in either arm but is a chronic condition. Ulcer and
pancreatitis may mimic a heart attack, but with a normal ECG

19.A 47-year-old man presents with progressive right hand swelling two days after being bitten by a
dog.

On examination there is a puncture wound with pus over the dorsum of the hand, cellulitis, ascending
lymphangitis and tender axillary lymphadenopathy.

What is the most appropriate antibiotic therapy in this case?

(Please select 1 option)

1 Benzylpenicillin and flucloxacillin

2 Ceftriaxone
3 Ciprofloxacin
4 Co-amoxiclav CORRECT
5 Erythromycin

Only 15 - 20% of dog bites become infected, and providing the wound is appropriately cleaned and
not considered at risk (for example, crush or deep wounds) then antibiotic prophylaxis may not be
required.

However, this patient has an infected wound and infective organisms include Pastuerellaspp, Staph.
aureus and anaerobes like Corynebacterium.

The most appropriate antibiotic therapy in dog bites associated with cellulitis would be co-amoxiclav

20.A 78-year-old male who presents with increasing dysphagia is diagnosed with an inoperable
carcinoma of the distal oesophagus. Oesophageal spasm causes food to stick after swallowing which
causes odynophagia.

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Which drug would be most helpful in relieving his chronic pain?

(Please select 1 option)

1 Clodronate
2 Dexamethasone
3 Nifedipine CORRECT
4 Oxybutynin
5 Pinaverium

Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal
tumours and could be used to relieve his odynophagia.

Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the
associated hypercalcaemia.

Pinaverium is used to reduce the pain duration associated with irritable bowel syndrome (IBS).

Corticosteroids are used to treat pain from central nervous system tumours and painful bladder spasm
may be relieved by oxybutynin

21.Which of the following statements regarding the subclavian vein and its relations is correct?

(Please select 1 option)

1 Begins at the lateral border of the first rib Correct

2 Forms the axillary vein
3 Joins the superior vena cava
4 The thoracic duct joins the right subclavian
5 The subclavian vein passes posterior to scalenus anterior

The subclavian vein is a continuation of the axillary vein, beginning at the lateral border of the first
rib.

It passes anterior to scalenus anterior.

The subclavian and internal jugular vein unite to form the brachiocephalic vein, subsequently the left
and right brachiocephalic veins unite to form the superior vena cava.

The thoracic duct enters the left subclavian.

The brachiocephalic trunk is a branch of the aortic arch, which divides to form the right subclavian
and right common carotid arteries

22.Which of the following statements regarding the internal jugular vein and relations is true?

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(Please select 1 option)

1 Lies lateral to the common carotid artery Correct

2 Originates at the carotid canal
3 Passes behind the clavicle to join the superior vena cava
4 Passes posterior to the subclavian artery
5 Receives a lymphatic trunk at its union with the external jugular vein

The internal jugular vein originates at the jugular foramen.

It initially lies posterior to the carotid artery, as it descends in the carotid sheath it lies lateral first to
the internal then the common carotid artery within the carotid sheath.

It passes anterior to the subclavian artery to join the subclavian vein and then form the
brachiocephalic vein; the left and right brachiocephalic veins unite to form the superior vena cava.

The internal jugular vein receives a lymphatic trunk at its union with the subclavian vein.

The external jugular vein drains into the subclavian vein

23.A 67-year-old man complains of dizziness and faintness. He has insulin dependent diabetes
mellitus and he had a sigmoid colectomy three days previously.

His blood pressure is 80/50 mmHg, his pulse 110 beats per min, his respiratory rate 24/min, and he
has SpO2 99% on air. His plasma glucose concentration is 18 mmol/L (3.0-6.0 fasting)

Which of the following is the most appropriate investigation for this patient?

(Please select 1 option)

1 Arterial blood gas

2 Chest x ray
3 Electrocardiogram CORRECT
4 Serum lactate
5 Urine ketones

This man may have a cardiac cause for his dizziness.

The highest prevalence of myocardial infarction is 72 hours post operation. Patients with diabetes
may not have chest pain due to autonomic dysfunction.

The differential diagnosis would include pulmonary embolus. It may also include diabetic
ketoacidosis, but this would be unlikely with his glucose at 18 mmol/l and would not directly explain
his hypotension. Also, he would be expected to have a slightly higher respiratory rate than 24/min.

The most appropriate immediate investigation in this scenario would be ECG.

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If the scenario involved a shorter postoperative time frame (up to 48 hours), exclusion of
haemorrhage would take high priority

24.A patient needs central venous access for total parenteral nutrition (TPN)..Which of the following
is the cleanest site for placement?

(Please select 1 option)

1 Left femoral
2 Left internal jugular
3 Right femoral
4 Right internal jugular
5 Right subclavian CORRECT

Right or left subclavian is regarded as the cleanest site for central venous access. It also the most
tolerated by patients.

However the incidence of subclinical pneumothorax even in the hands of experienced clinicians has
led to it falling out of favour.

25.A 26-year-old female is admitted to ICU with severe asthma.

She is ventilated for one week and receives IV co-amoxiclav/clarithromycin, magnesium,

prednisolone, sedatives and muscle relaxants.

She improves gradually but two days after stopping muscle relaxants she still is unable to be weaned
from ventilatory support.

On examination, she is alert but has flaccid weakness of all limbs.

Which of the following is the likely diagnosis?

(Please select 1 option)

1 Critical illness polyneuropathy

2 Guillain-Barré syndrome
3 Hypermagnesaemia
4 Prolonged neuromuscular blockade CORRECT
5 Steroid induced myopathy

The history suggests prolonged neuromuscular junction (NMJ) blockade which may be exacerbated
by both corticosteroids and magnesium.

This condition was originally described with suxamethonium due to hereditary reductions in plasma
cholinesterase activity.

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MRCP 1 On examination ITU 2015
However, drugs and electrolyte abnormalities may exacerbate this.

26.A 23-year-old man is taking part in an expedition in the Andes and has recently ascended to
above 3000 metres. Even accounting for sleeping in a small expedition tent he has a very poor night's
sleep and begins to vomit profusely with a severe headache.

On examination his BP is 145/72 mmHg, pulse is 85 and regular. There are bilateral crackles on
auscultation of his chest.

You are the expedition doctor and suspect he is suffering from acute altitude sickness.

Which of the following is the optimal next step?

(Please select 1 option)

1 Acetazolamide
2 Descent CORRECT
3 Dexamethasone
4 Furosemide
5 Oxygen therapy

The headache, nausea and vomiting is thought to relate to cerebral oedema, which occurs because of
changes in cerebral blood flow at altitude. Optimal treatment is clearly to descend to lower altitude if
possible. If individuals have previously suffered altitude sickness they may be able to avoid it in
future by slowing the rate of ascent to altitude or treatment with acetazolamide.

Acetazolamide, dexamethasone and hyperbaric oxygen may all impact on symptoms of altitude
sickness, but they are subsidiary to descent in their degree of efficacy.

The pulmonary crackles indicate this gentleman has probably also got high altitude pulmonary
oedema. Treatment is again descent and suplimental oxygen.

Acetazolamide is preferred to loop diuretics such as furosemid

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