(2019) Passmedicine - Passmedicine MRCP Part I

Question 1 of 382
A 70-year-old man with an existing diagnosis of 5.0 em abdominal aortic aneurysm and
atrial fibrillation presents with acute onset abdominal pain radiating to his back. He is still
actively bleeding and his observations show the following:
Blood pressure 90/40 mmHg

Heart rat e 140 beats per minute
The decision is made to proceed with emergency surgery with in the next thirty minutes
Whi ch of the following is the most appro priate management of warfarin therapy?
Give 5 mg vitam in K intravenously
Stop warfarin and commence treatment dose enoxaparin only
Continue warfarin but bridge with enoxaparin immediately after surgery
Give four-factor proth rombin complex concentrat e 25-50 units/ kg
m
se
As
Begin dual therapy with warfarin and enoxaparin until INR is in range
Dr
Give 5 mg vitam in K intravenously
Stop warfarin and commence treatment dose enoxaparin only
Continue warfarin but bridge with enoxaparin immediately after surgery
I Give four-factor prothrombin complex concentrate 25 -50 units/ kg
Begin dual therapy with warfarin and enoxaparin until INR is in range
Patients on warfarin undergoing emergency surgery - give four-factor prothrombin

complex concentrate
Important for me Less ' mpc rtC~nt
British Journal of Haemat ology Guidelines in patients on warfarin having emergency

surgery:
If surgery can wait for 6-8 hours - give 5 mg vitamin K IV

If surgery can't wait - 25-50 units/kg four-factor prothrombin complex
The guidance is to stop warfarin before elective or emergency surgery, so options 3 and 5
m
are incorrect
se
Because this is emergency surgery, reversal of anti-coagu lation is necessary so option 2 is
As
incorrect
Dr
A 71-year-old man who had rheumatic fever as a child is admitted t o the cardiology ward
with suspected infective endocarditis. This is confirmed by blood cultures and
echocardiography. Which one of the following is most likely to be represent a need for
su rgical intervention?
A septic embolism in the right kidney
Persistent pyrexia after 48 hou rs of antibiotics
Lengthening o f the PR int erval on ECG
Pre-existing left ventricular impairment
m
se
As
Streptococcus viridans isolat ed on blood cultu res
Dr
I A septic e mbolisT in the right kidney
Persistent pyrexia after 48 hou rs of antibiotics
Lengthening of the PR interval on ECG
Pre-existing left ventricular impa irment
Streptococcus viridans isolated on b lood cu ltures
Infective e ndoca rditis - indications for su rge ry:

• seve re valvular inco mpete nce
• a o rtic ab scess (often indicated by a lengthe ning PR interva l)
• infections resista nt to antib iotics/ fu ng al infections
• ca rdiac fa ilure refracto ry to sta ndard medica l treatment
• recurrent embo li a fter antibiotic the ra py
Important for me Less 'mpcrtant
m
se
Lengthening o f the PR interval is like ly to represent a n aortic root abscess which will
As
require su rgical intervention.
Dr
A 65 -year-old patient with chronic kidney disease is found to have a deficiency of
antithrom bin III after he p resented to emergency department with left leg pain and
swelling .
A doppler-ultraso und scan of the leg confirms deep venous thrombosis (DVT). The
patient is started on dabigatran.
What is the mecha nism o f action of dabigatran?
Activates anti -thrombin III
P2Y12 inhibitor
Glycoprotein lib/Ilia inhibitor
m
Direct th rombin inhib itor
se
As
Direct factor X activator
Dr
P2Y12 inhibitor
Glycoprotein lib/lila inhibitor
Direct throm bin inhibitor
Direct factor X activator
Dabigatran is a direct thrombin inhibitor

Important for me Less ' m ::~c rtant
Below is a table of the drugs and their mechanisms of actions (MOA):
Drug name MOA
Heparin activates anti-thrombin III
Clopidogrel P2Y12 inhibitor
Abciximab glycoprotein lib/lila inhibitor
Dabigatran direct thrombin inhibitor
m
se
As
Rivaroxaban direct fact or X inhibito r
Dr
Which one o f the following is a cause of a soft second heart sound?
Ao rtic stenosis
Ao rtic regurgitation
Mitral stenos is
m
Mitral regurgitation
se
As
Pu lmonary hypertension
Dr
I Aortic stenosis CD
Aortic regurgitation 6D
Mitral stenosis CD
Mitral regurgit ation «ED

Pulmonary hypertension «ED
Second heart sound (S2)

• loud: hypertension
• soft: AS
• fixed split: ASD
• reversed sp lit: LBBB
Important for me Less imocrtont
m
se
As
S2 is soft in severe aortic stenosis
Dr
A 62-year-old man is reviewed two hou rs after a successfu l elective DC cardioversion for
atrial fibrillation. Six weeks ago he p resented in fast atrial f ibrillation. A d ecision was made
at the time t o wa rfa rinise him for six w eeks after which he was to be cardioverted. During
this time he had a normal t ransthoracic echocardiog ram. He has no past medical history
o f note other than treatment for a basal cell carcinoma. What is the most app ropriate
plan regarding anticoagulation?
Can stop immediately
Continue warfarinisation for 1 week then review following
Lifelong warfarin
Lifelong aspirin
m
se
As
Continue warfarinisation for 4 weeks then review
Dr
Can stop immediately
Continue warfarinisation for 1 week then review following

-
~
Lifel ong warfarin
Lifelong aspirin
m
se
As
Continue warfarinisation for 4 weeks then review
Dr
Which one o f the following cl inical feat u res wou ld b e least consist ent w it h a diagnosis of
severe pre-eclampsia?
Head ache
Epigastric pain
Ref lexes difficu lt to elicit
Low platelet count
m
se
As
Papilloed ema
Dr
Headache
Epigastric pain
Reflexes difficult to elicit
Low platelet count
Papilloedema
m
se
Severe pre-eclampsia is associated with hyperreflexia and clonus. A low platelet cou nt
As
may indicate the patient is developing HELLP syndrom e
Dr
Which one of the following is least associated with aortic regurgitation?
Rheumatic f ever
William's syndrome
Syphilis
Bicuspid aortic valve
m
se
As
Post-rheumatic disease
Dr
Rheumatic fever f!D
~li a m's syndrome CD
Syphi lis GD
Bicuspid aortic valve QD
Post-rheumatic disease CD
m
se
As
Wi ll ia m's syndrome is associated with suprava lvular aortic stenosis.
Dr
A 67 -year-old wo man presents t o the cardiology clinic for urgent review. She is known to
have mitral stenosis, but feels like her exercise tolerance has deteriorat ed rapidly over the
past few months. She is short of breath on minimal exercise and suffers from haemoptysis
Current medication includes bisopro lol lOmg, isosorbide dinitrat e 60mg, and furosemide
40m g daily. Her blood pressure is 105/ 88 mmHg, pulse is 62 (slow atrial fibrillation). There
are crackles at both lung bases on auscultation of the chest.
Which of the following is the most appro priate next st ep?
Surgical valve replacement
Percuta neous mitra l valvotomy
Digoxin
Increased furosemide dose
m
se
As
Ram ipril
Dr
Percuta neous mitral valvoto my
Digox\Ln _ _
Increased furosem ide d ose
Ram ipril
Percutaneous mitral com missu roto my is the inte rvention of cho ice fo r severe mitra l
stenosis
Important for me l ess 'mocrtont
At this point, with a na rrow pulse pressure, resista nt ca rdiac fa il ure, a nd a narrow, low
pulse pressu re, it seems app ropriate to move to percutaneous va lvotomy.
Co ntra -i ndications to va lvotomy include a mitra l va lve area > 1.5 cm 2, presence of leh
a trial th rom bus on ECHO, greate r than mild mitra l regurgitatio n, severe va lve ca lcification,
seve re concom itant aortic valve disease, seve re comb ined mixed tricuspid va lve disease,
and concomitant coro na ry a rte ry d isea se requ iring bypass su rgery. In the event symptoms
are not resolved by va lvoto my, fo rma l surg ical valve rep la cement is indicated.
Surgica l va lve re p lace ment is on ly indicated where valvotomy is contra indicated o r is

unsu ccessful. There is ve ry limited opportu nity to increase med ical the rapy in th is
m
populatio n, with systolic blood p ressu re o nly just above 100, and a heart rate of 62 beats se
As
oer minute.
Dr
A 71-yea r-old man who is known to have atrial fibrillation co mes fo r review. He had a
tra nsie nt ischaem ic attack two weeks ago and takes bendroflumethiazide fo r hype rtens ion
but is otherwise well. His latest b lood p ressure is 124/ 76 mmHg . You are discussing
management o ptions to try and reduce his future risk o f having a stroke. What is his
CHA2DS2-VASc sco re?
m
se
As
5
Dr
1 CD
2 GD
3 fD
r4 CiD
5 GD
m
se
One point for hypertension, one point for being over the age of 65 years (but und er the
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age of 75 years) and two point s ('52') fo r the recent TIA.
Dr
A 28-yea r-o ld ma n with hypertrophic o bstructive ca rd iomyo pathy is investigated for
pa lpitatio ns. A 24 hour ECG revea ls runs o f no n-susta ined ve ntricu la r tachycardia. What is
the most a pp ropriate ma nagement?
AV node ablation
Accessory pathway a blation
Am iodaro ne
Im p la nta ble ca rdioverter defibrillator
m
se
As
Sotalo l
Dr
AV node a blation
Accessj ry pathway a blatio n
Am iodarone
~plantable cardioverter defibrillator

Sota lo l
-
"""
m
se
Most ca rd io log ists wou ld now proceed to inserting a n imp lantab le cardioverte r
As
d efibri llato r to lower the risk of sud den cardia c d eath
Dr
Which o f the fo llowing is not true rega rd ing B-type natriuretic peptide?
Secreted ma inly by the ventricles
Acts as a d iu retic
Acts as a vasoconstricto r
Leve ls rise in leh ventricula r fa ilu re
m
se
As
Reduces sympathetic tone
Dr
Secreted ma inly by the ventricles
Acts as a d iu retic
Acts as a vasoconstrictor
Leve ls rise in leh ventricula r fa ilu re
Reduces sympathetic to ne
BN P - actions:
• vasodilator
• diuretic and natriuretic
• suppresses both sympathetic tone an d the renin-angiotensin-aldoste rone
m
se
system
As
Important for me Less impcrtont
Dr
What is the role of troponi n in cardiac muscle?
Component of the thick filaments
Acts as a linin g of the T tubules
Anchors thick filament to Z-discs
Component of the thin filaments
m
se
As
Anchors thick and thin filaments together
Dr
What is t he role of tropo nin in cardia c muscle?
Component of the thick filaments CD

Acts as a lining of the T tubules f!D
Anchors thick filament to Z-discs .
(D
I Component of the thin filaments ED

Anchors thick and thin filaments together fD
m
se
The other compo nents of thin filaments are actin and tropomyosin. Thick filaments are
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primarily composed of myosi n.
Dr
An 11-year-old boy who is known to have Down's syndrom e is reviewed in the cardiology
clinic. Over the past year his pa rents report that he is more tired and breathless when he
plays with his peers and siblings.
On exam ination he appea rs cyanosed at rest. His p ulse is 90/min with no rad io-femoral
d elay. There is a systolic mu rm ur and a loud second heart sound. A right ventricular heave
is noted and the JVP is elevated.
What is the most likely diagnosis?
Eisenmenger's synd rome
Fulm ina nt patent ductus arteriosus
Fulm ina nt tra nsposition o f the great arteries
Ebstei n's a nomaly
m
se
As
Tetralogy of Fa llot with pu lmonary atresia
Dr
Eisenmenger's syndrome
Fulminant pat ent ductus arteriosus
I Fulr inant tra nsp osition of t he great arteries
Ebstein's anomaly
Tetralogy of Fallot w ith pulmonary at resia
m
se
This boy is likely to have b een born with a at rioventricular sept al d efect. Over t ime t he
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shunt is likely t o have reversed resulting in Eisen menger's syndrome.
Dr
A 45-yea r-o ld fe mal e is d ue to unde rg o a denta l extractio n fo r re lief o f ne uralg ic pain.
Additio na lly, she is having a hyste recto my in 4 weeks fo r a fibro id ute rus with
me no rrhagia. She me nti ons to you that s he has previously been d iagnosed with a heart
murmur and wa nts to know if this will affect her o pe ration.
In regard to her va lvula r heart disease and associated risk, what is the most a ppro priate
thing to advise he r?
She should have a ntibiotic p rophylaxis a t the time o f hysterectomy o nly
She should have a ntibiotic p rophylaxis for both proced u res
She is not at risk o f infective endoca rd itis so shou ld not wo rry
She is at theo retical risk o f infective e ndoca rditis b ut antibiotic pro phylaxis is no
longer a dvised routine ly fo r e ither procedure
m
se
She should b e offe red chlo rhexidine mouthwash as pro phylaxis when undergoing
As
the denta l extraction
Dr
She should have a ntibiotic p rophylaxis a t the time of hysterectomy only (D
She should have antibiotic p rophylaxis for both p rocedures CD

She is not at risk of infective endocarditis so should not worry f!D
e is at theoretical risk of infective end ocarditis b ut antib iotic prophylaxis is no
ger advised rout inely for e ither procedure GD
She should b e offered chlorhexidine mouthwash as prophylaxis when undergo ing CD

the denta l extraction
Antibiotic pro hylaxis to prevent infective e ndoca rditis is not routi nely reco mmend ed
in the UK fo r d ental and othe r p roced ures
Important for me l ess ' m ::~c rtont
The answe r to th is question is based on NICE Gu idance (CG64 - Ma rch 2008).
Acco rding to th is guidance, as neither procedure requ ires prophylaxis (either antibiotics
or mouthwash) the only app ropriate answer he re is 4 : that the patient is at theoretical risk
m
se
o f infective endoca rditis but that antibiotic prophylaxis is no longer routine ly
As
recom mended. Dr
Which one o f the followin g conditions is most associated with a b isferiens pulse?
Cardiac ta mponade
Severe leh ventricu la r failure
Aortic stenosis
Patent ductus arteriosus
m
se
As
Mixed aortic valve disease
Dr
Which one of the followin g conditions is most associated with a bisferiens pulse?
Card iac ta mponade
Severe leh ventricular failure
Aortic stenosis
Patent d uctus a rteriosus
m
se
As
Bisfe riens p ulse - mixed aortic valve d isease
Dr
A 54-yea r-old man with angina has a p ercutaneous coro na ry intervention with in serti on
of a drug-eluting stent. What is the s ing le most important risk facto r for stent
thro mbosis?
Age of patie nt
Premature withdrawal of a nti platelet the ra py
Faili ng to adhe re to ca rd iac rehab ilitation p rog ram
Duration o f proced u re
m
se
As
Histo ry of diabetes mellitus
Dr
Age of patient
Premature withdrawal of a nti platelet t herapy
Faili ng to adhere to card iac reha bilitation p rogram
Duratio n o f procedure
History of d iabetes mellitus
PC!: stent throm bosis - with drawal of a ntiplate lets b igg est risk factor
Important for me Less im:>crtc.nt
m
se
As
Diabetes mell it us is a risk factor for restenosis rather than stent throm bos is
Dr
A 52-yea r-old man is seen in the hypertension clinic. He was d iagnosed a rou nd three
months ago and sta rted on ram ipril. This has b een titrated up to lOmg o d but his b lood
p ressure remains around 156/92 mmHg. What is the most ap po priate next step in
management?
Add bendroflumethiazide
Add bisop rolol
Switch ramipril to perindopril
Add am lodipine
m
se
As
Add losa rta n
Dr
Add bendroflumethiazide D.
Add bisoprolol CD
Switch ra mipril to perindopril

•
I Add amlodipine fD
Add los arta n
•
Calcium channe l blockers are now preferred to thiazides in the treatment of
hypertension
Important for me Less imocrtant
The 2011 NICE guidelines reflect ed the chang ing evidence base supporting the use o f
m
se
calcium channel blockers in preference to thiazide-type diuretics in the management of
As
hypertension.
Dr
Which one of the followi ng is not a risk factor for the development of pre -eclampsia?
Body mass index of 38 kg/m"2
Smoking
A woman carrying twins
Nulliparity
m
se
As
Diabetes mellitus
Dr
Body mass index of 38 kg/m"2 CD
Smoking ED
A womar carrying twins CD
Nulliparity CD
Diabetes mellitus CD
m
se
As
There is some evidence to suggest that pre-eclampsia is actually less common in smokers
Dr
A 34-year-old man is investigated following an unexplai ned collapse whilst at work. A
resting ECG shows convex ST elevation in Vl-V3 with a partial right bundle bra nch block
pattern. What is the most likely diagnosis?
Catecholam inergic polymorphic ventricular tachycardia
Hypertrophic obstructive cardiomyopathy
Arrhythmogenic right ventricular ca rdiomyopathy
Brugada syndrom e
m
se
As
Normal variant
Dr
Catecholaminergic polymorphic ventricular tachycardia
Arrhythmogen ic right ventricular cardiomyopathy
Brugada syndrome
m
se
As
Normal variant
Dr
An 83-year-old male p resents with ischaemic sou nding che st pain th at has persisted for
the past one hour. A 12-lea d ECG is p erformed and s hows deep T wave inversio n in leads
Vl and V2.
Which is the mo st like ly imp lica ted corona ry arte ry?
Left circumflex artery
Left mai n stem artery
Proxima l left anterior descending artery
m
Right corona ry artery
se
As
Distal left a nterior d escending artery
Dr
Left circumf lex artery
Left main stem artery
Proximal left anterior descending artery
Right co ronary artery
Dista l left ant erio r descen ding artery
Ischaem ic changes in leads Vl-V4 - left anterior descending

Important for me Less imocrtc.nt
Wellens' syndrome is an ECG manifestation of critical proximal left anterio r descending
m
se
(LAD) coronary artery stenosis in patients with unstable angina. It is characterized by
As
sym metrical, often deep (> 2 mm), T wave inversions in the anterior precordial leads.
Dr
A 62-yea r-old female with no past medical history is adm itted to hospita l with a left-sided
he mipa resis. Exa mination reveals that she is in atrial fibrillation. CT scan of her brain
shows a cerebral infarction. What is the most appropriate anticoagulation strategy for this
patient?
Life-long warfa rin, sta rted immed iately
Aspirin started immediately switching to life-long warfarin after 2 weeks
Life-long aspirin, started immed iately
Life-long aspirin started after 2 weeks
m
se
As
6 months of warfarin, started im mediately
Dr
Life-long warfa rin, sta rted immediately fiD
Aspirin started immediately switching to life-long warfarin after 2 weeks GD

Life-long aspirin, started immediately m
Life-long aspirin started after 2 weeks C)
m
se
As
6 months of warfarin, started immediately m
Dr
A 55-year-old man presents w ith a 2-hour hist ory palpitations. He has no other history of
note and is generally fit and well. An ECG confirms fast atrial fibrillation with a rate of
140/ min. He has a fear of sedation an d requests pharmacologica l cardioversion. Which
one of the following agents is most likely to cardiovert him int o sinus rhythm?
Atenolol
Procainamide
Flecainide
Disopyramide
m
se
As
Digoxin
Dr
Atenolol CD
Procain amide GD
Flecainide CD
Disopyramide CD
Digoxin fD
m
se
As
Atrial fibrillation - ca rdioversion: amiodarone + flecainide
Dr
You are asked to urgently review a 61-year-old fema le on the ca rdiology wa rd due to
difficu lty in breathing. On examination she has a raised JVP with bilateral fine crackles to
the mid zones. Blood pressure is 94/60 mmHg and the pulse is 140-150 and irregular.
ECG confirms atrial fibrillation. What is the most appropriate management?
IV amiodarone
IV digoxin
Urgent synchronised DC cardioversion
Oral digoxin
m
se
As
IV flecainide
Dr
IV amiodarone
IV digoxin
Urgent synchronised DC cardioversion
Ora l digoxin
IV flecainide
m
se
Heart fa ilure is one of the adverse signs indicating the need for urgent synchronised DC
As
cardioversion
Dr
A 72-year-o ld man p resents to the Emergency Department with a broad complex
tachycardia. Which o f the following features wou ld make it more likely that this was due
to a supraventricular tachycardia rath er tha n a ventricu lar tachycardia?
History of ischaem ic heart d isease
Left axis deviation
Capture beats
Absence o f QRS concord ance in chest leads
m
se
As
QRS comp lex greater than 160 ms
Dr
I Histo{ o f ischaem ic heart d isease flD
Left axis deviation GD
Capture beats fiD
I Absence of QRS concordance in chest leads CD

QRS complex greater than 160 ms flD
m
se
As
Positive QRS concordance in the chest leads is associated with ventricu la r tachycardia
Dr
A 60-yea r-o ld ma le has a past med ical history of hypertension, type II diabetes a nd
ischaem ic heart disease. He has recently been started o n a new me d icatio n. His GP
notices that his HbAlc has increased sig nifica ntly over the same period. Which
me d icatio n is most li kely to have adversely a ffected his g lycaemic control?
Alendronic acid
Am iodarone
Allopurinol
Bendroflumethiazid e
m
se
As
Calcium carbonate and vitamin D3
Dr
Alendronic acid
Amiodarone
AlloRurino l
Bend rof l u methiazide
Calcium carbonate and vita min D3
Bendroflumethiazides can wo rsen glucose tolerance

Important for me Less · m oc rtC~nt
The correct answer is bend roflumet hiazide. Thiazides can worsen g lycaemic control and
increase urate levels w hich can worsen gout . The other drugs are not known t o have an
effect on glycaem ic control.
m
se
BN F:
As
https:/ / b nf.nice .o rg. u k/ d rug/ bend rofl u meth iazid e. html#s ideE ffect s
Dr
A 65-year-old female with a known history of heart failure presents for an annual check-
up. She is found t o have a blood pressure of 170/ 100 mmHg. Her current medications are
furosemide and aspirin. What is the most appropriate medication to add?
Bendroflumethiazide
Spironolactone
Bisoprolol
Vera pamil
m
se
As
Enalapril
Dr
Bendroflumethiazide CD
Spironolactone
Bisoprolol
•
.
GD
Verapamil f!D
Enalapril fD
Both enalapril and bisoprolol have been shown to improve prognosis in patients with
heart failure. Enalapril however would also be better at treating the hypertension. NICE
m
se
guidelines recommend the introduction of an ACE inhibitor prior to a bet a-blocker in
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patients with chronic heart failure
Dr
Each one of the fo llowing is associat ed w ith left axis deviation on ECG, except:
Left ant erior hemiblock
Ostium primum ASD
Left posterior hemiblock
Obesity
m
se
Left bundle branch block
As
Dr
Left ant erior hemiblock
Ostium primum ASD
~ posterior hemiblock
Obesity
-
~
m
se
As
Right axis deviation - left posterior hemiblock
Dr
A 55-year-old man with a history o f ischaemic heart disease presents t o the Emergency
Department w ith palpitations for the past 10 days. Examination of his pulse reveals a rate
o f 130 bpm which is irregularly irregular. He has had one previou s episode of atrial
fibrillation 3 months ago which was t erminated by elective cardioversion following
warfarinisation. What term best descri bes his arrhythmia?
Paroxysmal atrial fibrillation
Atrial flutter
Permanent atrial fibrillation
Persistent atrial fibrillation
m
se
As
Secondary atrial fibrillatio n
Dr
II. 55-yea r-o ld man with a histo ry o f ischaemic hea rt disease presents to the Eme rgency
De partment with pa lpitations fo r the past 10 d ays. Exa mination of his p ulse reveals a rate
Jf 130 bp m which is irregularly irregu la r. He has had one previous ep isode of atria l
fibrillation 3 months ago which was te rminated by e lective ca rdiove rsion fo llowing
Na rfarin isation. What term best d escri bes his a rrhythmia?
Paroxysma l atrial fibrill ation
Atrial flutter
-
~
Permanent a trial fibrillation
~sistent atrial fibrillation
m
se
As
Secondary atrial fibrillation
Dr
A 64-year-old man with a history of type 2 diabetes mellitus is admitted with chest pain
to the Emergency Department. An ECG shows ST elevation in the anterior leads and he is
thrombolysed and transferred to the Coronary Ca re Unit (CCU). His usual medication
includes simvastatin, gliclazide and met formin. How should his diabetes be managed
whilst in CCU?
Stop metformin. Continue gliclazide at a higher d ose
Stop metformin & gliclazide. Start subcutaneous insulin (basal- bolus regime)
Continue metformin & gliclazi de at same d ose
m
Stop metformin & gliclazide. Start intravenous insu lin infusion
se
As
Stop metformin & gliclazide. Start subcutaneous in su lin (biphasic insulin regime)
Dr
Stop metformin. Continue gliclazide at a higher dose
Stop metformin & gliclazide. St art subcutaneous insulin (basal-b olus regime)
Continue metformin & gliclazide at same dose
Stop metformin & gliclazide. Start intravenol!ls insu lin infusion

-
"""'
Stop metformin & gliclazide. St art subcutaneous insulin (biphasic insulin regime) CD
The benefits o f tight glycaemic control following a myocardial infarction were init ially
established by the DIGAMI study. These findings were not repeated in the later DIGAMI 2
study. However modern clinical practice is still that type 2 diabetics are converted to
intravenous insulin in the immediat e period following a myocardial infarction.
NICE in 2011 recommended the following: 'Manage hyperglycaemia in patients admitted
m
to hospital for an acute coronary syndrome (ACS) by keeping blood glucose levels below
se
11.0 mmol/litre while avoiding hypoglycaemia. In the first instance, consider a dose-
As
adjusted insulin infusion with regular monitoring of blood glucose levels.'
Dr
Each one of the following may cause leh bu ndle branch block, except:
Cardiomyopathy
Atrial septa l defect (ostium secund um)
Hypertension
Idiopathic fibrosis
m
se
Ischaemic heart disease
As
Dr
Cardiomyopathy CD
Atrial septal defect (ostium secundum) 6D
HypertensL
jo_n_ _ GD
Idiopathic fibrosis 6D
m
Ischaem ic hea rt disease
se
As
Dr
A 55-yea r-old female p rese nts to the e mergency depa rtment with an e ight-ho ur history
o f heart palpitations. She has a hea rt rate of 200 b eats pe r minute and an ECG shows
regular QRS com plexes o f 0.08 seconds . She ha s not had a ny chest pa in or episode s o f
syncope and has no signs o f heart fa ilu re. Her bloo d pressu re is 130/90 mmHg a nd her
oxyg en saturations a re 97% on a ir. What should you d o first?
Carotid s in us ma ssage
Adenosine 6mg
Adenosine 12mg
Am ioda ro ne 300mg
m
se
As
Atro pi ne O.S mg
Dr
I Carotid sinus massage
Adenosine 6mg
-CD
r :f enosine 12mg CD
Amiodarone 300mg m
Atropine O.S mg m
This fema le has a regu la r narrow complex tachycardia with no adverse featu res. The first
step in this instance wou ld, the refore, be to try va gal manoeuvres, for example, a carotid
sinus massage. If this is unsuccessful, IV adenos ine should b e given (6mg at first, followed
by 12mg if no response, and then by a furthe r 12mg if a ga in no response). If this is
unsu ccessfu l cons ider atrial flutter as the d iagnosis a nd treat as appropriate.
Amiodarone can be used for rhythm control if the patients' narrow complex tachycardia is
due to atrial fibrillation or atrial flutter. It co uld a lso be used in the ma nagement of b road
com plex tachycardia.
m
se
As
Atropine is used in the management of bradyca rdia .
Dr
An 89-year-old man attends your clinic, comp laining of bright spots in his vision that
come and go. He has a past medical hist ory o f asthma, triple vessel coronary artery
disease opting for medical management of his anginal sympt oms, and has just completed
a course of itraconazole for a fungal infection. His heart rate is 60bpm and blood pressure
120/70mmHg.
Which of his regular medications is most likely resp onsible for his sympt oms?
Am lodipine
Beza fibrat e
Ivabradine
Ranolazine
m
se
Ventolin
As
Dr
I Ivab rad ine ED
Ranolazine GD
Ventolin CD
Ivabrad ine is ind icated fo r the sympto matic re lief of angina in patients with a heart rate
> 70, as an a lternative to first line the rap ies. It is a lso ind icated fo r the treatm ent of chronic
heart fail ure (NYHA II-IV) in addition to standa rd the rapy, in patients with a heart rate of
> 75.
The mode o f action o f ivabradi ne is by inhibition of If channels (known as funny channe ls),
I = current, f =funny. These funny channels are so called because of their unusual features
compared to other ion channe ls. They a re mixed sodium and potass ium channe ls found in
spontaneously active reg ions o f the heart such as the s inoatrial node and are triggered by
hyperpola risation. Activated funny channe ls a llow an influx o f positive ions, triggering
d e polarisation and are therefo re responsible for the spontaneous activity o f cardiac
myo cytes.
m
se
By inhibiting If channels ivabrad ine de lays d epola risation in the sinoatria l nod e and
As
the refore selectively s lows heart rate .
Dr
A 71-yea r-o ld woman is a dmitted with acute dysp noea to the Emergency Departme nt.
Oxygen satu rations a re 94% on 28% supp le me ntary oxyge n and her resp iratory rate is
30/min. A rap id B-type natriu retic p eptide (BNP) assay is rep orted as fo llows:
BNP 62 pg/ml
What is the b est interpretation o f this resu lt?
No co nclus io n ca n b e drawn fro m this result
Pulmonary em bolis m is the most like ly cause of her symptoms
If a further BNP level is above 50 pg/ml after o ne hour then this is diag nostic of
hea rt failu re
Heart fa ilure is u nlike ly to be the cause of her dyspnoea
m
se
As
Heart fa ilure is highly likely to be the ca use of he r dyspnoea
Dr
No concl usion can be drawn from this resu lt
I Pulmonary embolism is the most likely cause of her symptoms
If a further BNP level is above SO pg/ml after one hour then this is diagnostic of
-
~
heart failure
I Heart failure is unlikely to be the cause of her dyspnoea
m
se
Heart failure is highly likely to be the cause of her dyspnoea
As
Dr
A 72-year-old man with a history of chronic heart failure secondary to ischaemic
cardiomyopathy is reviewed. He was discharged two weeks ago from hospital following a
myocardial infarction. An echocardiogram done during his admission showed a left
ventricular ejection fraction of 40% but did not demonstrate any valvular problems.
Despite his current treatment with furosemide, ramipril, carvedi lol, aspirin and simvastatin
he remai ns short of breath on minimal exertion such as walking 30 metres. On
examination his chest is clear and there is minimal peripheral oedema. What is the most
appropriat e next step in management?
Stop aspirin
Refer fo r cardiac resynch ronisation therapy
Switch carved ilol to bisoprolol
Add angiotensi n-2 receptor blocker
m
se
As
Add an aldosterone antagonist
Dr
Stop asp irin
Refer for card iac resynchro nisati on therapy
Switch ca rved ilol to b iso prolol
Add angiotensin-2 receptor b locker
I Add an aldosterone antagonist
The updated 2010 NICE gu id elines now su ggest that in additio n to a ld osterone
antag onists both angiotensi n-2 receptor blockers a nd hydralazine in combinatio n with a
nitrate are suitable second -li ne treatments for heart failure. However, g iven that he has
m
se
had a recent myo ca rdial infa rction the best choice is a n a ld osterone antag on ist - please
As
see the NIC E guide li nes for mo re d eta ils.
Dr
A 76-year-old woman is admitted with palpitations. During the cardiovascular
examination you notice irregular can non 'a' waves. Wh ich one of the following wou ld
account for this finding?
Atrio-ventricular nodal re-entry tachycardia
Atrial fibrillation with tricuspid stenosis
Ventricular tachyca rdia with 1:1 ventricular-atrial conduction
Complete heart block
m
se
Tricuspid regu rgitation
As
Dr
A 76-yea r-old wo man is admitted with palpitations. During the ca rdiovascular
exa mi nation you notice irregular cannon 'a' waves. Wh ich one of the following would
account fo r this finding?
Atrio-ventricular nodal re-entry tachycardia
Atrial fibrillation with tricuspid stenosis
Ventricular tachycardia with 1:1 ventricular-atrial conduction
I Complete hea rt block
m
se
Tricuspid regurgitation
As
Dr
A 63-yea r-old female is brou ght to the Emergency De partment due to a decreased level
of consciousness. An urgent CT head is performed as she takes warfa rin for atrial
fibrillation an d shows an intracranial haemorrhage. What is the most appropriate
management?
Protamine sulphate
IV vitamin Kalone
IV vitamin K + prothrombin com plex concentrate
Fresh frozen plasma alone
m
se
As
IV vitamin K + fresh froze n plasma
Dr
Protamine sulphate
IV vit amin K alone
IV vitamin K + prothrombin complex co ncentrate
Fresh frozen plasma alone
IV vitamin K + fresh frozen plasma
Major bl eeding - stop warfarin, give intravenous vitamin K Smg, prothrombin

complex co ncentrate
Important for me l ess im:>crtc.nt
As fresh frozen plasma takes time to defrost prothrom bin complex concentrate (PCC)
m
se
should be used in such an urgent situation. The use of PCC is currently limited by
As
availability
Dr
A 66-yea r-old ma n with no past med ical history of note p resents with central chest pain
to the Emergency Department. An ECG shows ST e levation in the anterior leads. He is
given aspirin and ticagrelor before going fo r a percutaneous coronary intervention. What
is the mecha nism of action of ticagrelor?
Inhibits ATP bind ing to its p latelet receptor
Phosphodiesterase V inhibitor
Non-selective phosphodiesterase inhib itor
m
se
Inhibits ADP b ind ing to its platelet receptor
As
Dr
Inhibits ATP binding to its platelet receptor
Phosphodiest erase V inhibit or
Non-selective phosphodiesterase inhibitor
I Inhibits ADP binding to its platelet receptor
Ticagrelor has a similar mechanism of action to clopidogrel - inhibit s ADP binding
m
t o platelet receptors
se
Important for me Less impc rtc.nt
As
Dr
Which of the follow ing cond it ions is least associat ed with coa rct ation of t he aorta?
Neurofibromatosis
Bicusp id aortic valve
Prad er-Willi syndrome
Tu rner's syndrome
m
se
As
Berry aneurysms
Dr
Which of the following cond it ions is least associated with coa rct ation of the aorta?
Neurofibromatosis fD
Bicuspid aortic valve CD
I Prader-Willi syndrome ED.

Tu rner's syndrome CD
m
.
(!D
se
Berry aneurysms
As
Dr
A 74-year-old man is admitt ed with chest pain associated with ECG changes. A troponi n T
t aken 12 hours after admission indicates an acute myocardial infarction. Which one of the
following is most likely to predict a poor prognosis?
Hist ory of diabetes mellitus
Loss of heart rate variability
Left ventricu lar ej ection fraction of 40%
Diast olic blood pressure of 110 mmHg
m
se
Male sex
As
Dr
History o f diabetes mellitus
Loss o f heart rate variability
I
Left ventricular ejection fraction of 40%
-
~
Diastolic b lood pressure of 110 mmH g
m
se
Male sex ~
As
Dr
Which one of the following is least recognised as an adverse effect of taking
bendroflumethiazide?
Hypokalaemia
Pseudogout
Hypercalcaemia
Impotence
m
se
As
Impaired glucose to lerance
Dr
Hypokalaemia
Pseudogout
Hypercalcaer r l
Impotence
-
~
Impa ired glucose tolerance

-
~
m
se
As
Bendroflumethiazide predisposes to gout, rather than pseudogout
Dr
A 65 -yea r-o ld wo man comp lain s o f chest pa in on exertio n such as when wa lki ng up the
stairs o r do ing ho usewo rk. She d escribes the pain as a constricting discomfo rt in front o f
the chest. The pain typ ically radiates to the left shou ld e r and disa ppea rs on resting .
She su ffe rs from severe osteoarthritis of the left knee, which limits he r mo bility. She also
suffe rs fro m b rittle asthma a nd high blood pressu re. Her last cho leste ro l check wa s 4
years ago and this was no rma l. She is a no n-s moker. On exam inatio n, she ap pea rs well
a nd pa in-free. Hea rt sou nd s we re normal with no murmur. Resting ECG is normal.
What is the next step in the investigation of th is lady's symptoms?
Check her cholesterol leve l to d etermine the investig atio n of choice
Exe rcise (stress) echoca rd io gram
Contrast-enhanced coronary CT angiog raphy
Adenosine stress-CM R
m
se
Invasive coronary a ngiog raphy
As
Dr
I Contrast-enhan ced coronary CT ang iog ra phy
Adenosine stress-CM R
Invasive coronary a ngiog ra phy
Contrast-en hanced CT corona ry angiog ra m is the first line investigation fo r stab le

c hest pain of suspected coro nary arte ry d isease aetio logy
Important for me Less : m ::~c rtant
This lady c hest pa in cha racteristics are consistent with typical angina. The first- line
investigation reco mmended by NICE is contrast-enhanced CT co ro na ry angiogram cCTA.
The new NICE gu ideline no longe r reco mmends using pre-test likeli hood o f the CAD to
d etermine the ap propriate first -line investigation.
This lady may not b e suitable fo r exercise (stress) echocard iogra m as she suffers fro m
seve re osteoa rthritis o f the knee. Stress echocard iogra m with d o buta mine may be
a ppropriate but is less sensitive than cCTA (and is not an option fo r this q uestion).
Adenosine stress-CM R is ve ry sensitive in d etecting CAD but the use o f a denosine in
someone with asthma is contra indicated due to the risk o f bro nchospasm. Immediate
invasive co ronary ang iogra phy is typica lly not the first-line investig atio n method due to
the cost and possible complications. The use of invasive angiography without a
'g atekeeper' non- invasive test is not recommended by NICE but is still recommended by
m
ESC and AHA in patients with very high p re-test likelihood of CAD. Othe r than her age
se
As
a nd hypertension, she does not have other ca rdiovascu la r risk facto rs e .g. smoking,
dia betes, etc.
Dr
A 71-year-old man with a history o f ischaemic heart disease is brought to the Emergency
Department following a 'collapse'. He now feels back to normal. The ECG shows sinus
rhythm, 94/min with leh bundle branch block. Given the ECG findings, w hich one of the
following is most likely to be found on auscultatio n o f the heart?
Fixed split 52
Lou d 51
Th ird heart sound (53)
Widely split 52
m
se
As
Reversed split 52
Dr
Fixed sp lit 52 CD
Lou d Sl CD
Th ird heart sou nd (S3) GD
W idely split 52 CD
Reversed sp lit 52 CXD
Second heart sound (52)

• soft: AS
m
se
As
Dr
You are an SHO working at district general hospit al in Cornwall. A 56-year-old man
p resents to the emergency department w ith crush ing central chest pain that started 30
minutes ago. His ECG demonstrates ST elevation in the anterior leads and he is treated for
an ST -elevation myocard ial infarction (STEM!). So fa r he has been given aspirin,
clopidogrel, low -molecu lar weight heparin (LMWH) and his chest pain has signif icantly
improved with sublingual GTN and IV morp hine + metoclopramide. There is no cath- lab
on site and and the nearest percutaneous coronary intervention (PC!) centre in Truro is
approximately 2 '12 hours away. Which of the following is the most appropriate cou rse of
action?
Transfer to PC! centre
Give b ivalirudin
Start infusion o f unfractionated heparin and transfer to PC! centre
Give alteplase
m
se
As
Give ticagrelor
Dr
I Give alteplase
Give ticagrelor
In management of STEM! if primary PC! cannot be delivered w ithin 120 minutes

then th rombolysis should be given
In the management of STEM! fibrinolysis w ith a drug such as alteplase should be offered
if primary PC! cannot be delivered within 120 minutes o f the time when fibrinolysis could
have b een given.
This problem is most often encountered when a patient initially presents to a district
general hos pital that lacks a PC! centre. Am bulances are generally direct ed to PC! centres
in cases of chest pain and this has reduced the frequency with which this occurs.
If a repeat ECG at 90 minutes does not show resolution of ST elevation the patient w ill
require transfer t o a PC! centre regardless.
1- This is inappropriate. The transfer time is over 120 minut es from w hen fibrinolysis
cou ld b e given. This would therefore b e an unaccept able delay.
2- This is a direct thrombin inhibit or. It has a role in STEM! management but wou ld not
m
se
address the main issue which is the need for PCI/ fibrinolysis.
As
Dr
3- Though sometimes used in STEM! again, fibrinolysis or PC! are needed. Additionally,
You a re called to the co ronary care un it. A patient who has been a dmitted following a
myocardial infa rction has deve loped a b road complex tachyca rdia . You suspect a
diagn osis of polymo rph ic ventricu la r tachyca rd ia . Which one of the following facto rs is
most li kely to have precipitated this?
Hypoglycaem ia
Bisoprolo l
Hypomagnesaem ia
Dehydration
m
se
As
Hyperkalaem ia
Dr
Yo u are ca lled to the corona ry ca re u nit. A patient who has been a dmitted following a
myo ca rdial infarctio n ha s develop ed a b road co mplex ta chyca rdia . You suspect a
diagnosis of polymo rphic ve ntricula r tachycardia . Which one of the following factors is
most li ke ly to have precipitated this?
Hypoglycaem ia CD
Bisoprolo l CD
I Hypomagnesaemia CD
Dehydration CD
Hyperka laemia 8D
Hypokalemia is the most importa nt cause of ventricu lar tachycardia (VT) clinica lly,
fo llowed by hypomagnesae mia. Severe hype rkalaem ia may cause VT in certain
m
se
circumsta nces, fo r exa mple in patients with structu ra l hea rt disease, but it is not as
As
com mon a cause as hypomag nesaem ia.
Dr
A 62-year-old man comes for review. In the past month he has had two ep isodes of
'passing out'. The first occurred whilst going upsta irs. The second occurred last week
whilst he was getting out of a swimming pool. There were no warning signs prior to these
episodes. He was told by people who witnessed the episode last week that he was on ly
'out' for a rou nd 15 seconds. He reports feeling 'groggy' for only a few seconds after the
episode. On exam ination pulse is 90 I minute, b lood pressure 110/ 86 mmHg, his lungs
are clear and there is a systolic murmu r which radiates to the carotid area. Which one of
the following investigations shou ld be a rranged first?
24 hour ECG mon itor
Echoca rdiogram
Exercise tolerance test
CT hea d
m
se
Carotid d oppler
As
Dr
24 hou r ECG mo nitor GD
Echoca rdiogram ED
Exercise tolera nce test
•
CT hea d
Carotid d opp ler

•
GD
The systo lic murmur may be a po inte r to aortic stenosis (AS). Synco pe is a late sig n and
typica lly occurs o n exertion in patients with AS. It is the refo re impo rta nt to exclud e this
conditio n as a p riority.
m
se
An exercise tolerance test wou ld be contraindicated in a patie nt with susp ected aortic
As
stenosis.
Dr
A 56-year-old man w it h a past histo ry of ischaemic heart disease is admitt ed w ith cent ral
chest pain radiat ing to his left arm associated w it h nausea. On arrival in t he Coronary Ca re
Unit he is not ed to be in complete heart block. Which coronary artery is likely t o be
affect ed?
Circumflex
Right coronary
Obtuse marginal
Left ant erior descending
m
se
As
Po sterior d escending
Dr
Circumflex m
Right coronary 6D
Obtuse ma rgina l m
Left anterior descending CD
Posterior d escending m
m
se
As
The right coronary artery supplies the atrioventricular node in 90% of patients
Dr
A 60-year-old man who is investigated for exertional chest pain is diagnosed as having
angina pectoris. Which one of the following drugs is most likely to improve his long-term
prognosis?
Atenolol
Aspirin
Isosorbide mononitrate
Ram ipril
m
se
Nicorandil
As
Dr
Atenolol
Asp irin
Ram ipril
Nico randil
Strong evidence exists supporting the use of aspirin in stable angina. The benefit of ACE
inhibitors and beta-blockers are significant in patients who've had a myoca rdial infarction
m
se
but modest in those with stable angina. Please see the CKS li nk for a review of the most
As
recent trials.
Dr
An 84-year-old female has become progressively more short of breath over the past 2
months. She is finding it difficu lt t o breath e when lying down and so ha s been sleeping
upright in her cha ir for the past two weeks. She also has a cough productive o f frothy
sputum and swollen legs. What is the most likely description of her pulse?
Pulsus alt ernans
Collapsing
Jerky
Slow rising
m
se
Pulsus bisf eriens
As
Dr
I Pulsus alternans CD
Collapsing CD
Jerky .
CD
Slow rising f!D
Pulsus bisferiens «ED
Pulsus a lternans - seen in left ventricular failure

Important for me Less im:>c rtc.nt
Pulsus a lternans is when the upstroke of the pu lse alte rnatives between strong and weak.
It indicates systolic dysfunction and is seen in patients with heart failure.
A collapsing pu lse has a forcefu l rapid upstroke AND descent.
A jerky pu lse is characterised by a rapid forcefu l upstroke.
A slow-rising pu lse has a slow upstroke.
m
se
As
A bisferiens pu lse occurs when there a re two sharp upstrokes du ring systole.
Dr
Which one of the following features is not part of the modified Duke criteria used in the
diagnosis of infective endocarditis?
Prolonged PR inte rval
Positive serology for Coxiella burnetii
Fever > 38°C
Roth spots
m
se
Positive microbiology from embolic fragments
As
Dr
I Prolonged PR inte rval
Positive serology for Coxiella burnetii
Fever > 38°C
Roth spo ts
Positive microbiology from embolic fragment s
A prolonged PR interval is part of the diagnostic criteria o f rheumatic fever. The modified
m
se
Duke criteria have now b een adopted in th e latest guidelines from the European Society
As
o f Cardiology. Det ails ca n b e found in the link b elow
Dr
Which part of the jug ular venous wavefo rm is associated with the fall in atria l pressu re
during ventricu lar systole?
y descent
vwave
x descent
cwave
m
se
a wave
As
Dr
y descent fD
vwave CD
I x descent CID
c wave CD
a wave .
(D
m
se
JVP: x descent = fall in atrial pressu re during ventricu lar systole
As
Important for me l ess i m ::~c rtc.nt
Dr
A 37 -year-old who is 38 weeks p regn ancy is an inpatient on the obstetric ward for the
management of pre-eclam psia. Blood pressure is 172/114 mmHg and urine dipstick
shows proteinuria +++. A d ecision has been made to start magnesium sulphate thera py
as she is deemed at risk of eclampsia. Of the following options, which are the most
important pa rameters to monitor whilst the patient is receiving magnesium?
Blood sugar + pu lse rate
Reflexes + respiratory rate
Blood sugar + respiratory rate
Reflexes + pu lse rat e
m
se
As
Gla sgow coma sca le + pulse rate
Dr
Blood sugar + p ulse rate
Ref lexes + resp irat ory rate
Bloo d sugar + resp irat ory rate
Reflexes + pu lse rate
Glasgow coma sca le + pulse rate

-
. .wr
m
M ag nesium su lphate - monito r reflexes + res piratory rate
se
Important for me Less · m::~c rtant
As
Dr
A 17-yea r-o ld gi rl is brought into resus in cardiac arrest. On adm ission she is in asystole
a nd attem pts to resuscitate are u nsuccessful. She collapsed whilst competing in a l ,SOOm
race at college. The only past medical of note was asthma for which she occasio nally used
a sa lbutamo l inhaler. There is no relevant fa mily history. What is the most li ke ly
unde rlying cause o f d eath?
Long QT synd rome
Catecho lam inergic p olymorphic ventricula r tachycardia
Brug ada syndro me
m
se
Arrhythmogen ic right ve ntricula r dysp lasia
As
Dr
Long QT syndrome
Catecholaminergic polymorphic ventricular t achycardia
Brugada syndrome
Arrhythmogenic right ventricular dysplasia
HOCM is the most common cause of su dden cardiac death in the young
Hypertrophic obstructive cardiomyopathy (HOCM) is a more common cause of su dden

cardiac death than arrhythmogenic right ventricular dysplasia (ARVD).
Catecholaminergic p olymorphic ventricular t achycardia (CPVT) is a form of inherited

cardiac disease which is also associated with sud den ca rdiac death. It is inherited in an
autosom al dominant fashion and has a prevalence of around 1:10,000.
Brugada syndrome is a fo rm of inherited cardiovascular disease which again may present
m
se
with sudden cardiac death. It is inherited in an aut osomal dominant fashion and has an
estimated prevalence of 1:5,000-10,000. Brugada syndro me is more common in Asians.
As
Dr
Which one o f t he followin g ECG findings is least associated wit h digoxin use?
Bradycardia
Down -sloping ST d epression
Flattened T waves
Prolonged QT interval
m
se
As
AV block
Dr
Bradycardia
Down -s loping ST depression
Flattened T waves
~longed QT interval
m
AV block
se
As
Dr
A 49-year-old female is admitted t o the Emergency Department with shortness of breath.
On examination the pulse is 114 bpm with blood pressure 106/ 66 mmHg, t emperature
37.7°( and respiratory rate 30/ min. Exam ination of the ca rdiorespirato ry system is
unremarkable with a p eak expiratory flow rat e of 400 1/min. Arterial blood gases on air
reveal:
pH 7.41
pC02 4 .0 kPa
p0 2 7.2 kPa
Follow ing the initiation of oxygen therapy, what is the next most important st ep in
management ?
IV aminophylline
IV hydrocortisone
Low molecular weight heparin
IV fluids
m
se
IV co -trimoxazole
As
Dr
IV aminophylline m
IV hydrocortisone GD
I Low molecular weight heparin CD

IV fluids GD
IV co-trimoxazole m
Patients with a su spected pulmonary embolism should be initially mana ged with
low-molecular weight hepari n
Type 1 respirat ory fai lure in a tachycard ic, t achypnoeic fema le with an absence of chest
signs points towards a diagnosis o f pulmonary embolism.
m
se
As
Low-grade pyrexia is common in pulmonary embolism.
Dr
Which one o f t he followin g non-invasive met hod s provid es t he most accurat e assessment
o f whet her a patient has coronary artery disease?
Contrast enhanced ca rdiac CT
Cardiac MRI wit h gadolinium
Exercise ECG
Card iac SPECT wit h reversibility studies
m
se
Transoesophageal echocardiog raphy
As
Dr
I Contrast enhanced cardiac CT fD
Cardi ac MRI with gadolinium GD
Exercise ECG G'D
Cardiac SPECT w it h revers ibility stud ies fD
m
se
Transoesophageal echocardiography m
As
Dr
A 30-year-old fema le patient tells you that she is planning to become pregnant over the
next year. You note from her reco rds that she has a history of ventricular septal defect.
Which one of the followin g would represent a contraindication t o her becoming
pregnant ?
Aortic regurgitation
Having a peri membranou s rather than a muscular defect
A previous episode of infective endocarditis
Pulmonary hypertension
m
se
As
A history of previous surgical repair
Dr
Having a peri membranous rather than a muscular defect
A previous episode of infective endocarditis
Pulmonary hyperten sion
A history o f previous su rgica l repair
Women with pulmonary hypertension should avoid becoming pregnant due t o very
m
se
high mortality levels
As
Dr
The most commo n cause of restrictive cardiomyopathy in the UK is:
Diabetes mellitus
Systemic lupus erythematous
Haemochromatosis
Tuberculosis
m
se
As
Amylo idosis
Dr
Diabetes mellitus
Haemochromatosis
Tuberculosis
Amyloidosis
Restrictive cardiomyopathy: amyloid (most common), haemochromatosis, Leffler's
m
syndrome, sarcoidosis, scleroderma
se
As
Dr
You receive t he blood results of a 76 -year-o ld man who t akes wa rfarin following a
pulm onary embolism two months ago. He recently complet ed a cou rse of ant ibiotics.
JNR 8.4
On reviewi ng t he patient he is well with no bleed ing or b ru ising. What is t he m ost

appropriat e action?
Stop warfa rin + restart when INR < 5.0 + give low-molecu lar weight hepa rin unti l
warfa rin rest arted
Ora l vitam in K Smg + stop warfarin + rep eat I NR aher 24 hours
Stop warfa rin + restart when INR < 3.0
Stop warfa rin + restart when INR < 5.0
m
se
As
Fresh f rozen plasma + restart warfarin when INR < 5.0
Dr
Stop warfarin + resta rt when INR < 5.0 + give low-molecu lar weight heparin until CD
wa rfarin rest arted
I Oral vitam in K Smg .,. sto p warfarin .,. rep eat I NR aher 24 hours
Stop warfarin + resta rt when INR < 3.0
Stop warfa rin + resta rt when INR < 5.0
Fresh frozen plasma + restart warfarin when INR < 5.0

-~
INR > 8.0 (no b leed ing)- st op warfarin, g ive oral vitamin K 1-Smg, repeat dose of
vitamin K if INR high aher 24 hours, rest art when INR < 5.0
Important for me l ess 'moc rtont
m
se
As
The BNF recommends a dose of between 1 to 5mg o f vitamin K in this situation.
Dr
A 54-year-o ld man is admitted following a myocardia l infarction associated with ST
elevation. He is treated with thro mbolysis and does not undergo ang iop lasty. What advice
s hould he be given regarding driving?
Can continue driving but must info rm DVLA
Cannot drive until an ang iogram has been performed and reviewed by a
cardiolog ist
Cannot drive for 1 week
Cannot drive for 4 weeks
m
se
As
Dr
Can continue driving but must inform DVLA
Cannot drive until an angiogram has been performed and reviewed by a

ca rdiologist
Cannot drive for 1 week
Ca not drive for 12 weeks
m
DVLA advice post Ml - cannot drive for 4 weeks
se
Important for me Less :mpcrtant
As
Dr
A 45-yea r-o ld man p resents with chest pain an d breathlessness on exertion. On
exam ination, he is bradycardic with a rate of 31 bp m. You notice irregu lar canon 'a ' waves
in the JVP.
What unde rlying diagnosis is associated with this JVP wavefo rm patte rn?
Complete hea rt block
Ventricu la r tachyca rdia
Atrio-ventricular nodal re-entry ta chyca rd ia
Tricusp id stenosis
m
se
Atrial flutte r
As
Dr
I Comp lete heart block
Ventricular tachycardia
Atrio-ventricular nodal re -entry ta chycardia
I Tricusp id stenosis
Atrial flutter
-
........
Irregular cannon 'a' waves points towards complete heart block

m
se
Once the JVP waveform pattern is identified as canon 'a' waves, irregularity can identify
As
the underlying rhythm.
Dr
You are a CTl in Acut e Medicine covering the hospital at night. You are call ed t o the
surgical ward to see a 35-year-old patient w ho is reporting palpitations. She is known to
have Wolff- Parkinson-White syndrome. Her ECG shows fast atrial fibrillation. On
examination, there is no evidence of haemodynamic instability. What is the most
appropriat e pharmacolog ical management option for th is patient?
Adenosine
Verapamil
Met oprolol
Digoxin
m
se
Flecainide
As
Dr
Adenosi e flD
Verapamil flD
Metoprolol fD
Digoxin .
CD
I Flecainide CD
In patients with accessory pathways, such as those with Wolff-Parkinson-White synd rome,
AV noda l blocking drugs should be avo ided in atrial fibrillation. This is because blocking
the AV node may enhance the rate of conduction through the accessory pathway, causing
atrial fibrillation to degenerate into ventricular fibrillation (VF).
Verapa mil exerts the most reliable and long-lasting effect on AV node refracto riness and
therefore is the most contra-indicated in this scenario. Adenosine has a similar effect and
has also been associated with precipitating VF in pre-excited atrial fibrillation.
Beta-blockers and di goxin also inhibit AV node conduction.
m
se
Flecainide is a sodium channel blocker (ClassIc anti-arrhythmic) which will reduce the
As
excitability of the atrial and ventricular myocardium without AV nodal blockade.Dr
A 65 -yea r-o ld ma n is a d mitted with pa lp itations. The ECG shows a ventricula r rate of
150/ min with a n unde rlying atria l rate of 300/ min. A diagnos is of atrial flutte r is
sus pected . What is the treatme nt o f cho ice to pe rmanently resto re sinus rhythm?
Radio frequency ablatio n of the accesso ry pathway
Radiofrequency ablatio n of the AV node
Radio frequency ablatio n of the tricus pid valve isthmus
Life lo ng a mio da ro ne
m
se
As
Permanent pace maker
Dr
Radiofrequency ablation of the accessory pathway CD
Radiofrequency ablation of the AV node GD

Radiofrequency ablation of th e tricuspid valve isthmus CD
Lifelong amiodarone CD
m
se
Permanent pacemaker CD
As
Dr
A 57 -year-old man comes t o the emergency department w ith severe, central, crushing
chest pain. By the time he arrives on the medical admissions unit he is pain-free.
He had a myocardial infa rction (MI) two years ago; additionally he has type 2 diabet es
mellitus, hypertension and hypercholesterolaemia. His brother died of a MI at a similar
age. His repeat prescriptions include aspirin, metformin, ramipril, amlodipine and
atorvastatin.
On examination he looks pale and sweaty. On auscultation he has vesicu lar breathing and
norma I heart sounds. He is overweight.
His oxygen saturations are 98% on air; respiratory rate 14 breaths p er minut e; blood
pressure 150/88 mmHg, heart rate 90 beats per minute. His blood sugar (BM) is 22.5.
There are no ischaemic changes on his ECG; however a 12 hou r troponin is elevat ed. The
admitting doct or has already given aspirin, clopi dogrel and fondaparinux.
What is the next step in the management of th is patient?
IV GTN infusion
15L oxygen via non -rebreathe mask
Primary PC! within 4 hours
m
se
As
Additional dose metformin
Dr
I IV GTN infusion (D
lSL oxygen via non- rebreathe mask m

Primary PC! within 4 hours fD
Additional dose metformi n CD
Angiography with in 96 hours GD
This man is having a NSTEMI. His myriad risk facto rs him catego rise him as high risk, and
therefore he should have definitive angiography+/- stenting within 96 hou rs. He is
mainta ining his oxygen saturations, is pain free and has no ST elevation, making the other
options incorrect. Metformin is act ua lly best avoided in acute tissue ischaemia due to its
association with lactic acidosis.
m
se
See http://nice.o rg.u k/guidance/cg94 for current NICE gu idelines on management of
As
NSTEM I.
Dr
A 70 yea r-old ma n presents with a history of chest pa in on exerti on. He is known to have
hypertension, currently treated with a mlodipine, and he is also on s imvastatin fo r primary
prevention. The chest pain is dull in nature a nd is relieved within a few minutes of rest. His
symptoms have been relieved by the use o f his wife's GTN.
Which additional medication wou ld be indicated here?
Doxazosin
Verapamil
lsoso rbide mononitrate
Atenolol
m
se
As
lvab rad ine
Dr
Doxazosin
Verapa mil
Atenolol
Ivab rad ine
A beta- bloc ke r or a calcium channel blocker is used first-line to prevent angina

attacks
This ma n presents with classic features o f a ngina. He is already taking a calcium channel
blocker for hyperte nsion, so the next most appro priate trea tment would b e a beta
blocker. Verapamil wo uld be an alternative if he was n"t ta king a ny other medications.
m
se
Doxazosin is a n alpha blocker used in refracto ry hyperte nsion. Isosorbid e mono nitrate
As
and ivabradine a re used in the man agement o f angina, but not at this stage.
Dr
A 74-year-old man with symptomatic aortic stenosis is reviewed in the cardio logy clin ic.
He is otherwise fit and well and keen for int ervention if possible. What type of
intervention is he most likely to be offered?
Annua l echocardiography, intervention when valve gradient > 75 mmHg
Aortic bypass graft
Bioprosthetic aortic valve replacement
Balloon valvu loplasty
m
se
Mechanical aortic valve replacement
As
Dr
An nual echocardio graphy, intervent ion when valve gradient > 75 mmHg
Aortic bypass graft

-
~
I Bioprosthetic aortic valve replacement
Balloon valvu loplasty
Mechanica l aortic valve replacement
Prosthetic heart valves - mechanical valves last longer and tend to be given t o
younger patients
m
l ess i m ::~c rtc.nt
se
Important for me
As
Dr
A 31-year-old woman of Malaysian origin presents wit h head ache, malaise and j oint
pains. For t he past few months she has also experienced pain in t he calves aher wa lking
any sign ificant distance. On examination her pu lse is 78/min and blood pressure in t he
leh arm is noted t o be 154/98 mmHg. Due to t his raised reading it is measured in t he
right arm and fou nd t o be 132/ 80 mmHg. An early diastolic murmur is noted in aortic
area and a b ruit is present in t he carot id s. Exam ination of the respirato ry system is
unremarkable. What is the most likely diagnosis?
Coarctation o f t he aorta
Supravalvular aortic stenosis
Ta kayasu's arteritis
Buerger's disease
m
se
Polyarteritis nodosa
As
Dr
Coa rctation o f the aorta
Sup rava lvul ar a o rtic stenosis
Ta kayasu's arteritis
Buerger's d isease
Polyarte ritis no dosa
m
se
The ea rly d iasto lic mu rmu r is caused by aortic regu rg itatio n, which is seen in a ro u nd 20%
As
o f patients with Takayasu's arteritis.
Dr
Which of the following factors is most strongly associated w ith risk of sud den death in the
first six months aher myocardial infarction?
Ventricular ectopics
Cigarette smoking
3-vessel coronary disease at angiography
Low leh ventricular ejection fraction
m
se
High LDL (low density lipoprotein) cholest erol
As
Dr
Ventricular ectopics
Cigarette smoking
3-vessel coronary d isease at ang iography
p ow left ventricular ejection fraction

-
~
High LDL (low d ensity lipoprotein) cholestero l
The most important factor predicting outcomes post-STEM! is the presence of new
systolic heart fai lu re. It suggests that a large amount of myoca rdial damage. Those with
m
systolic heart fai lu re post Ml can be up to lOx mo re li kely to d ie than those that do not
se
have an MI.
As
Dr
A 62-year-o ld man is referred from the Emergency Department with a pu lse o f 40
beats/m in. Which one o f the following factors carries the least risk of asysto le when risk
stratifyin g the patient?
Ventricu la r pause o f 5 seconds
Recent asystole
Complete heart block with a narrow complex QRS
Mobitz type II AV block
m
se
As
Complete heart block with a b road complex QRS
Dr
Ventricular pause o f 5 seconds
Recent asystole
r Complete hea rt block with a narrow co mplex QRS
Mobitz type II AV block
Complete heart block with a b road complex QRS
Complete heart block with a narrow complex QRS complex carries the least risk o f
asystole as the atrioventricular junctional pacemaker may provide an haemodynam ically
m
se
acceptable and stable heart rate. The other four factors are ind icatio ns for transvenous
As
pacmg
Dr
A 55-yea r-old man is ad mitted with centra l chest pa in. His ECG shows ST d ep ression in
the inferior lead s and the chest pa in req uires intrave nous morphine to settle. Past medica l
histo ry includ es a throm bo lysed myocardial infa rction 2 yea rs ago, asthma a nd type 2
diab etes mellit us. Treatment with aspirin, clop id ogre l and unfra ctionated heparin is
com menced. Wh ich one of the fo llowing facto rs shou ld determine if an intravenous
glycoprotein Db/lila rece ptor antagonist is to be given?
High GRACE (Globa l Reg istry of Acute Ca rd iac Eve nts) risk sco re + whethe r a
percutaneous coro nary inte rventio n is to be performed
Degree of ST d e press ion
High GRACE (Globa l Reg istry of Acute Card iac Eve nts) risk sco re
Presence of a left ventricu Ia r thrombus
m
se
The presence o f recurrent card ia c chest pa in
As
Dr
I High GRACE (Global Registry of Acute Cardiac Events) risk score + w hether a
percutaneous coronary intervention is to be performed
Degree of ST depression
I High GRACE (Global Registry of Acute Cardiac Events) risk score
Presence of a left ventricu lar thrombus
m
The presence of recurrent ca rdiac chest pa in
se
As
Dr
A 50-year-old man is admitted to Resus with a suspected anterior myocardial infarction.
An ECG on arrival confirms t he diagnosis and t hrombolysis is prepared. The patient is
stable and his pain is well controlled with intravenous morp hine. Clinical examination
shows a b lood p ressure of 140/ 84 mmH g, pu lse 90 bpm and oxygen sat urati ons on room
air o f 97%. What is the most appropriat e management with rega rds t o oxygen therapy?
2-4 1/min via nasal cannu lae
No oxygen therapy
15 1/min via reservoir mask
28% via Venturi mask
m
se
As
Dr
2-4 1/min via nasal cannulae CD
I No oxygen therapy CD.

15 1/min via reservoir mask

•m
~
35% via Venturi mask m
m
se
Please see the note below and p rovid ed link - there are now specific guidelines relating to
As
the use o f oxygen in emergency situations.
Dr
Which one of the fo llowin g statements is not correct regarding hypertension in
p reg nancy?
An increa se above booking rea dings of > 30 mmHg systo lic o r > 15 mmHg
diastolic sugg ests hyperte nsion
Pre-ecla mpsia occurs in aroun d 5% of pregna ncies
Urine d ipstick showing p rotein + is consistent with gestatio nal hypertensio n
A rise in blood pressure before 20 weeks sug gests p re-existing hypertension
m
With g estatio na l hypertensio n the blood pressure rises in the second half of
se
p regna ncy
As
Dr
An increase above booking rea dings o f > 30 mmHg systo lic o r > 15 mmHg
d iasto lic suggests hypertension
Pre-eclampsia occu rs in a roun d 5% of p regnancies

-
~
I Urine dipstick showing prote in + is consistent with gestational hypertension
A rise in b lood pressu re befo re 20 weeks suggests p re-existing hypertensio n
With gestational hype rtension th e blood pressu re rises in the second hal f of
pregnan
m
se
As
Proteinu ria suggests pre-ecla mps ia
Dr
A 19-yea r-old ma n co llapses a nd d ies whilst playing rug by at un iversity. At post-mortem
a symmetrical ventricu la r septa l hypertrophy is noted. Analysis of the ca rd iac tissue is most
likely to demonstrate a d efect in which o ne o f the following?
Tropomyosin
Myosin light-chain kinase
Calmodulin
Troponin C
m
se
Beta - myosin heavy cha in protein
As
Dr
A 19-year-old man collapses and dies w hilst playing rugby at university. At post-mortem
asymmetrica l ventricular septal hypertrophy is noted. Analysis of the cardiac tissue is most
likely t o demonstrate a defect in which one o f the following?
Tropomyosin
Myosin light-chain kinase
Calmodulin
,---,
Tr ponin C
Beta- myosin heavy cha in protein
m
se
As
Dr
A 67 -year-old man with a history of hypertension presents to the emergency department
with a 24hr history of dyspnoea an d palpitations. He also complains of mild chest
discomfort. On examination, you note an irregularly irregular pulse of 115 beats per
minute, blood pressure 95 I 70 mmHg and a respiratory rat e of 20 breaths/ min. He denies
any regular medication and insists he has never experienced anything like this before. An
ECG shows absent P waves with QRS com plexes irregularly irregular intervals.
What is the most appropriate management?
Clopidogrel
Direct cu rrent cardioversion
Bisoprolol
IV adenosine
m
se
Digoxin
As
Dr
Clopidogrel
Direct current cardioversion
Bisoprolol
IV adenosine
Digoxin
New onset AF is considered for electrical card ioversion if it presents w ithin 48 hours
of presentation
Important for me Less impcrtant
This is an individual presenting a clinical picture of new-on set atrial fibrillation. A blood
pressure of 95/70 mmH g in a patient with a history o f high blood pressure, who is
currently not taking any blood pressure medication is quite concerning. It suggests that
he is hemodynamically unstable. The most appropriate treatment for new-onset atrial
fibrillati on (AF) within 48hrs is DC cardioversion if unstable or either DC card ioversion or
pharmacological card ioversion. Bet a-blockers ca n be used fo r rate contro l. Clopidogrel is
not a treatment of AF. Bisoprolol would be a suitable alternative if the patient was more
m
se
stable. Digoxin is ideal for patients with AF and heart fa ilure. IV adenosine is a treatment
As
for narrow complex supraventricular tachyarrhythmias
Dr
A 17 -yea r-old ma le is ta ken to the Emergency Department due to a lco hol intoxication. On
examination he is noted to be tachycardic with a rate of 140b pm. An ECG shows atria l
fibrillation. The following morning he is noted to be in sinus rhythm. What is the most
a ppropriate management?
Sotalol and a spirin
Sotalol and wa rfarin
Refer fo r accessory pathway ab lation
Amio darone and as pirin
m
se
As
Discha rge
Dr
A 17-year-old male is taken to t he Emergency Department due to alcohol int oxication. On
examination he is not ed to be t achycardic with a rate of 140b pm. An ECG shows atrial
fibrillation. The following mornin g he is noted to be in sinus rhythm. What is the most
appropriat e management?
Sotalo l and aspirin
Sotalo l and warfarin
Refer for accessory pathway ablation
Amiodarone and aspirin
Discharge
m
se
Supraventricular arrhythmias secondary to acute alcohol intake are well characterised and
As
have been termed 'holiday heart syndrome'. No specific t reatment is required
Dr
You review a 51 -year-old hypertensive patient who you started on 2.5mg of ramipril one
month ago. He is complaining of a tickly cough since starting the medication which is
keeping him awake at night. However, is blood pressure is now within normal limits.
What should you advise him?
The cough is unlikely t o b e caused by the ramipril, continue the medication and
review in a month
The cou gh should settle within the next mont h, continue the medication and
review in a month
Stop the ramipril and prescribe a different ACE-inhibito r
Stop the ramipril and prescribe Smg amlodipine
m
se
Stop the ramipril and prescribe candesartan
As
Dr
The cough is unlikely t o be caused by the ra mipril, continue the medication and
review in a month
The cough should settle within the next month, continue the medication and
review in a month
Stop the ramipri l and prescribe a different ACE -inhibito r
Stop the ram ipri l and prescribe 5mg amlodipine
Stop the ram ipril and prescribe candesartan
For a patient under 55 who is intolerant to an ACE -i the next st ep wou ld be to offer
an angiotensin 2 receptor blocker (ARB)
ACE inhibitors are commonly associated with a dry, persistent cough. A cough is unlikely
to settle without stopping the ACE-inhibitor and prescribing a different class of drug. For
m
se
a patient under 55 who is intolerant to an ACE- inhibito r the next step would be to offer
As
an angiotensin 2 receptor blocker (ARB), eg candesartan.
Dr
What is the usual target IN R for a patient with a mechanical mitral valve?
2.0
2.5
3.0
3.5
m
se
4 .0
As
Dr
What is the usual target INR for a patient with a mechanical mitral valve?
no m
2.5 CID
3.0 CD
I 3.5
4.0
C'D
Mechanical valves- target INR:

• aortic: 3.0
m
se
• mi tral: 3.5
As
Important for me _fss · m::~crtant
Dr
Which part of the jug ula r venous wavefo rm is associated with the opening o f the tricuspid
va lve?
x descent
vwave
a wave
cwave
m
se
As
y descent
Dr
x descent flD
vwave GD
a wave GD
c wave (ID
y desce nt CD
m
JVP: y descent = o pening of tricuspid valve
se
As
Dr
A patient who is intolerant of as pirin is started on d opid ogrel for the second ary
p revention of ischaemic heart disease. Concu rrent use of which one o f the following
drugs may make clopidogrel less effective?
Warfarin
Omeprazole
Codeine
Long -term tetracycl ine use (e.g. For acne rosacea)
m
se
Selective serotonin reuptake inhibitors
As
Dr
Warfarin CD
Omeprazole GD
Codeine a
Long -term tetracycline use (e.g. For acne rosacea) GD
Select ive serotonin reuptake inhib itors CfD
m
se
As
Dr
Each one of the following p hysiolog ical changes occu r during exercise, except:
Increased myocardial contractib ility
50% increase in stroke vo lume
Up to 3-fo ld increase in heart rate
Rise in diasto lic blood pressu re
m
se
Venous constriction
As
Dr
Each one of the following physiolog ical changes occu r during exercise, except:
Increased myocardial contractibility
50% increase in stroke vo lume
Up to 3-fold increase in heart rate

-
~
Rise in diastolic blood pressure
Venous constriction
m
se
As
Dr
A 59-year-old patient was found to have a moderate hyperca lcae mia i n a routine blood
sample order by his general practitioner. He is only t aking a non -prescribed prophylactic
dose of vitamin D for the last six mont hs, which he had bought o ver the counter. On
examination he is bright and alert, wel l perfused with moist mucous membranes. There is
no neurological symptoms and electrocardiogram shows a normal sinus rhythm.
Hypercalcaemia is a relatively frequent cl inical pro blem and although clinical signs and
sympt oms of all hypercalcaemia tend to be similar, there are several clin ical features that
may help to distinguish them according to aetiology. Which of the follow ing medical
conditions is less likely to produce hypercalcem ia?
Multiple myeloma
Primary hyperparathyroidism
Sarcoidosis
Hodgkin's lymphoma
m
se
Familial hypom agnesemia with hypercalciuria and nephrocalcinosis
As
Dr
A 59-yea r-old patient was found to have a moderate hypercalcae mia in a routine b lood
sample ord er by his g eneral p ractitioner. He is only taking a non -prescribed p rophylactic
d ose of vitamin D fo r the last s ix months, which he had bought o ver the counter. On
exam ination he is bright and alert, well perfused with moist mucous membra nes. There is
no neuro logical symptoms a nd electrocardiog ram shows a normal sinus rhythm .
Hypercalcaemia is a relatively frequent clinical p rob lem and a lthough clinica l signs and
sympto ms of a ll hypercalcaem ia tend to be sim ila r, there a re several clinical featu res that
may help to distinguish them accord ing to aetiology. Which o f the following med ica l
conditions is less likely to produce hypercalcem ia?
Multip le myeloma
p mary hyperparathyro idis m
Sa rcoid osis
Hod g ki n's lymphoma
m
se
Fa mi lial hypomag nesem ia with hypercalciuria and nephrocalcinosis
As
Dr
A 57 -yea r-old patient with acute pulmona ry oed ema is ad mitted to th e ITU d epa rtme nt.
She has no past medical histo ry of note. A Swan-Ga nz catheter is inserted to enable
measu rement of the pulmonary capilla ry wed ge p ressure. Whi ch chambe r of the hea rt
d oes th is pressure generally equate to?
The d ifference between the leh atrium a nd right ve ntricle
Leh ventricle
Leh atrium
Right ventricle
m
se
Right atrium
As
Dr
The difference between the leh atrium and right ventricle
Leh ventricle
Leh atrium
Right ventricl e
Right atrium
m
se
As
Dr
A 51-year-old man presents four weeks after being discharged from hospital. He had
been admitted with chest pain and th rombolysed for a myocardial infa rct ion. This
morning he developed marked tongue and facial swelling. Which one of the following
drugs is most likely to be res ponsible?
Atorvastatin
Atenolol
Aspirin
m
se
Ra mipril
As
Dr
Atorvastatin m
I IsosorbJ e mononitrate f!D
Ateno lo l m
Aspirin GD
Ram ipril CD
m
se
As
ACE inhi bito rs a re the most common cause o f drug -i nduced a ng ioedema.
Dr
Which one o f the following is least associa ted with Wolff-Parkinson White synd rome?
Mitral valve pro la pse
Ebstein's ano maly
Thyrotoxicosis
Coa rctation o f the ao rta
m
se
Hypertrophic ca rdiomyopathy
As
Dr
Mitral valve prolapse
Ebstein's ano maly
Thyrotoxicosis
Coarctation of the aorta
Hypertrophic cardiomyopathy
m
se
As
Dr
A 71-yea r-old man who had a bioprosthetic aortic valve replacement three years ago is
reviewed. What antithrom botic therapy is he likely to be taking?
Noth ing
Aspirin
Warfarin: INR 2.0-3.0
Aspirin + clopidogrel
m
se
As
Dr
Nothing fiB
~irin &D
Warfarin: INR 2.0-3.0 fiD
( lspirin + clopidogrel

•
(ID
Prosthetic heart valves - antithrombotic therapy:

• bioprosthetic: aspirin
• mechanical: warfarin + aspirin
m
se
As
Dr
Which one of the followin g treatment s is not app ropriate in the management of Wolff-
Parki nson White?
Verapamil
Sot alol
Amioda rone
Flecainide
m
se
As
Radio frequency ablation of the accessory pathway
Dr
I Verapa mil
Sotalol
Amiodarone
Flecainide
Radiofrequency ablation of the accessory pathway
m
se
Verapamil and digoxin should be avoided in patients with Wolff-Parkinson White as they
As
may precipitate VT or VF
Dr
A 76-year-old man is reviewed. He was recently admitted aher being found to be in atrial
fibrillation. Th is was his second episode of atrial fibrillation. He also takes ram ipril for
hypertension but has no other history of note. During admission he was warfarinised and
discharged with planned follow-up in the cardiology cl inic. However, on review today he
is found to be in sinus rhythm. What should happen regarding anticoagulation?
Stop wa rfa rin
Continue warfa rin for 1 month
Stop wa rfa rin + start aspirin
Continue lifelong warfarin
m
se
Continue warfa rin for 6 months
As
Dr
Stop warfa rin
Continue warfa rin for 1 month
Stop warfa rin + start aspirin
Contin ue lifelong warfarin
Continue warfarin for 6 months
m
se
Warfarin should be continued indefinitely as this is his second episode of atrial fibrillation
As
and he has risk factors for stroke (age, hypertension)
Dr
A 47 -yea r-old man is ad mitted to hos pita l fo ll owing an acute co ronary syndro me. He has
a history peptic ulcer d isease and his ca rdiologist d ecid es to use clo pidogrel. What is the
mechanis m of action of clop id ogrel?
Non -selective p hospho diesterase inhib itor
Phospho diesterase V inh ibito r
Inhibits ATP bindi ng to its p latelet recepto r
Inhibits ADP binding to its platelet recepto r
m
se
Glycop rotein lib/lila inhib ito r
As
Dr
A 47 -yea r-old ma n is admitted to hospital following an acute co ronary syndrome. He has
a history peptic ulcer disease and his cardiologist decides to use clopidogrel. What is the
mechanis m of action o f clopidogrel?
Non -selective p hosphodiesterase inhibitor
Phosphodiesterase V inhibito r
Inhibits ATP binding to its platelet recepto r
Inhibits ADP b inding to its platelet receptor
Glycoprotein lib/lila inhib itor

-
~
Clopidogrel inhibits ADP binding to platelet receptors
m
se
As
Dr
What is the main reason fo r checking the urea and e lectrolytes p rior to commencing a
patient on am io da rone?
To detect hyponatra em ia
To detect impaired renal function
To detect a metabolic acidosis
To detect hyperkalaemia
m
se
As
To detect hypokalaemia
Dr
What is the main reason for checking the urea and e lectrolytes p rior to commencing a
patient on am io da rone?
To detect hyponatraemia
To detect im paired rena l function
To detect a metabolic acidosis
To detect hyperkalaemia
I To detect hypoka laemia
m
se
All antia rrhythmic drugs have the potential to cause arrhythmias. Coexistent
As
hypoka laem ia significantly increases this ris k.
Dr
A 44-year-old gentleman presents to the emergency department with chest pain. As the
acting cardiology reg istra r, you are asked to see him immediately as he ECG shows ST
segment elevatio n in multiple lead s. When you a rrive, he is sitting in bed lean ing forward
to rest his arms on his knees.
His past medica l history in cludes hypertension, type 1 diabetes me ll itus (diagnosed aged
11) and his father died from a myocardial infarction age 60. In addition to this, he tells
you he has been we ll recently apart from a slight 'sore th roat' 2 weeks ago that cleared up
with no problems. He first noticed the chest pain 4 hours ago while still in bed th is
morning and he describes it as left s ided chest pain with no radiation. He has taken l g
pa raceta mo l with minima l improvement.
Given the likely diagnosis, which of the following is the most spe cific ECG find ing in this
condition?
Reciprocal ST de pression
Shortened PR interval
'Tombstoning' ST elevation in all precordial leads
Peaked T waves
m
se
PR depress ion As
Dr
Reciprocal ST depression
Shortened PR interva l
'Tombstoning' ST elevation in all precordial lead s
Peaked T waves
I PR depress ion
The most li kely diagn osis in the case is acute pericarditis. Though he d oes have some risk
factors for ischaemic hea rt disease, there are points in the history which lead you towards
a diagnosis of pericarditis: the history of vira l illness, wid espread ST e levatio n and posture
o f the patient (sitting forwa rd suggesting th is is comforta ble/gives some pa in re lief) a re
typical.
All of the above ECG features may be seen in pericarditis. However, the only s pecific
m
finding is PR depression and therefo re this is the most app ropriate a nswer. In addition to
se
this, ST e levation in perica rditis would classically be described as 'saddl e -sha ped .'
As
Dr
A 72-year-old man is st arted on amlodipine 5mg od for hypertension. He has no other
past medical history of not e and routine bloods (incl uding fasting glucose) and ECG were
normal.
What should his target blood pressure be once on treatment?
< 130/80 mmHg
< 140/80 mmHg
< 140/85 mmHg
< 140/90 mmHg
m
se
< 150/90 mmHg
As
Dr
< 130/80 mmH g CD
< 140/80 mmHg .
CID
< 140/85 mmHg CD
I < 140/90 mmHg
< 150/90 mmHg

CiD
m
se
As
Blood pressure target ( < 80 years, clinic reading) - 140/90 mmHg
trrpor.art "or me _ess -~oc1:! "l t
Dr
A 76-year-old gentleman is admitt ed through the Emergency Department with worsening
shortness of breath and ankle swelling on a background of left ventricular failure
secondary to ischaemic heart disease. He has bibasal crepitations on auscultation and a
raised JVP of 4 em with periphera l pitting oedema to his knees. He is commenced on IV
fu rosemide.
What is the mechanism of action of fu rosemide?
Inhibition of the Na +CI - transporter in the distal convolut ed tubule
Aldosterone antagonist
Inhibition of the Na +/K+/2CI- co-transporter in the thick ascending limb of the

loop of Henle
Inhibition of the Na +/K+/ 2CI- co-transporter in the proximal tubule
m
se
Inhibition of sodium channels in the collecting tu bules
As
Dr
Inhibition of the Na+CI- transporter in the dist al convolut ed tubule fl3
Aldosterone antagonist fD
Inhibition of the Na+/K+/2CI- co-transporter in the thick ascending ~mb of the GD
loop of Henle
Inhibition of th e Na +/K+/2CI- co-transporter in the proximal tubule 8

In ibition of sodium channels in the collecting tu bul es 8
Furosemide- inhibits the Na-K-CI cotrans porter in the thick ascending limb of the
loop of Henle
Loop diuretics (furosemide, bumet anide) act by inhibiting the Na+/K+/ 2CI- cotransporter
in the thick ascending limb of the loop of Henle. This causes loss of wat er along with
sodium chloride, potass ium, calcium, and hydrogen ions.
Explanation fo r other options:

• 1. Describes mechanism of thiazide diuretics
• 2. Spironolact one and eplerenone are examples of aldost erone antagonists
m
• 4. This answer is incorrect
se
As
• 5. Describes mechanism of amiloride and triamterene
Dr
Which one of the following diuretics works by inhibiting a transmembrane cotra nsporter
protein?
Indapamide
Eplerenone
Furosemide
Am iloride
m
se
Mannitol
As
Dr
Indapamide fD
Eplerenone GD
Furosemide CD
Amiloride GD
Mannitol CD
Furosemide- inhibits the Na-K-CI cotrans porter in the th ick ascending limb of the
m
loop of Henle
se
Important for me l ess ' m ::~c rtc.nt
As
Dr
A 62-yea r-old man is reviewed . His blood p ressure is poorly controlled at 152/ 90 mmH g
d es pite treatment with ram ip rillOmg o d, bendro flumethiazide 2.5mg o d an d am lo dipi ne
lOm g od.In addition to the antihypertensives he a lso takes asp irin and simvastatin. His
most recent b lood tests show the fo llowing:
Na• 139 mmol/ 1
K• 4.2 mmol/1
Urea 5. 5 mmolfl
Creatinine 98 IJffiOI/1
What is the most ap propriate change to his med ication?
Add frusemide
Increase ramipri l to 20mg od
Add sp iro nolactone
Add candesarta n
m
se
Add atenolol
As
Dr
Add frusemide
Increase amipril to 20mg od
Add spironolactone
Add candesartan
Add atenolol
Poorly contro lled hypertension, already t aking an ACE inhibitor, calcium channel
blocker and a thiazide diuretic. K+ < 4.5mmol/l - add spironolactone
m
se
This patient has reached step 4 in the NICE hypertension guidelines. As their potassium is
As
less than 4.5 mmol/1 spironolactone 25mg od should be started.
Dr
Which of the following statements concerning the third heart sound is correct?
Caused by systo lic filling of the ventricle
May be heard in constrictive pericarditis
Associated with atrial septal defects
Is characteristically soft in aortic stenosis
m
se
Caused by atrial contraction against a stiff ventricle
As
Dr
Which o f the following statements concern ing the third heart sound is correct ?
Caused by syst olic filling of the ventricle fD

I May be heard in constrictive p ericarditis ED
Associated w it h atrial septal defect s fD
Is charact eristically soft in aortic st en osis CD
Caused by atrial contraction ag ainst a stiff ventricle fD
Third heart soun d - constrictive perica rditis

m
se
As
A t hird heart sound is often heard in left ventricular failure and constrictive pericardit is
Dr
A 68-year-old gentleman is brou ght into resus in yo ur local emergency depa rtment after
a syncopa l episode. He is alert but clea rly d istressed.
The monitor above the bed showed a heart rate of 190bp m with a blood pressu re of
85/SOmmHg. His oxygen saturations are 98% in high flow oxygen (lSL per mi nute via
non -rebreathe mask). You a re awa iti ng a full 12 lead ECG to be performed but the tra ce
on cardiac monitor a ppears to show a regular broad complex tachycard ia. A formal ECG
subsequently confirms that the arrhythmia is a ventricular tachyca rdia (VT) with a QRS
complex duration of lSOms.
With regard to the JVP waveform, which of these featu res wou ld you expect to see?
Giant v waves
Cannon a waves
Prominent x d escent
Slow y descent
m
se
Large a waves
As
Dr
Gia nt v waves (D
Cannon a waves caD

Prom ine nt x descent fD
A ydescent CD
Large a waves ([D
The correct answer is B: cannon a waves.
Cannon a waves resu lt from atria l contraction a gainst a closed tricusp id valve a nd
the refo re ca n be seen in VT when a trial a nd ve ntricu la r contraction is not co-o rd inated.
They ca n a lso be seen in co mplete/3 rd d egree hea rt block a nd atrial flutte r fo r the same
rea son.
Gia nt V waves are a features of tricuspid regurgitation; p rom ine nt x d escent is a feature of
constrictive pericarditis; s low y descent is a featu re of ca rd iac tamponad e a nd tricuspid
m
se
stenosis; a nd large a waves can be fou nd in tricusp id stenosis, right heart fa ilure and
As
pulmona ry hypertension.
Dr
A 53-year-old man presents as he is worried about palp itat ions. These are described as
fast and irregular and typica lly occur twice a d ay. They seem to be more common after
drinking alco hol. There is no history of chest pain or syncope. Examination of his
cardiovascu lar symptoms is normal with a pu lse of 72/min and a b lood pressu re of
116/78 mmHg. Blood t ests an d a 12-lead ECG are unremarkable. What is the most
appropriate next step in manag ement?
Reassure and repeat 12-lead ECG in 3 months time
Request a troponin I
Arrange an echocardiog ra m
Arrange a Holter monitor
m
se
Arrange an external loop recorder
As
Dr
Reassure and repeat 12-lead ECG in 3 months tim e
Request a troponin I
Arra nge an echocardiogram
Arrange a Holter monitor
Arrange an external loop recorder

-
"""'
Palpitations should first be investigated with a Holter monitor after initial
bloods/ ECG
These episodes are characteristic of an arrhythmia, possibly atrial fibrillation. First-lin e

investigations are normal and it is appropriate t o investigate further to exclude an
arrhythmia.
Holter monitoring should be arranged to try and capture such an episode. Given the
episodes occur daily it is reasonable to do this over a 24 hour period initially.
A troponin is not indicated given the absence of chest pain and there is no suggestion of
heart failure to warrant an echoc.ardiogram.
m
se
As
An extern al loop recorder should only be considered if the Holter monitoring is normal
Dr
and the patient continues t o have symptoms.

A 73 yea r-old male has progressive exertional dyspnoea due to progressive systolic heart
fa ilure with a left ve ntricu la r ejection fraction of 30%. What investigation is most usefu l in
p redicting sym ptomatic res ponse to ca rdiac resynchro nisation therapy?
Cardiac MRI
Transo esophageal Echo
Coro na ry angiogram
ECG
m
se
Nu clear perfusion sca n
As
Dr
Cardiac MRI fD
Transoesophageal Echo «ED
Coronary angiogram fD
ECG tD
Nuclear perfusion scan fD
The key diagnostic tests used to identify patients likely to benefit from ca rdiac
resynchronization t herapy is the t ranst horacic echocardiogram and ECG. Those with left
ventricular ejection fractions of <35% and a LB BB (QRS du ration greater than 120 ms) on
ECG are excellent candidates for CRT (biventricu lar pacing). The echo w ill show
asynchronous contraction of the LV and RV and su bsequently reduced ejection fraction. A
transoesophag eal echo is not required.
Biventricular pacing improves quality of life and exercise to lerance amongst other
endpoint s, and d oes so by ensuring t hat the ventricles contract at the same t ime
m
se
(resynchronization) due to asynchronous stimulation (LBBB causing asynchronous
As
activat ion) via the co nduction system.
Dr
A 24-year-old female who is 10 weeks in to her first pregnan cy presents for review. Her
blood pressure t oday is 126/ 82 mmHg. What normally happens t o blood pressure during
pregnancy?
Falls in first half of pregnancy before rising to pre-pregnancy level s before term
Syst olic + diastolic rises by < 10 mmHg
Syst olic + diastolic fa lls by < 10 mmHg
Rise in first half o f pregnancy before fa lling to pre-p regn ancy levels before term
m
se
Doesn't cha nge
As
Dr
I Falls in first half of pregnancy before rising to pre-pregnancy levels before te rm GD
Systolic + diastolic rises by < 10 mmHg 8

Systolic + diastolic fa lls by < 10 mmHg G3
Rise in first half of pregnancy before falling to pre-pregnancy levels before term CD
m
m
se
E oesn't change
As
Dr
A 35-year-old woman who p resents wit h progressive dyspnoea is diagnosed as having
p rimary pu lmonary hypertension. She is started on an endothelin receptor antagonist.
What is the aim of th is t reatment?
Increase b lood flow to the lungs
Reduce the risk of secondary pu lmonary f ib rosis
Reduce pulmonary vascu lar res istance leading to reduced right ventricle (RV)
systolic pressure
Decrease the pulmonary venous pressure
m
se
As
Increase the oxygen saturation of venous blood f lowing to the left atrium
Dr
Increase b lood flow to the lungs
Reduce the risk of secondary pu lmonary f ibrosis
I Reduce pulmonary vascular resistance leading to reduced right ventricle (RV)

systolic pressure
Decrease the pulmonary venous pressu re
crease the oxygen saturation of venous blood f lowing to the left atrium
Endothelin receptor antagonists decrease pulmonary vascu lar resistance in patient s

wit h p rimary pulmonary hypertension
Important for me l ess :mocrtant
m
The aim of endothelin receptor antagonist therapy is to reduce pulmonary vascular
se
resistance and hence reduce the strain on the right ventricle. Right ventricular failure is
As
the most common cause of d eath in patients with primary pulmonary hypertension.
Dr
A 70-yea r-old man with a background of ischaem ic heart disease and periphe ra l arterial
disease presents to the Emergency De partment. He has been feeling generally unwell fo r
the pa st two d ays with fever and myalg ia but this morning d eve loped a pu rple, cold left
middle toe. On exa mination there a re s ig ns of ea rly ischaem ia to the toe and a fa int livedo
reticu la ris rash is seen on the foot. A diagnosis of cho leste ro l embo lisation is suspected .
Which of the fo llowing featu res would b e most sup portive of th is diagnosis?
Lym p ho cytosis
Thrombo cytosis
Neutrophilia
Thrombo cytopaenia
m
se
Eo sinop hil ia
As
Dr
Lym phocytosis CD
Thrombocytosis G'D
I Neu) rophilia fD
Thrombocytopaenia tED
I Eosinophilia
I e:D.
m
se
As
Eosinophilia is seen in around 70% of cases of cholesterol embolisation.
Dr
Your next patient is a 74-year-old woman who is known to have type 2 diabetes mellitus.
Her blood pressu re has been borderline for a number of weeks now but you have decided
she would benefit from treatment. Her latest blood pressu re is 146/ 88 mmHg, HbAlc is
7.5% and her BMI is 25 kg/ m" 2. What is the most appropriat e drug t o prescribe?
Bisoprolol
Bendroflumethiazide
Am lodipine
Ram ipril
m
se
Orl istat
As
Dr
Bisoprolol CD
Bendroflumethiazide m
Amlodipine ED
Ram ipril eD
Orlistat CD
Hypertension in diabetics -ACE-inhibitors are first-line regard less of age
m
se
As
Dr
A 45-year-old man p resents w ith pleuritic central chest pain and flu-like sympto ms to the
Emergency Department. The pain started yesterday and is worse at night when he lies flat.
Which one of the following ECG f indings is most sp ecific fo r the likely diagnosis?
PR d epression
T wave inversion
Short PR interval
U waves
m
se
ST elevation
As
Dr
I PR depression
T wave inversion
CD
m
Short PR interval fD
U waves
ST elevation mt
m
se
As
ST elevation is seen but is not specific as it may also indicate ischaemia
Dr
A 17-yea r-old female presents with recurrent attacks of collapse. These episodes typically
occur without warning and have occurred whilst she was runn ing for a bus. There is no
s ignificant past medica l history and the only family history of note is that her father d ied
suddenly when he was 38-years-old. What is the like ly cause?
Vaso -vagal attacks
Anxiety
Epilepsy
Cardiogenic syncope
m
se
Malingeri ng
As
Dr
Vaso-vagal attacks f.D
r r nxiety f.D
Epilepsy f.D
Cardiogenic syncope (D
Malingering f.D
Sudden death, unusua l collapse in young person - ? HOCM

m
se
This is a rather vague question. However, a fa mily history of su dden death shou ld make
As
you think of conditions such as hypertrophic obstructive cardiomyopathy
Dr
A 55-yea r-old man is ad mitted to the Emergency De partment with 'tea ring ' chest pain
radiating th rough to his back. Examination reveals a pulse of 96 I min regular, blood
pressure of 130/ 85 mmHg and oxygen satu rations of 97% on room a ir. A chest x-ray
shows mediastinal widening . ACT shows dissection o f the ascending aorta. What is the
most su itab le initial management?
IV sodium nitro prusside
Oral verapamil
O bserve o nly
IV lab etalol
m
se
As
Surgical re pai r
Dr
IV sodium nitroprusside fD
Oral verapamil m
Observe only m
I IV labetalol Cl'D
Surgical repair ED
Aortic dissection
• type A- ascending aorta - control BP(IV labetalol) + surgery
• type B - descending aorta -cont rol BP(IV labetalol)
The quest ion t ests ability t o apply t extbook knowledg e to real world situat ions. Whilst
m
se
su rgical referral shou ld be made as soon as possible definit e surg ery will inevitably take
As
tim e and t he b lood pressure should be controlled in t he meant ime
Dr
Which one o f the followi ng cli nical sig ns wou ld best ind icate severe aortic stenosis?
Valvu lar gradient of less than 30 mmHg
Soft second heart sound
Qu iet first heart sound
Development of an opening snap
m
se
Carotid radiation of ejection systolic murmur
As
Dr
Which one o f the following cl inical sig ns wou ld best indicate severe aortic stenosis?
Valvu la r gradient of less than 30 mmHg
I Soft second heart sound
Quiet first heart sound
Development of an open ing snap

-
""""
Carotid radiation of ejection systolic mu rmur
m
se
Questions may sometimes refer to a soft A2 rathe r than a soft 52 (seco nd heart sou nd},
As
s pecifically mentioning the aortic component.
Dr
A 70-year-old ret ired office worker is admitted to the medical unit with a 2 day history of
shortness of b reath and chest pain on insp iration. He has had a normal chest x-ray and
ECG. Full blood count, C-reactive p rotein, urea and electrolytes are unremarkable.
Observations are w ithin normal levels. Which scoring system should be used to det ermine
which investigation to perform next?
CHA2DS2-VASC score
Two level Wells score
CURB -65 score
Rocka ll score
m
se
PERC score
As
Dr
I Two level Wells score
CURB-65 score
Rockall score
PERC score
The two level Well's score can be used in patients presenting w ith signs and
symptoms suggestive of PE to guide the next investigation
This patient has symptoms suggestive o f PE but normal investigations and normal
observations. The two -level Wells score for PE is d esigned to aid decision making in
choosin g investigations. The full Wells score can be found in the background notes.
Patients in t he 'PE likely' group with > 4 points should have an urgent CTPA. Patients in
the 'PE unlikely' group should have a d-dimer. If t he d -dimer is positive they should go on
t o have a CTPA. If the d-dimer is negative an alternative diagnosis should be considered
for their symptoms.
1. CHA2DS2-VASC score- a scoring system for risk of stroke in AF
m
se
3. CURB-65 score -a scoring system for prognosis in community acquired pneumonia
As
Dr
4 Rn rk';:d l c::.rn rP - <:rnrinn C::. \J<tPm for • JnnPr l,l hleeds
A 54-yea r-old ma n with a history o f ischaemic heart disease is currently taking
atorvastati n 40mg at night. A repeat lipid profile is ordered:
Total cholesterol 3.9 mmoljl
HDL 0 .7 mmolfl
LDL 2.6 mmol/1
Triglycerides 1. 2 mmoljl
What wou ld be the most effective way of increas ing HDL levels?
Add nicotinic acid
Add ezetimibe
Switch atorvastatin to pravastatin
Add bezafibrate
m
se
As
Add colestyram ine
Dr
I Add nicotinic a_ci_d- - - - - - - - ' CD
Add ezetimibe GD
Switc1 atorvastatin to pravastatin CD
Add bezafibrate fiD
Add colestyram ine CD
Nicotinic acid increases HDL levels
m
se
As
Dr
Which one of the following stat ement s regarding percutaneous coronary intervention
(PC!) is inco rrect ?
Stent thrombosis usually occurs in the first month
Restenosis is more common than stent thrombosis
Around 95% o f patients have a stent fitted during a PC!
Renal impairment is a risk facto r for restenos is
m
se
Patients with drug -eluting stents require a shorter duration of clopidogrel therapy
As
Dr
St ent thro mbosis usually occurs in the first month
Restenosis is more common than stent thrombosis
Around 95% of patient s have a stent fitted during a PC!
Renal impairment is a risk factor for restenos is
Patients with drug -eluting stents require a shorter duration of clopidogrel

therapy
PC! - patients w ith drug-eluting stents require a longer duration of clopidogrel

therapy
m
se
As
Dr
A 79-yea r-old female p resents to the low-risk chest pain clinic with intermittent substernal
chest pains. The pain typically comes on with exertion and imp roves with rest. A tria l of
GTN has been g iven by her GP which he lps with her pain. She is a known ex-smoker of 30
pack-yea rs . She has no diabetes, hyperlipidaemia, hypertensio n, and no family histo ry of
corona ry artery disease.
On exam ination her observatio ns are stable. On auscu ltations of her chest, her first and
second heart sounds are aud ib le with no ad ded sounds an d her lungs a re clea r.
A pre-test probability is calculated for coronary artery disease wh ich gives a resu lt o f 45%.
What is the most impo rtant investigatio n to pu rsue given her risk for co rona ry artery
disease?
CT calcium scoring
Coronary ang iogram
Stress test ECG
Myocard ial perfusion scintigraphy
m
se
As
No further investigations
Dr
CT calciu m scoring
~ronary angio~
Stress test ECG
I Myoca rdia l p erfus io n scintigraphy
No further investigatio ns
The answer is myoca rdia l perfusio n scintig ra phy which is ap prop riate fo r a p re-test
coronary artery disease pro bability of between 30-60%. If the pre-test pro bability is a bove
this, then invasive coronary angiography is a ppro priate, below this CT ca lcium sco ring.
Given th is chest pa in is typical for co rona ry a rtery di sease, the no furthe r investigations
a nswer wou ld be inappro priate.
The 2010 NICE gu idance fo r patients p resenting with chest pa in recommends that neither
exercise ECG nor MR coro na ry a ng io grap hy s hou ld be used to diag nose o r exclude stable
m
se
a ng ina fo r peop le without known CAD (Refe rence: Chest pain of recent onset; NICE Clin ical
As
Guideline (March 2010, updated Nov 2016) ).
Dr
A 61-year-old man is admitted w ith centra l crush ing chest pain to the Em ergency
Department. An ECG taken immediately on arriva l shows ST -elevation in leads ll, III and
aVF. His only past medical history of note is hypertension fo r which he takes ramipril.
aspirin and simvastatin. What is the optimum management o f this patient?
(LMWH = low-molecular weight heparin)
Aspirin + clopidogrel + LMWH + repeat ECG in 20 minut es
Clopidogrel + LMWH + alteplase
Aspirin + clopidogrel + LMWH + tenecteplase
Asp irin + clopidogrel + LMWH + altep lase
m
Aspirin + clopidogrel + IV heparin + immediate percutaneous coronary
se
int ervention
As
Dr
Asp irin + clopidogrel + LMWH + repeat ECG in 20 minut es
Clopidogrel + LMWH + alteplase
Aspirin + clopidogrel + LMWH + tenecteplase
Asp rin + clopidogrel + LMWH + alteplase
Aspirin + clopidogrel • N heparin + immediate percutaneous co ronary

int ervention
I
-
~
Primary percutaneous coronary int ervention is the gold-st andard treatment forST-
elevation myocardial infarction
m
se
Important for me l ess important
As
Dr
A 48-year-old gentleman present s with a 3-day hist ory of palpitations. This is on a
background of recurrent atrial fibrillation with previous failed cardioversion attempts but
had successful electrical cardioversion 8 months previously. An ECG confirms that he is in
atrial fibrillation w ith a rate of 80 b eats per minute. He currently takes bisoprolol an d
apixaban. The cardiology consu ltant reviews and has planned electrical cardioversion fo r 4
weeks time.
Until he is cardioverted, which of the following should be given in addition to his cu rrent
medications?
Digoxin
Ami odarone
Flecainide
Procainamide
m
se
Verapamil
As
Dr
I Amiodarone ED
Flecainide fD
(1roca inamide
Verapamil
•.
(D
If high- risk of failu re of cardiove rsion (previous failure), o ffer e lectrica l ca rdiove rsi on
a fter at lea st 4 weeks treatment with a miodaro ne
NICE recommend giving a mio da rone o r sotalol fo r at least 4 weeks p rio r to e lectrical
cardioversion in cases where there is a high risk of failure (recu rrent AF o r previous fa iled
cardioversion attempts).
Digoxin a nd verapamil can be used for rate control in AF, but the rate is a lready well
controlled with bisopro lol.
Flecainide can be used fo r pha rmacolog ica l ca rdiove rsion o f AF in patients without
structu ra l heart di sease, but the q uestion states that electrica l cardioversion is planned so
the re is no ro le fo r that he re .
m
se
As
Procaina mide has a ro le in ventricula r tachyca rd ia but is not indi cate d here.
Dr
A 48-year-old Asian lady was seen by her general practit ioner (GP) with a 3-week history
o f fever, fat igue and night sweats. On examinat ion, she was found t o have absent limb
pulses with blood t ests revealin g;
Hb 101 g/ 1
ESR 87 mm/hr
Her sym ptoms improved following a cou rse of steroids. Which blood vessel is most likely
t o be affected by her condition?
Arteries of the han ds and feet
Inferior vena cava (IVC)
Superior vena cava (SVC)
Renal arteries
m
se
Aorta
As
Dr
Arteries of the han ds and feet
Inferio r ve na cava (IVC)
J i perior ve na cava (SVC)
Renal a rteries
Aorta
-
"""'
Ta kayasu' s arteritis is an obliterative a rte ritis affecting the aorta

Important for me Less · m ::~c rtant
Ta kayasu's arteritis is a la rge vessel vasculitis typica lly affecting the aorta and lea ds to
a bsent limb pulses.
Arteries o f the han ds and feet - cha racteristic of Buerger d isease
IVC and SVC- involved in venous return a nd d o not belong to the arteria l system
m
se
As
Renal a rteries - a med ium-s ized vessel
Dr
You review a 34-year-old woma n w ho is 13 weeks pregnant. During her previous
pregnancy she developed pre-eclampsia and had to have a caesa rean section at 36 weeks
gestation. Her blood pressure both following the last pregnancy and today is normal.
Which one o f the followi ng interventions should be o ffered to reduce the risk o f
developing pre-eclampsia again?
Prophylactic nifedipine therapy
Prophylactic labatelol therapy
Vitamin 86 supplementation
Extended folic acid supplement ation
m
se
Low -dose aspirin
As
Dr
You review a 34-year-old woman w ho is 13 weeks pregnant. During her previous
pregnancy she developed pre-eclampsia and had to have a caesarean section at 36 w eeks
gestation. Her blood pressure both following the last pregnancy and today is normal.
Which one of the following interventions should be offered to reduce the risk of
developing pre-eclamp sia again?
Prophylactic nifedipine therapy
Prophylactic labatelol th erapy
Vitamin 86 supplementation
Extj nded folic acid supplementati on
Low-dose aspirin
m
se
As
Dr
A 45-yea r-old man is diagnosed with endocarditis o f the aortic valve. He is treated with
intravenous benzylpenicillin and gentamicin. What is the most important ECG change to
monitor fo r?
Left ventricu la r hypertro phy (by voltage criteria)
Reflex tachycardia
ST segment d e pression
Prolonged QT interva l
m
se
Prolonged PR inte rva l
As
Dr
Left ventricu lar hypertrophy (by voltage criteria)
Reflex tachycardia
ST segment depression
Prolonged QT interval
I Prolonged PR interval
A prolonged PR interval -ao rtic root abscess

m
se
A prolonged PR interval cou ld indicate the development of an aortic abscess, an
As
indication for surgery
Dr
You are on the cardiac a rrest tea m and are called to the emergency depa rtment for a 25-
year-old male who has arrived in ca rdiac arrest. He collapsed while p laying football. His
brother is present: he reports that their father d ied suddenly in h is 30s and they were later
told he had hypertrophic obstructive cardiomyopathy (HOCM). Screening had been
discussed with both his children but this had not happened yet.
Assum ing the d iagnosis is the same, wh ich of the fo llowing is likely to confer the poorest
prognosis?
Genetic mutation in troponin T
Left ventricu la r wa ll thickness 25mm
Preceding sym ptoms of chest pa in
Atrial fibrillation on 24 hour halter monitoring
m
se
Increased blood pressure during exercise
As
Dr
I Genetic mutation il troponin T
Left ventricu lar wa ll thickness 25m m
Preced ing symptoms of chest pain
Atrial fibrillation on 24 hour holter mo nitori ng
Increased blood pressure during exe rcise
Of those listed above, o nly one is an a ppropriate a nswer. Specific genetic mutations (such
as in myosin bi nding protein C and tro ponin T) have b een recognised as poor prognostic
features in HOCM. B is incorrect as it is a ventricu la r wall thickness > 30mm that has been
associated with a poor outco me. C is incorrect as it is p receding symptoms o f syncop e,
not chest pain that is associated . Non sustained ventricu la r tachycardia, not atrial
fibrillation, on ho lte r monitoring is associated with a poor outcome, therefore D is
inco rrect. Fi nally, it wou ld be a low b lood pressure during exercise that would be
associated with a poor prognosis the refo re E is a lso an inap prop riate answe r.
The question in this case concerns poor p rognostic features of hype rtro phic o bstructive
m
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ca rdio myopathy. Of those listed ab ove, the on ly a pp rop riate answer of a poor p rognostic
As
feature is mutations in tro ponin T. The o th ers are incorrect fo r the poor p rognostic criteria
Dr
A 34-year-old woman is referred to cardiology as her p rimary care doctor has id entified a
systolic murmur. As part of the invest igat ions she undergoes cardiac catherisation. The
following results are obtained f rom the right side of the heart:
Oxygen sat urat ion
Right atrium 71%
Right ventricle 82%
Pulmonary art ery 81%
The leh side of t he heart is also assessed:
Oxygen sat urat ion
Left atrium 99%
Left ventricle 98%
Aorta 97%
Ventricular septal defect
m
se
As
Atrial septal defect with Eisenmenger's syndrome
Dr
I Ventricu lar septal defect CD
Patent ductus arteriosus tiD

Atrial septal defect with Eisenmenger's syndrome m
Atrial septal defect tiD
Ventricula septal defect w ith Eisenmenger's syndrome GD
m
se
As
Dr
A 65-yea r-old female is admitted with a suspected infective exacerbation of chronic
obstructive pu lmonary disease. On exam ination she is dyspnoeic with a b lood p ressu re of
112/68 mmHg. Electrocardiogram shows an irregular, narrow-complex tachyca rdia with a
rate of 130 bpm. At least three di fferent P wave mo rp hologies are seen. A diagnosis of
multifocal tachyca rdia is suspected. What is the most appropriate management?
Adenosine
Digoxin
Verapamil
Atenolol
m
se
DC card iovers ion
As
Dr
Adenosine fD
Digoxin .
(D
I
Verapamil CD
Atenolol GD
DC cardioversion GD
m
se
As
Dr
A 62-yea r-old man is a d mitted with to the cardiology ward with infective endoca rd itis.
Blood cultures grow Streptococcus bovis. What is the most appropriate investigation given
the b lood cultu re findings?
Small bowel mea l
Bronchoscopy
Cystoscopy
Gastroscopy
m
se
Colonoscopy
As
Dr
A 62-year-old man is admitted with to the cardio logy ward with infective endocarditis.
Blood cu ltures grow Streptococcus bovis. What is the most appropriate investigation given
the b lood culture findings?
Small bowel mea l CD

Bronchoscopy CD
Cystoscopy m
Gastroscopy CD
Colonoscopy GD.
m
se
As
Streptococcus bovis endocarditis is associated with colorectal cancer
Dr
A 57 -y ea r-old man who had a prosthetic m itra l valve replacement 7 years ago p resent s
with fever. An urgent echocard iogram shows features consist ent w ith endocardit is. What
is the most su itab le antibiotic t herapy until b lood cu lt ure resu lt s are known?
IV ceftriaxone + benzylpenicill in
IV vancomycin + rifampicin + gentamicin
IV benzylpenicill in + gentam icin
IV flucloxacillin + gentamicin
m
se
IV vancomycin + benzylpenicillin
As
Dr
IV ceftriaxone + benzylpenicillin CD
I IV vancomycin + rifampicin + gentamicin ED

IV benzylpenicillin + gentamicin GD
IV flucloxaoillin + gentam icin GD
IV vancomycin + benzylpenicillin CD
If the patient has a prosthetic valve and endocard it is is suspected the initial therapy
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se
should consist of intravenous vancomycin + rifamp icin + gentamicin. Please see the
As
current BNF fo r m o re information.
Dr
Each one of t he following is associat ed w ith aortic dissection, except:
Vent ricu lar septal d efect
Tu rner's syndrome
Noonan's syndrome
Pregnancy
m
se
As
Marfan's syndrome
Dr
I Ventricular septal defect
Turner's syndrome
CD
GD
Noonan's syndrome CD
Pregnancy fiD
Marian's syndrome m
m
se
As
Dr
A 24-year-old male is admitted with difficulties breathing. He states that he was at a
restaurant having dinner when he noticed a rash on his arms, followed by nausea and
difficulties with taking in a breath. On examination, th ere is genera lised urticaria and
swelling of his tongue and pharynx. There is audible inspiratory stridor. You treat him with
intramuscular adrenaline, intravenous hydrocortisone, and intravenous chlorphenamine.
He respo nds well to treatment.
You decide to monitor him on the ward therea fter. How long will you monitor the patient
for?
1 hour
2 hours
8 hours
48 hou rs
m
se
As
1 week
Dr
1 hour CD
2 hours CD
8 hou rs 6D
48 hours fl'D
1 week
•
In anaphylaxis, biphasic reactions can occur in up to 20% of patients
The patient has clea rly had an anaphylactic reaction which has been treated ap p ropriately.
A bip hasic reaction includ es a recurrence of symptoms that d evelops after apparent
resolution of the initial reaction. Biphasic reactions have been re ported to occu r in
1%-20% of anaphylaxis episodes and typically occu r about 8 hou rs after the first reaction,
although recu rrences have been repo rted up to 72 hours later.
Although there is no d efinite consensus on monito ring post ana phylaxis, most cl inicians
and loca l policies advise monitoring fo r a period of 6-8 hours afte r reso lution of
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se
sympto ms. Patients shou ld be advised of the possibility of b iphasic reactions and to ld to
As
seem emergency medica l care if they deve lo p any of the sym ptoms or signs. Dr
A 72-year-old man presents with lethargy and palpitations for the past four or five days.
On examination his pulse is 123 bpm irregularly irregular, blood pressure is 118/70 mmH g
and his chest is clear. An ECG confirms atrial fibrillation. What is the appropriate drug to
control his heart rate?
Amiodarone
Bisoprolol
Digoxin
Amlodipine
m
se
As
Flecainide
Dr
Amiodarone CD
Bisoprolol fD
Digoxin CD
Amlod ipine m
Flecainide m
Atrial fibrillation: rate control - beta blockers preferable to digoxin

A number of factors including age and symptoms would favour a rate control strategy.
m
se
The NICE guidelines suggest either a beta -blocker or a rate limiting calcium channel
As
blocker (i.e. Not amlodipine) in this situation.
Dr
An 82-yea r-old man is referred to cardiology by his GP with increasing dyspnoea o r
exerti on and a systolic murmu r. Examination d emonstrates a b lood p ressure of 100/80
mmHg an d a slow rising pu lse. What is the most likely cause of his underlying condition?
Ventricu la r septa l defect
Post rheu matic fever
Calcification of the aortic va lve
m
se
Hype rtro phic obstructive cardiomyopathy
As
Dr
Ventricu la r septa l d efect
Post rheumatic fever
Calcification of the aortic valve
l'l ypertrophic o bstructive cardio myo pathy
Aortic stenosis - most co mmon cause:

• you nger patients < 65 years: b icuspid aortic va lve
• o lder patients > 65 years: calcification
m
se
As
This patie nt has ao rtic ste nosis.
Dr
A 32-year-old fema le patient presents with an 8-month history of progressively worsening
shortness of breath, general fatigue and weight gain. There is no significant past medical
history. In particular, there is no history of cardiorespiratory conditions. On examination,
the patient is tachycardic with central cyanosis and general oedema. A chest rad iograph
shows cardiomegaly and dilatation of the pulmonary arteries. An echocardiogram
suggests a ra ised pulmonary arterial pressure.
Which of the following is the mainstay treatment used for this condition?
Bendroflumethiazide
Aspirin
Ra mipril
Prostacycli n
m
se
As
Bisoprolol
Dr
Aspirin m
Ram ipril CD
Prostacycl in CD.
Bisoprolol m
Prostacyclins is used in the treatment of primary pulmonary hypertension
Prostacycli ns are used in the treatment of primary pulmonary hypertension(PAH).
Bendroflumethiazide is not used to treat PAH but it can be used to treat heart failure and
hypertension although not first-line for either.
Aspirin has no effect on PAH.
m
se
As
Ramipril and bisoprolol are not used to treat PAH but they are the first line treatments fo r
heart failure.
Dr
You are a new speciality tra inee in cardiology and in the middle of a busy outpatient
clinic. You r next patient is a 27 -year-old female with Arrhythmogenic Right Ventricular
Dysplasia (ARVD) who is attending today for counselling/planning of prophylactic lCD
insertion. She was diagnosed with this condition following the sudden death of her
brother 2 yea rs ago but has no history of problems herself.
Her echoca rdiogram (ECHO) done ea rlier today shows a moderately dilated and
dyskinetic right ventricle with a mildly reduced ejection fraction wh ich is similar to her last
ECHO done around 18 months ago.
She is concerned as she drives to work every day and wants to know if the re will be any
restrictions to this.
What is the most appropriate thing to tell her?
She will not be permitted to drive aga in with an lCD
She will have to stop driving for 1 month only
There are no restrictions so she can drive again imm ediately
As she has had an lCD inserted she needs to wait 6 months befo re driving again
m
se
She must have another ECHO afte r 1 month and if this is satisfactory can drive As
aga1n
Dr
She will not be p ermitted to drive aga in with an lCD
She will have to stop driving for 1 month only
There are no restrictions so s he can drive again imm ediate ly
As she has had an lCD inserted she needs to wait 6 months b efore driving again fiD
She must have another ECHO after 1 month and if this is satisfactory can drive
aga1n
The answer to this question re lies on knowledge of DVLA guidelines but also in
recognising that this is a prophylactic lCD not one for secondary prevention. The ECHO
findings a re a red herring as these are not actually mentioned in the guidan ce for this
situation.
The correct answer is 1 month (B): E is incorrect as she is not required to have a further
ECHO (unless co ncern) p rior to d riving agai n. If this was a secondary p reventative lCD or
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se
following lCD shock therapy then the correct answer would be 6 months. A lifelong ban
As
applies only to group 2 drivers.
Dr
A 53-yea r-old man is reviewed in the cardiology clinic with a history of chest pain and
syncope. On examination he has an ejection systolic mu rmu r rad iating to the carotid area.
What is the most likely cause of his symptoms?
Aortic root abscess
Post rheu matic fever
Posterio r myocard ia l infarction
m
se
As
Dr
Aortic root abscess
Post rheumatic fever
Posterior myocardial infarction
Aortic stenosis - most common cause:

• younger patients < 65 years: bicuspid aortic valve
m
se
• older patients > 65 years: calcification
As
ln'portar1 tor me _ess l"'":>crtant
Dr
A 51-year-old man is st arted on lisinopril aher being found t o have an average blood
pressure of 154/93 on ambulat ory blood pressure monitoring. Around two weeks aher
st arting treatment he represents with a persistent dry cou gh. Accu mulation of w hich one
of the fo llowing proteins is responsible for this?
Adenosine
Hist amine
Bradykinin
Acetylcholine
m
se
Neurokinin A
As
Dr
Adenosine CD
Hist amine CD
I Bradykinin (D
Acetylcholine CD
Neurokinin A fD
m
se
As
Dr
Which one o f the followi ng rad iotracers is used during cardiac Positron Emission
Tomography (PET) scans?
Gallium
Fluorodeoxyglucose
Technetium (99mTc)
Thallium
m
se
Fluorine-18
As
Dr
Gallium CD
I Fl uorodeoxyg lucose CI'D

Technetium (99mTc) 6D
Tha llium CD
CD
m
se
As
Dr
Which one o f the following is least associated with ST depression on ECG?
Myocardial ischaemia
Syndrome X
Acute perica rdit is
Hypoka laem ia
m
se
As
Digoxin
Dr
Myocardial ischaemia CD
Syndrome X (D
I
Acute pericarditis
Hypoka la emia
GD
.
(D
Digoxin .
(D
m
se
As
Dr
A 74-year-old man presents for a medication review. Blood pressure is recorded as
184/72 mmHg. This is confirmed on two further occasions. What is the most appropriate
first line therapy?
Ramipril
Losarta n
Bendroflumethiazide
Am lodipine
m
se
Atenolol
As
Dr
Ramipril CD
Losa rtan CD
Amlodipine f.D
Atenolol CD
The 2011 NICE guidelines recommended treating isolated systolic hypertension the sa me
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se
way as standard hyperte nsion. In this age group calcium chan nel blockers would be first-
As
line.
Dr
You review a 60-year-old man who had a d rug-eluting stent inserted 6 months ago fo r
ischaemic heart disease. His current medication includes aspirin, clopid og rel. atorvastatin,
ra mipril and bisoprolol. He has developed an inguinal hernia and is keen fo r su rgica l
repair. The cardio log ists plan was to continue clopidogrel for 12 months following stent
inserti on. What is the most approp riate course of action?
Stop clo pidogrel the day before the operation
Stop clo pidogrel 7 days before the operation
Continue clopidogrel as normal
Delay operation for 6 months
m
Stop clo pidogre l the day before the operation and start low-molecu lar weig ht
se
heparin (prop hylaxis dose)
As
Dr
Stop clo pidogrel the day before the operation
-'"""
I St op clopidogrel 7 days before the operation
Continue clopidogrel as normal

-
~
~ay operation for 6 months I
Stop clopidogrel the day before the operation and start low -molecu lar weight
heparin (prophylaxis dose) -
~
The AHA/ACC/SCAI/ACS/ADA published recommendations in 2007 stressed the
m
se
importance of 12 months of dual anti platelet therapy after placement of a drug-eluting
As
stent (0 ES).
Dr
Yo u are reviewing a 74-year-ol d ma n with hypertension, type 2 d ia betes a nd
o steoa rthritis. He ta ke s l Omg o f ramipril once a day, l Omg of a mlo d ipine o nce a day,
indapamid e 2.5 mg o nce a day, 500mg of Metfo rm in twice a d ay, co-codamol PRN an d
a torvastati n 20mg at night.
His blood p ressure (B P) is co nsistently ra ised on his hom e BP monito r and tod ay in the
clinic today is 158/95 mmHg. You wou ld like to start a further medicatio n to try and lowe r
his BP. His K• is 4.0 mmol/1.
What would b e the mo st app ropriate next medication to ad d a ccording to the NICE
guidelines?
Bendroflumethiazide
Chlortalidone
Cande sarta n
Spiro nolactone
m
se
As
Doxazosin
Dr
I Chlortalidone ~
Candesarta n CD
I Spironolactone fD
Doxazosin fD
Poorly contro lled hypertension, already t aking an ACE inhibito r, calcium channel
blocker and a thiazide diuretic. K+ < 4.5mmoljl - add spironolactone
This patient has resistant hypertension as he is already on three agents to try and control
his BP. He is already taking an ACE-inhibitor (ramipril) and a calcium channel blocker
(a mlodipine) at the maximum doses. He is also t aking a thiazide-like diuretic
(indapamide). The next step wou ld be t o add spironolactone if the K• is <4.5 mmol/1.
Therefore, option 4, spironolact one is the correct answer.
If his K• was > 4.5 mmol/1, the next step wou ld be to consider higher-dose thiazide-li ke
diuretic treatment.
Bendroflumethiazide is a conventional thiazide diuretic which is inappropriat e here as the

patient is on indapamide. Chlortalidone is a thiazide-like diuretic (as is indapamide) so is
m
inappropriate t o add in. Candesartan is an angiotensin receptor blocker and shouldn't be
se
As
used in combination with an ACE-inhibitor. Doxazosin is an alpha blocker which is used if
Dr
A 70-year-old man presented to the emergency department following a fall and head
injury. Th is is his third fa ll in the past 12 months. He has a background of persistent atria l
fibrillation, type 2 d iabetes mell itu s and Parkinson's disease. He is taking apixaban Smg
BD, b isopro lol Smg OD, co-beneldopa lOOmg QDS, and metformin lg BD.
CT head reveals no acute find ings.
What is the most a p propriate management rega rding his anticoagu lation?
Stop apixaban for now, optim ise his Pa rkinson's med ication, an d consider
restarting in 6 months
Switch to aspirin
Stop anticoagulatio n
Stop apixaban for now, optim ise his Pa rkinson's med ication, an d consider starting
wa rfarin in 6 months
m
se
Continue apixaban
As
Dr
Stop apixaban for now, optim ise his Parkinson's medication, and consider
restarting in 6 months
I Switch to aspirin
Stop anticoagulation
Stop apixaban for now, optimise his Parkinson's medication, and consider
-
..wr
starting wa rfarin in 6 months
Continue apixaban
Risk o f fa lls alone is not sufficient reasoning to w ithhold anticoagulat ion

Do not w ithhold ant icoagu lation so lely because of t he risk o f fa lls (NICE CG180). There is
no o ther reason to cons ider withdrawing ant icoagulation here. One study used
experimental modelling to conclude that a patient with a 5% annual stroke risk (CHADS 2-
3) wou ld need to fall app roximat ely 295 t imes per year for the benefits of anticoagu lation
m
se
to be out -weig hed by the risk of fall- related intracranial haemorrhage. All of t he other
As
answers involve stopping or pausing oral anticoagulation and are t herefore incorrect.
Dr
Which one of the following features wou ld best indicate severe aortic stenosis?
Valvular gradient of 35 mmHg
Quiet first heart sound
Lou dness of ejection syst olic murmur
Fourth heart sound
m
se
Development of an opening snap
As
Dr
Valvular gradient of 35 mmHg GD
Quiet first heart sound GD
Lou dness of ejection systolic murmur CD
I Fourth heart sound C!D
Development of an opening snap f!D
m
se
As
Ao rtic st enosis - 54 is a marker of severity
Dr
Six weeks after having a prosthetic heart valve a patient develops infective endocarditis.
What is the most likely causative organism?
Streptococcus viridans
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus bovis
m
se
One o f the HACEK group
As
Dr
I Staphylococcus epidermidis
Streptococcus bovis
-
~
[ one of the HACEK group
Most common cause of endocarditis:

• Staphylococcus aureus
• Staphylococcus epidermidis if < 2 months post va lve su rgery
Coagulase-negative staphylococci such as Staphylococcus epidermidis are the most
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se
common causative organisms in the first 2 months following surgery. Aher this time the
As
spectrum of organisms causing endocarditis returns to normal.
Dr
You have ordered a B-type natriuretic p eptid e (BNP) t est on a pat ient wit h suspect ed
heart failure. It has come back as being slight ly elevated. Which one of the following
factors may accou nt for a falsely elevated BNP?
ACE inhibitor t herapy
Beta- blocker t herapy
Furosemide t herapy
Obesity
m
se
COPD
As
Dr
You have orde red a B-type natriuretic peptide (BNP) test on a patient with suspected
heart fail ure. It ha s come back as being slightly e levated. Which one of the following
factors may account for a falsely e levated BNP?
ACE inhibito r therapy fD

Beta- blocker therapy
Fu rosel ide therapy

•
flD
Obes ity fD
I COPD fD
m
se
As
Dr
An obese 45 -year-old male, with known hyperlipidaemia and peri pheral vascula r disease,
presents with a right parietal ischaemic stroke. He reports trouble sleeping and laying flat
at night that began aher a flu-like illness 3 months ago, and reports some exertional
dyspnoea. Which of the following investigations are most likely to find the cause of the
stroke?
Echoca rdiogram
CT bra in with angiog rap hy
Magnetic resonance imaging I Magnetic resonance angiogra phy(MRI/MRA)
Carotid d opp ler of carotid vessels
m
se
CT Chest with contrast
As
Dr
I Echocardiogram
CT brain w ith angiography
Magnetic resonance imaging I Magnetic resonance angiography(MRI/MRA)
Carotid doppler of carotid vessels
CT Chest with co ntrast
The underlying diagnosis is a viral myocarditis precipitating a dilated cardiomyo pathy and
causing a cardioembolic stroke. Previously, the ent eroviruses (including coxsackievirus)
were the most common identified viruses. Currently, parvovirus B-19 and human herpes
virus 6 are considered the most common causes of viral myocarditis. The echo may show
reduced left ventricular ejection fraction, myocardial dyssynchrony (myocardial segments
contract at different points in time), thinning of the left ventricular wall an d a dilated left
ventricle. Trouble sleeping and laying flat at night and the exertional dyspnoea after a flu-
like illness are key features suggestive of a viral myocarditis.
CT brain and M RI/M RA will show the effect of the stroke, and not the cause. Carotid
m
se
doppler ultrasonography of the caroti ds will not show the cause, as the cause is
As
cardioem bolic stroke.
Dr
A 67 -yea r-old man with a history of chronic obstructive p ulmonary disease and ischaem ic
heart disease is taken to the Emergency Department with dys pnoea . On exam ination his
respirato ry rate is 24 I min, JVP is not e levated and crackles are heard in both lung bases.
Which other finding would most strongly indicate that his dysp noea is seconda ry to
isolated left ventricu la r failure?
Pulsus pa radoxus
Gallop rhythm
Tachycardia
Periphe ral oede ma
m
se
Cardi omegaly on chest x-ray
As
Dr
Pulsus pa radoxus CfD
I Gallop rhythm eD
Tachycardia m
Peripheral oedema C!D
Cardiomegaly on chest x-ray C!D
Gallop rhythm (53) is an early sign of LVF

m
se
Whilst all of the above features may be seen in patient s with left ventricu lar failure a
As
gallop rhyt hm is one of the most sp ecific and early signs
Dr
A 24-yea r-old woman who is 34 weeks p regnant presents with pleuritic chest pain and
shortness of b reath. She has noticed some pain in her leh calf for the past 3 days and on
examination she has clinica l s igns co nsistent with a leh calf deep vein throm bos is. What is
the most a pp ropriate investigation?
D-dimer
Compression duplex Doppler
Computed tomograph ic pu lmona ry angiography
Venogram
m
se
Ventilation-perfusion scan
As
Dr
D-dimer
I Compression duplex Doppler
Computed tomographic pulmonary angiography
Venogram
Ventilation -perfusion scan
Confirming a DVT is the first step as this may provide indirect evidence of a pulmonary
m
se
embolism. As both conditions require anticoagu lation this may negate the need for
As
further radiation exposure.
Dr
A 64-year-old man is admitted to the Emerg ency Department with chest pain radiating
through to his back. On examination pulse 90 regular, BP 140/90. A CXR shows
mediastinal w idening. ACT shows dissection of th e descending aorta. What is the most
suitable initial management?
Observe only
IV labetalol
IV sodium nitroprusside
Immediate surgical referral
m
se
Oral verapamil
As
Dr
Observe only f.D
I IV lab eta lol CD

IV sodium nitroprusside f.D
Immediate surg ical referral GD
•
Aortic dissection
• type A- ascendin g aorta - cont ro l BP(IV labetalol) + surgery
• type B - d escending aorta -control BP(IV labetalol)
m
se
Dissection of t he descending aorta indicat es a type B dissection, which shou ld be
As
managed medically with IV labetalol
Dr
A 30-yea r-old woman is a dmitted to the Emergency Department fo llowin g the acute
onset of pal pitations. Blood p ressure is 124/ 84 mmHg and her p ulse is 150/min. An ECG
shows a narrow complex tachycardia. Intravenous access is gained and 6mg of adenosine
is given with no effect. What is the most ap pro priate next step?
Intravenous adenosine 12 mg
Intrave nous adenosine 6mg
Intrave nous ve rapa mil 2.5-5 mg
Radio -freque ncy ab lation
m
se
Electrica l ca rdiove rsion
As
Dr
I Intravenous adenosine 12 mg
Intravenous adenosine 6mg
Intravenous verapamil 2.5-5 mg
( ladio-frequency ablation
Electrical cardioversion
m
se
A further dose of adenosine should be given if there is no response to the initial inj ection.
As
Please see the Resuscitation Council (UK) link for further details.
Dr
A 54-yea r-old male w ith no past m edica l history is fo und to be in atrial fibrillatio n d u ring
a consultation regarding a sp rained ankle. He repo rts no history o f palpitatio ns or
dyspnoea. Aher discussing treatment o pt io ns he elects not to be cardioverted.
Examination of the card iovascular syste m is otherwise u nremarkab le with a blood
p ressu re of 118/ 76 m mHg. According to the latest NICE guid el ines, if t he patient remains
in ch ron ic atrial f ibri llation what is the most suita ble t reat ment to offer?
No t reatment
Warfarin
Dab igatran
Aspirin + dipyrid amole
m
se
Asp irin
As
Dr
I No t reatment ED
Warfarin CD
Dabigatran GD
Asp irin +dipyridamole fl'D
Aspirin GD
Young man with AF, no TIA or risk factors, no t reatment is now preferred to aspirin
m
se
The CHA2DS2 -VASc score for this man is 0. NICE the refore recommend that he does not
As
require ant icoagulation.
Dr
A 65-year-old man is discharged from hospital following a thrombo lysed ST-elevation
myoca rdial infarction. Other than a history of depress io n he has no past med ical history
of note. Exa mination of his card iorespiratory system today was normal. His stay on the
coronary care unit was complicated by the development of dyspno ea and an echo show a
reduced left ventricular ejection fraction. Other than standard treatment with an ACE
inhibitor, beta-blocker, aspirin, clopidog rel and statin, what other type of drug should he
be taking?
Angiotensin 2 receptor antagonist
Potassium channel activator
Aldosterone antagonist
Thiazide diu retic
m
se
Loop diuretic
As
Dr
Ang iotensin 2 recepto r a ntagonist CD
Potassium channe l act ivato r CD
I Aldosterone antagonist ED.

Thiazide diuretic CD
Loop diu retic fD
An a ld osterone antagon ist is recom me nd ed by current NICE gu id elines a s the patient has
m
se
a red uced left ventricu la r ejection fractio n. A loop diuretic is not indicated unl ess the re is
As
evide nce o f flu id ove rload .
Dr
A 61-yea r-old woman is admitted to the Emergency Department with central chest pain. It
feels li ke her previous ang ina but is not rel ieved by nitrates. She has a history o f ischaemic
hea rt disease and 4 weeks ago underwent a percutaneous co ro na ry intervention during
which a stent was placed. This is her first episode of angina since the procedu re. What is
the most likely diag nosis?
Pericarditis
Aortic dissectio n
Coronary artery dissection
Restenosis
m
se
Stent thro mbosis
As
Dr
A 61-yea r-old woman is admitted to the Emergency Department with central chest pain. It
feels li ke her previous ang ina but is not rel ieved by nitrates. She has a history o f ischaemic
heart disease and 4 weeks ago underwent a percutaneous co ro na ry intervention during
which a stent was placed. This is her first episode of angina since the procedu re. What is
the most likely diag nosis?
Pericarditis
Aortic dissectio n
Coronary artery dissection
Restenosis
m
se
Stent thrombosis ~
As
Dr
A 58-yea r-o ld man presents to the Eme rgency Depa rtment fo ll owing a n ep isode of
tra nsient rig ht -s id ed weakness which lasted ap proximately 20 minutes. He has had two
p revious e pisodes of a simila r natu re. On examinatio n he is found to be in atria l
fibrillatio n at a rate o f 80 b pm.
CT head norma l
He is sta rted on asp irin 300mg o d . Two days later he has a ca rotid d o pple r which is
normal. What is the most a ppro priate manageme nt?
Sta rt d ig oxin
Switch to asp irin 300mg od + d ipyridamole 200mg bd lo ng-term
Wait two weeks from the date o f the last eve nt then switch fro m aspirin to warfa rin
Switch to asp irin 75mg od long -te rm
m
se
Sta rt warfa rin
As
Dr
Start digoxin
Switch to aspirin 300mg od + d ipyridamole 200mg bd long-term
Wait two weeks from the date of the last event then switch from aspirin to
wa rfa rin
Switch to aspirin 75mg od lo ng-te rm
I Sta rt warfarin
This patient has atria l fibrillation. As a consequence he has had a number o f trans ient
ischaemic attacks (T!As) and hence needs to be anticoagulated with warfa rin.
In patients who've had an ischaemic stroke the guidelines recommend waiting two weeks
before anticoagulation is com menced to reduce the risk of haemorrhag ic transformatio n.
m
se
However, NICE reco mm end for TIA patients: 'in the absence of cere bral infarction o r
As
haemo rrhage, anticoagulation therapy shou ld beg in as soon as possible.'
Dr
A 52-year-old man is admitted to the Emerg ency Department. He was foun d co llapsed by
neighbou rs. An ECG on arrival shows t orsades de point es. Which one of his medications is
most likely to have contributed to this presentation?
Bisoprolol
Cimetidine
Risp eridone
Phenytoin
m
se
Doxycycline
As
Dr
A 52-year-old man is admitt ed to th e Emergency Department. He was foun d co llapsed by
neighbours. An ECG on arrival shows t orsades de point es. Which one of his medications is
most likely t o have contribut ed to this presentation?
Bisoprolol fD
Cimetidine f!D
~peridone ED
Phenytoin tiD
fi!D
m
Doxycycline
se
As
Dr
A 68-yea r-o ld man is admitted with central crushing chest pain and raised card iac
enzymes was diagnosed with myocardial infarction (MI). In a dd ition to ST segment
changes, his ECG a lso showed new second-degree heart block.
In light of this, which myocardial territory is most like ly to have been affected?
Anterior
Posterio r
Septal
Inferior
m
se
Late ral
As
Dr
Anterior CD
Posterior GD
Septal flD.
Inferior aD
Lateral m
AV block can occur following an inferior MI

The patient has develo ped second-degree heart block, a type of atrioventricular block. as
a complication of his myocardial infa rct ion (Ml). Atrioventricular block most commonly
follows an inferior MI.
m
se
Infa rctions affecti ng the other myocardial territories, listed in the options, are less likely to
As
cause an atrioventricular block.
Dr
Which one of the following conditions is most associated with aortic dissection?
Acromegaly
Actinomycosis
Sarcoidosis
m
se
Adult polycystic kidney d isease
As
Dr
Acromegaly QD
Actinomycosis m
Sarcoidos is CD
I Bicuspid aortic valve ED

Ad ult polycystic kidney d isease GD
m
se
As
A bicuspid aortic valve increases the risk o f aortic dissection six-fold
Dr
You review a patient who has been admitted with a non-ST e levation myocardial
infarctio n in the Emergency Depa rtment. Th ey have so far been treated with as pirin
300mg stat and glyceryl trinitrate s pray (2 puffs). Following recent NICE gu ida nce, which
patients shou ld receive tic.agrelor?
Patients < 75 yea rs of age
Patients who have a history of hypertension, ischae mic heart disease or diabetes
me ll itus
Those who have a pre d icted 12 month mortality > 10%
Those who have a pre d icted 6 month mo rtality < 10%
m
se
As
All patients
Dr
Patients < 75 years of age
Patients who have a histo ry of hype rtens ion, ischae mic hea rt disease o r diabetes fliD
mell itus
Those who have a pred icted 12 month mortality > 10%
Those who have a pred icted 6 month mortality < 10%
m
se
All patients
As
Dr
A patient is given asp irin 300 mg after deve loping an acute co ronary syndrome . What is
the mecha nism o f action of aspirin to achieve an antiplatelet effect?
Inhibits the p rod uction of thromboxa ne A2
Inhibits ADP binding to its platelet receptor
Inhibits the p rod uction of prostag la ndin H2
Glycop rotein lib/lila receptor antago nist
m
se
Inhibits the p rod uction of prostacyclin (PGI2)
As
Dr
Inhibits the production of thromboxane A2
Inhibits the production of prostaglandin H2
Glycoprotein Ilb/llla receptor antagonist m
m
m
se
Inhibits the production of p rostacyclin {PGI2)
As
Dr
A 45-year-old woman suffered from sudden onset central crushing chest pain. Her
electrocardiogram showed ST-segment elevation. Troponin is slightly ra ised. She was
rus hed for an emergency invasive angiogram but th is revealed slight wall irregularities
with no luminal obstruction. Subsequently, cardiovascular MR (CMR) showed an apical
ballooning of the myocardium resembling an octopus pot.
She did not have any significant past medical history. There is a fam ily history of
premature corona ry artery disease. Her partner recently passed away of prostate cancer.
What is the most likely cause of the ST-segment elevation?
Coronary artery disease
Takotsubo card iomyopathy
Left ventricular aneurysm
Myocardial infarction
m
se
As
Dr
Coronary artery disease CD
I Ta kotsubo cardiomyopathy fD
Left vent ricular aneurysm GD
Myocardial infarction CD
Hypertrophic cardio myopathy m
Ta kotsubo card iomyopathy is a different ial fo r ST -elevation in someone with no

o bstructive co rona ry artery disease
The different ial diagnosis for ST -elevation:

• myoca rdial infarct ion
• perica rdit is/myocarditis
• normal variant - 'high take-off'
• Ta kotsubo ca rdiomyopathy
• Left ventricu lar aneurysm
m
• Prinzmet al angina
se
• Subarachno id haemorrhage
As
Dr
An 85-year-old man is admitted on the medical take with a 4 day history of a productive
cough, followed by 2 days of shortness of breath, fever and confusion. He has an obvious
shadow over the lower zone of h is left lung on chest x-ray which was not t here on a
routine x-ray one month earlier. He has a past medical history of asthma, ischaemic heart
disease and gallstones. Which of the following is most strongly associated w ith a poor
p rognosis?
CURB -65 score of 3
Past medical history of asthma
Ex-smoker
Patient meets criteria for sepsis
m
se
As
Saturations of 92% on 8 litres of oxygen via non -rebreathe mask
Dr
CURB-65 score of 3
Pa st medica l histo ry of a sthma

-~
Ex-smoker
Patie nt meets criteria fo r sepsis
Satu rations o f 92% o n 8 litres of oxyg en via non -rebreathe mask
The CURB-65 score can be used for assessing the prognosis of a patient with
community acqu ired pnuemonia
Important for me Less impc rtc.nt
This patie nt has com munity-a cq uired pneumon ia. Th e CURB-65 score is used to assess
prog nosis a nd risk o f mo rtal ity in patients with com munity-acq uired pneumonia . The full
sco re can be found in the backgrou nd notes. A hig her score is linked to a hig he r risk o f
in-hos pital morta lity.
Having asthma, be ing a n ex-smo ke r, be ing septic o r having a sign ificant o xygen
req u irement are like ly a ll associated with worse prognos is b ut d o not have the stre ngth of
evide nce be hi nd them to compa re to the CURB-65 sco re.
m
se
As
NICE pathways - assessment of com munity-acquire d pneumonia
https:// pathways.n ice.o rg .u k/. ../assessment-of -commun ity-acq uired -pneu mo nia .pd
Dr
A 76-year-old female is admitted after being found on the floor at her home. On
examination she has a core temperature of 30°C. Her serum electrolytes are with in normal
range. Which one of the ECG f indin gs is most like ly to b e seen?
Long QT interval
·u· waves
Short PR interval
Second degree heart b lock
m
se
As
Flattened T waves
Dr
I Long QT interval
'U ' waves

CD
CD
I
Shot PR interval
Second degree heart block

m
CD
m
se
Flattened T waves .
CD
As
Dr
Eight months after having a prosthetic heart va lve a patient develops infective
endocard itis. What is the most likely causative organism?
Coxiella burnetii
m
se
One of the HACEK group
As
Dr
I Staphylococcus aureus
Coxiella burnetii
One of the HACEK group
Most common cause of endocarditis:

• Staphylococcus aureus
• Staphylococcus epidermidis if < 2 months post valve surgery
Coagulase-negat ive staphylococci such as Staphylococcus epidermidis are t he most
m
se
commo n causat ive organisms in t he first 2 months following su rgery. Ah er t his t ime t he
As
spectrum of organisms causing endocarditis returns to normal.
Dr
A 67-year-old man is admitted with palpitations. During examination of his JVP he is
noted t o have regular ca nnon waves. Which one of the following arrhythmias is most
likely t o be responsible for this finding?
Atrio-ventricular nodal re-entry ta chycardia
Atrial fibrillation
Atrial flutt er
m
se
Ventricu lar fibrillation
As
Dr
I Atrio-ventricular nodal re-entry ta chyca rdia
Atrial fibrillation
Atrial flutter
-
. .wl'
Ventricular fibrillation
Atrio-ventricular nodal re-entry tachycardia and ventricular tachycardia with 1:1
m
se
ventricular-atrial conduction may produce regular cannon waves. Complete heart block
As
causes irregular cannon waves
Dr
Which one of the following drugs is best avoided in patients with hypertrophic
obstructive cardiomyopathy?
Am iodarone
Verapamil
Ramipril
Amoxicillin
m
se
Atenolol
As
Dr
Which one of the following drugs is best avoided in patients with hypertrophic
obstructive cardiomyopathy?
Am iodarone CD
Verapamil CD
p .mipril ED
Amoxicillin m
Atenolol CD
ACE- inhibitors should be avoided in patients with HOCM

m
se
Vera pamil should however be avoided in patients with coexistent Wolff- Parkinson White
As
as it may precipit ate VT or VF
Dr
A 14-year-old boy is admitted with palpitations and is noted to have a long QT i nterval.
His on ly past medical history is deafness. What is the likely diagnosis?
Leriche's syndrome
Wolff-Pa rkinson White syndrome
Jerveii-Lange-Nielsen syndrom e
Romano-Ward syndrome
m
se
Osler-Weber-Rendu syndrome
As
Dr
Leriche's syndrome CD
Wolff-Parkinson White syndrome m
I Jerveii-Lange-Nielsen syndrome CD
Romano-Wa rd syndrome fD
Osler-Weber-Rendu syndrome CD
Inherited long QT syndrome, sensorineural deafness - Jervell and Lange-Nielsen

syndrome
m
se
Jerveii-Lange-Nielsen syndrom e is associated with profound deafness and a prolonged
As
QT interval
Dr
A 74-year-old woman is reviewed. She recently had ambulatory blood pressure
monitoring that showed an average reading of 142/ 90 mmHg. There is no significant past
medical hist ory of not e other than hypothyroidism. Her 10-year ca rdiovascular risk score
is 23%. What is the most appropriate management?
Start amlodipine
Start bendroflumethiazide
No treatment requ ired - monitor blood pressure every year
Start ram ipril
m
se
Repeat ambulatory blood pressure monitoring
As
Dr
I Start amlodipine
Start bend roflumethiazide
No t reatment requ ired - mon itor b lood p ressure every yea r
Start ramipril
Repeat am bulato ry blood pressure monitoring

-
"""
New ly diagnosed patient w ith hypertension (> 55 years) - ad d a calcium channel
b locker
m
se
The average reading is above t he treatment threshold for patient s b elow the age of 80
As
years. Treat ment w it h a calcium channel b locker shou ld the refore be st arted.
Dr
A patient who was commenced on a simvastatin six months ago presents with
general ised muscles aches. Wh ich one of the following is not a risk factor for statin-
induced myopathy?
Female gender
Large fa ll in LDL-cholesterol
Low body mass index
Advanced age
m
se
Hist ory of diabetes mellitus
As
Dr
Female gend er m:t
I Large fall in LDL-cholest erol CD

Low body mass index m:t
Advanced age CD
History of diabetes mellitus
m
se
As
Dr
Each one of the following is associated w ith atrial myxoma, except:
Clubbing
Mid-diastolic murmur
Pyrexia
'J' wave on ECG
m
se
Atrial fibrillation
As
Dr
Clubbing
Mid-diastolic mu rmur
Pyrexia
'J' wave on ECG
Atrial f ibrillation
m
se
As
A 'J' wave is seen in hypothermia
Dr
Which one o f t he following elect rolyt e dist u rbances is most associat ed with t he
d evelop ment of a prolonged QT interval on ECG?
Hyponatraemia
Hypocalcaemia
Hyperkalaemia
Hypercalcaem ia
m
se
Hypophos phataemia
As
Dr
Hyponatrae mia CD
I Hypocalcaemia GD
Hyperka laemia CD
Hypercalcaem ia .
(D
Hypophos phataemia m
Hypoca lcem ia is associated with QT interva l pro longation; Hyperca lcemia is
associated with QT interval shortening
m
se
As
Dr
Which of the following is least associated with mitra l valve p rolapse?
Osteogenesis imperfecta
Pseudoxanthoma elasticum
Turner's syndrome
Marfan's syndrome
m
se
As
Acromegaly
Dr
Pseudoxanthoma elasticu m
Turner's syndrome
Marfan's syndrome
Acromegaly
-
~
Whil st so me patients with acromegaly have mitral va lve p rolapse (MVP) it is not a
m
se
common associat ion. It shou ld be remembered that the p reva lence of MVP in a standard
As
populat ion is around 5- 10%
Dr
Which one o f the fo llowi ng cli nical sig ns wou ld best indicate severe calcified aortic
stenosis?
Lou dness of murmur
Lou d second hea rt sound
Radiation to the carotids
Hypertensi on
m
se
Displaced apex beat
As
Dr
Which one of the fo llowin g cl inical signs wou ld best indicate seve re ca lci fied aortic
stenosis?
Lou d ness of murmu r «ED

Lou d second hea rt sound «ED
r :diation to the carotids tiD
Hypertension fD
I Displaced apex beat CD
m
se
The apex beat is not norma lly displaced in aortic stenosis. Displacement would ind icate
As
left ventricula r dilatation and hence seve re disease
Dr
A 62-year-old female with a history of mitral regurgitation attends her dentist, who
intends to perform dental polishing. She is known to be penicillin allergic. What
prophylaxis aga inst infective endocarditis should be given?
Oral doxycycline
Oral erythromycin
No antibiotic prophylaxis needed
Oral ofloxacin
m
se
Oral clindamycin
As
Dr
Oral doxycycline
Oral erythromycin
No antibiotic prophylaxis needed
Oral o floxacin
-~
Oral clindamycin
Antibiotic prohylaxis t o prevent infective endocarditis is not routinely reco mm ended

in the UK fo r dental and other procedures
Important for me l ess impcrtc.nt
m
se
The 2008 NICE guidelines have fundamentally changed th e approach to infective
As
endocarditis prophylaxis
Dr
A 63 -year-old female on long-term wa rfarin for atrial fibrillation attends the
anticoagulation clinic. Despite having a stable INR for the past 4 yea rs on the same dose
o f warfarin her INR is measured at 5.4. Which one o f the following is most likely to be
responsible?
StJohn's Wort
Smoking
Carrot juice
Cra nberry j uice
m
se
Camomile t ea
As
Dr
StJohn's Wort tiD
Smo king m
Carrot juice CD
Cranbe rry juice CD
Camomile tea CD
m
se
StJohn's Wort is an inducer of the P450 enzyme system so would cause the INR to
As
decrease, rather than increase.
Dr
A 60-year-old man presents with increasing shortness-of- breath on exertion. During the
examination a third heart sound is hea rd. Examination of the respiratory system is
unremarkable. Which one of the following is most consistent with this findi ng?
Dilated cardiomyopathy
Atrial fibrillation
Mitral stenosis
m
se
Norma l variant
As
Dr
r ;ated cardiomyopathy
Atrial fibrillation
Mitral stenosis
Normal variant
m
se
As
A third heart sound is only considered a normal variant in patients < 30 years of age.
Dr
A 64 -yea r-old man who is known to have ischaemic heart disease is due to sta rt a
chemothe ra py regime which includes doxorub icin. His ca rdiolog ist wants to accu rate ly
assess his leh ve ntricula r functio n as he is concerned the d oxo rubicin may d amag e his
myo ca rdium. Which one of the fo llowing is the most accurate method to determine his
leh ventricula r function?
Cardiac co mputed tomog ra phy
Echo ca rdiog raphy
Exercise ECG
MUGA scan
m
se
Coro na ry ang io grap hy
As
Dr
Cardiac computed tomogra phy
Echocardiography
Exr cise ECG
MUGA scan
I
m
se
Coronary angiography
As
Dr
A 62-year-old man is examined in the ca rdiology clinic. During cardiac auscultation it is
noted that the pulmonary comp onent of the second heart sound occurs before the aortic.
Which one o f the following is associated with this finding?
Pulmonary stenosis
Right bundle bra nch block
Atrial septal defect
m
se
Deep inspiration
As
Dr
Pulmonary stenosis tD
I Left bundle b ra nch b lock GD

Right bundle b ra nch b lock mt
Atrial septal defect mt
Deep inspiration CfD

• soft: AS
Important for me l ess :mocrtont
m
se
Left bundle b ranch b lock causes a reversed sp lit second heart sound. Atrial septal defect s
As
cause fixed sp litting o f 52
Dr
A 72-yea rs-old lady attends to her genera l practitio ne r with a history of d iabetes mell itus,
hyperlipidaemia, hypertension, hypertensive cardiomyopathy, atrial fibrillation and
polymyalgia rheumatica. She ha d a non-displaced hum e ral shah fracture 3 years ago
treated non -operatively. She is currently taking ato rvastatin, warfarin, furose mide,
bendro flumeth iazi de and a low d ose of prednisolone. Which o f the following drugs can
increase the osseous matter and decrease the further risk of fracture by decreas ing the
amount of calcium excreted by the kidneys?
Atorvastatin
Warfarin
Fu rosem ide
Bendroflumethiazide
m
se
Prednisolo ne
As
Dr
Atorvastatin CD
Warfarin
Furosem ide
•
flD
Bend rofl u methiazide GD
Prednisolone CD
Th iazide diuretics can cause hyponatraemia, metabolic alkalosis, hypokalaemia and

hypocalciuria
Thiazid e diuretics can cause hyponatraemia, met abolic alka losis, hypokalaemia and
hypocalciuria. They can conserve calcium by d ecreasing its excretion by kidneys, whereas
loo p diuret ics (such as fu rosemide) and cause increase calcium excretion and decrease
m
serum calcium levels. Prednisolone as any other st eroid can shift t he calciu m from t he
se
As
bone to t he kidneys to be excret ed, possibly causing st eroid-induced ost eop orosis.
Atorvastat in and warfari n d o not interfere w ith calcium homeostasis significantly.
Dr
A 67 -year-old diabetic g ent leman who recently und erwent aortic valve replacement
p resent ed w ith a fev er, raised inflammat ory markers and d eranged renal function. Which
one of the following organisms contribute to the highest rat e o f mortality in patient s with
his condit ion?
Enterococci
Streptococci
Staphyloco cci
Pseudomonas
m
se
HACEK Organisms
As
Dr
Streptococci f!D
Staphylococci (D
Pseudomonas m
HACEK Organisms f!D
Stap hylococci is the lea ding organism cont ributing to mortality in infective
endocarditis
Staph au reu s followed by coagulase-negative staphylococci are two of the most common
organisms caus ing infective endocardit is.
Enterococci - Belongs to the bowel organisms group and contributes to only 15% o f
mortality.
Streptococci - Only contribute to around 5% of mortality.
Pseudomonas - Rare cause of endocarditis, occu rs when infected water enters t he

b loodstream.
m
HACEK Organisms - Lives on dental gums and are more common in intravenous drug se
As
IJSP.rs.
Dr
A 65-year-old man is admitted to the Emergency Department with chest pain, nausea and
feeling lethargic. He has a history of type 1 diabetes mellitus and is known to have
chronic kidney disease stage 4 secondary to diabetic nephropathy. An ECG taken on
admission shows widespread ST elevation. Bloods tests show the following:
Na• 140 mmol/ 1
K• 5.8 mmolfl
Urea 26 mmol/ 1
Creatinine 305 ~mol/1
His rena l fu nction one mo nth ago was as follows:
Na• 142 mmol/ 1
K• 4.9 mmolfl
Urea 7.9 mmolfl
An echoca rdiogram s hows a small effus ion. What is the most appropriate next step in
management?
m
Ora l colchicine
se
As
Pericardiecto my
Dr
I Oral colchicine f!D
Pericardiectomy fD
Pericardiocentesis CD
Intravenous corticosteroids GD
Haemodialysis ED
m
se
This patient has uraemic pericarditis. Haemodialysis is urgently required to correct the
As
uraemia which in turn will improve the symptoms of pericarditis.
Dr
A 24-year-old fema le develops transient slurred speech following a flight from Australia
to the United Kingdom. Both aCT head and ECG are normal. Which one of the following
tests is most likely to reveal the underlying cause?
Transoesophageal echo
MRI brain
Carotid USS Doppler
Cerebral angiogram
m
se
Transthoracic echo
As
Dr
I Transoesophageal echo
MRI brain
ED.
CD
Carotid USS Doppler flD
Cerebral angiogram CD
Transthoracic echo fD
Parad oxical embo lus - PFO most com mon cause - do TOE
Transesop hageal echocardiograp hy provid es su perior views o f the atrial septum and
m
se
therefore is p referred to t ransthoracic echocardiograp hy for det ecting pat ent foramen
As
ovale
Dr
Where is B-type natriuretic peptide mainly secreted from?
Atrial myocardium
Juxtaglomerular cells
Zona glomerulosa
Ventricu lar myocardium
m
se
As
Hypothalamus
Dr
Atrial myocardium GD
Juxt aglomerular cells CD
Zona glomerulosa fD
Ventricular myocardium 6D
Hypothalamus fD
m
se
As
B-type natriuretic peptide is mainly secret ed by the ventricu lar myocardium
Dr
A 72-yea r-old female is ad mitted fo r an elective abdomina l ao rtic a neurysm repair. She
has a past med ical history of long-standing asthma and an undiagnosed periphe ral
neu ro pathy. On day 4 post-op, she d eve lops a net-like rash over her torso with fevers,
mya lgias and d iscolouration o f her toes.
Blood tests reveal:
Hb 128 g/ 1
Plat elet s 240 * 109/ 1
8
WBC 12.2 109/ 1
Eosinophils 2.3 * 109/ 1
Na• 138 mmol/ 1
K• 4 .1 mmol/1
Urea 8 .8 mmol/1
Creatinine 176 J,Jmol/ l
What is the most li kely diagnosis?
DRESS syndro me
Cholesterol em boli
m
se
As
Churg-Strauss
Dr
DRESS syndrome
Cholesterol em boli
Chu rg-Strauss
Chronic eosinophilic syndrome
Arterial thromboembolism
The answer is cholestero l emboli which presents aher a precipitating event such as
angiography or abdominal aortic aneurysm repa ir. Clinical features include livedo
reticu laris, eosinophilia, pu rpu ra, and rena l failu re.
Chu rg-Strauss wou ld be associated with late-onset asthma, chronic eosinophilic

syndrome is a diagnosis of exclusion and is a more long-term event, and arterial
m
se
thromboembolis m would not be associated with eosinophilia. DRESS syndrome wou ld be
As
associated with a drug precipitant which is not mentioned in the question.
Dr
Which one of the following statements regarding warfarin is correct?
Warfarin can be used when breast-feeding
Hypothyroidism may develop in a small minority of patients
Ao rtic prosthetic valves gene rally require a higher INR tha n mitral valves
The ta rget INR following a pulmonary embolism is 3.5
m
se
All patients with an IN R of greater than 6.0 should be given vitamin K
As
Dr
I Warfarin can be used when breast-feet ng
Hypothyroidism may develop in a small minority of patients
Aortic prosthetic valves generally require a higher INR than mitral valves
The target INR following a pulmonary embolism is 3.5
m
se
All patients with an INR of greater than 6.0 should be given vitamin K
As
Dr
A patient with known heart fa ilure has slight limitation of physical act ivity. She is
comfortable at rest but ordinary activit ies such as walking to t he loca l shops resu lts in
fatigue, palpitations or dysp noea. What New York Heart Association class best d escribes
the severity of their disease?
NYHA Ciass 0
NYHA Class I
NYHA Class II
NYHA Class III
m
se
NYHA Class IV
As
Dr
NYHACiass 0 m
NYHA Class I G'D
NYHA Class II ED
NYHACiass ill CD
m
se
NYHA Class IV m
As
Dr
A 65 -year-old man is found to have an eject ion systolic murmur and narrow pu lse
pressure on examination. He has experienced no chest pain, b reathlessness or syncope.
An echo confirms aortic st enosis and shows an aortic valve gradient o f 36 mmHg. How
should this patient be managed?
Routine aortic valve replacement
Urgent aortic valve replacement
Anticoagu lation
Aortic valvulop lasty
m
se
Regular cardiology outpatient review
As
Dr
Routine aortic valve rep lacement GD
Urgent aortic valve replacement m.
Ant icoagul ation CD
Aortic valvuloplasty CD
I Regu lar cardiology outpatient review CD
Aortic st enosis management: AVR if sympto matic, otherwise cut-off is gradient o f

40 mmHg
No action shou ld b e taken at present as he is cu rrent ly asymptomatic. If t he aortic valve
m
se
gradient > 40 mmHg or t here is evid ence o f significant left ventricular dysfunct ion t hen
As
su rg ery is sometimes co nsidered in select ed asymptomatic patient s
Dr
You get b leeped in the middl e of you r nig ht sh ift to tal k to a wo rried father who's
daug hter has been adm itted with cyanosis. He tells you that they were aware she has had
a murmu r s ince b irth, but it ha s on ly been the last few days in which she has had
sympto ms. You believe that th is is a ca se of Eisen menge r's synd rome.
What is the medical definitio n of Ei senmenger's synd ro me?
The reve rsa l of a right-to-left shunt
An au dible ventricu lar septa l d efect
Presence of a ventricu lar septa l defect a longside an atrial se ptal d efect
The reve rsa l of a left-to- right shunt
m
All four o f the following: overrid ing aorta, pulmonary stenosis, right ventricu la r
se
hypertrophy, ventricu la r septa l defect
As
Dr
The reversa l of a right -to-left shunt
(tn au dible ventricular septal d efect
Presence of a ventricular septa l defect alongside an atria l septa l defect
I The reve rsal o f a left-to-right shunt
All four of the following: overriding aorta, pulmonary stenosis, right ventricular
hypertrophy, ventricular septal defect
Ei senmenger's syndrome - the reversa l of a left-to -right shunt

m
se
Eisenmenger's synd ro me is the reversal of left-to-right shunt associated with ventricular
As
septal defects, atrial septa l defect and a patent ductus a rteriosus.
Dr
Your review a 41-year-old woman. Four months ago she develop ed a deep vein
thrombosis and was warfari nised with a target INR of 2.5. She has presented with a
swollen, tender leh calf and a Doppler sca n confirms a fu rther deep vein thrombosis. Her
IN R has been above 2.0 for the past three months. You organise some investigations to
exclude an underlying prothrombotic condition. What should happen regarding her
anticoagulation?
Switch to treatment dose low-molecular weig ht hepa rin
Continue on wa rfa rin, continue with IN R ta rget of 2.5
Add aspirin 75 mg od
Continue on wa rfa rin, increase INR ta rget to 3.0
m
se
Continue on wa rfa rin, increase INR ta rget to 3.5
As
Dr
Switch to treatment dose low -molecular weight heparin
I Continue on wa rfarin, continue with INR target of 2.5
Add aspirin 75 mg od
I
Continue on wa rfarin, increase I NR target to 3.0
-
~
m
se
Continue on warfarin, increase INR target to 3.5
As
Dr
A 34-yea r-old woman is a dmitted to the Emerge ncy Department fo llowin g a colla pse. An
ECG shows a polymorphic ventricula r ta chycardia . Which one of the fo llowing is not
associated with an in creased ris k o f d evelo ping torsade de p ointes?
Tricyclic a ntidepressants
Subarachnoid haemorrhage
Hype rcalcaem ia
Roman o -Wa rd syndrome
m
se
Hypothe rmia
As
Dr
Su barachno id haemorrhage
Hypercalcaemia
Romano-Ward syndrome
Hypothermia
Hypoca lcemia is associated with QT interva l prolongation; Hyperca lcemia is

associated with QT interval shortening
m
se
Hypoca lcaem ia, not hypercalcaemia, causes p ro longation of the QT interval and hence
As
may p red isp ose to the deve lop ment of torsad e d e pointes
Dr
Which one o f the following featu res is not part o f the modified Duke criteria used in the
diagn osis of infective endocarditis?
Fever > 38°C
Positive molecular assays for specific gene targets
Indwelling central line
Intravenous drug use
m
se
Janeway lesions
As
Dr
Fever> 38°C
Positive molecular assays for sp ecific gene targets
Indwelling cent ral line
Janeway lesions
-
. .wJ
m
se
The modified Duke criteria have now been adopted in the latest guidelines from the
As
European Society of Cardiology. Details can be found in the link below
Dr
A 71-yea r-old woman is reviewed in the fa ll s clinic. Her blood pressure is 146/ 94 mmHg.
This is confirmed o n a second rea ding . In line with recent NICE gu ida nce, what is the most
a ppropriate next-step?
Ask he r to come back in 6 months fo r a b lood pressure check
Arra nge 3 blood pressure checks with the pra ct ice nurse over the next 2 wee ks with
med ica l review following
Arra nge ambulatory blood p ressu re monito ring
Rea ssu re her th is is acceptable for he r age
m
se
Sta rt treatm e nt with a calcium cha nnel b lo cker
As
Dr
Ask her to come back in 6 months for a b lood pressure check
Arrange 3 blood pressu re checks with t he practice nurse over the next 2 weeks
wit h medical review following
I Arrange ambulatory blood pressure monit oring
Reassure her t his is acceptable for her age
Start t reatment w ith a ca lcium channel blocker
Hypertension - NICE now recommend ambulatory blood pressure monitoring to aid

diagnosis
The 2011 NICE guidelines recognise that in t he past t here was overtreat ment o f 'w hite
coat' hypertension. The use o f ambulatory blood p ressure monito ring (ABPM) aims t o
reduce t his. There is also good evidence that ABPM is a better p redictor o f cardiovascular
risk t han cl inic b lood p ressure readings. See the followin g st udy for more details:
m
se
Verdecchia P. Prognostic value of ambulatory blood pressure: current evidence and clinical
As
implications. Hypertension 2000; 35: 844-851 Dr
A 75-year-old woman is brought to the Emergency Department by her fa mily. She has
been getting more short-of -breath over the last 6 w eeks and says her energy levels are
low. An ECG on arrival shows atrial fibrillation at a rate of 114 I min. Blood pressure is
128/80 mmHg and a chest x-ray is unremarkable. What is the appropriate drug to control
the heart rate?
Felodipine
Am iodarone
Digoxin
Flecainide
m
se
As
Bisoprolol
Dr
Felodipine CD
Am iodarone .
(D
Digoxin GD
Flecainide m
Bisoprolol GD
Atrial fibrillation: rate control - beta blockers preferable to digoxin

This question reiterates an important p oint which frequently comes up in exams - digoxin
is no longer first-line for rat e control in atrial fibrillation. Her shortness-of -breath is likely
t o be rat e related and does not necessarily mean that she is in heart failure. This is
supported by a normal chest x- ray.
m
se
As
Please see the NICE guidelines fo r further information.
Dr
A 36-year-old man has present ed to the emergency department with pa lpitations. His
heart rate was 138 beats per minut e and an ECG showed a likely su praventricular
t achycardia. The registrar asks you t o draw up 6mg of adenosine.
Which of t he follow ing drugs may reduce t he action of adenosi ne?
Dipyridamole
Bupivacaine
Aminop hylline
Amiodarone
m
se
Montelukast
As
Dr
Dipyridamole GD
Bupivaca ine CD
I Aminophylline fD
Am iodarone CD
Montelukast CD
Aminophylline reduces the effect of adenosine

The answer is aminophylline. dipyridamole classically enhances t he act ion. This is

commo nly remembered w ith t he mnemonic DEAR. Bupivicaine (and other -caines) all also
enhance t he action of ad enosine.
m
se
As
Am iodarone and mont elukast are dist ractors, that have no notable effect.
Dr
You are ca lled to review a 78-year-old man on the surgica l wa rds. He is three days post-
op following a colectomy. He was recently diagnosed with colon cancer (Duke's C) and
has a history of po lymyalgia rheumatica. Current medications include co-codamol 30/ 500,
p rednisolone and prophylactic dose low-molecular weight heparin. Five minutes ago he
started to co mpla in of severe central chest pa in. An ECG performed by the nurses shows
ST elevation in the anterior leads. Aspirin a nd oxygen have been g iven by the Foundatio n
1 doctor. What is the most a ppropriate treatment?
IV dia morphine + increase low-molecular wei ght heparin to treatment dose +

d ouble his p redn isolone d ose
IV diamorphine + arra nge echoca rdiogram urgently to exclude pericard ia I

ta mponade
IV dia morphine + call the fam ily in to discu ss withdrawa l o f treatment
IV diamorphine + arra nge percutaneous coronary intervention
m
se
IV dia morphine + thro mbolysis
As
Dr
IV di amorphine + increase low-molecular weight heparin t o t reatment dose +
double his p rednisolone d ose
IV di amorphine + arra nge echocardiogram urgently t o exclude p ericard ia!

-
~
tamponade
IV di amorphine + call t he fam ily in to discuss wit hdrawal o f treatm ent
IV diamorphine + arrange percutaneous coronary intervention
IV di amorphine + t hro mbolysis

-
~
m
se
Primary percutaneous coronary intervent ion is the most appropriate treatment given his
As
recent operation and associat ed risk of bleeding .
Dr
A 60-year-old man is admitted with severe central chest pain to the res us department.
The admission ECG shows ST elevation in leads V1 -V4 with reciprocal changes in the
inferior leads. Which one of the following is most likely to account for these findings?
75% occlusion of the leh ant erior descending artery
75% occlusion of the leh circumflex artery
75% occlusion of the right coronary artery
100% occlusion of the leh circumflex artery
m
se
100% occlusion of the leh anterior descending artery
As
Dr
75% occlusion of the leh anterior d escending artery
75% occlusion of the leh circu mflex a rtery
75% occlusion of the right coronary artery
100% occlusion o f the leh circumflex artery
100% occlusion of the leh anterior d escending I ery
m
se
Widespread ST elevation in this territory implies a comp lete occlusion of the left anterio r
As
descend ing artery.
Dr
A 58-year-old man is admitted to the cardiology wa rd aher presenting with fever, malaise
and a new murmur. An echocardiogram has s hown a vegetatio n on the aortic valve. Blood
cultu res a re reported as follows:
Streptococcus sanguinis isolated
What is the most appropriate follow-up given the b lood cu lture resu lts?
Colonoscopy
HN test
Dental review
High resolution CT o f the chest
m
se
Complement levels
As
Dr
Colonoscopy
HIV test
Dental review
High resolution CT of the chest
Complement levels
-
........
Patients with very poor dental hygiene - Viridans streptococci e.g . Streptococcus
sanguinis
Important for me l ess :mpcrtont
Streptococcus sanguinis is one o f the viridans g roup streptococci, or a-hemo lytic

streptococci, which are common causes of infective endocarditis. They are commensal in
the mouth and invasive infection is associated with denta l disease. The American Heart
Association recommend:
m
'A thorough dental evaluation should be obtained and all active sources of oral infection
se
should be eradicated.·
As
Dr
A 79-year-old woman is reviewed. She has taken bendroflumethiazide 2.5mg od for the
past 10 years for hypertension. Her current blood pressure is 150/94 mmHg. Clinical
examination is otherwise unremarkable. An echocardiogram from two months ag o is
reported as follows:
Ejection fraction 48%, moderate left ventr icular hypertrophy. Minimal MR noted
What is the most appropriate next step in management?
Increase bendroflumethiazide to Smg od
Stop ben droflumeth iazi de + start frusemide 40mg od
Add ram iprii 1.2Smg od
Stop ben droflumeth iazi de + start ramipril1.25mg od
m
se
As
Add amlodipine Smg od
Dr
Increase bendroflumethiazide to Smg od
Stop ben droflumethiazide + start frusemide 40mg od
Add ram iprill.25mg od
Stop ben droflumethiazide + start ramiprill.25mg od
Add amlodipine Smg od

-
" "'
The echocardiogram shows a degree of left ventricular impairment. It is important an AC E

inhibitor is started in such patients. This will help t o both control her blood pressure and
also slow the deterioration in her cardiac function.
Even though bendroflumethiazide is no longer the recommend thiazide of choice, and

thiazides now co me 'third' in the A + C + D guidelines, NICE do not recommend stopping
treatment in patients who are alrea dy taking the drug.
m
se
A beta- blocker should also be added in the near future given the left ventricu lar
As
impairment.
Dr
Each one of the fo llowing may cause secondary hypertension, except:
Patent ductus a rteriosus
Cush ing 's syndrome
Liddle's syndrome
11-beta hyd roxylase deficiency
m
se
Combined ora l contraceptive pill
As
Dr
Ea ch one of the following may cause seconda ry hypertensio n, except:
Cushing 's syndrome
Liddle's syndrome
P .-beta hyd rJ ylase deficiency
Com bined oral co ntraceptive pill

-
~
m
se
As
Dr
A 54-year-old man is admitted to the Emergency Department (ED) aher col lapsing shortly
aher complaining of palpit ations. On arrival in the ED he is found to be in ventricular
tachycardia and is successfully cardioverted. Later investigations show that he has an
underlying long QT syndrome. A implantable cardioverter-defibrillato r (lCD) is inserted.
He works as a heavy goods vehicle (HGV) driver. What is the most appropriate advice with
regards to driving HGV vehicles?
Permanent bar
Cannot drive for 12 months
m
se
Can drive stra ightaway
As
Dr
Permanent bar
Can drive straightaway
m
se
As
lCD means loss of HGV licence. regardless of the circumstances
ltrpor:a.r! "or me _ess r-oc-tart
Dr
A 44-year-old man is seen in the cardiology clinic. Fo r the past 6 months he has been
experiencing e pisodes of pa lpitations associated with pre-syncopal symptoms. An ECG
taken in clin ic shows T wave invers ion in leads Vl-3 associated with a notch at the end of
the QRS complex. He is known to have a fam ily history of sudden ca rdiac death. What is
the most li kely diag nosis?
Catecho lam inerg ic polymorphic ventricul ar tachycardia
Long QT synd rome
m
se
Brugada syn drome
As
Dr
I Arrhythmogenic right ventricular qardiomyopathy
long QT syndrome
Brugada syndrome
m
se
As
The notch at the end of the QRS complex is referred to as an epsilon wave.
Dr
A 34-year-old woman attends a routine antenatal cl inic at 16 weeks gestation.
She has no sign ificant past medica l history but suffe rs with occasional frontal headaches.
She is noted to have a blood pressure of 148/ 76mmHg.
Urina lysis reveals;
pH 6 .5
Protein +1
Nitrates 0
Leuc 0
Blood 0
Gestational hype rtension
Pre-eclampsia
HELLP
Nephrotic syndrome
m
se
As
Chronic hypertension
Dr
Gestationa l hype rtension
P ,e -eclampsia
HELLP
Nephrotic syndrome
I Chronic hypertension
I
The answer here is chronic hypertension.
At 16 weeks gestation, this lady is too early into her pregnancy to have developed any of
the p regnancy re lated causes of hypertension. The sma ll a mount of protein in her uri ne
may also indicate re latively long stand ing hyperte nsion. Inte rmittent frontal headaches
are a co mmo n occurre nce and are not a sign of pre-ecla mpsia in this case.
Pre-eclampsia and gestational hypertension would only occu r ah er 20 weeks gestation.

Pre-eclampsia with sign ificant p roteinuria, g estational hypertens io n without.
Neph rotic synd rome would be associated with a la rg e r deg ree of p roteinuria.
m
se
For further info rmation on hypertension in p regnancy:
https:/ /www.nice.o rg.uk/ g u idance/cg 107/ chapter/guida nee As
Dr
A 62-year-old m an is ad mitted to hospital following a myocardial infarction. Four days
after admission he develops a further episode of central crush ing chest pain. Which is t he
best ca rdia c marker to investigate his chest pa in?
LDH
Troponin I
Troponin T
CK- MB
m
se
AST
As
Dr
LDH m
Troponin I (D
Troponin T GD
I CK-MB GD
AST
•
m
se
By day four the CK-M B levels should have returned to normal from the initial myocardial
As
infarction. If the CK-MB levels are elevated it would indicat e a further coronary event
Dr
A 76-yea r-old woman is admitted to the resus depa rtment after collaps ing whilst
s hop pi ng. The pa ramedics report she is hypotensive and tachycardia. Initial observations
include a heart rate o f 160 bpm and a b lood pressure of 98 I 60 mmHg . A 12 lead ECG
s hows a broa d complex tachyca rdia. Which one of the following features on the ECG
wou ld suggest a ventricular tachycardia rather tha n a su praventricular tachyca rdia with
aberrant conduction?
QRS < 160 ms
A corrected QT interva l o f 420ms
Atrioventricular dissociation
Marked right axis deviation
m
se
Heart rate o f 160 bpm
As
Dr
QRS < 160 ms
A co rrected QT interval o f 420ms
Atrioventricular dissociation
Marked right axis deviation
m
Heart rat e o f 160 bpm
se
As
Dr
A 26-year-old female is admitted to hospital with palpitations. ECG shows a shortened PR
interval and wide QRS complexes associated with a slurred upstroke seen in lead n. What
is the definitive management of this condition?
Accessory pathway ablation
Lifelong aspiri n
AV node ablation
Lifelong amiodarone
m
se
Permanent pacemaker
As
Dr
I Accessory pathway ablation
Lifelong aspirin
m:t
fD
'
AV node ablation m
Lifelong amiodarone m
Permanent pacemaker CD
m
se
This patient has Wolff-Pa rkinson White syndrome, with accessory pathway ablation being
As
the definitive treatment
Dr
A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of
the following features would most guide the timing of surgery?
Sym ptomatology of patient
Aortic valve gradient of 36 mmHg
Pul se pressure
Lou dness of murmur
m
se
Left ventricu lar ej ection fract ion
As
Dr
I Sym ptomatology of patient
Aortic valve gradient o f 36 mmHg

GD
CD
Pulse pressure m
Loudness o f murmur m
Left ventricular ejection fraction GD
m
Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of
se
40mmHg
As
Irrportar1 "or me _ess ·rrxrtc.rt
Dr
A 42-year-old man has his blood pressure measured as part of a routine medical exam.
His blood pressure is recorded as 155/ 95 mmH g. This is unexpected as it has been normal
fo r the past 5 annual medica l exams.
Which one of the following factors may accou nt for this finding?
Elevation of the measured arm above heart level
The measured arm being supported during the reading
The patient lying on an examination couch during the readin g
The patient ta lking during the reading
m
se
An undersized blood pressure cuff
As
Dr
r
Elevation of the measured arm above heart level
r.e measured arm being supported during the reading
The patient lying on an examination couch during the readin g
The patient ta lking during the reading
An undersized blood pressure cuff
An undersized blood pressure cuff may lead to an overestimation of blood pressure
m
se
As
Dr
A 52-year-old man with a history o f hypertension is found to have a 10-year
ca rdiovascular disease risk of 28%. A decision is mad e to start atorvastatin 20m g on. Liver
f unction tests are p erformed p rior to initialisi ng t reatment:
Bilirubin 10 IJmol/1 (3 - 17 umol/1)
ALP 96 u/1 (30 - 150 u/1)
ALT 30 u/1 (10- 45 u/1)
Gamma-GT 28 u/1 (10 - 40 u/1)
Three mont hs lat er t he LFTs are rep eated:
Bilirubin 12 IJmol/1 (3 - 17 umol/1)
ALP 107 u/1(30- 150 u/1)
ALT 104 u/1( 10- 45 u/1)
Gamma-GT 76 u/1 (10 - 40 u/1)
What is the most app ropriate course o f action?
Cont inue treatment and rep eat LFTs in 1 mont h
Check creat ine kinase
m
se
As
Reduce d ose t o atorvastatin 10mg on and repeat LFTs in 1 month
Dr
I Continue treatment and repeat LFTs in 1 ~onth
Check creatine kinase
Reduce dose to atorvastatin 10mg on and repeat LFTs in 1 month
Stop treatment and consider alternative lipid lowering drug
Stop treatment and refer to gastroenterology
m
se
Treatment with statins should be discontinued if serum transaminase concentrations rise
As
to and persist at 3 times the upper limit of the reference range.
Dr
A 72-yea r-old ma n who is known to have chronic kid ney disease sta ge 4 is admitted to
the Em ergen cy Depa rtment. Since yesterday he has felt short-of-b reath on exertion and
has b een co ughing up bloo d. On examination he tachyca rdic at 110/min with a norma l
chest exam ination. What is the most suitable initial im agi ng investigation to exclude a
pulmona ry e mbolism?
Ventilati on -perfusion sca n
Com puted tomograph ic pu lmo na ry a ngiography
Pulmonary ang iography
MRI thorax
m
se
Echocardiogram
As
Dr
I Ventilation-perfusion scan
~ulmonary angiography
MRI thorax
Echocardiogram
Pulmonary embolism and renal impairment- V/Q scan is the investigation of

choice
Computed tomograph ic pulmonary angiography (CTPA) is now used first-line to

investigate the possiblity of pulmonary embolism. Patients with renal impairment however
m
se
should be offered Ventilation-perfusion (V/Q) scans as the contrast media used during
As
CTPAs is nephrotoxic.
Dr
A 79-year-old man is referred to the acute medical unit following a fall. He is unsure why
he collapsed but is now fully alert. He is complaining of abdominal pain but his bowel
habits are unchanged.
He has a past medical history of p rostatism and hypertension. He tells you he doesn't take
any medication.
On examinat ion he has a Glasgow coma sca le score of 15, a blood pressure o f 98/46
mmHg and a heart rate o f 98beats per minute.
Hb 115 g/ 1
Platelets 32 1 * 109/ 1
WBC 6 .6 * 109/ 1
His radiology results are reported as follows:
Chest PA film, lung fields clear, widened mediastinum
Abdomen normal bowel gas pattern
Which of t he following is t he next most appropriate step in t his man's management?
Urgent echocardiogram
m
se
As
CT aortic angiogram
Dr
Urgent echoca rdiog ram
CT aortic ang iogram
Start IV labetalol
Bronchoscopy with pleu ra l b iopsy
Pericardiocentesis
In a man with low blood pressure and vague abdomina l pain, always be mind fu l of the
possibility of dissection o r aneurysmal rupture. CT imaging with a rterial contrast is the
m
se
gold stan dard for d iag nosis. Whilst an echoca rdiogram mig ht identify disruption of the
As
aortic root in a backwards tear, it wou ld not identify mo re distal aortic pathology.
Dr
A 60-year-old man is admitted w ith palpitations to the Emergency Department. An ECG
on admission shows a broad complex t achycardia at a rate of 150 bp m. His blood
p ressure is 124/82 mmHg and t here is no evidence of heart fa ilure. Which one of t he
following is it least appropriate to give?
Procainamide
Lidoca ine
Synch ron ised DC shock
Adenosine
m
se
Vera pamil
As
Dr
Proc.ainamide
Lidocaine
Synchronised DC shock
-
"""'
Adenosine
Verapa mil
-
~
Ventricular tachycardia - verapamil is contraindicated

Verapa mil should never be given to a patient with a broad complex tachycard ia as it may
precipitate ventricular fibrillati on in patients with ventricular tachycard ia. Adenosine is
m
se
sometimes given in this situation as a 'trial' if there is a strong suspicion the underlying
As
rhythm is a supraventricular tachycardia with aberrant co nduction
Dr
Which of the following conditions is not associated with the development of aortic
regurgitation?
Rheumatic fever
Ankylosing spondylitis
Marfan's syndrome
Syphilis
m
se
As
Dr
Rheumatic feve r
Ankylosing s po ndylitis
Ma rfan's syndrome
Syphi lis
-
~
m
se
Dilated cardiomyo pathy is associated with the deve lop ment o f mitral regu rgitation, not
As
aortic reg u rgitation
Dr
Which one o f the followin g cardiac conditions is most associated with a lou der murmur
fo llowing t he Valsa lva manoeuvre?
Mitral stenosis
Aortic st enosis
m
se
As
Dr
Mitral stenosis
Aortic stenosis
Hypertrophic o bstructive cardio myo pathy
m
se
Aortic reg urgitation
As
Dr
A 65 -year-old man admitted to the Acute Medical Unit is not ed to have cannon 'a' waves
of his j ugular venous pressure during cardiovascu lar examination. Which one of the
following wou ld not cause this finding?
Tricuspid stenosis
Ventricu lar tachycardia
Single chamber ventricular pacing
m
se
Nodal rhythm
As
Dr
I Tricuspid stenosis ClD
Complete heart block «ED
I Ventricu lar tachycard ia flD
Single chamber ventricular pacing GD
Nodal rhythm tiD
m
se
As
Whilst t ricuspid stenosis may cause large 'a' waves it does not cause cannon 'a' waves
Dr
A 72-year-old man is admitted to the Emergency Department with chest pain. On initial
assessment he is not ed to be pale, have a heart rate of 40/ min and a b lood pressure of
90/ 60 mmH g. Which one of the coronary arteries is most likely t o b e affected?
Po sterior d escending
Left ant erior descending
Right co ronary
Anterior interventricular
m
se
As
Left circumf lex
Dr
Posterior descending
Left anterior descending
Right coronary
Anterior intervent ricular
Left circumflex
Complete heart block following a MI? - right coronary artery lesi on

This patient has d eveloped complete heart block secondary to a right co ronary artery
(RCA) infarction. The atrioventricular nod e is supp lied by the post erior interventricu lar
artery, which in the majority of patients is a branch of t he right coronary artery. In t he
m
se
remaind er of patients the p ost erior interventricu lar artery is supplied by the left circumf lex
As
artery.
Dr
Which one o f the followin g is least likely t o cause dilated ca rdiomyopathy?
Wilson's disease
Haemochromatosis
Coxsackie B
Hypertension
m
se
As
Alcohol
Dr
I Wilson's disease CiD
Haemoch romatosis flD
Coxsackie B GD
Hypertension fD
Alcohol m
Haemoch romatosis is more commonly associated with restrictive ca rd iomyopathy but a
m
se
dilated pattern may a lso be seen. There is a known association between Wilson's d isease
As
and cardiomyopathy but this is extremely ra re and not oh en clin ically significa nt
Dr
Yo u a re the STl wo rking on card iology. The nurses have a sked yo u to review a 56-yea r-
old ma n complaining o f dyspnoea which is li miti ng his mobil ity.
He presented th ree days ago with an infe rior STEM!. He was loa ded with 300mg asp irin
and 180mg ticagrelor before b ei ng taken to the cath -lab whe re he unde rwent prima ry PC!
with a drug eluting stent for a sub-total occl us ion of the right co rona ry artery. He wa s
su bsequently comm e nced on a spirin l OOmg od, tica gre lor 90mg bd, ato rvastati n 80mg
o d, bisoprolo l Smg od a nd p erind opril Smg od. His echo demonstrated only mildly
reduced LV systol ic function (LVEF 50%).
His vital s ign s are stable with a blood p ressure 125/70mmHg, heart rate 64b pm, oxygen
saturations 98% on room air and te mperature 36.5°C. Examination reveals du al heart
sounds with no murmurs and his chest is clear on auscultatio n with no wheeze. JVP is
+2cm and there is no peripheral oed ema. His calves a re soft and non tende r. A Chest X-
Ray shows mild atelecta sis a t the bases. His bloods a re unre markable. His ecg shows
normal sinus rhythm with inferior q wave s.
With res pect to his dys pnoea, what would be the next best step in his management?
Cease bisopro lo l
Substitute ti cagre lor for clo pidogrel
m
Order an urg ent repeat echo
se
As
Cease ticagrelor and continue asp irin o nly
Dr
I Su bstitute ticagrelor for clopidog rel
Order an urgent repeat echo
Cease ticagre lor and continue aspi rin on ly
Start antibiotics for a nosocomial pneu monia
Dyspnoea is a common side effect of ticag re lor and is estimated to occur in up to 15% of
-
"""'
patients started on this medication. It is hypothesised that the sensation of dyspnoea in
ticagrelor-treated patients is triggered by adenosine, because ticagrelor inhibits its
clea ra nce (by inhibiting the enzyme adenosine deam inase), thereby increasing its
concentration in the circulation. It is important to be aware of this s ide effect in order to
avoid unnecessary treatment and/ or investigation, as it is easily remed ied by switching
the patient to clopidog rel.
With res pect to the other options, in this scenario there are no cl inica l featu res to suggest
into lerance to a beta-b locker or heart failu re. There a re also no clin ical signs to suggest a
hospital acquired pneumonia with basal atelectasis a not uncommon finding in previously
ambient patients who are hospitalised. It is important to be aware of the possibility of
acute mitra l regurgitation or a ventra l sepal defect post STEM! as these requ ire urgent
diag nostic echo and surg ica l repa ir; however, given the fact that this patient is otherwise
clinically well apart from subjective dyspnoea, has no murmurs on exam ination or signs of
m
heart failu re, this option is an unlikely cause of his dyspnoea. Whilst ticagrelo r is
se
As
associated with dyspnoea and cessation of th is medication will most likely result in
" . •. .
· · to continue on single agent anti -platelet
Dr
A 70-year-old woman is brought to the Emergency Department by her relatives. For the
past two hours she has experienced palpitations and 'tightness' in her chest. An ECG
t aken on arrival shows baseline atrial act ivity of around 300/ min with a ventricular rate of
150/min. What is the most likely diagnosis?
Atrioventricu lar nodal re-entry t achycardia (AVNRT)
Atrial flutt er
Atrioventricu lar re-entry tachycardia (AVRT)
Junctional tachycardia
m
se
Atrial fibrillation
As
Dr
Atrioventricular nodal re-entry tachycardia (AVNRT)
Atrial flutt er
Atrioventricular re-entry tachycard ia (AVRT)
Junctional tachyca rdia

-
.....,
Atrial fibrillation
m
se
As
Tachycardia with a rate of 150/min ?atrial flutter
Dr
A 45 -yea r-old man presents w ith fever. On examinatio n he is noted to have a pan -syst o lic
m urmur and sp linter haemo rrha ges. He is genera lly unwell w ith a b lood pressu re of
100/60 m mHg and a t em perature o f 38.8°C. What is t he most suita ble antibiotic therapy
until blood cu lt ure results are known?
IV amoxicillin + gentam icin
IV benzylpenicill in + g entam icin
IV vancomycin + gentam icin
m
se
As
IV ceftriaxone + benzylpenicill in
Dr
I
IV amoxicillin + gentamicin
IV benzylpenicillin + gentamicin
ED.
GD
N vancomycin + gentamicin CID.
N vancomycin + benzylpenicillin crD
m
se
As
N ceftriaxone + benzylpenicillin CD
Dr
A 54-year-old man is admitted to the Emergency Department with a 15 minute history of
crushing centra l chest pain. Which one of the following rises first following a myocardial
infarctio n?
AST
Troponin I
CK
CK- MB
m
se
Myoglobin
As
Dr
AST D
Troponin I GD
CK m
CK-MB GD
Myoglobin ED
Myoglobin rises first following a myocardial infarction

m
se
As
Dr
A 39-year-old ma le is d iagnosed with pulmonary arterial hyperte nsion. He was started on
sildenafil four months ago after testi ng negative during vasodi lator testing but has ha d a
poor respo nse to treatment with continued s hortness of b reath on exertion and
peripheral oedema.
What add itiona l medications should be co nsidered to delay disease progression and ease
sympto ms?
Diltiazem
Isoso rbide mononitrate
Ambrisenta n
Nifedipine
m
se
As
Furosemide
Dr
Diltiazem
-.....,.,
I
Am b rise ntan
-.....,.,
Nifed ipine
Furosemide
-
~
Pulmonary a rte rial hypertensi on patie nts with negative response to vasodilator
testi ng s houl d be treated with p rosta cyclin analo gues, e ndotheli n recepto r
antag o nists or phosphod iesterase inhib ito rs. Often com b inati on the rapy is required
The correct answer here is to combine si ldenafil a phosphodiesterase inhibitor with an

alternative med ication used for treating patients who do not respond to acute vasod ilato r
testing. These patients a re candidates fo r treatment with prostacyclin analogues such as
iloprost or epoprostenol, endothel in receptor antagonists such as bosentan or
ambrisentan and phosphodieste rase inhibitors such as sildenafil. Studies suggest that the
use of these medications can improve symptoms, d e lay disease p rog ression and improve
survival. As such the correct answer is to ad d in ambrisentan an endothel in recepto r
m
se
antagonist. As the popularity o f combination therapy increases this is often being do ne at
or soon after initiation of treatment. As
Dr
A 79-year-old man is a d mitted with congestive cardiac fail ure. Bloods on admission show:
BNP 3 54 pgfml
Which one o f the followin g wou ld result from elevated BNP levels?
Decreased sodium d iu resis
Vasoconstriction of the coronary arteries
Inhibition of the renin -angiotensin -a ldosterone system
Vasoconstriction of the pu lmo na ry vessels
m
se
Increased sympathetic tone
As
Dr
Decreased sodium d iuresis
Vasocor striction of the coronary arteries
Inhibition of the renin-ang iotens in-aldosterone !ystem
Vasoconstriction of the pu lmo na ry vessels
Increased sym pathetic tone

-
~
BN P - actions:
• vasodilator
• diuretic and natriu retic
• suppresses both sympathetic tone an d the renin-angiotensin-aldoste rone
system
m
se
As
Dr
A 36-year-old wo man presents for a routine antenatal review. She is now 15 weeks
pregnant. Her blood pressure in cl inic is 154/ 94 mmHg. Th is is confirmed with ambulatory
blood pressure monitori ng. On reviewing the not es it app ears her blood pressure four
weeks ago was 146/ 88 mmHg. A urine dipstick shows is normal. There is no significant
past medical hist ory of note. What is the most likely diagnosis?
Pre-ecl ampsia
Pregnancy-i nduced hypertension
Whit e-coat hypertension
Normal physi ologi cal change
m
se
As
Pre-existing hypertension
Dr
Pre -eclampsia
Pregnancy-i nduced hype rtension
White-coat hypertension
No rma l physiologi cal change
This lady has pre-existin g hypertens io n. Preg nancy-related b lo od pressure p roblems (su ch
a s p regnancy-induced hypertension or pre-ecla mpsia) do not occur before 20 weeks. The
ra ised a mbulatory b lood p ressure readi ngs exclude a diagnosis of white-coat
hyperte nsion.
No te the use of the term 'pre-existi ng hypertension' rather than essential hyperte nsion.
m
se
Ra ised blo od pressure in a 36-year-o ld female is not that com mon and raises the
As
possibility o f seconda ry hype rtens ion.
Dr
A 43-yea r-old man who is known to have Wolff-Parkinson White syndrome presents to
the Emergency Department with palpitations. He has no other signi ficant history of note.
The pa lp itations started around 4 hours ago and a re not associated with chest pa in or
shortness of b reath. On examination blood p ressure is 124/80 mm Hg and the chest is
clea r on auscu ltation. An ECG show atrial fibrillation at a rate of 154 bpm. Of the followin g
options, what is the most appropriate management?
Adenosine
Fleca inide
Verapamil
Digoxin
m
se
As
Sota lo l
Dr
Adenosine CD
Flecainide ED
Verapamil CD
Digoxin .
(D
Sot alol GD
Adenosine should be avoided as blocking the AV node ca n paradoxically increase

ventricular rat e resulting in fall in ca rdiac output. Verapamil and digoxin should also be
m
avoided in patients with Wo lff- Parkinson Whit e as they may precipitat e VT or VF.
se
As
Another option to consider in this situation wou ld be DC ca rdioversion
Dr
A 72-year-old woman who takes bendroflumet hiazide for hypertension is admitted to t he
Em ergency Department. Admission blood s show t he followi ng:
Na• 131 mmol/ 1
K• 2.2 mmol/1
Urea 3 . 1 mmol/1
Glucose 4 .3 mmol/1
Which one o f t he followin g ECG features is most likely to be seen?
Short PR interval
Short QT interval
Flattened P waves
J waves
m
se
U waves
As
Dr
Short PR interval GD
Short QT interval
Flattened P waves
•
«ED
J waves m
U waves CD
Hypokalaemia - U waves on ECG

m
se
J waves are seen in hypothermia whilst delta waves are associated with Wolff Parkinson
As
White syndrome.
Dr
A 56-year-old gentleman is brou ght in by paramedics. The patient faint ed this morning
and has not regained consciousness. No inj uries reported from his faint. On examination
his heart rate is 37 beats/ minute, respirat ory rate is 16 breaths/ minute, blood pressure is
105/70 mmHg. You order an ECG:
The ECG shows prolonged PR interval.
What would be the initial management?
IV atropine
IV adenosine
External pacing
IM adrenaline
m
se
Oral atropine
As
Dr
I IV atro p ine GD
IV ad eno sine m
External pacing (D.
~M a d re nal ine CD
Oral a tropine
•
~mptomatic b radyca rdi a is treated with atropine
This patient is suffering fro m b radyca rdia with adverse features (syncope) like ly due to his
first d egree hea rt block (p rolong ed PR interval). Adverse fea tu res of b radyca rdia are
shock, myocardia l ischemia, heart failure a nd synco pe. The initia l treatment is IV atro pine.
IV ad enosine is not used in bradyca rdia, it is used in supraventricu la r tachycardias.
Externa l pacing is o nly used if there is no improvement afte r s ix d oses of atro pine.
IM a d rena line is indicated fo r anap hylaxis
m
se
As
Ora l a tro pine is o nly indicated for GI disorders caused by smooth muscle spasms.
Dr
A 71-year-old man is reviewed in the coronary care unit. He was admitted w it h an ant erior
ST-elevation myocardial infarction and received thrombolysis with alt ep la se. Ninety
minut es follow ing t his an ECG shows a 30 -40% resolut ion in t he ST elevation. What is t he
most app ropriate mana gement?
Percuta neous coro nary intervention
Repeat ECG in 4 hou rs, if still not a 50% resolution in ST elevation t hen proceed to
percutaneous coronary int ervent ion
Repeat thrombo lysis w ith alteplase
Start a nitrat e infusion
m
Inform his relat ives that further intervention is fut ile and ensure adequate pain
se
As
relief
Dr
Percutaneous coronary intervention
Repeat ECG in 4 ~ou rs, if still not a 50% resolution in ST elevation then proceed 6D
to percutaneous coronary intervention
Repeat thrombolysis with alteplase m

Start a nitrate infusion m
m
Inform his relatives that further intervention is futile and ensure adequate pain
se
As
relief
Dr
What is the mechanism of action of nico randil?
Fast-sodium channel antagonist
Nitric oxide reductase inhibitor
Acts on the If ion cu rrent in the sinoatrial node
Potassium-channel act ivator
m
se
Glutathione S-transferase inhibitor
As
Dr
Fast-sodium channel antagonist
Nitric oxide reductase inhibitor
Acts on the I f ion current in the sinoatrial node
-
.....,
m
Potassium-channel activator
se
As
Glutathione S-transferase inhibitor
Dr
Which one of the following may reduce the effects of adenosine?
Dipyridamole
Diltiazem
Clopidogrel
Amiodarone
m
se
As
Aminophylline
Dr
Dipyridamole QD
Diltiazem m
Clopidogrel .
CD
Amiodarone CD
I
Aminophylline ED
Adenosine
• dipyridamole enhances effect
m
se
• aminophylline reduces effect
As
lmportart "or me _ess :rr oc"'ta""tt
Dr
A middle -aged woman is admitted to the Emergency Department with pleu ritic chest pain
ten days after having a hysterectomy. There is a clinical suspicion of pulmonary embolism.
What is the most commo n chest x-ray finding in patients with pul monary embolism?
Right heart enlargement
Normal
Pleural effusion
Linea r atelectasis
m
se
As
Dilatation of the pulmonary vessels proximal to the em bolism
Dr
Rig ht heart enlargement CD
I Normal 6D
Pleural effusion
~near atelectasis
•
Dilatation o f the pulmonary vessels proximal to the embolism
•
(fD
Pulmonary embolism - normal CXR

m
se
As
The vast majority of patients w ith a pu lmonary embolism have a normal chest x-ray.
Dr
A 60-yea r-old man is investigated for progressive shortness of breath. On examination a
loud P2 is noted associated with a left parasterna l heave. An ECG shows evidence of rig ht
ventricular strain and a diagnosis of pulmonary hypertension is suspected. Wh ich one of
the following is the sing le most im portant test to confirm the dia gnosis?
Echoca rdiography
High resolution CT thorax
Cardiac catheterisation
Pu lmonary angiography
m
se
Ventilation perfusion scanning
As
Dr
Echoca rdiography
High resolution CT thorax
Pulmonary angiography
Whilst echocard iog ra phy may strong ly po int towa rds a d iagnosis of pu lmona ry
hypertension a ll patients need to have right heart pressu res measu red . Card iac
m
se
catheterisation is therefore the single most im portant investigation. Please see the British
As
Thoracic Society gu id elines for mo re d etails.
Dr
A 42-year-old man of Afro-Caribbean origin is diagnosed as having hypertension.
Secondary causes of hypertension have been excluded. What is the most appropriate
initial drug therapy?
Losartan
Bisoprolol
Indapamide
Ram ipril
m
se
Amlod ipine
As
Dr
Losartan CD
Bisoprolol fD
Indapamide m
Ram ipril GD
I Amlodipine GD
m
ACE inhibitors have reduced efficacy in black patients and are therefore not used
se
As
first-line
Dr
A 76-year-old man with a history of ischaemic heart disease and hypertension present s
fo r review. He ha d a myocardial infarction 20 years ago but has had no problems since.
His current medication is clopidogrel, atorvastatin, ramipril and bisoprolol. He has recently
been feeling light-headed an ECG shows atrial fibrillation.
What antithrombotic medication should he now be ta king?
Continue clopidogrel monotherapy
Swit ch to aspirin + clopidogrel
Swit ch to an oral anticoagulant + clop idogrel
m
Swit ch to an oral anticoagulant
se
As
Swit ch to long-term low molecul ar weight hepari n
Dr
Continue clopidogrel monotherapy
Switch to aspirin + clopidogrel
Switch to an oral anticoagu lant + clopidogrel
I Switch to an oral anticoagulant
Switch to long-term low molecular weight hepari n
Patients with stable CVD w ho have AF are generally managed on an anticoagulant

and the anti platelets stopped
Important for me Less ·mpcrtant
This patient is at risk o f st roke given his CHADS-VASC score (cardiovascu lar disease,
m
se
hypertension, age etc). He, t herefore, requires treatment. As his cardiovascu lar disease is
As
stable, he shou ld stop his ant iplatelet and switch to oral anticoagu lant monotherapy.
Dr
Where is the site of action of furosemide?
Proximal collecting duct
Ascending loo p of Henle
Descending loop of Henle
Distal collecting duct
m
se
As
Macula densa
Dr
Proximal collecting duct CD
Ascending loop of Henle fD

Descending loop of Henle flD
Distal co llecting duct m
~
Macula densa m
m
se
Furosemide- inhibits the Na-K-CI cotrans porter in the thick ascending limb of the
As
loop of Henle
Dr
A 68-year-old ma n presents with a 4-day history of palp itations and increased
breathlessness on exertion. An ECG shows atria l fib rillation with a rate of 118 beats per
minute.
His past medical history in cludes brittle asthma, hypertensio n and congestive ca rdiac
failu re and his recent echocard iogram showed a left ventricula r ejection fraction of 32%.
What is the most appropriate med ication to control the heart rate in this man?
Vera pa mil
Sotalo l
Diltiazem
Digoxin
m
se
As
Am iodarone
Dr
Verapamil CD
Sotalo l CiD
Diltiazem fliD
Digoxin ED
Amiodarone GD
Rate-lim iting CCBs should be avoided in patients with AF with heart fai lure with
reduced EF (H FrEF) due to their negative inotropic effects
Rate-l imiting calcium channe l blockers (diltiazem and verapamil) should be avoided in
patients with atrial fibrillation (AF) with heart failure with reduced ej ection fract ion (HFrEF)
due to their negative inotropic effects.
Digoxin monotherapy is no longer considered first-line for rate control but may be
preferred in patients w ith heart fa ilure and a sedentary lifestyle.
Sot alol and amiodarone are used t o maint ain sinus rhythm in AF.
m
se
Standard beta-blockers (not including sotalol) are commonly used for rate control in AF As
but they are not among the options and should be avoided in this patient with brittle
Dr
asthma.
A 50-year-old man presents t o the emergency departm ent w ith heart palpitations. He is
not experiencin g chest pain. He has a long history of alcohol abuse. On examination there
is no signs of shock, heart fa ilure or syncope. He app ears malnourished. An ECG shows an
irregular tachycardia of 165 beats per minute with a QRS duration of 155ms. Laboratory
results reveal a pot assium of 2.1 mmoljl.
What should be the next step in management?
Administration of l mg of intravenous adrenaline and 300mg of intravenous

amiodarone
Defibrillation
Defibrillation and 1mg of intravenous adrenaline
Defibrillation and 300mg of intravenous amiodarone
m
se
As
Administration of 2g of magnesium
Dr
Administration of lmg of intravenous adrenaline and 300mg of intravenous
am ioda rone
Defibrillation
-
"""'
~efibrillati on and lmg of intravenous adrena line

Defibrillation and 300mg of intravenous amiodarone
Admin istration of 2g of mag nesium
The irregular tachycardia with a broad QRS complex is suggestive of either polymorphic
ventricular tachycardia (VT), pre -excited atrial fibrillation, or atrial fibrillation with bundle
branch block. The long history of alcohol abuse and the severe hypokalaemia make
polymorphic ventricular tachycardia (Torsade de Pointes) the most likely diag nosis in this
m
se
case. As per the Resuscitation Cou ncil tachyca rdia guidelines, as the patient has no
As
adverse featu res, they should receive 2g of mag nesium.
Dr
A 34-yea r-old ma n is noted to have a pa n-systo lic murmur associated with la rge V waves
in the JVP and pulsatile hepatomegaly. Wh ich one of the following types of congen ital
heart disease is most associated with tricuspid regu rgitation?
Atrial septal d efect
Ebstei n's ano maly
Coarctation o f the aorta
m
se
As
Dr
Atrial septal d efect fD
I Ebstein's anomaly CD
Coarctation o f the aorta fD
Patent ductus arteriosus m
m
se
As
Ventricular septal defect &D
Dr
A 45-year-old female develops pleuritic chest pain following a hysterectomy 10 days ago.
Low -molecu lar weight heparin is given initially and CTPA confirms a pulmonary embolism.
There is no previous history of venous thromboembolism. How long should the patient be
warfarinised for?
Not suita ble for anticoagulation
At least 4 weeks
At least 3 months
At least 6 months
m
se
As
12 months
Dr
Not suita ble for anticoagu lation m
At least 4 weeks m
I At least 3 months CD
At least 6 months m
12 months m
'Provoked' pulmonary embol isms are typically treated for 3 months
m
se
As this patient has a temporary risk factor for a throm boem bolic event the recommended
As
period of anticoagu lation is 3 months.
Dr
How long shou ld a patient stop driving for following an e lective ca rdiac a ngioplasty?
No restriction
1 week
2 weeks
4 weeks
m
se
As
8 weeks
Dr
No restriction GD
1 week CD
2 weeks fD
4weeks 6D
8weeks m
m
se
As
DVLA advice following angioplasty • cannot drive for 1 week
Irrportar t "or me _ess ·rroc"1! '1t
Dr
Where is the most co mmon site for primary cardiac tumours to occur i n adults?
Left atrium
Right ventricle
Right atrium
Left atrial appendage
m
se
As
Left ventricle
Dr
Left atrium ED
Right ventricle m
Right atrium fD
Left atrial appendage GD.
Left ventricle D
Atrial myxoma - com monest site = left atrium

Important for me Less ' m ::~c rte;nt
m
se
As
The most com mon site of atrial myxomas is at the fossa ovalis border in the left atrium
Dr
Which one o f the fo llowin g statements rega rd ing statin -ind uced myo pathy is incorrect?
Rhabdomyolysis may cause re na l failu re
Patients with an e levated creatine kinase often have no symptoms
Female sex is a ris k fa ctor
Creatine ki nase d oes not need to be routinely checked prio r to co mmenci ng a

stat in
m
se
As
Pravastatin is more likely to cause myopathy than simvasta tin
Dr
Rhabdomyo lysis may cause rena l failure
Patients with an e levated creatine kinase often have no symptoms

-
Female sex is a ris k fa ctor
Creatine kinase does not need to be routine ly checked prior to commenci ng a

statin
Pravastatin is more likely to cause myo pathy than simvastatin

-
~
m
se
Myopathy is more common in lipoph ilic stat ins (s imvastatin, ato rvastatin) than re lative ly
As
hydroph ilic stat ins (rosuvastatin, pravastatin, fluvastatin)
Dr
A 38-yea r-old lady p resents to the emergency depa rtment with increased shortness of
b reath for the last 5 days. On full history taking, yo u find she has a lso recently had some
ep isod es of chest pa in o n exertion. She is no rmally fit and we ll but d oes report
g enera lised aching and a high temperature a p proximately 2 weeks ago.
On exam ination you find that she is haemodynam ica lly stable with a blood pressure on
100/ 65mmHg in the right a rm and a heart rate of 95 bpm. The ra dial p ulse on the right
s id e is absent. Heart sounds a re normal and the apex b eat is non d isp laced . He r oxygen
saturations a re 95% on a ir and he r respirato ry rate at rest is 20 b reaths pe r minute.
Given the history and exa minatio n find ings g iven, what is the most likely d iagnos is?
Type B a ortic dissecti on
Acute myocarditis
Com mu nity acquired p neumonia
Ta kayasu' s arteritis
m
se
As
Periphe ral arterial embolus Dr
Acute myocarditis tiD
Com mu nity acquired p neumonia fD
I Takayasu's arteritis CD
Periphe ral arteria l embolus fD
The correct answe r he re is D: Takayasu 's a rteritis.
The key to this q uestion is that a ll but this a nswe r will give some features of
histo ry/exam inatio n mentio ned but th is is the o nly a nswe r that explains a ll po ints.
Aortic d issection cou ld have simila r symptoms and if invo lving the subclavia n could give
an absent radial pulse, however a d escend ing d issectio n (type B) would not normally do
this. Commu nity acquire d p neumonia would explain the shortness of breath and perhaps
chest pa in seconda ry to pleurisy, but wo uld not exp la in othe r fin dings. Acute myoca rd itis
would exp la in shortness o f breath a nd chest pa in but not a bsent radial pulse. Whereas a
periphera l arte ria l emb olus wo uld explain the abse nt ra dia l pulse but not the othe r
findings.
Ta kayasu's arte ritis is the refo re the on ly app ro priate a nswe r as it expla in s a ll findings.
m
se
Othe r causes of a n absent radia l pu lse in clude: aortic dissection with su bclavian As
involvement and perip hera l a rteria l e mbo lus (as me ntioned above), trauma and iatroge nic
Dr
Where is the site of action of bendroflumethiazide?
Proximal convoluted tubu les
Ascending loop of Henle
m
Proximal part of the distal convoluted tubules
se
As
Distal part of the distal convoluted tubu les
Dr
Proximal convoluted tu bules
Ascending loop of Henl e
I Proximal part of the distal convoluted tubules
Distal part of the distal convoluted tubules
m
se
Bendroflumethiazide- inhibits sodium reabsorption by blocking the Na- -CI-
As
symporter at the beginning of the distal convoluted tubule
trrportar t "or me _e,ss -,.. :>c'tant
Dr
A 52-year-old woman with a history of breast cancer is admitt ed w ith acute dyspnoea.
Her respiratory rat e on admi ssion is 42 I min and her oxygen saturations are 87% on
room air. A pulmonary embolism is suspected and she is transferred to the high
dependency unit after being treat ed with oxygen and enoxapari n. Which one of the
following would be strongest indication fo r thrombolysis?
Extensive deep venous thrombosis
Hypot ension
Patient choice following info rm ed consent
Hypoxaemia despite high flow oxygen
m
se
As
ECG showing right ventricu lar strain
Dr
Extensive deep venous thrombosis
I Hypotension
Patient choice following informed consent
Hypoxaemia despite high flow oxygen
ECG showing right ventricular strain
m
se
As
Massive PE T hypotension - thrombolyse
Dr
A 75-year-old woman was admitted t o the Acute Medica l Unit with pneumonia. Her only
past medical hist ory of note is transient ischaemic attack 2 months previously. On initial
assessment, ECG revealed atrial fibrillation with a ventricu lar rat e o f 103. She was treat ed
with intravenous fluids and antibioti cs. She improved significantly. Two further ECGs
overnight revealed normal sinus rhythm. The following day, she was deemed medically fit
for discharge.
What is the si ngle most appropriate mana gement option regarding her episode of atrial
fibrillation?
No follow-up required
Repeat ECG in two weeks
Oral anticoagulation
m
Aspirin
se
As
24-hour t ape and consider oral anticoagulation
Dr
No follow-up required
Repeat ECG in two weeks

-
~
I Oral anticoagulation
Aspirin
-~
24-hour ta pe and consider oral anticoagulation
A single episode of paroxysmal atrial fibrillation, even if provoked, should still

prompt consideration of anticoagulation
This patient has a CHADSVASC score of three therefore initiating anticoagulation would
be appropriate. Despite being provoked by pneumonia, this patient is at high risk of
having further episodes of atrial fibrillation. Aspirin is no longer recommended. A 24-hour
t ape is useful in patients with sym ptomatic palpit ations, or those who have experienced a
thrombo-embolic event without known AF.In this example we have already 'found' atrial
fibrillation, and we should initiate treatment. While some studies have linked paroxysmal
AF 'burden' on cardiac monitoring to stroke risk, this is not cu rrently in guidelines. We
know from the CHADSVASC score that on average, the risk is likely to be high
(approximately 3.2% per yea r) regardless of burden. A 24-hour tape may be useful when
m
se
considering an ablation, or assessing the response to rhythm control medication. As
Repeating the ECG in two weeks is not an unreasonable suggestion, but should not
Dr
preclude initiation of anticoagulation.

Each one of the following is an indication for an implantable ca rdiac defibrillato r, except:
Previous myocardial infarction with non -sustained VT on 24 hr monitoring
Wolff-Parkinson White syndrome
Previous cardiac arrest due to VF
m
se
As
Long QT syndrome
Dr
Previous myocardial infarction with non-sustained VT on 24 hr monitoring
I
Wolff-Parkinson White syndrome
Previous cardiac arrest due to VF

-
m
~
se
As
Long QT syndrome
Dr
A 52-year-old female with a known history o f systemic sclerosis presents for annual
review t o the rheumatology clinic. Which one o f the following symptoms is most
charact eristic in patients who have developed pulmonary arterial hypertension?
Exertional dyspnoea
Paroxysmal nocturnal dyspnoea
Cough
m
Early morning dyspnoea
se
As
Orthopnoea
Dr
I
Exertional dyspnoea
Paroxysma l nocturnal dyspnoea
Cough
-
Early morning dyspnoea
Acute vasodilator testing should be used in patients with pulmonary artery
m
hypertension to determine which patient show a significant fall in pulmonary
se
As
arterial pressure following vasodilators and help guide treatment
ltrporta r~ ~or me _ess rr xrtart
Dr
A 28-year-old wo man presents with palpitations. Her heart rate is 160/min an d irregular.
Her blood pressu re is 123/ 65 mm Hg, and her oxygen saturation is 97% on breathi ng
room air. Her chest is clear on auscultation. Her ECG shows irregular broad complex
monomorphic tachyca rdia w ith a stable axis. She has no previous medical history an d has
never b een t o a hospital before. What is the most appropriate treatment ?
Diltiazem
Bisoprolol
Amiodarone
Magnesium
m
se
As
Adenosine
Dr
Diltiazem CD
Bisoprolol GD
Amiodarone ED
Magnesium .
flD
Adenosine GD
The correct answer is am iodarone. This a haemodynamically stable patient with irregular
broad complex tachycardia. As the broad-complex tachycardia is irregular it is most likely
atrial fibrillation with left bundle branch block or an alternative aberrant conduction
pathway such as Wolff-Parkinson-White syndrome. Diltiazem, bisoprolol and adenosine
are all contraindicated as they could enhance the aberrant pathway leading to ventricular
fibrillation. Magnesium would be appropriate fo r to rsades de pointes but is unlikely as the
rhythm is monomorphic.
Source:
m
se
Pitcher, David, and Jerry Nolan. 'Peri-arrest Arrhythm ias.' Peri-arrest Arrhythm ias. N.p.,
As
2015. Web. 09 Feb. 2017
Dr
A 72-yea r-old man is investigated fo r exertional chest pain and has a positive exercise
tolerance test. He d eclines an a ng iogram and is discharged on a com bination of aspirin
75m g o d, simvastatin 40mg on, atenolol SOmg o d and a GTN s pray prn. Exa mination
reveals a pulse of 72 bp m and a blood p ressure of 130/ 80 mmHg. On review he is still
regula rly using his GTN spray. What is the most a pp ropriate next step in management?
Add nifedipine MR 30mg o d
Add isosorb ide mononitrate 30mg bd
Increase ateno lol to l OOmg od
Add nicora ndil l Omg bd
m
se
As
Add ve rapam il 80mg td s
Dr
Add nifedipine MR 30mg od
Add isosorbide monl nitrate 30mg bd
Increase atenolol to l OOm g od
Add nicorandil lOmg bd
Add verapamil 80mg tds
When treating angina, if there is a poor response to the first-l ine drug (e.g. a beta-
blocker), the dose should be titrated up before adding another drug
Important for me l ess 'mpcrtont
m
se
The BNF recommends an atenolol dose of l OOm g daily in 1 or 2 doses for angina. The
As
starting dose of isosorbide mononitrate is l Omg bd.
Dr
Which of the fo llowing is a cause of a loud second heart sound?
Aortic regu rg ita tion
System ic hyperte nsion
m
Aortic ste nosis
se
As
Mitral stenosis
Dr
Aortic regu rgitation CD
Ventricular septal defect m
I Systemic hypertension CD
Aortic stenosis GD
Mitral stenosis fD

• soft: AS
m
se
• reversed split: LBBB
As
Important for me _ess ;rrocrtant
Dr
A 54-yea r-old man with atypical chest pain is referred to cardiology. An exercise ECG
s hows non -specific ST and T wave changes. Fo llowing th is an coronary ang iogram is
performed which demonstrates no evidence of atherosclerosis. A d iagnosis of
Prinzmeta l's ang ina is suspected. What is the most appropriate first-line treatment?
Nicorand il
Atenolol
Felod ipine
Fluoxetine
m
se
As
Dr
Nicorandil
Atenolol
Felodipine
F~oxetine
Prinzmeta l angina -treatment = dihydropyridine ca lcium channel blocker

m
se
As
See the SIGN guidelines for more det ails.
Dr
Which one o f the following types o f hyperlipidaemia are eruptive xa nthoma most
com monly associated w ith?
Familial hypertriglyceridaemia
Familial hypercholesterolaemia
Familial co mbined hyperlipidaemia
Remna nt hyperlipi daemia
m
se
As
Hyperlipidaemia secondary to nephrotic syndrome
Dr
I Familial hypertriglyceridaemia CD
Familial hypercholesterolaemia GD
Familial combined hyperlipidaemia CD
m
Remnant hyperlipidaemia CID
se
As
Hyperlipidaemia secondary to nephrotic syndrome CD
Dr
A 64-year-old man with a history of ischae mic heart disease and poor left ventricular
function presents with a b road complex tachycardia of 140 bpm. On examination b lood
p ressure is 110/74 mmH g. Fusion and capture beats are seen on the 12 lead ECG. What is
the first line drug management?
Sotalol
Am iodarone
Adenosine
Flecainide
m
se
As
Lidoca ine
Dr
Sotalol fD
I Amiodarone flD
Adenosine fl!D
~cainide fD
Lidocaine m
The history of ischaem ic heart disease combined w ith t he presence of fusion and capture
beats strongly suggests a diagnosis of ventricular tachyca rdia (VT). Whilst lidocaine can
also be used in VT, amiodarone wou ld be preferred given his history of poor left
m
se
ventricular function. In the 2010 joint European Resuscitation Council and Resuscitation
As
Council (UK) guidelines amioda rone is also considered first- line in a peri-arrest situation
Dr
You are considering prescribing an antibiotic to a 28 -year-old man who t ells you he has
Long QT syndrome. Wh ich antibiotic is it most important to avo id?
Doxycycline
Trimethoprim
Erythromycin
Rifampicin
m
se
As
Co -amoxiclav
Dr
Doxycycline fD
Trimethoprim m
I Erythromycin GD
Rifampicin m
[ co-amoxiclav m
m
se
As
Erythromycin can cause a prolonged QT interval
Dr
A 15-year-old boy collapses and dies whilst playing football at school. He had no past
med ical history of note. Post-mo rtem exam ination revea ls asymmetric concentric
en largement of the myocardial septum. Given the like ly diag nosis, what is the chance his
s ister will also have the same u nderlying d isord er?
0%
25%
50%
m
100%
se
As
66%
Dr
0% CD
25% f1D
I so% fZD
100% fD
6%
•
Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the
anterior leaflet of mitral valve on echocardiogram or cMR support HOCM
m
se
The underlying diagnosis is hypertrophic obstruct ive cardiomyopat hy w hich is an
As
autosomal dominant disorder. His sister therefore has a 50% chance of being affected.
Dr
Which one of the following is not an indication for insertion of a temporary pacemaker?
Complete heart block following an inferior MI - blood pressure normal
Complete heart block following an anterior MI - blood pressure norm al
Trifascicular block prior to surg ery
m
Mobitz type II heart block following an anterior MI - blood pressure normal
se
As
Symptomatic bradycardi a not responding to drug treatment
Dr
I Complete heart block fo llowing an inferio r MI - blood pressure normal
Complete heart block following an anterior MI- blood pressure normal
Trifascicular block prior to surgery
Mobitz type II heart block follow ing an anterior MI - blood pressure normal
Symptomatic bradycardia not responding to drug treatment
Complete heart block following an inferior MI is NOT an indication for pacing,

unlike with an anterior MI
m
se
Post-inferior MI complete heart block is co mmon and can be managed conservatively if
As
the patient is asymptomatic and haemodynamically stable
Dr
A 21-yea r-old man colla pses whilst p laying football with his friends at the weekend . By
the time he is bro ught into the emergency department he is p ronounced d ea d fo llowing
ca rdiac a rrest despite ad equate life support be ing g iven. His fa mily cannot understand
how this has hap pened sayi ng that he has a lways been fit and healthy and was a keen
sportsman, they do however note that two other fa mily members have died young in
similar circu mstances.
Which of the following methods of inheritance is correct fo r this cond ition?
Autosomal d om inant
Autosomal recessive
X-li nked recessive
X-li nked d omina nt
m
se
As
Mito chon dria l
Dr
I Autosomal dominant CD.
I
Autosomal recessive
X-linked recessive
- m
X-lin ked dominant CD
Mitochondrial fD
Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the

anterior leaflet of mitral valve on echocardiogram or cMR support HOCM
Given the circumstances in which this person has died and the fam ily history, one can
infer that hypertroph ic cardiomyopathy may be a cause. In hypertrophic cardiomyopathy,
the myocardium becomes thickened which can lead to functional impairment of cardiac
muscle and sudden death, especially in young athletes.
It can ohen run in fam ilies and fam ilial hypertrophic cardiomyopathy is inherited in an
autosomal dominant pattern and is attributed to a mutation in one of the genes that
m
se
encodes for a sarcomere protein.
As
Dr
A 58-year-old man with no past medical history of note is admitted to hospit al with
crushing central chest pain. ECG on arrival shows ant erior ST elevation and he is
subsequently thrombolysed with a good resolution of symptoms and ECG changes. Four
weeks following the event, which comb ination of drugs should he be t aking?
ACE inhibitor+ beta-blocker + st atin + aspirin
Spironolactone + beta -blocker + statin + aspirin
ACE inhibitor+ beta-blocker + st atin + aspirin + clopidogrel
ACE inhibitor + statin + aspirin + clopidogrel
m
se
As
Beta-blocker + st atin + aspirin + clopidogrel
Dr
ACE inhibitor + beta-bl ocker + statin + aspirin
!Spironolactone + beta -blocker + statin + aspirin
ACE inhibitor + beta-blocker + st atin + aspirin + clopidogrel
ACE inhibitor+ statin + aspirin + clopidogrel
Beta- blocker + statin + aspirin + clopidogrel

-
"""'
NICE made the following reco mmendatio n in 2013 relating to people who have had a
STEM! and medica l management w ith or without reperfusion treatment with a fibrinolytic
agent
m
• offer clopidogrel as a treatment option for at least 1 month and consider continuing
se
for up to 12 months
As
Dr
A 62-yea r-old patient presents to the Emergency Depa rtment with a 25 minute history of
crush ing centra l chest pain. ECG shows ST elevation in leads I and aVL. Which co ronary
territory is likely to be affected?
Late ral
Posterior
Anteroseptal
Anterolatera l
m
se
As
Inferior
Dr
Late ral GD
Po sterio r m
Anteroseptal CD
Anterolateral GD
Inferior CD
m
se
These ECG changes a re most consistent with a latera l myo ca rdia l infa rction. An
As
anterolate ra l infa rction is more likely to have chang es in the chest lea ds.
Dr
A 62-year-old female with a known history of a si gmoid adenocarcinoma is adm itted to
hospital with s hortness of b reath and pyrexia . On examination a murmur is heard and an
echo revea ls a vegetation on the aortic valve. Which one of the fo llowing organ is ms is
most characteristically associated with causing infective endocard itis in patients with
colorecta l cancer?
Escherichia coli
Enterococcus faecalis
Salmonella
Campylobacter
m
se
As
Streptococcus bovis
Dr
Escherichia coli fD
Enterococcus faecalis CD
Salmanella m
Campylobacter m
I
Streptococcus bovis G13
m
se
As
Streptococcus bovis endocarditis is associated with colorectal cancer
Irrportart "or me _ess ·rroc'1.:.'1t
Dr
Which one of the following is an example of a centrally acting antihypertensive?
Minoxidil
Hydralazine
Sodium nitroprusside
Moxonidine
m
se
As
Diazoxide
Dr
Minoxidil
Hydralazine
-
Sodium nitroprusside
Moxonidine
m
se
As
Diazoxide ........
Dr
A 68-yea r-old wo ma n is admitted to hos pita l with com plete hea rt b lo ck. After initia lly
being treated with a temporary pacing wire she goes o n to have a pe rma nent pace make r
fitted. How soo n a fter the procedu re ca n she drive a ga in?
Immed iately
24 ho urs
3 d ays
m
1 we ek
se
As
4 we eks
Dr
Immediate ly GD
24 hours .
(D
3 days
•
J CI!D
m
p :eek
se
As
4 weeks fD
Dr
Which one of the following stat ement s regarding the management of pregnant women
with severe pre-eclampsia an d eclampsia is incorrect?
Intravenous fluids should be given to prevent rena l failure
Magnesium sulphate treatment should continue for 24 hours post-partum
Problems are only seen aher 20 weeks gestation
Reflexes should be monitored during magnesium sulphate infusion
m
se
As
Magnesium sulphate is given to both prevent and treat seizures
Dr
I Intravenous fluids should be given to prevent renal failure
Magnesium su lphate t reatment should cont inue for 24 hou rs post-partum

-
~
Problems are only seen aher 20 weeks gest ation
Reflexes should be monitored during magnesium sulphate infusion
Magnesium su lphate is given to both p revent and treat seizures
Severe pre-eclam psia - restrict f luids

Important for me Less ' m::~c rtant
m
se
Pulmonary and cerebral oedema are important causes of morb idity and mortality in
As
severe pre-eclampsia
Dr
A 56-yea r-old man is a d mitted to the Emergency Depa rtment with head aches, chest pa in
a nd confusion. His initial o bservations show a blood pressu re of 250/ 140 mmHg, pu lse
90/min and tem perature of 36.4°. On exa minatio n the blood pressu re is confirmed and is
eq ual in both arms. Blurri ng of the o ptic d iscs is noted o n exa mination. He has no
significant med ical history an d takes no regular medications. What is the most su ita ble
initial manage ment?
Oral ramipril
Intravenous phe ntolam ine
Venesection
Intrave nous nitroprussi de
m
se
As
Intravenous hydralazine
Dr
Oral ram ipril
Intravenous phentolam ine
Venesection
Intravenous nitroprusside
Intravenous hydralazine
m
se
This patient has ma lig nant hypertension. The presence o f papilloed ema is an indi cation
As
for the use of intravenous agents rather than slower acting o ral prepa rations.
Dr
A 75-yea r-old ma n is a d mitted fo llowing a fter feeling faint. An ECG taken in the
d epartment shows a ventricular tachyarrhythmia. His blood p ressure is stable and it is
decided to give IV am io darone, with a loadi ng dose being given.
What is the reason for the loading dose being given?
Autoinductio n o f the P450 syste m by am ioda ro ne
High ventricular rate leading to rapid dilutio n
Long half-life o f am iodarone
m
Reduce the risk of extravasation injury
se
As
Am ioda ro ne exhibiti ng zero -o rd er kineti cs
Dr
Autoinduction of the P450 system by amiodarone
High ventricular rate leading to rapid dilution
Long half -life of amiodarone
Reduce the risk of extravasation injury
Amiodarone exhibiting zero -order kinetics
Amiodarone has a very long half- life of 20-100 days - loading doses are therefore
ohen needed
m
se
As
Dr
A 71-year-old woman presents with palpitations and 'lightheadedness'. An ECG shows
that she is in atria l fibri llation with a rate of 130 I min. Her blood pressure is no rmal and
exam ination of her cardiorespiratory system is otherwise unremarka ble. Her past medical
history includes well contro lled asthma (salbutamol & beclomethasone) and dep ression
(cita lopram). Her symptoms have been present fo r around three days. What is the most
appropriate med icatio n to use for rate control?
Diltiazem
Sota lo l
Digoxin
Atenolol
m
se
Amiodarone
As
Dr
Diltiazem ED
Sotalol m
Digoxin QD
[ :enolol GD
Amiodarone CD
Her history of asthma is a co ntraindication to the prescription of a beta-blocker. NICE

therefore recommend a rate-limiting calcium channel blocker.
m
se
As
Consideration should also be given to antithromboti c therapy.
Dr
11'1/hich one o f t he following wou ld not be considered a normal variant on t he ECG o f an
3thlet ic 28 -year-o ld man?
W enckebach phenomenon
Sinus bradycardia
Junctional rhythm
First d egree heart bl ock
m
se
Left bu ndle b ranch b lo ck
As
Dr
Wenckebach pheno menon
Sinus bradycardia
Junctional rhythm
-
. .wJ
First degree heart block

-
. .wJ
m
se
~L-eft__b_u_nd_l_e_b_ra_n_c_h_b_lo_c_k--------------~~
As
Dr
Which one o f the followi ng is least associated wit h p rolongation of the PR interva l?
Digoxin to xicity
Hypocalcaemia
Lyme disease
Rheumatic fever
m
se
As
Dr
Digoxin toxicity tD
I Hypocalcaemia CD
Lyme disease GD
Rhel matic fever
Isc haem ic heart d isease

•
GD
m
se
Hypocalca em ia is associated with a p ro longed QT interva l. Hypokalaemia is associated
As
with a pro long ed PR interval
Dr
Which of the following physiological effects wou ld be expected following administratio n
of atropine?
Bradycardia + mydriasis
Tachycardia + miosis
Bradyca rdia + salivation
Bradyca rdia + miosis
m
se
As
Tachycardia + mydriasis
Dr
Bradycardia + mydriasis CD
Tachycardia + miosis GD
Bradyca rdia + salivation
Bradycardia + miosis
•
CD
I Tachycardia + mydriasis e:D
m
se
As
Dr
A 44-year-old fema le is investigated for suspect ed idiopathic pulmonary hypertension.
Which one of the following is the best method fo r deciding upon management strategy?
Genetic testing
Acute vasodilator t estin g
Trial of endothelin receptor antagonists
Serial echocardiography
m
se
As
Trial of calcium channel blockers
Dr
Genetic t esting m
I Acute vasodilator t esting fD
Trial of endothelin receptor antagonists «D
Serial echocardiography CD
Trial of calcium channel blockers m
Acute vasodilator t estin g should be used in patients with p ulmonary artery
m
hypertension to d etermine w hich patient show a si gnificant fa ll in pu lmona ry
se
As
arterial p ressure follow ing vasodilators and help guid e t reatment
Dr
The neprilysin inhibitor, sacubitril, in com bination w ith the angiote nsin II receptor blocker,
va lsartan, has been shown to reduce mortality, reduce hospitalisations and improve
sympto ms in comparison to enalapril in the treatment of heart failure w ith reduced
ej ection fraction. What is its mechanism of action in heart fa ilure?
Improves myocardial contraction
Prevent s the degradation of natriuretic p eptides such as BNP and AN P
Reduces heart rat e
Multiple inhibition o f renin, angiotensinogen and aldost erone
m
se
As
Inhibition of vasopressin release therefore promoting diuresis
Dr
Improves myocardial contraction
I Prevents the d egrad ation of natriuretic peptid es such as BNP and AN P
Reduces heart rat e
Multiple inhibition o f renin, angiotensinogen and aldost erone
Inhibit ion of vasop ressin release th erefore promoting diuresis

-
~
The correct answer is prevent s the degrad ation of nat riuretic peptides such as BNP and
ANP.
The nat riuretic peptide system regulat es the detrimental effects of the upregulation of the
renin -a ngiotensinogen-a ldost erone syst em (RAAS) which occurs in heart failure. Sodium
and wat er retention and vasoconstriction caused by activation o f t he RAAS, sympathetic
nervous system and t he action of vasopressin, lead t o increased ventricu lar preload and
afterload an d elevated wall stress which in tu rn lead t o p roduction of BNP. BNP acts to
p romote natriuresis and vasodilation. At rial st retch leads to t he production o f ANP which
has similar biolog ical properties to BNP. Two strat egies have been employed to t ry an d
improve out comes in heart failure via modulat ion of t his pat hway. The first is t he
m
administration of exogenous natriu retic peptides. Nesiritide, a recombinant human BNP,
se
As
initially showed p romising beneficial effects on haemodynamics and nat riuresis in patients
wit h HF. However, in a large-scale randomised controlled trial, it failed to improve
Dr
An 84-year-old female with a backg round of osteoporosis is g iven an infus ion of
pa midronate. A week later she p resents to her GP compla ining of paraesthesia. On
examination she has hyperreflexia and carpopeda l spasm.
Given the electrolyte abnormality she is likely to have developed, what ECG abnorma lity is
most associated with th is?
Atrioventricular node block
Delta waves
Tented T waves
Long QT
m
se
As
Atrial flutter
Dr
Delta waves CD
Tented T waves CD
Long QT fD
~
Atrial flutter m
Long QT is associated with hypocalcaemia. Bisphosphonate infusions can lead to
hypocalcaemia although it is more common when using large r doses in malignancy
induced hypercalcae mia as oppose to the smaller dose used in osteoporosis.
A QT interval of greater than 0.44 seconds is associated with the development of

ventricular arrhythm ia, syncope and sudden cardiac death.
Long QT causes:
• electrolyte abnorma lities: hypokale mia and hypocalcemia
• drugs: tricyclic antidepressants, antihistam ines, erythromycin, clarithromycin,
am iodarone, haloperidol
• congenital long QT syn dromes: more than 10 d ifferent types recog nised
• myoca rdial infa rction/s ign ificant active myocard ia l ische mia
m
se
• cerebrovascu lar accid ent (subarachnoid haemo rrhage)
As
• hypotherm ia
Dr
A 60-yea r-o ld man is ad mitted following a n acute coronary syndro me. He receives aspirin,
clo pi dogre l, nitrates and morphin e. His 6 -mo nth risk score is hig h and pe rcutaneous
coro nary interventio n is planned. He is th ere fo re g ive n intrave no us tirofiban. What is the
mecha nis m of action o f this drug?
Inhibits the p rod uction o f thromboxa ne A2
Activates a ntithromb in III
Coro na ry vasodilator
Glycop rotein lib/lila receptor antag on ist
m
se
As
Reversible d irect thro mbin inhibito r
Dr
Inhibits the p roduction of thromboxane A2 m
Activates antithrombin III CD
Coronary vasodilator CD
I Glycoprotein lib/lila receptor antago nist GD
m
se
As
Reversible di rect thrombin inhibito r CD
Dr
What is the main mechanism o f action of simvastatin?
Bile acid seq uestrant
Decreases hepatic HDL synthesis
Inhib its lipoprotein lipase
Decreases intrinsic cholestero l synt hesis
m
se
As
Agonists of PPAR-a lpha
Dr
Bile acid sequestrant
Decreases hepatic HDL synthesis
Inhibits lipoprotein lipase
Decreases intrinsic cholesterol synthesis
Agonists of PPAR-alpha
m
Statins inhibit HMG-CoA reductase, t he rate-limiting enzyme in hepatic cholesterol
se
synthesis
As
Dr
Which one of the followin g is the strongest risk factor for developing infective
endocarditis?
Previous episode o f infective endocardit is
Previous rheumatic fever
Permanent central venous access line
m
se
As
Recent denta l surgery
Dr
I
Previous episode o f in fective endocarditis

CD
GD
I
Previous rheumatic fever
Permanent central venous access line

CD
m
Recent d ental surgery m
m
Infective endocarditis - strongest risk factor is previous episode of infective
se
As
endoca rd itis
trrportart '"or me _ess rr.oo1.Jnt
Dr
An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still
getting regular attacks of angina despite taking atenolol l OOmg od. Examination of his
cardiovascular system is unremarkable with a pulse of 72 bpm and a blood pressure of
148/92 mmHg. What is the most appropriate next step in management?
Add verapamil 80mg tds
Add nicorandillOmg bd
Add diltiazem 60mg tds
Add nifedipine MR 30mg od
m
se
As
Add isosorbide mononitrate 30mg bd
Dr
Add ve rapamil 80mg td s CD
Add nicorandil lOmg bd GD
Add d iltiazem 60m g tds m.
I Add nifedipine MR 30mg od CD
.
Add isosorb ide mononitrate 30mg bd ED
If angina is not contro ll ed with a beta -blocker, a ca lcium cha nnel blocke r should be
a dded
NICE gui delines recom mend ad d ing a calciu m channe l blocke r for angina which is not
a deq uately controlled with beta- blocker monotherapy. Verapa mil is contraindicated
whilst ta king a beta-b locke r and diltiazem should be used with caution d ue to the risk of
bra dyca rdia .
m
se
As
The sta rti ng dose of isosorbide mononitrate is l Omg bd.
Dr
Which one o f the fo llowing is least associated with myoca rditis?
Chagas' disea se
Lyme disease
Le ishma nias is
Coxsackie virus
m
se
As
Toxop lasmos is
Dr
Chagas' disease CD
Lyme disease .
CD
Leishmaniasis CD
Coxsackie virus m
m
se
As
Toxoplasmosis tD
Dr
A 41-yea r-old man is ad mitted with left-sided pleu ritic chest pain. He has a dry cough and
reports that the pain is relieved by sitting fo rward. For the past three days he has been
experiencing flu-li ke symptoms. Given the likely diag nosis, what is the most li kely finding
on ECG?
Large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III
Atrial fibrillation
Widesprea d ST elevation
ST segment depression in the anterior leads
m
se
As
Hyperacute T waves
Dr
Large S wave in lead I, a large Q wave in lead lli and an inverted T wave in lead III G:)
Atrial fibrillation
Widespread ST elevation
ST segment depression in the anterior leads

-
~
m
se
As
Hyperacute T waves
Dr
A 30-yea r-old woman presents to the Emergency Department with a one-d ay history o f
central chest pain. The pa in is d escribed as severe, non-radiating and eases on expiration.
Cl inical examination of her card iorespirato ry syste m is un rema rkable othe r than a heart
rate of 96 I min. An ECG shows widespread ST elevatio n in the anterior, inferior and latera l
leads. Bloods show the fo llowing :
Full blood count Normal
Urea and electrolystes Normal
Troponin I 0.8 ng/ml ( < 0.2 ng/ml)
Pulmonary embolism
Acute co rona ry syndrome
Acute pericard itis
m
se
As
Dr
I Pt_::>nary embolism
Acute co rona ry syndrome

-"'lo:oWl'
Acute pericarditis
Arrhythmogenic right ventricular cardiomyopathy

-
~
m
se
As
A modest rise in troponin is seen in around one-third of patients with acut e pericarditis.
Dr
A 58-yea r-old man presents with breathlessness and chest discomfort. He has d iet
controlled dia betes, hypertens ion and hyperlipidaemia. He has a weak rapid, regular pulse
of 160 bp m, blood pressure is 80/SOmmHg, he is cold p eripherally and crepitations are
heard bibasally on auscultation of the chest. An ECG shows a regular broad complex
tachycardia.
What is the b est initia l management of this arrhythmia?
Adenosine
Amiodarone
Diltiazem
m
se
As
Vaga l man oeuvres
Dr
l Adenosine
Am iodarone
Diltiazem
-
~
Electrica l cardiove rs ion
Vaga l man oeuvres

-
""""
This patient presents with a reg ular broad com plex tachyca rdia with a p alpa ble pulse and
the adve rse feature of shock (systo lic blood p ressure <90mmHg), the refo re a
synchronised DC cardiove rsion is ind icated . If this patient had no adverse featu res an
intravenous a mio da rone infusion wou ld b e indicated .
Intravenous adenosine and vagal manoeuvres (e.g carotid massage, Va lsalva manoeu vre)
a re indicated fo r the terminatio n o f a regula r na rrow comp lex tachycardias.
Diltiazem may b e used fo r rate control in atrial fibrillation.
m
se
See: ALS g uidelines, peri a rrest arrhythmias, resuscitatio n council, UK.
As
https:/jwww .res u s.org. u k/resu scitation -g uide Iin es/pe ri-a rrest-a rrhythmias/
Dr
Yo u a re cle rking a 67 -yea r-old man who has been a d mitted with chest pa in. His past
med ical histo ry includ es hypertension, angina and he continues to smoke 20 ci ga rettes I
d ay. Blood tests d one in the Emergency Department show the fo ll owing:
Na• 133 mmol/ 1
K• 3.3 mmol/1
Urea 4.5 mmol/1
Whi ch one of the fo llowin g factors is most likely to exp lain the ab no rmalities seen in the
electro lytes?
Enalap ril therapy
Felod ipine therapy
Bendroflumethiazid e therapy
His smoking histo ry
m
se
As
Sp ironolactone therapy
Dr
Enalapril therapy
Felodipine therapy
Bendroflumethiazide therapy
His smoking history

-
~
Spironolactone therapy
Bendroflumethiazide causes both hyponatraemia and hypokalaemia. Spironolact one is

associated w ith hyperkalaemia. His smokin g wou ld on ly be relevant if he had lung cancer
m
se
cause syndrome of inappropriate ADH secretion - there is no indication of this from the
As
question.
Dr
A 37-yea r-old woman who was investigated for progressive shortness-of-breath is
diagn osed with p rimary pulmonary hypertension and started on bosentan. What is the
mechanis m o f action o f bosentan?
Activato r of soluble guanylate cyclase
Phosphodiesterase type 5 inhibitors
Endotheli n receptor antagonist
Prostanoid
m
se
As
Slow calcium channel blocker
Dr
Activator of soluble guanylate cyclase m
Phosphodiesterase type 5 inhibi tors CD
I Endothelin receptor antagonist CD

Prostanoid CD
Slow calcium channel blocker m
m
se
As
Bosentan - endothelin-1 receptor antagonist
irrportar t "or me _ess ·rroc'i! "lt
Dr
A 47 -yea r-old lady with a fam ily history of sud den cardiac death deve loped palpitations
while vis iti ng a relative in the emergency department. When attached to a cardiac
monitor her heart rate was 164/min and the rhythm strip showed a b road complex
tachycardia. Which antiarrhythm ic may p recipitate ventricular fibrillation (VF) if used in
such circumstances?
Verapamil
Amiodarone
Proca ina mide
m
Lidoca ine
se
As
Flecainide
Dr
I Verapamil GD
Amiodarone GD
Procainamide CD
Lidocaine CD
Flecainide GD
Patients with VT shou ld not be prescribed verapamil

Verapamil should not be used in patients with Ventricular Tachycardia (VT) as they are
class IV antiarrhythmic which only acts on nodal tissue and significantly increase t he risk
of ventricular fibrillation.
Amiodaron e, Procainamide and Lidocaine - All can be used to treat VT.
m
se
As
Flecainide - Has a limit ed use in certain types of VT.
Dr
A 28-year-old intravenous drug use r is brought into the Emergency Department as a
stand-by call following a cardiac arrest. He has b een using methadone for the past 3
months. Unfortunat ely attempts t o resuscit ate him fail. Which one of following underlying
problems is most likely to have caused his su dden death?
Prolonged QT int erval
Complet e heart block
Pulmonary arterial hypertensi on
Cardi omyopathy
m
se
As
Hypokala emia
Dr
Prolonged QT int erval
Pulmonary arterial hypertension
Cardiomyopathy
m
se
As
Methadone is a common cause of QT prolongation
ltrpor:ar: "or me _ess r-x"tart
Dr
A 30-year-old woman is admitted to the Emergency Department following a suspected
peanut a lle rgy. On exam ination she has gross facial and tongue oedema. Her oxygen
saturations are 97% on room a ir, pulse is 96 I min and blood p ressure is 90/62 mmH g .
The pa ramedics have alrea dy gained intravenous access. What is the most appropriate
way to give adrenaline in this situ ation?
Nebu lised
Subdermally
Intramuscularly
Intravenously
m
se
As
Subcutaenously
Dr
Nebulised m
Subdermally m
Intramuscularly GD
Intravenously GD
Subcutaenously
•
m
se
The Resuscitati on Council gu ideli nes only recommend giving adrenaline intramuscu larly,
As
regardless of whether the patient has intravenous access or not.
Dr
A 41-yea r-old ma le is diagnosed with id iopathic pulmonary a rterial hypertension. He
undergoes vasodilator testing with intravenous epoprostenol to which he has a positive
response.
What is the most appropriate first-lin e treatment for his co ndition?
Sildenafil
Treprostin il
Bosentan
m
se
As
Nifedip in e
Dr
Bosentan
Isosorbid e mononitrate
Nifedi pine
Pulmonary a rte rial hyperte nsion patients with pos itive respo nse to vasodi lato r
testi ng s houl d be treated with calcium channel blocke rs
Patients who test positive to vasodi lato r testi ng a re typica lly treated with ca lcium channel
blockers such a s nifed ipine, d iltiaze m and increasing ly am lod ip ine, making o ption 5 the
correct answer.
Sildenafil is a phos phodiesterase inhibitor used in patients who test negative to

va sodilators.
Trep rostinil is a prostacycl in analogue used in patients who do not res pond to acute
va sodilator testing.
Bosentan is an end othe lin recepto r antagonist also used fo r patients with pulmonary
arterial hype rtension who are neg ative during va sodilator testing.
m
se
Isoso rbide mononitrate is used in the treatment of an gina not pulmonary a rte ria l As
hvnP.rtPn~inn.
Dr
A 42-year-old female who presented with progress ive shortness of breath, exertional
chest pain and syncope, is found to have a right pulmonary artery pressure of 32 mmHg.
She has no other medica l conditions and is not on any regular medications. After ruling
out other causes she is diagnosed w ith idiopathic pulmonary arterial hypertension.
What additional investigation will help guide her treatment?
Pulmonary artery wedge pressure
High resolution CT
Ventilati on/perfusion scan
m
Vasodilator testing
se
As
Echocardiogram
Dr
Ventilation/pe rfusion scan
Vasodi lato r testing
Echoca rdiogram
Acute vasodilator testin g s hould be used in patients with p ulmona ry artery

hyperte nsion to d etermine which patient s how a si gnificant fa ll in pu lmona ry
arte ria l p ressure following vasod ilato rs and he lp gu id e treatment
Th is patient has a diagnos is of idiopathic pulmonary artery hypertension with typica l

sympto ms and pulmonary artery pressure g reater than 25 mmHg. In patients with
pu lmonary a rtery hypertension, initia l treatment cho ice should be guided by acute
vasodilator testing. Where the administration of inhaled nitrous oxide or intravenous
epoprostenol resu lts in a s ignificant fall in pulmona ry arterial pressure patients can be
treated with calcium channel blockers. In those, without a fall in pulmonary a rtery
p ressure, alternative treatments inclu ding phosphodiesterase inhibitor, prostacyclin
analogues and endothel in recepto r antagonists, should be considered.
Pulmonary artery wedge pressu re is an estimate of left atrial pressure, measured by

wedging a pu lm onary catheter with an inflated balloon into a branch of the pulmonary
m
se
artery. It is used in diagnosing the severity of left side heart failure, in pa rticular, looking
As
at causes of pulmonary oedema and as such, is not the correct answer.
Dr
A 75-year-old gent leman present s to outpatient clinic. He has recent ly been referred by
his g eneral p ract itioner (GP) after being diagnosed with a left femoral d eep vein
thro mbosis (DVT) 2 weeks ago. In addition to this, he had a met allic aortic valve
replacement (AV R) 3 months ago fo r crit ical aortic stenosis and has been on warfarin
since. As far as you are aware, his int ernational normalised ration (INR) has been rel iably
in the target range fo r this period of time. His other past medical history inclu des a
p revious DVT 30 years ago t hat was unprovoked.
He asks you more about anticoagulation treatment. What is t he most approp riate th ing to
t ell him about t he du ration of therapy requ ired and ta rget INR?
It would be advisable t o switch h im to rivaroxaban as t his is the easier alternative to

warfarin
Lifelong anticoagulation with a target INR of 3.5
Lifelong anticoagulation with a target INR 3.0
Ant icoagulation fo r 6 months with a ta rget I NR o f 3.0
m
se
As
Lifelong anticoagulation with a target INR of 2.5
Dr
It woul d be advisable to switch him to rivaroxaban as this is the easier alternative fD
to warfarin
Lifelong anticoagulation with a target INR of 3.
Lifelong anticoagu lation with a target INR 3.0
Anticoagulation for 6 mo nths with a target INR of 3.0
Lifelong anticoagu lation with a target INR of 2.5

-
......,
There are a number of factors to consider in this case: a metallic aortic valve replacement
requires lifelong anticoagulation but the incidence of recu rrent DVT while on
anticoagu lation is the factor that really determines the correct target INR. NIC Eguidelines
state that for recu rrent DVT (while on anticoagulation) the target INR should be 3.5. The
target INR for a metallic ao rtic valve alone is 3.0, while for a prosthetic valve with history
of systemic embolism (DVT) the target would be 2.5. Therefore the former option is the
m
se
most appro priate in this gentleman given the history of recurrent DVT which in this case
As
has more influence than the presence of metallic AVR.
Dr
Which of the following congenital heart defects may p rog ress to Eisenmenger's
syndrome?
Tetralogy of Fa llot
Coarctation of t he aorta
Pat ent ductus arteriosus
Tricuspid atresia
m
se
As
Transposition of the great arteries
Dr
Tetralogy of Fa llot .
flD
Coa rctation o f the aorta CD
I Patent ductus arteriosus mt

Tricuspid atresia CD
Transpos ition of the great arteries CD
m
se
As
Although patients with tetralogy of Fa llot have, by defin ition, a ventricular septal defect
Dr
they do not go on to deve lop Eisen me nger's syndrome
A 35-yea r-old female presents with a d eep vein thrombos is in the third trimeste r of
pregnancy. Whilst in the Emergency Department she d evelops a left he mipa resis. What
unde rlying cardiac a b norma lity is most like ly to be respons ible?
Primum ASD
Secundum ASD
Pate nt fo ramen ova le
VSD
m
se
As
Pate nt ductus a rteriosus
Dr
Primum ASD
Secundum ASD
Patent foramen ovale
VSD
Patent ductus a rteriosus

-
"""'
m
se
Whilst atria l septa l defects may a llow embo li to pass from the right side of the heart to
As
the leh side, the most common cause is a patent foramen ova le
Dr
A 57 -year-old man p resents t o t he Emergency Department wit h a 15 minute hist ory of
severe cent ral chest pain radiating to his left arm. ECG shows T-wave inversion in lead s I,
VS and V6. Which coronary artery is most likely to be affect ed?
Left circumflex
Posterio r inte rventricular
Left main stem
Right coronary
m
se
As
Dr
I Left circum flex
Posterior interventricular
~eft main stem

Right coronary
Ischaemic changes in leads L aVl +1- VS-6 - left circumflex

lrrporrar: "or me _ess rr x -tart
m
se
This is most typical of a left circumflex occlusion although may rarely be seen if the left
As
anterior descending is affected
Dr
The use o f beta-b lockers in treating hypertension has declined sharply in the past five
years. Which one of the following best describes the reasons why this has occu rred?
Less li ke ly to p reve nt stroke + potential im pairment of g lucose to le rance
Less li ke ly to p revent myoca rdial infarctions + potential impairment of glucose

tolerance
High rate o f interactions with other common ly prescrib ed med ications (e.g .
Calcium channe l blocke rs)
Increased incidence of reported adve rse effects
m
se
As
Increased incidence o f chronic obstructive pulmonary disease
Dr
The use o f beta-b lockers in treating hypertension has declined sharply in the past five
years. Which one of the following best describes the reasons why this has occurred?
Less likely to prevent stroke + potential im pairment of g lucose to le rance
Less li kely to p revent myoca rdial infarctions + potential impairment of glucose

tolerance
High rate o f inte ractions with other common ly prescribed med ications (e.g .
Calcium channel blocke rs)
Increased incid ence of reported adve rse effects
Increased incidence of chronic obstructive pulmonary disease
m
se
This was demonstrated in the Anglo-Scandinavian Ca rd iac Outco mes Trial-Blood Pressure
As
Lowering Arm (ASCOT-BPLA).
Dr
A 64-year-old man is having a dual chamber pacemaker inserted. The vent ricu lar lead is
to be inserted via t he co ronary sinus. Where does the coronary sinus drain int o?
Right atrium
Left ventricle
Right ventricle
Inferior vena cava
m
se
As
Left atrium
Dr
I Rig ht atrium
left ventricle
CD
m
Right ventricle
I Inferior vena cava
left atrium
CD
CD
m
se
As
Dr
A 66-year-old lady presented to the emergency department with a 5-minute history of
right upper limb weakness which spontaneously resolved. She had a past medical history
o f hypertension, for wh ich she is t aking amlodipine l Omg once daily. She is not diabetic.
She currently smokes 10 cigarettes a day. Her examination was remarkable for an
irregularly irregular heartbeat. Electrocardiogram confirms a diagnosis o f atrial fibrillation.
CT head showed no evidence of intracra nial haemorrha ge. She is o therwise well with a
normal renal function. What is the most appropriate next step?
Refer to anti coagu lation clinic
Start 300mg aspiri n and discharge home
Non-urgent referral to the TIA clinic
Commence th e patient on anticoagu lation
m
se
As
Refer the patient to psychiatry
Dr
Refer to anti coagu lation clinic
Start 300mg aspiri n and discharge home

-
~
Non-urgent referral to the TIA clinic
Commence the patient on anticoagulation

-
~
Refer the patient to psychiatry
This lady has had a transient ischaemic attack (TIA) on a background of atrial f ibrillation.
In view of her ABCD2 score, she w ill require referral to the TIA clinic. The p resence of AF is
independently considered to place t he patient in the high-risk category, and will,
therefore necessitate urgent referral to the TIA clinic.
Her CHADS-VASC score w ill necessitate anti-coagulation. Given the lack of effica cy of
aspirin in AF, it is important t hat this lady is commenced on anticoagulation as a priority
to reduce t he risk of further stroke in t he interim. The CT head has ruled out int ra-cranial
haemorrhage, and t herefore this TIA is likely a cardio -embolic p henomenon for which
m
se
anticoagulation is more efficacious than aspirin. Clearly, a psychiatric referral is
As
inap propriate.
Dr
A 33-year-old male w ho is an ex-N drug user on methadone collapses suddenly whilst
out shopping. A paramedic crew are quickly on the scene. The patient remains conscious
but w hilst attached t o the defibrillator multi ple self-t erminating runs of polymorphic
ventricular tachycard ia are seen. He is transferred urgently to the emergen cy department
where torsades de points is con firmed . He is successfully treat ed with an infusion of IV
ma gnesium. An ECG post i nfusion shows a QTc of 590ms and he tells you that he is
cu rrently on day five of a seven day course o f erythro mycin for a lower respiratory tract
inf ection. You susp ect drug induced QTc prolongation secondary t o a co mbination of
methadone and erythro mycin predisposing him to to rsa des de points. Which cardiac ion
channel is most likely to b e affected?
Sodium cha nnel
Magnesium chan nel
Calcium cha nnel
Po ta ssium channel
m
se
As
Chloride channel
Dr
Sodium channe l GD
Magnesium channel fD
Calcium channel «D
r Potassium channel CD
Chloride channel fD
Several med ications, including drugs p rescribed for non -ca rdiac indicatio ns, have been
associated with a prolongation of the QT interval on th e surfa ce ECG. Under certain
circumsta nces, this cli nica l manifestation may reflect an increased risk for patients
presentin g with a polymorphi c ventricu lar tachycardia known as to rsade de pointes.
Drugs th at pro long th e QT interval belong to seve ral pha rma cologica l classes, but most of
them share one pharmacologi cal effect: they lengthen ca rd iac repo la risation mostly by
blocking specific cardiac potassium channels. The potent blocki ng of cardiac potassium
cha nnels and excessive lengthening o f card iac re-pola risation favou r the development of
membrane oscillations (ea rly after-depolarisation) due to calcium/ sod ium re-entry. Early
a fter-depolarisation, when propagated, may trigger torsade de pointes. In addition to
excessive lengthenin g of the QT interval, other p redisposing facto rs to drug-ind uced
m
se
torsade de po intes include bradyca rdia, electrolyte imbalance, female sex and genetic
As
polymorphisms in various ion channel constituents. Dr
Which one of the following is the most common underlying mechanism caus ing
prolongation of the QT segment?
Opening of calcium channels
Blockage o f sodium channels
Opening of sodium chan nels
Blockage o f potassium channels
m
se
As
Opening of potassium channels
Dr
Blocka ge of sodium channels
Opening of sodium channels
Blocka ge of potassium channels
Opening of potassium cha nnels
Long QT syndrome - usually due t o loss-of-function/blockage of K+ channels

In long QT syndrome QT prolongation is due to overload of myocardial cells with
m
se
positively charged ions during ventricu lar repolarisation. Around 90 -95% of inherit ed
As
causes are due to defects in potassium cha nnels
Dr
A 45-yea r-old man p resents with palpitations that began around 40 minutes ago. Other
than having a stressful day at work there app ears to have been no obvious trigger. He
d enies any chest pain or dyspnoea. An ECG shows a regular tachyca rdia o f 180 bp m with
a QRS duration of O. lOs. Blood pressure is 106/70 mmHg and oxygen saturations are 98%
on room air. You ask hi m to perform the Valsava manoeuvre but this has no effect on the
rhythm. What is the most a pp ropriate next cou rse of action?
Intravenous labetalo l
Intravenous adenosine
Intravenous amiodarone
m
se
As
Re-attempt Va lsava manoeuvre in 5 minutes
Dr
Electrical cardiove rs ion
Intravenous labetalo l
Intravenous amioda rone
Re-attempt Valsava manoeuvre in 5 minutes
This patient has a supraventricu la r tachycard ia with no adve rse signs (e .g. shock,
m
se
myoca rdia l ischaem ia etc). If vagal manoeuvres fail intravenous adenosine should be
As
given.
Dr
Which one of the followin g statements regard ing Brugada syndrome is correct?
Usually inherited as an autosomal recessive disease
Is associated with left bund le branch block
Most common presentation is dilated cardiomyopathy
Management is with beta-blockers
m
se
As
Mo re common in Asians
Dr
Usually inherited as an autosomal recessive disease CD
Is associated with left bundle branch block GD
Most common presentati on is dilated cardiomyopathy
Management is with beta- blockers

•
CD
.,
m
I
se
As
More com mon in As ians
Dr
A wo man who is 34 weeks pregnant is admitted to t he obstetric ward. She has been
monitored for the past few weeks due to pregnancy-induced hypertension but has now
developed proteinuria. Her blood pressu re is 162/ 94 mmHg. Which one of the following
antihypertensives is it most appropriate to commence?
Nifedip ine
Atenolol
Labeta lol
Losartan
m
se
As
Methyld opa
Dr
A woman who is 34 weeks pregnant is adm itted to the obstetric wa rd . She has been
monitored for the past few weeks due to pregnancy-induced hypertension but has now
developed protein uria. Her blood pressure is 162/94 mmHg . Which one o f the following
antihypertensives is it most appropriate to commence?
Nifed ip ine .
(D
Atenolo l
•
I Labetalol ED.
Losa rtan
Methyldopa
•
ED.
m
se
As
Labetalol is first- line fo r pregnancy-i nduced hypertension
Dr
A 62-year-old male is admitted with right sided hemiplegia. An MRI confirms a diagnosis
of a leh sided partial anterior circulating stroke. He is treated with high dose aspirin for 14
days. He is then started on clopidogrel wh ich he was unfortunately intolerant of. You
therefore start him on dual aspirin and dipyridamo le.
What is the mecha nism of action of dipyridamole?
Inhibition of production of factors II, VII, IX and X
Increases the effects of adenosine
Cyclooxygenase inhibitor
m
se
As
Direct thrombin inhibitors
Dr
Increases the effects of adenosine
Cyclooxygenase inhibitor
Glycop rotein lib/lila inhib itor
Direct thromb in inhibitors

-
~
Dipyrid amo le increases the effects o f adenos ine

Dipyrid amole increases the levels adenosine a nd inhib its the phosphodiesterase enzymes
that normally break d own cAMP. Exogenous use o f adenos ine (e.g. treatment of
supraventricular tachyca rd ia) is contra indicated in patients on d ipyrida mole fo r this
reason.
Clopidog rel is an ADP receptor antagon ist.
Aspirin is a cycle-oxygenase inhibitor.
Dab igatran and biva li rud in are direct thrombin inh ibito rs.
m
se
As
Tirofiban a nd a bciximab are glycop rotein lib/ Ilia inhibitors. Dr
Mr Brown is a 62 -year-old man w it h colon cancer. He is undergoing adjuvant
chemotherapy, however in the past six months ha s su ffered four d eep vein t hrombotic
(DVT) events, d espit e being optimally anti-co agulated wit h t he maximum d ose of
d ab ig atran. On one occasion he suffered a DVT during treatment with d alteparin (a low
molecular weight heparin). He has been admitt ed with sympt oms of another DVT.
How shou ld his DVT be t reated?
Add apixaban to h is prescription
Initiate end o f life drugs and prepa re the family
Increase t he dose o f dabigatran off- licence
Prescribe Thrombo -Embolic Det errent (TED) stocking s
m
se
As
Insert an inferior vena caval f ilter
Dr
Increase t he d ose o f dabig atran off-licence
Prescri be Thrombo -Embolic Det errent (TED) stocking s

-
Insert an inferior vena caval f ilter
Patients with recurrent venous th romboembolic disease may be considered for an

inferior vena cava f ilter
Important for me Less ·mpc rte;nt
This patient has cancer and su ffered multiple DVTs in a short space o f time, d espite being
fully anti -coagulated. NICE have produced guidelines on su ch patients:
"Consider inferior vena caval filters for patient s w ith recurrent proximal DVT or PE despite
adequate anticoagulati on t reatment only after cons idering alternative t reatment s such as:
• increasing target INR to 3-4 for long t erm high- intensity oral anticoagulant t herapy
or
• switching t reatment to LMWH.'
[NICE (2015) Venous thrombo embolic disea ses: diagnosis, manag ement and
thrombop hilia testing. CG144]
Add apixaban to h is prescription -This is not t he most app ro priate answer. This patient
m
se
has already been tra iled on a LMWH. An inferior ven a caval filter is t he most appropriate As
next step.
Dr
A 60-year-old man is transferred from the loca l psychiatric unit to the Emergency
Department. Throughout the d ay he has compla ined of palpitations and feeling light-
headed. The psychiatry consu ltant noted he was tachycardic and requested a transfer. An
ECG taken following ad mission shows a b road complex tachyca rdia consistent with
torsardes de pointes, rate 120/ min. His b lood pressu re is 122/80 mmHg an d there are no
signs of heart failu re . What is the most a pp rop riate management?
Intravenous naloxone
Intravenous magnesium sulphate
DC cardi overs ion
Intravenous am ioda rone
m
se
As
Intravenous vera pamil
Dr
Intravenous naloxone m
Intravenous magnesium sulphate GD
DC card ioversion m
Intravenous amiodarone flD
m
se
As
m
Dr
A 13-year-old male immigrant from India presents to his primary care physician with a
gradually worsening shortness of breath wo rse on physical exertion as well as widespread
joint pain. His past medical history includes a severe throat infection which was untreated.
His vaccinatio n record is complete. On physical examinatio n, there is a high-pitch
holosystolic murmur loudest at the apex with radiation to the axilla.
Hb 135 g/ 1
Platelet s 150 * 109/1
WBC 9. 5 * 109/ 1
Anti -streptolysin 0 titres >200units/ml
What is the most likely histological finding in his heart?
Aschoff bodies
Council man bodies
Mallory bodies
Cali- Exner bodies
m
se
Schiller-Duval bodies
As
Dr
I Aschoff bo dies
Council ma n bod ies

f.D
m
Ma llory b odies G'D
Ca li- Exner bodies D
Schille r- Duva l bo dies fD
Aschoff bodies are granulomatous nodu les found in rheumatic heart feve r
This p atient has rheumatic hea rt disease. Mitral valve is the most common va lve to be
affected . ASO titre indicates exposure to g ro up A stre ptococcus bacte ria.
Aschoff bo dies (granuloma with g iant cel ls) and Anitschkow cells (en larged macro phages
with ovo id, wavy, rod -like nu cleus) are seen in rheu matic heart disease.
Other answers:
• Council man bod ies - > hepatitis C, ye llow fever
• Mallory bo dies-> alco ho lis m (hepatocytes)
m
se
• Cali- Exner bodies- > granulosa cell tumour
• Schi ller-Du val bo dies-> yo lk-sac tumour As
Dr
Which one of the following co mplications is least associated with ventricular septal
defects?
Right heart failu re
Aortic regu rgitation
Eisenmenger's com plex
Infective endocarditis
m
se
As
Atrial fibrillation
Dr
Which one of the following complications is least associated with ventricular septal
defects?
Right heart fa ilure
I Eisenmenger's complex
-
~
Atrial fibrillation
m
se
As
Atrial fibrillation is associated more with atrial septal defects
Dr
A 31 yea r-old s moker is seen in the Emergency Department with a 3-day history of
worsen ing, left-sid ed p leuritic chest pa in, associated with worsening shortness of breath.
He has no past medi ca l history. His observations are: blood pressu re 78/46 mmH g,
saturations 81% on 8l/min oxygen via face mask, heart rate 147 bp m and te mperatu re
37.3 d egrees Celsius. He appears clam my, pale and unwell.
On exam ination, lung auscu ltation is normal. An ECG shows sinus tachyca rdia with right
heart stra in. He has not respon ded to ad equate fluid resuscitation. After applying high-
flow oxygen, what is the best course of action?
Urgent computed to mography pulmonary a ngiogram (CTPA)
Intravenous flui d resuscitation and b road -spectru m antibiotics
Intravenous alteplase
Urgent transthoraci c echocardiography
m
se
As
Adm ission for treatment-dose low molecular weight heparin (LWM H)
Dr
Urgent computed tomo graphy p ulmonary a ngiogram (CTPA)
Intrave nous flui d resuscita tion a nd b road -sp ectrum antibiotics
I Intravenous alteplase
Urgent transthoraci c echo ca rdiography
Adm ission for treatment-dose low molecular we ight heparin (LWM H)
Massive PE + hypotension - thrombolyse

This ma n has a history consistent with pulmona ry embo lism (PE), with s ig nifica nt
haemodynam ic instability as evid enced by his hypotension and tachyca rd ia. Although
both a transtho raci c echo ca rdiog ra m and CTPA would b e useful investigations, treatment
should not be delayed in these circumstances. The British Tho racic Society g ui de lines fo r
m
se
treatment of PE state that thro mbolys is 'may b e instituted on cl in ical g rounds alone if
As
ca rdiac a rrest is imminent' a s in this case.
Dr
A 34-year-old man is seen in the cardiology clinic. He has been referred by his GP with a
history of increasing dyspnoea and exercise-related syncope. His father died suddenly
when at the age o f 42-years-old. An ECG attached to the a dmission letter s hows left
ventricular hypertrophy with widespread T wave inversion. Given the likely diagn osis, what
is the most appropriate next investigation?
Card iac ang iogram
Transthoracic echo
Transoesophageal echo
Exercise ECG
m
se
As
24-hou r ECG
Dr
Cardiac angiogram m
I Transthoracic echo GD
Transoesophageal echo ED
Exercise ECG CD
~
24-hour ECG m
The likely diagnosis is hypertrophic obstructive cardiomyopathy which should be
investigated w ith a transthoracic echocardiogram, as recommended by th e 2011
m
se
American College of Cardiology Foundation (ACCF) and the American Heart Association
As
(AHA) guidelines.
Dr
An 82-yea r-old lady is b rought into the emergency department by the paramed ics. She
has been off her feet for the last week in her ca re home and is now unresponsive. When
she arrives her temperatu re is recorded and found to be 28°C.
Given her presentation what changes wou ld you expect to see on an ECG?
Q-waves
Delta waves
Saddle ST -elevation
Sinus tachycardia
m
se
As
J-waves
Dr
Q-waves fD
Delta waves CD
I Saddle ST -elevation .
(D
Sinus tachyca rdia

•
I J-waves GD
J-waves are associated with hypothermia

This question is asking about an 82-year-old lady presenting with hypothermia and
asking for ECG changes you would expect to see. There fore the correct a nswer is J-waves.
These a re small bumps at the end of the QRS complex.
• Q-waves a re associated with a previous myoca rd ia l infarction

• Delta waves are associated with Wolff-Parkinson-White Synd rome
• Saddle ST e levation is associated with p erica rd itis
m
se
• Sinus tachycardia would not b e expected as patients with hypothermia a re often
As
b radyca rd ic
Dr
You review a 62-year-old man who has recently been discharged fro m hospital in
Hungary fo llowing a myocardial infarction. He brings a copy o f an echoca rdiogram report
which shows his left ventricular ejection fractio n is 38%. On exam ination his pulse is 78 I
min and regula r, blood pressure is 124 I 72 mmHg and his chest is clear. His current
med icatio ns include aspi rin, s imvastatin and lisi nopril. What is the most app ropriate next
step in terms of his medication?
Add atenolol
Add furosemide
Add b isoprolol
Add isosorb ide mononitrate
m
se
As
Make no changes
Dr
Add atenolol
Add furosemide
Add bisoprolol
t dd isosorbide mononitrate
Make no changes
Both carved ilol and bisoprolol have been shown to reduce mortality in stable heart failure.
The other beta-blockers have no evidence base to support their use.
m
se
NICE recommend that all heart failure patients should take both an ACE- inhibitor and a
As
beta-blocker.
Dr
A 37 -year-old wo man presents fo r review. She is 26 weeks pregnant and has had no
problems with her pregnancy to dat e. Blood pressure is 144/ 92 mmHg, a rise from her
booking rea ding of 110/80 mmHg. Urine dipstick reveals the following:
Protein negative
Leucocytes negative
Blood negative
What is the most appropriate description o f her con dition?
Moderate pre-eclampsia
Mild pre-eclampsia
Gestational hypertension
Normal physiological change in blood pressu re
m
se
As
Dr
Mod erate pre-eclampsia fD
Mjld pre-eclampsia m
Gestational hypertension GD
I
Normal physiologi ca l change in blood pressure «ED
m
se
As
Pre-existi ng hypertension CD
Dr
A patient is a dmitted with central chest pa in and a diagnos is of no n-ST elevation
myoca rdial infarction is mad e. Aspirin an d fonda parinux are given. What is the mechanism
o f action of fo ndapa rinux?
Reversible d irect thrombin inhibito r
Glycoprotein lib/lila receptor antago nist
Inhibits antithrombin III
Inhibits ADP b inding to its platelet receptor
m
se
As
Activates antithrombin III
Dr
Reversible direct thrombin inhibitor
Glycoprotein lib/lila receptor antago nist
Activates antithrombin Ill
m
se
As
Fonda parinux works in a similar way to low-molecular weight hepa rin.
Dr
Which of the fo llowing is least associated with a poor p rognosis in hypertrophic
cardiomyopathy?
Non -susta ined ve ntricula r tachycard ia on 24 or 48-hour Ho lter monitoring
Reduced left ventricu lar outflow g rad ient
Family history of sudd en d eath
Syncope
m
se
As
Early a ge at p resentation
Dr
Non-sustained ventricular ta chyca rdia on 24 or 48 -hour Holter monitoring f1D
~duced left ventricular outflow gradient CD
Family history of sudden death CD
Syncope CD
Early age at presentation cr!D
m
se
As
There is no recognised prognostic association with left ventricular outflow gradient
Dr
A 65-year-old female with a history of ch ron ic obstructive pulmonary disease (COPD) is
reviewed in the Emergency Department. She has presented with a sudden worseni ng of
her dyspnoea associated w ith haemoptysis. What is the most suitable initial imaging
investigation to exclude a pulmonary embolism?
Echocardiogram
m
se
As
MRI tho rax
Dr
Ventilati on -perfusion scan
Echoc.ardiogram
MRI thorax
-
~
Pulmonary embolism - CTPA is first-line investigation

m
se
It is still common in UK hospit als, despit e guidelines, for a ventilation-p erfusion scan t o be
As
done first -l ine
Dr
Which one of the following is not a risk factor for the development of pre-eclampsia?
Previous history of pre-eclampsia
Age of 42 years
Multiple pregnancy
m
se
As
Multiparity
Dr
Previous history of pre -eclampsia
I Body mass index of 34 kg/mA2
Age of 42 years
Multiple pregnancy
Multiparity
-
~
m
se
No previous pregnancies is a risk factor for pre-eclampsia. Questions on maternal health
As
during pregnancy are now common in the MRCP
Dr
A patient who takes bendroflumethiazide is noted to have a pota ssium of 3.1 mmol/1.
What is the main mechanism causing hypokala em ia in patients taking
Decreased flow rate in the neph ron resu lting in a decreased potass ium gradient
Increased sodium reaching the collecting ducts
Inhibition o f ren in -angiotensin-a ldosterone system secon da ry to hypovo laem ia
Decreased sodium reaching the d ista l convoluted tubule
m
se
As
Open ing o f potassium channe l in p roximal convo luted tubule
Dr
Decreased flow rate in the nep hron resultin g in a decreased potassiu m g ra dient CD
Increased sodium reaching the co llecting ducts eD
Inhib ition o f renin -angiotensin-a ldosterone system seconda ry to hypovolaem ia 8
Decreased sod ium reaching the d istal convoluted tubule fllD

Opening of potassium channel in p roximal convoluted tu bule QD
Bendroflumethiazid e - inhibits sodium rea bso rption by b locking the Na • -CI-

sympo rte r at the beginni ng of the dista l convo luted tubule
Important for me l ess 'moc rtc.nt
Increased delivery of sodium to the collecting ducts causes the sod ium-potassium
m
se
exchanger to re lease more potassiu m into the urine. Another cause is activation of the
As
renin-angiotensin-aldosterone system secondary to hypovolaem ia
Dr
A 54-yea r-old man is admitted with suspected pu lmonary embolism. He has no past
med ical history of note. Blood pressu re is 120/ 80 mmHg with a pu lse of 90/min. The chest
x- ray is norma l. Following treatment with low-molecular weight heparin, what is the most
appropriate initial lung imag ing investigation to perfo rm?
Pu lmonary angiography
Echocardiogram
MRI tho rax
m
se
As
Computed tomog raph ic p ulmonary an giog raphy
Dr
Echocardiogram
MRI tho rax
Ventilation -perfusion scan
Pulmonary embolism - CTPA is first-line investigation

This is a difficu lt question to answer as both com puted t omographic pulmonary

angiography (CTPA) and ventilati on -perfusion scanning are commonly used in UK clinical
pract ice. The 2003 British Thoracic Society (BTS) guidelines, however, recommended that
m
se
CTPA is now used as the initial lung imaging modality of choice. Pulmonary angiography
As
is o f cou rse the 'gold standard' but this is not w hat the question asks for
Dr
A 59-yea r-old female is admitted t o the Emergency Department with a 30 minut e history
o f central chest pain radiating to her left arm. An ECG shows ST elevation in leads II, III,
aVF. Which coronary artery is most likely to be affected?
Right coronary
Left main stem
Left circumf lex
m
se
As
Dr
Right coronary
Left main stem
Left circumflex
-
""""
m
se
Inferior MI - right co ronary artery lesion
As
Dr
Which one of the following treatments have not been shown t o improve mortality in
patients with ch ronic heart failure?
Beta- blockers
Spironolactone
Furosemide
m
Nitrates and hydralazine
se
As
Enalapril
Dr
Beta- blockers
Spironolactone
-
. .wr
Furosemide
Nitrates and hydralazine
Enalapril
m
se
Whil st useful in managing t he symptoms of acut e and chronic heart fa ilu re fu rosemide
As
o ffers no p rognost ic benefits.
Dr
What is t he mechanism o f actio n of biva lirudin in acute coronary synd rome?
Activates a ntith rom bin ni
Inhibits the p rod uctio n of thromboxane A2
Coro na ry vasodilato r
Reversible d irect thrombin inhibito r
m
se
As
Glycop rotein lib/lila receptor antag on ist
Dr
Dr
As
se
m
A 54-yea r-old ma n is diagnosed with type 2 diabetes mell itus. A decis ion is made to start
simvastatin 40mg. What is the idea l time to advise patients to take this medication?
After b reakfast
Last thi ng in the even ing
After even ing meal
Just before evening meal
m
se
As
First thing in the morning
Dr
After b rea kfast
Last th ing in the eve ning

•
f.D
After evening mea l fD
~st before evening meal CD
First thing in the morning
•
m
se
As
Ta king simvastatin at night improves efficacy
Dr
An elderly patient with a history of atrial fibrillation develops torsades de pointes shortly
after being started on sotalol. What effect does sot alol have on the cardiac cell membrane
to make this more likely?
Blockage of sodium channels
Opening of potassium channels
Blockage of potassium channels
m
se
As
Opening of sodium channels
Dr
Blockage of sodium channels f!D
Opening of potassium channels f!D
I Blocka ge of potassium channels (D
Opening of calcium channels CD
Opening of sodium channels CD
Long QT syndrome - usually due t o loss-of-function/blockage o f K+ channels

Important for me l ess :mpcrtant
m
se
This patient is likely to have developed t orsades de pointes secondary to a prolonged QT
As
interval.
Dr
A 70-year-old female presents to the Emergency Department (ED) with fever, tachycardia
and hypotension. She has no significant past med ical history. On examination, there is a
loud systolic murmur in the mitral region which was not documented in an attendance to
the ED the previous month. She reports previous rash and lip swelli ng with penicillin.
Which of the following empirical antibiotic thera pies is the most appropriate?
Intravenous ceftriaxone + gentamicin
Intravenous teicoplanin + streptomycin
Intravenous vancomycin + gentamicin
Intravenous teicoplanin + gentamicin + rifampicin
m
se
As
Intravenous vancomycin + meropenem
Dr
Intravenous ceftriaxone + gentam icin
Intravenous teico pla nin + streptomycin
I Intravenous vancomycin + gentamicin
Intravenous teico pla nin + gentamicin + rifampici n
Intravenous vancomycin + meropenem
This patient has presented with severe sepsis as evid enced by the fever, tachyca rdia, and
hypotension. The q uestion states that she has no s ig nificant past medical history, so it can
be assumed that she has native va lves and is not at increased risk of pseudo mona l o r
enterococcal infections.
Cu rrent gu idelines suggest that presenting with severe sepsis increases the probability
that the causative o rgan ism isS. aureus, and therefo re the treatment regimen needs to
m
se
cover MRSA. The recommended treatment fo r this is vancomycin + low-dose gentam icin.
As
This is of course safe to use in pen icilli n allergy.
Dr
Which one of the followin g statements regard ing catecho lam inergic po lymorphic
ventricular tachycard ia (CPVD is correct?
Resting ECG typically shows T wave inversion in leads Vl-V3
Beta - blockers are contrai ndicated in patients with CPVT
Is associated with cleh pa late
In the majority of cases is due to a defect in the potassium channel
m
se
As
Sym ptoms generally d eve lop before the age of 20 years
Dr
Resting ECG typically shows T wave inversion in leads Vl-V3 mt
Beta - blockers a re contra indicated in patients with CPVT flD
Is associated with cleh pa late fD
In the majority of cases is due to a defect in the potassium channel f.D
m
se
As
Symptoms generally develop befo re the age o f 20 years ED
Dr
A 57 -year-old man with NYHA class III heart failure is currently treated with fu rosemide
and ram ipril. What is the most suitable beta -blocker to add to improve his long-term
prognosis?
Acebutolol
Labetalol
Bisoprolol
Sotalo l
m
se
As
Esmolol
Dr
Acebutolol
Labetalol
•m
I Bisopro lo l .
GD
Sotalo l m
Esmolol
•
m
se
Both carvedilol and b isoprolol have been shown to reduce mortality in stable heart fail ure.
As
The other beta-blockers have no evidence base to support their use
Dr
A young man suddenly collapses out side his home. He is found to be in cardiac arrest and
passes away in hospital. He is diagnosed posthumously w ith arrhythmogenic right
ventricular card iomyopathy.
What changes would th is condition cause in the heart?
Myocardium rep laced by fatty and fibrofatty tissue
Asymmetrical thickening of the ventricle and septum
Hypertrophy of the left ventricle
Transient apical ballooning o f the myocardium
m
se
As
Poor diastolic function but normal systolic function
Dr
I Myocardium replaced by fatty and fibrofatty tissue
Asymmetrical th icke ning of the ventricle and se ptum
Hypertrophy of the left ve ntricle
~nsient apica l ballooning o f the myo ca rdium

Poor d iasto lic function but no rmal systolic funct io n
Arrhythmogen ic right ventricula r cardiomyopathy is characterised by right

ventricu la r myoca rdium replaced by fatty and fibrofatty tissue
Asymmetrical thicke ni ng of the se ptum is associated with hype rtro phic obstructive
ca rdiomyopathy, the lea ding cause of sud den cardia c d eath
Left ve ntricu la r hype rtrop hy has a number of ca uses which inclu de hype rtension, ao rtic
va lve ste nosis, hype rtrophic ca rdiomyo pathy and athletic tra in ing .
Arrhythmoge nic right ventricula r ca rdiomyopathy in late sta ges ca n cause d ilatio n of the
ventricles, howeve r, this would not b e tra nsie nt. A transient ballooning wou ld p oint to a
diagn osis of Ta kotsubo ca rd io myopathy which is trigg e red by acute stress.
m
se
As
Poo r d iasto lic function but norma l systolic function is a finding in restrictive
Dr
ca rdiomyopathy
A 34-year-old woman has emergency su rgery after a rupt u red ect opic pregnancy. She is
recovering in ITU w hen her blood pressure su ddenly rises to 210/ 170 mmHg and her
heart rate to 120 b pm. Wh ich of her regular medications is most likely to have caused the
hypertensive crisis?
Clom ifene
Esom ep razole
Phenelzine
Sertraline
m
se
As
Levonorgest rel
Dr
Clomifene flD
Esomeprazole a
Phenelzine ED
Sertraline eD
Levonorgestrel fD
Phenelzine is a monoamine oxid ase inhibitor (MAO!), a class of drugs ra rely used now in
m
part due to the risk o f hypertensive crises. In emergency settings like this scenario, t here is
se
a substantial elevation of that risk due to interactions w it h vasopressors used to t reat
As
hypotension.
Dr
A 25-year-old female is found to have a leh hemipa resis following a deep vein
thrombosis. An ECG shows RBBB with right axis deviation. What is th e most likely
underlying diag nosis?
Ostium prim um atrial septal defect
Ostium secundum atrial septal defect
m
se
As
Tetralogy of Fallot
Dr
Ostium p rim um atrial septa l defect
Ostium secundum atrial septal defect
m
se
The ostium secundu m in this patient has allowed passage o f a n embolus from the right-
As
sided circulation to the left causing a stroke
Dr
A 55-year-old man who has a hist ory of ischaemic heart disease presents with myalgia.
His long-term medications include aspirin, simvastatin and atenolol. Given his statin use a
creatine kinase is measured and reported as follows:
Creatine kinase 1,420 u/1 ( < 190 u/1)
His problems seem t o have followed the prescription of a new medication. Which one o f
the following is most likely t o have caused the elevation in creatine kinase?
Rifa mpicin
Felodipine
Clarithromyci n
Ciprofloxacin
m
se
As
Amitriptyline
Dr
Rifa mpicin «D
Felodipine
•
I Clarithromycin ED
Ciprofloxacin ED
Am itriptyline .
(D
Statins + erythromycin/clarithromycin - an important and common interaction

This patient has developed statin -i nduced myopathy secondary to clarithromycin, wh ich is
a known inhibitor of the CYP3A4 enzyme system.
Whilst ciprofloxacin is a 'P450 inhibitor' it affects a different enzyme system and does not
m
se
produce a clin ically significant interactio n. Also, in the BNF the int eraction is not
As
considered significant, unlike the interaction with macrolides.
Dr
A 72-yea r-o ld man who has a history of ischaem ic hea rt d isease and leh ventricu la r
dysfunctio n is ad mitted with dyspnoea. He has not ta ken his d iuretics fo r three d ays as he
ra n out. On exam inatio n yo u note b ilatera l crackles to th e midzones and a respiratory rate
o f 30/ min. Which othe r clin ical finding is most sp ecific with this presentation?
Bisfe rie ns p ulse
Wid e pulse pressu re
Warm periphe ries
Pu lsus a lte rna ns
m
se
As
Fo urth heart sound (S4)
Dr
Bisferiens pu lse CD
I Wide pulse pressure m.
Warm peripheries m
I Pulsus alternans
Fourth heart sound (54)

CD
E)
m
se
As
Pulsus alternans -seen in left ventricular failure
Dr
A 71-year-old man with a four-month hist ory of exertional chest pain is reviewed. The
pain typ ically co mes on when he is walking up a hill, is centrally located and radiates to
the leh arm. It then settles wit h rest aher about 2-3 minutes. Clinical examination and a
resting 12 lea d ECG are normal. Following NICE guid elines, w hat is the most app ropriate
diagnostic strat egy?
CT co ronary angiography
Manag e as angina, no further diagnostic t ests required
Exercise tolerance t est
M PS w ith SPECT
m
se
As
Invasive coronary angiography
Dr
I CT coronary ang iography
Manage as angina, no further diagnostic tests required
Exercise tolerance test
~S with SPECT
m
se
As
Invasive coronary angiogra phy
Dr
A 66-year-old man presents with shortness -of-breath on exertion. On examination his
blood pressure is 128/ 76 mmHg, pulse 78 I min and regular. Auscu ltation of his chest
reveals an early diast olic murmur. Which one of the following conditions is most
associated w ith this kind of murmur?
Mitral stenosis
Ao rtic regurgitation
m
se
As
Mitral regurgit ation
Dr
Mitral stenosis
Mitral regu rgitation
m
Aortic regurgitation - ea rly d iastolic mu rmur, high-p itched and 'blowing' in
se
cha racte r
As
Dr
You a re seeing John, a 50-yea r-old man who is co mpla ining of central constricting chest
pa in. Walking up the sta irs triggers the pa in. The pain goes away with resting. He
experiences some shortness of b reath but d en ies any syncope or palpitations. He suffers
from hypertension and d iabetes. He takes ve rapam il for migra ine p rophylaxis. His other
med ications include GTN spray, aspirin, atorvastatin, Ram ipril and metformin. On
exam ination, his rhythm seems to be irregu lar. There is no murmu r on auscu ltation of the
heart. There is no tenderness on chest wa ll palpation.
He is asking fo r a medication that would be helpfu l to prevent the chest pa in from

occurring . What is the most appropriate treatment?
Bisoprolol
Digoxin
Metoprolol
Nico rand il
m
se
As
Ibu profen
Dr
Bisoprolol ED
Digoxin .
(D
Metoprolol .
(D
Nicorandil CD
Ibupro fen CD
Beta- blockers e.g. bisoprolol should not be used w ith verapamil due t o the risk of
bradyca rdia, heart block, congestive heart fa ilure
This is a typical angina hist ory. Beta-blocker is a first line Angina prophylaxis. However,
this man is t aking verapamil for his migraine. Verapamil should not be used with beta
blocker due to the risk o f bradycardia, heart block or even congestive card iac failure.
Therefore, bisoprolol and metopro lol are incorrect answers. Ibuprof en and digoxin do not
m
se
reduce the frequency of angina. Therefore, the next line for prophylaxis o f angina is
As
Nicorandil.
Dr
You review a 24 -year-old woman with a history of asthma in the Emergency Depa rtment.
She has been adm itted with a cute shortn ess of breath associated with tongue tingling
and an urticaria l rash a fter eating a meal containi ng shellfish. Her symptoms settle with
nebulised sa lbutamol and intravenous hydrocortisone. What is the most usefu l test to
esta blish whether this episode was due to anaphylaxis?
Seru m tryptase
Seru m IgE
Plasma histamine
Eosinophil count
m
se
As
C-reactive p rotein
Dr
Serum t ryptase GD
Serum IgE fiD
Plasma histam ine CD
Eosinophil count .
(D
[ c-reactive protein
•
Anaphylaxis - serum t ryptase levels rise following an acute episode
m
se
As
Serum trypt ase levels may remain elevated for up to 12 hours following an acute episode
o f anap hylaxis.
Dr
What is t he initial physiolog ical response to t he Valsa lva manoeuvre?
Reduction in ca rdiac output
Reduced mean arterial blood pressure
Reduced heart rat e
m
Reduced venous ret urn
se
As
Reduction in int rathoracic pressure
Dr
Reduction in ca rdiac output (D
Reduced mean arterial blood pressure fD

Reduced heart rate fD
I
Reduced venous return
J eD
m
se
As
Reduction in intrathoracic pressure «!D
Dr
You have been asked to supervise an exercise tolerance test (ETT) for a 70-year-old
patient with suspected ischae mic heart disease who has been experiencing exertional
chest pa in. He has had no recent episodes of severe chest pa in and feels well today.
Before starting the test his pulse is 84/min and blood p ressure is 130/80 mm Hg. Once the
En has begu n, which one of the fo llowing is the strongest indication for sto pping the
test?
Blood p ressu re o f 105/70 mmH g
Hea rt rate o f 130/min
Systolic blood pressu re of 215 mmH g
ST depression of 2mm
m
se
As
ST e levation o f lmm
Dr
I Blood pressure of 105/70 mmHg
Heart rate of 130/min
Systolic blood pressure of 215 mmHg
ST depression of 2mm
m
se
As
ST elevation of lmm
Dr
A 60-year-old heavy goods vehicle (HGV) driver with a one month history of ankle
swelling and orthopnoea presents t o clinic for review. His departmental echocardiogram
shows he ha s a left ventricu lar ejection fraction (LVEF) o f 35%. Which of the following
statements most accurately counsels th is patient as regard to his driving?
An LVEF of< 40% ba rs him from driving a lorry, even if he becomes asymptomatic
with treatment
His symptoms bar him from driving both a lorry and a car
The implantation of a CRT-d efibrillator wou ld allow him to drive in 6 weeks' time
m
He does not need to inform the DVLA
se
As
An LVEF of< 40% ba rs him from driving a lorry only if associated with incapacity
Dr
I An LVEF of< 40% bars him from driving a lorry, even if he becomes
asymptomatic with treatment
His symptoms bar him from driving both a lorry and a car
The implantation of a CRT -d efibrillator wou ld allow him to drive in 6 weeks' time CD
He does not( eed to inform the DVLA
An LVEF of< 40% bars him from driving a lorry only if associated with incapacity f D
Heart failure is very commonly encountered in clinical practice. DVLA guidance for Group
2 entitlements (H GVs and buses) is much more strict than Group 1 entitlements (cars and
vans).
Sym ptomatic heart failure will lead to revocation of a Group 2 licence, regardless of
whether the symptoms lead to incapacity. If a patient on treatment beco mes
asymptomati c, then they may be relicensed only if their LVEF is> = 40%.
For Group 1 entitlements, the DVLA does not need to be informed of symptomati c heart
failure if it does not lead to distracting or incapacitating sympto ms.
m
se
As
Any form of defibrillator is a bar to a Group 2 entitlement. Dr
A 75-year-old fema le p resents d ia p horetic and distressed with new onset sternal chest
pa in radiating th rough to the back. She has a past history of hypertension on
lercanidi pine. On examination her blood pressu re is 190/70 mmHg and there is an ea rly
diasto lic murmur heard best at the leh sternal e dge. Her ECG is unremarkab le. What is the
next best cou rse of action?
Aspirin/clo pidogre i/IV heparin
CT chest with contrast
Urgent echocardiog ram
m
se
As
Th rombolysis
Dr
CT chest with contrast
Urgent echocard iogram
Thrombolysis
This is a classi c exa mple of an aortic dissection ca usin g aortic regurgitation. The best
investigation is going to be a CT chest with IV contrast because the IV contrast will be
able to best demo nstrate the size and extent o f the false lumen.
The chest X-ray may show a widened mediastinum, but unfortu nately it is not a sensitive
o r specific investigation as 20% of patients present with normal chest X-ray and there a re
ma ny causes of a widened mediastinum. However, the chest X- ray is a useful first line
investigation for this cond ition because of how rea dily availa ble it is, and useful for ruling
out many other cond itions. Looking for a sepa ration of the intimal calcification from the
outer aortic soh tissue border by 10 mm is an indication of the presence of a dissection.
The CT chest with contrast will provid e the most a mount o f information by far, and can
demonstrate the extent of the d issection.
An echo is a reasonable investigatio n, but will not d emonstrate the extent of the vessel
m
lesion, for which a CT of the chest will demonstrate the lesion much better.
se
As
The next step is for surgery aher the initia l CT chest with contrast is co mp lete.
Dr
Which one o f the followin g state ments rega rd ing a rrhythmog enic rig ht ventricu lar
ca rdiomyo pathy is co rrect?
Inherited in an autosoma l recessive pattern
It is now the most common cause of sudden cardiac death in th e UK
All patients shou ld have an implantable ca rd iove rter defibrillator fitted
It is cha racterised by fibrofatty infiltrati on o f the rig ht ventricu la r myocardium
m
se
Naxos disease is the association o f a rrhythmog enic right ventricu la r
As
cardiomyopathy with d eafness
Dr
Inherited in an autosomal recessive pattern
It is now the most common cause of sudden cardiac death in the UK
All patients should have an im plantable cardioverter defibrillator fitted
It is characterised by fibrofatty infiltration of the rig ht ventricular myocardium
Naxos disease is the association of arrhythmogenic right ventricular

cardiomyopathy with deafness -
~
m
se
Drug the rapy is used in patients with well tolerated or non life-threatening ventricular
As
arrhythmias.
Dr
An e lde rly man with aortic ste nosis is assessed . Which one of the following wou ld make
the ejection systo lic murmur qu iete r?
Left ventricu lar systolic dysfunction
Thyrotoxicos is
Mixed a ortic valve disease
Expiratio n
m
se
As
Anaem ia
Dr
I Left ventricular systolic dysfunction
Thyrotoxicosis
Expiration
Anaemia
m
se
Left ventricular systolic dysfunction will result in a decreased flow-rate across the aortic
As
valve and hence a qu ieter mu rmur.
Dr
A 29-yea r-old woman is investigated fo r increasing dysp noea a nd feeli ng gene rally weak
a nd letharg ic. Over the past few months, she has had five episodes of syncope, some of
which occu rred fo ll owing exercise. There is no prior medica l history of note a lthough her
gra nd mothe r died aged 44 yea rs aher su ffering increasin g s hortness-of-breath and
syncop e. On examination her oxygen satu rations a re 98% on room air and the pulse is 78
I min. The second heart sound is loud b ut no murmu rs a re hea rd. Auscu ltation of the
c hest is u nremarkab le .
Pulmonary a rte rial hypertensi on
Fam ilial pulmona ry stenosis
Catecho laminerg ic p olymorphic ventricul ar tachycardia
m
se
As
Arrhythmogenic right ve ntricula r dys plasia
Dr
Pulmonary arterial hypertension
Familial pulmonary stenosis

-
~
m
se
As
Arrhythmogenic right ventricular dysplasia
Dr
A 51-year-old female presents to the Emergency Department following an episode of
transient right sided weakness lasting 10-15 minutes. Examination reveals the patient to
be in atrial fibrillation. If the patient remains in chronic atrial fibrillation what is the most
suitable form of anticoagulation?
Aspirin
Warfa rin, ta rget INR 2-3
No anticoagulation
m
se
As
Warfa rin, ta rget INR 2-3 for six months then aspirin
Dr
Asp irin
I Warfarin, target INR 2-3
No anticoagulation
-
~
-
Warfa rin, ta rget INR 2-3 for six months then aspirin
m
se
The CHA2DS2-VASc for this patient is 3 - 2 for the transient ischaemic attack and 1 for
As
being female. She should therefore be offered anticoagulation with warfa rin.
Dr
Each one of the following is associated w ith right axis deviation on ECG, except:
Right ventricular hypertrophy
Pulmonary embolism
Wolf- Parkinson -Wh ite syndrome w ith right -si ded accessory pathway
Chronic lung disease
m
se
As
Dr
Right ventricu lar hypertrophy
Pulmonary embolism
Wolf-Parkinson -White syndrome w ith right-sided accessory pa way
Chronic lung disease
Left axis deviation - Wolff- Parkinson-White syndrom e (right-sided accessory

pathway)
m
Wolff- Parkinson-White syndrome is associated with a short PR interval and a wide QRS
se
complex with a slurred upstroke, termed a delta wave. Axis deviation depends on the
As
position of the accessory pathway
Dr
I Staphylococcus aureus infection .
GD
Culture negative endocarditis CD
I Streptococcus viridans infection CD

Low complement levels m
~
Prosthetic valve endocarditis m
m
se
As
Infective endocarditis - streptococcal infection carries a good prognosis
rtrportar t "or me _e-ss -r; :lc'ient
Dr
A 72-yea r-old man is prescribed a dipyrida mo le in ad d ition to aspi rin fo ll owing an
ischaemic stro ke. What is the mechanism of actio n of d ipyridamole?
Phospho diesterase inhibitor
Glycoprotein lib/lila inhibito r
Inhibits ADP b ind ing to its platelet receptor
Agonist o f thromboxane synthase
m
se
As
Irreversibly acetylating cyclooxygenase
Dr
I Phosphod iesterase inh ibito r
Inhibits ADP bind ing to its platelet receptor
Agonist of thromboxane synthase
Irreversibly acetylating cyclooxygenase
Dipyridamo le is a non-spec ific phosphod iesterase inhibitor and decreases cell ular
uptake of adenos ine
m
se
Dipyridamole is genera lly described as a non-specific phosphodiesterase (PDE) inhibitor
As
but it is known to be particularly active against PDES (l ike si ldenafil) a nd PDE6.
Dr
A 65-year-old man with no significant past medical history is admitted to the Emergency
Department. His ECG is consistent with an anterior myocardial infarction. Unfortunat ely he
develops cardiac arrest shortly aher arriving in the department. What is the most common
cause of death in patients following a myocardial infarction?
Pulmonary embolism
Cardiogenic shock
Papillary muscle rupture
Ventricu lar fibrillation
m
se
As
Dr
Pulmonary embolism m
Cardiogenic shock CD
Papillary muscle rupture «ED
I Ventricular fibrillation CD
m
se
As
Complete heart block m
Dr
A 62-year-old man who had a mechanical mitral valve replacement fou r years ago is
reviewed. What long t erm antithrombotic therapy is he likely to be taki ng?
Noth ing
Direct acting oral anticoagulants
Aspirin
m
Aspirin + clopidogrel for the first 12 months
se
As
Warfarin
Dr
Nothing CD
I Direct acting oral anticoagulants m

Aspirin
•
Aspirin + clopidogrel for the first 12 months
•
I Warfarin (D
Prost hetic heart valves - antithrombotic t herapy:

• b ioprost heti c: asp irin
• mechanical: warfarin + as pirin
Following t he 2017 Euro pea n Society of Cardi ology guid elines, aspirin is on ly normally
m
given in addition if t here is an additio nal indicat ion, e.g. ischaem ic heart di sease.
se
As
Direct acting ora l ant icoagu lants are not used in patients with a mechanical heart va lve.
Dr
A 70-year-old woman is prescribed bumet anide for congestive ca rdiac fa ilure. Where is
the site of action of bumetanide?
Macula densa
Distal collecting duct
m
se
As
Proximal collecting duct
Dr
Descending loop of Henle CD
Macula densa
•
I Ascen ding loop of Henle ED
Dist al collecting duct CfD
Proximal collecting duct C!D
Furosemide- inhibits the Na-K-CI cotrans porter in the th ick ascending limb of the
loop of Henle
m
se
As
Bumetanide, like furosemide, is a loop diuretic.
Dr
Which one o f t he followin g clotting fact ors is not affected by wa rfarin?
Factor II
Factor VII
Factor XII
Factor IX
m
se
As
Factor X
Dr
Factor II f.D
Fal or VII (D
Factor XII GD
Factor IX m
Factor X CD.
Warfarin - clotting factors affected mnemon ic - 1972 (10, 9, 7, 2)

m
se
As
Fa ctor XII is not affected by warfarin
Dr
Which one of the following featu res wou ld indicate ca rdia c tamponade rather than
constrictive pericarditis?
Ra ised JVP
Muffled heart sounds
No Ydescent on JVP
Hypotension
m
se
As
Tachycardia
Dr
Raised JVP f.D
Muffled heart sounds ED
No Y descent on JVP fD.
Hypotension tiD.
Tachycardia m
m
se
As
In cardiac tamponade there is characteristically no Y desce nt o n the JVP. The o ther fou r
features are seen in both ca rdiac tamponade and constrictive perica rd itis
Dr
In patients with atria l fibrillation (AF), which one o f the following facto rs wou ld make a
rate co ntro l strategy, rather than rhythm contro l, mo re su itable?
Congestive heart fa ilure
AF secondary to a corrected precipitant
Sym ptomatic
Age> 65 yea rs
m
se
As
First presentation
Dr
Congestive heart fa ilure
AF secondary to a corrected precipitant
Symptomatic
-
~
m
Age > 65 years
se
As
First presentation
Dr
Which one of the followin g patients shou ld not automatically b e
p rescribed a statin in the absence of any contra indication?
A 51-yea r-old ma n who had a myocardial infarction 4 years ago and is now
a symptomati c
A 57 -yea r-old fema le sm oker with a 10-year card iovascular ris k of 23%
A 53-yea r-old ma n with intermittent claudication
A 62-year-old ma n who had a transient ischaemic a ttack 10 mo nths ago
m
se
A 57 -yea r-old ma n with well controlled diabetes mell itus type 2 with a 10-year
As
ca rdiovascular risk of 8%
Dr
A 51-year-old man who had a myocardial infarction 4 years ago and is now
asymptomati c -
A 57-year-old female smoker with a 10-year cardiovascular risk of 23%
A 53-year-old man wi th intermittent claudication

-
A 62-year-old man who had a transient ischaemic attack 10 months ago
m
se
A 57 -year-old man with well controlled diabetes mellitus type 2 with a 10-year
As
cardiovascular risk of 8%
Dr
Which one of the following drugs is most likely to cause a prolonged QT interval?
Metocloprami de
Verapamil
Ceftriaxone
m
Sot alol
se
As
Digoxin
Dr
Metoclopramide GD
Verapamil CD
Ceftriaxone
Sotalol CD
•
Digoxin CD
m
se
As
Sotalol is known to cause long QT syndrome
Dr
A 35-year-old female has paroxysmal atrial fibrillation and was successfully treated with
DC cardioversion 1 w eek ago. She is now resultantly on warfarin. A subsequent post -
cardioversion echocardiogram shows no structural abnormalities.
How long should the warfarin b e continued?
3 mont hs
Stop immediately
4 weeks
m
Indefinitely
se
As
6 mont hs
Dr
3 months «D
Stop immediately (D
4 weeks CD
Indefinite ly GD
6 months tiD
It is recom mend ed warfarin be co nti nued for at least 4 weeks afte r successful
ca rdiove rsion. If there is structura l abnormalities o r the atria l fibri llatio n is like ly to re-
occur the n long term anti-coagulation is recommended.
BMJ best pract ice: http://bestpractice.bmj.com/ best-

practice/ monogra ph/ 3/treatmenVste p-by-step.html
m
se
Resus Co uncil UK peri-arrest a rrhythmia (page 7) :
As
https:/fwww .res u s.org.u k/EasySiteWeb/Gatewayl in k.aspx? a lid =808
Dr
A 61-yea r-old man with p eriphera l a rterial d isease is prescribed simvastatin. What is the
most app ro priate blood test monito ring?
LFTs + creatinine ki nase at baseli ne, 1-3 months a nd at interva ls o f 6 months for 1
year
LFTs at baseline and every 3 months for first yea r
Routine blood tests not reco mmended
LFTs at baseline and annua lly
m
se
As
LFTs at baseline, 3 months a nd 12 months
Dr
LFTs + creatinine kinase at baseline, 1-3 months and at interva ls of 6 months for QD
1 year
LFTs at baseline and every 3 months for first year
Routine blood tests not recommended
LFTs at baseline and annua lly
LFTs at baseline, 3 mo nths and 12 months
m
se
As
A fasting li pid profile may a lso be checked du ring monitoring to assess response to
treatment.
Dr
Symptom-limited trea dmill exercise testing is often d o ne befo re discha rge after a STEM!.
Which o f the fo llowing pa ramete rs at exercise testing most strongly indicates a good
p rog nosis with medical treatme nt?
Absence o f ST d epressio n
Percent (%) predicted maximal heart rate achieved
Absence o f ve ntricular arrhythm ia
Absence o f chest pa in
m
se
As
Above ave rage exe rcise capacity
Dr
Absence o f ST d epressio n
Percent (%) predicted maximal heart rate achieved
Absence o f ve ntricular arrhythmia
Absence o f chest pa in
-
........
I Above average exercise capacity
Essentially, the q uestion asks: 'Which o f the fo ll owing is the best predictor o f mo rta lity
post-STEM!?'
Above ave rage exercise ca pacity pe rformed befo re di scharge is associated with a g ood
p rog nosis a fte r a STEM!. Exercise capacity has been re peatedly shown in studies of
m
se
exercise testing to be the strongest p red ictor o f morta lity and ca rdiovascular events,
As
pa rticu la rly in e ld e rly persons.
Dr
A 72-yea r-old male is adm itted to the Emergency Room fol lowing a collapse at church.
ECG reveals dissociation between the P and QRS complexes with a rate of 40 I minute.
Which one of the following clinical findings may also be found?
Loud Sl
Narrow pulse pressure
Giant v waveforms in the JVP
Variable intensity of Sl
m
se
As
Soft 52
Dr
Loud Sl m
Narrow pulse pressure flD
Giant v waveforms in the JVP fD
I Variable intensity of 51
Soft 52
CD
m
se
As
Complete heart block causes a variable intensity of Sl
Dr
Which o f the following signs is not associat ed w ith the development of Ei senmenger's
syndrome in a patient with a ventricu lar sept al defect?
Worsening of syst olic murmur
Ra ised JVP
Lou d second heart sound
m
Cyanosis
se
As
La rge 'a' waves in j ugular venous waveform
Dr
Worsening of systolic murmur
Ra isef JVP
Loud second heart sound
Cyanosis
Large 'a' waves in jugular venous waveform

-
"""'
m
Eisenmenger's syndrome is characterised by the reversal of the left- right shu nt due to
se
As
pulmonary hypertension. The orig inal murmur may disa ppea r once Eisenmenger's
syndrome develops
Dr
A 51-year-old male represents with chest pain, eight een days after he was diagnosed with
a non-ST elevation myocardial infarction. It is severe, central chest pain with radiations to
the left shoulder and worse w ith deep inspiration. The pain woke him from sleep at 03:00
and has improved slightly after getting up out of bed. Fi ndings on examination include
reduced air entry to both bases coup led with fine basal crepitations. Observations show:
Heart rat e lOSbpm
Blood pressure 130/ 78mmHg
Respirat ory rate 22bpm
Temperature 37 .8 celsius
Oxygen saturations 97%
An initial ECG shows diffuse saddle-shaped ST elevation. An echocardiogram shows a

small rim of fluid outside the pericardium. What is the most likely diagnosis?
Second myocardial infarction
Pulmonary embolism
Dressier's syndrom e
Cost ochondritis
m
se
As
Unstable angina
Dr
Second myoca rdial infarct ion m
Pulmonary embolism CD
Dressier's syndrome CID
Costochondritis m
~
Unstable angina m
The correct answer is Dressier's syndrome given the recent history of Ml, d escript ion of
pain (pleuritic, leh shou lder radiation, worse lying dow n), low-grade t emperature, ECG
changes and pericardia! effusion.
m
se
As
It is treated w ith NSA!Ds preferably or a prolonged cou rse of colchicin e or st eroids.
Dr
What does troponin T bind to?
Tropomyosin
Actin in thin myo filaments
Prot ein kinase C inhibit ors
Calcium ions
m
se
As
T -tubu le membrane wa ll
Dr
I Tropomyosin
Actin in thin myofilament s
Protein kinase C inhibitors
~cium ions
T -tubule membrane wa ll
m
se
As
Tropomyosin is a protein which regulates actin. It associates with actin in muscle fibres
and regulates muscle contraction by regulating the binding of myosin.
Dr
A 67 -year-o ld female is p rescri bed s imvastatin for hyperlipidaemia. Which one of the
following is most like ly to interact with her med icatio n?
Orange juice
Apple juice
Grapefruit juice
m
Cra nberry juice
se
As
Carrot juice
Dr
Orange juice m
Apple juice m
Gra pefru it juice ED
Cranberry juice eD
Carrot juice
•
m
se
As
Grapefruit j uice is a potent inhibitor of the cytochrome P450 enzyme CYP3A4
Dr
A 23-year-old woman presents to the Emergency Department with a friend from work.
Around 30 minutes ago she developed a 'fluttering' in her chest. She reports feeling 'a bit
faint' but den ies any chest pain o r s hortness of b reath. An ECG shows a regular
tachycardia of 166 bpm with a QRS duration of O.lls. Blood pressure is 102/ 68 mmHg
and oxygen saturations are 99% on roo m air. What is the most appropriate management?
Direct current cardioversion
m
se
As
Carotid s inus massage
Dr
Dire1 curre nt cardioversion

-~
Carotid sinus massage
The first-line management of supraventricular tachycard ia a re vagal manoeuvres such as
m
se
ca rotid sinus massage. On ly if these fa il shou ld adenosin e be given. There are no
As
indications fo r direct current cardiove rsion as per the ALS guide lines.
Dr
A 66-year-old male w ith a 75 pack year history of smoking is admitted with a 2 hour
history of central crushing chest pain radiating to his j aw. ECG revealed ST depress ion in
II, III, aVF. 6 hour troponin I was 450ng/ L. Grace score revealed 6 month mortality risk of
9%. The patient was started on Tirofiban w hilst waiting for angiography.
What is the mechanism of action of Tirofiban?
ADP receptor antagonist
Fa ctor Xa inhibitor
Gpllb/llla inhibitor
Cox inhibitor
m
se
As
Direct thrombin inhibitor
Dr
Fa ctor Xa inhibitor
Gpllb/llla inhibit or
Cox inhibitor
Direct th rombin inhibitor
This 66-year-o ld male has presented with a non ST elevated myoca rdial infarction.
Detailed management of NSTEMI's vary fro m trust to trust, but often involve performing a
6 month mortality score (GRACE) to guide treatment. If your score is greater th an
intermediate risk (>3%) a glycoprot ein inhibitor is started prior to angiography within 96
hours.
Grace score:
Lowest Intermediate
( <1.5%) Low (1.5-3.0%) (3-6%) High (6-9%) Highest(>9%)
Aspirin Aspirin + Glycoprotein Glycoprotein Glycoprotein

12 Clopidogrel for 12 inhibitor & inhibitor & inhibitor &
months months & angiography angiography angiography
outpatient within 96 within 96 within 96
m
se
perfusion/stress hours hours hours
As
imaaina
Dr
Which part of the jug ula r venous wavefo rm may be exaggerated in tricuspid
regurgitation?
x descent
vwave
y descent
a wave
m
se
As
cwave
Dr
x descent fD
I vwave CiD
y descent CD
a wave (D
c wave CD
JVP: gia nt v waves in tricusp id regurg itation
m
se
As
Dr
You review a 24 -yea r-old woman who has recently been d iagnosed as having long QT
syndrome type I (LQTSl). You a re d iscussing the need to avoid certain drugs and other
a ggravating factors. Which one of the following shou ld be avoided if possible?
Methotrexate
Sertraline
Grapefruit juice
Carbamazepine
m
se
As
Doxycycline
Dr
Met hotrexate CD
Sertraline ED
Grapef ru it j uice f!D
Carbamazepine GD
Doxycycline f!D
m
se
As
Dr
A 29-yea r-old man, with no past history, p resents with a leh middle cerebral artery (MCA)
territory stroke. He reports trouble sleeping and laying flat at night that bega n aher a flu -
like illness 3 mo nths ago, and reports some exertional dyspnoea . His leh ventricular
ejection fraction is 15% on a cardiac echocard iogram. Which of the following is the most
likely factor which contributed to the cause o f his stroke?
Epstein-Barr virus
Stenosed carotid arteries
Coxsackie virus
m
Influenza virus
se
As
Parvovirus 819
Dr
•
Influenza virus
Parvovirus B19
The underlying diagnosis is a viral myocarditis preci pitating a dilated ca rdiomyopathy and
causing a cardioem bolic stroke. Previously, the enteroviruses (including coxsackievirus)
were the most common identified viruses in the 1990's. Currently, parvovirus B-19 and
human herpes virus 6 are considered the most common causes of viral myocarditis. The
echo may show reduced left ventricular ejection fract ion, myoca rdial dyssynchrony
(myocardial segments contract at different points in time), thinn ing of the left ventricular
wall and a dilated left ventricle. Trou ble sleeping an d laying flat at night and the
exertional dyspnoea after a flu-like illness are key features suggestive of a viral
myoca rditis.
The cause of the stro ke is cardioembolic and not from carotid stenosis.
Vi ral Causes of Myoca rditis:

• Parvovirus B19
• Human herpes virus 6
• Coxsackie Bvirus
• Adenovirus
• Hepatitis C
• Cyto megalovirus
m
• Echovirus
se
As
• Influenza virus
• Epstein-Barr virus
Dr
A 52-yea r-old fema le with an acute presentation of chest pain undergoes an angiogram
to look for coronary artery disease. During the procedure, s he has a run of ventricular
tachycardia which self-resolves.
The report of the angiog ram revea led normal coronary arteries. All other cardiac
investigations were normal. What is the most like ly follow-up plan?
Inse rt internal ca rd iac defibrillator
Perform an exercise stress test
Discharge from ca rd io logy when med ically fit
Commence a miod arone
m
se
As
Repeat the angiogram
Dr
Insert internal card iac d efibrillator
Perform an exercise stress test
Discharge from cardiology when medically fit
Commence a miodarone
Repeat the angiogram

-
........
An uncom mon comp lication of a co ronary angiog ram is a ventricular a rrhythmia

secondary to irritation o f the myocardium. When present, the o ffendi ng catheter must be
pulled back immediately to resto re no rmal s inus rhythm.
m
Given the context of this q uestion, this is like ly a transient comp lication of the proced ure
se
rather than a patient factor. If all o ther cardiac investigations a re no rmal and the patient is
As
me d ica lly fit, then it wou ld be safe fo r her to be discharged.
Dr
Which one of the following agents is most useful in the maintenance of sinus rhythm in
patients with atrial fibrillation?
Verapamil
Diltiazem
Ibutilide
Am iodarone
m
se
As
Digoxin
Dr
I Verapamil flD
Diltiazem f.D
Ibutilide m
I Amiodarone CD
m
se
Digoxin GD
As
Dr
II. 57-yea r-o ld man presents to the Eme rgency Depa rtment with pa lpitations fo r the past
36 hou rs. He has no past histo ry o f note. The re is no a ssociated chest pa in o r shortness o f
J reath. Clinical examination is unre marka ble othe r than an irregular tachyca rd ia. An ECG
;hows atria l fibrillatio n at a rate of 126 bpm with no othe r changes. What is the most
3ppropriate management?
Beta -b locke r + warfa rin
Digoxin + a spirin
Heparinise + ca rd iovers io n in the Emerge ncy Department
Beta -b locke r + asp irin
m
se
As
Warfa rinise + transtho racic e cho with e le ct ive electrical cardiove rsion in 4 weeks
Dr
Beta - blocker + wa rfa rin
Digoxin + aspiri n
Heparinise + ca rdioversion in the Emerge ncy Department
Beta-blocker + aspirin
Warfarinise + transthoracic echo with elective electrica l cardiove rsion in 4 weeks CD
m
se
This patient is a good example of someone who would benefit from e lectrical
As
ca rdioversion.
Dr
A 40-year-old fema le present s to see her GP with progressive exertio nal shortness of
breath. She previously was able to walk each day to work but more recently has found
even short distances challenging. When questioned she also reports occasional
palpitations and has noted her socks becoming tight at the end of the day. She has no
o ther medical hist ory, smokes socially and drinks 12 units a week of alcohol.
Chronic obstructive pulmonary disease
Idiopathic pulmonary fibrosis
Chronic kidney disease
Idiopathic pulmonary arterial hypertension
m
se
As
Chronic pulmonary embolism
Dr
I Idiopathic pulmonary arterial hypertension
Chronic pulmonary embolism
Pulmonary arte rial hypertensi on most commonly presents w ith exertional dyspnoea.
Patients may also experience exertion al chest pain, syncope and peripheral oedema
Important for me Less · m::~c rtont
The most likely diagnosis in this young patient w ith no prior medical problems and only a
light smoking history is pulmonary arterial hypertension. Patients with pulmonary arterial
hypertension typically present with progressive exertional dyspnoea as in this case. They
may also experience chest pain, syncope, palpitations and peripheral oedema.
Examination findings can include peripheral cyanosis and oedema, a parasterna l heave,
loud pulmonary component o f the second heart sound, raised JVP with a prominent A
wave and small volu me pulse.
Chronic obstructive pulmonary disease is an incorrect answer and wou ld be unlikely in a

patient o f this age who is only a social smoker.
Idiopathic pulmonary fibrosis can present w ith progressive shortness o f breath as the
m
lungs become scarred, however, this condition is rare in patients under 50, making
se
pulmonary arterial hypertension w hich presents in patients aged 30-50 more likely.
As
Patients with pulmonary fibrosis also normally report cough, fatigue and weig ht loss.
Dr
Which of the fo llowing congenita l hea rt defects is associated with a bicuspid aortic valve
Tetra logy of Fa llot
Atrial septa l d efect
m
se
As
Transposition of the great arteries
Dr
Which o f the fo llowing congenital hea rt d efects is associated with a bicusp id aortic valve
Tetra logy of Fallot CfD

Ventr cu lar septa l d efect CD
Atrial septa l d efect fD
I Coa rctation o f the ao rta CD
m
se
Transpos itio n of the great arteries fD
As
Dr
Which one of the following stat ement s regarding B-type natriuretic peptide is incorrect?
Effective treatment for heart failure lowers a patients BNP level
Acts as a diuretic
A hormone produced mainly by th e left ventricu lar myocardium in response to

strain
Is a good marker of prognosis in patients with chronic heart failure
m
se
As
The positive predictive va lue of BNP is greater than the negative predictive value
Dr
Effective treatment for hea rt fai lure lowers a patients BNP level
Acts as a d iuretic
-
~
A hormone produced mainly by the left ventricu la r myoca rdium in response to

strain
Is a good ma rke r of prognos is in patients with chronic heart failure
The positive p red ictive va lue of BNP is greater~han the negative p redictive value &lt
m
se
As
BNP has a good negative pred ictive value rather than pos itive p redictive value
Dr
A 46-yea r-old fema le is brou ght to the hospita l after experie ncing a headache and blu rry
vision wh ich beg an two hours ago. She ap pea rs d rowsy but is o rientated to time, place
a nd perso n.She has neve r had a s imila r episod e befo re a nd does not remem ber the last
time she has seen a doctor. She d enies any chest pa in o r shortness of b reath. She has a
respirato ry rate of 16 breaths per minute, heart rate of 91 beats per min ute a nd blood
p ressure of 185/ 118 mmHg. A random blood g lucose was 6.1 mmo l/1. The attending
d octor d ecides to begin treatment with hydra lazine as it was the o nly d rug ava ilable to
him at that time. Wh ich of the followi ng best d escribes the way this medicatio n wo rks in
this patient?
It elevates the levels o f cyclic GMP leading to a re laxa tion of the smooth muscle to
a greate r extent in the vei ns tha n the arterioles
It e levates the levels o f cyclic AMP lea di ng to a rel axation of the s mooth muscle to
a greate r extent in the arterioles tha n the ve ins
It blocks the opening of the voltag e-d epending calcium channe ls in the smooth
muscle leade r to a decrease in the periphera l vascu la r resistance
It e levates the levels o f cyclic GMP leading to a re laxation of the smooth muscle to
a greate r extent in the arterioles tha n the ve ins
m
se
It elevates the levels o f cyclic GMP by causing a release o f nitric o xide which then
As
p roduce a relaxatio n o f the s mooth muscle Dr
n mocKs me open1ng orme vonag e-a epenamg ca1c1um cnanne1s 1n m e smoom
muscle leader to a decrease in the pe rip he ral vascu la r res istance
l it e levates the levels of cyclic GMP leading to a relaxa tion of the smooth muscle tm)
to a greater extent in the arterio les than the ve ins
It elevates the leve ls o f cyclic GMP by caus ing a re lease of nitric o xide which then CD
p roduce a re laxation o f the s mooth muscle
This patie nt has presented with the s ig ns and sympto ms of a hypertens ive e me rgency.
She had seve re hype rte nsio n which is d efined as a systo lic blood pressu re o f mo re than
180mmHg a nd/o r diasto lic b lood pressu re of more than 120 mmHg . She a lso has
evide nce o f end -o rgan d a mage characterized by b eing drowsy (possible e ncepha lo pathy)
a nd blurry visio n (pa p illoed e ma, retina l he mo rrha ges). Hydralazine is a blood pressu re
lowe ring ag ent commonly used in the acute setting .
1: This co rrectly d escribes the mechanism of actio n of hyd ralazine. Howeve r, the
vasodilating effect of hydra lazine te nd s to be mo re p ronounced in the arte rio les than the
vems.
2: Hydra lazine increases the leve ls o f cyclic GMP and not cyclic AMP.
3 : This d escribes the mechanism of act io n of calcium cha nn el blocke rs such as
am lo d ipine.
4: This d escribes the mechanism of act io n of hyd ra lazine. Increased leve ls o f cyclic GMP
m
cause the activatio n o f pro te in kinase G which in turns phospho rylates and activates
se
myosin lig ht c ha in phos phatase. This dep hos pho rylates myos in lig ht chains and preve nts
As
the ir binding to actin a nd the refo re p revents the smooth muscle fro m contracting. Th is
Dr
A 23 -year-old man with a family history of sudden cardiac death is diagnosed as having
hypertrophic obstructive ca rdiomyopathy. Which one of the following is the strongest
marker of poor prognosis?
Mitral regurgit ation
Apical hypertrophy
Systolic anterior motion of the anterior mitral valve leaflet
Septal wall thickness of > 3cm
m
se
As
Asymmetric hypertrophy
Dr
A 23-year-old man with a family history of sudd en cardiac death is diagnosed as having
hypertrophic obstructive card iomyopathy. Which one of the following is the strongest
marker o f poor pro gnos is?
Apical hypertrophy
Systolic ant erior motion of the anterior mitral valve leaflet
Septal wall thickness of > 3cm
Asymmetric hypertrophy
m
se
HOCM - poor prognost ic factor on echo = septal wall thickness of > 3cm
As
Dr
A 69-year-old man who takes warfarin for atrial fibrillatio n asks fo r advice. He is d ue to
have a tooth extraction at the dentist and is unsure what to d o with rega rds to his 'blood -
thinning ' tablets. There is no other past medical history of note. The last INR was taken
two weeks ago and reported as 2.8 with his ta rget INR being 2.0-3.0. What is the most
appropriate advice?
Admit to hospital + switch to subcutaneous low-molecu la r weight heparin prior to

extraction
Switch to aspirin prio r to extraction
Check INR 72 hours before procedure, proceed if INR < 4.0
Check INR 72 hours before procedure, proceed if INR < 2.5
m
se
As
Admit to hospital + switch to intravenous hepa rin p rior to extraction
Dr
Admit to hospital + switch to subcutaneous low-molecu la r weight heparin prior CD
to extraction
Switch to aspirin prio r to extraction
Check lNR 72 hours before procedure, proceed if INR < 4.0
Check INR 72 hours before procej ure, proceed if INR < 2.5
-
~
Admit to hospital + switch to intravenous hepa rin p rior to extraction
Dentistry in wa rfa rinised patients- check INR 72 hours befo re procedure, proceed if
INR < 4.0
The BNF g ives specific advice with regards to this, in the sectio n 'Prescribing in denta l
m
se
p ractice'. If a patient has a history of an unstable IN R th en it shou ld b e checked with in 24
As
hours of the dental procedure.
Dr
Yo u are ca lled to the o bstetric ward to see a woma n who is fitti ng. She is 34-weeks
p regna nt a nd currently an in patient fo r the treatme nt of seve re p re-ecla mpsia. The
anaesthetist has secured the airway and is giving 100% oxyge n. What is the most
appropriate next step?
IV ca lcium gluco nate
IV la betalo l
IV methyld opa
IV lorazepam
m
se
As
IV mag nesium sulphate
Dr
Yo u are ca lled to the o bstetric ward to see a wo ma n who is fitti ng. She is 34-weeks
pregna nt a nd currently an in patient fo r the treatment of seve re p re-ecla mpsia. The
anaesthetist has secured the airway and is giving 100% oxyge n. What is the most
appropriate next step?
IV ca lcium gl uconate fD
IV la betalol .
CD
IV methyldopa CD
IV lorazepa m m
IV mag nesium sulphate CD.
m
se
Ecla mps ia - give magnesium su lphate first -line
As
Important for me Less · m::~c rtC~nt
Dr
You are reviewing a 75-year-old male patient w ith hypertension. He takes l Omg once a
day of ramipril and lOmg once a day of amlodipine. His blood pressure remains
uncontrolled and you want to start a third agent. His K+is 4.3 mmol/1.
According to th e NICE guidelines, w hat wou ld be the most appropriate third-line agent
for this man?
Bendroflumethiazide
Candesarta n
Hydrochlorothiazide
Spironolactone
m
se
As
l ndapamide
Dr
Bendroflumethiazid e fi!D
Cande sarta n m
Hydrochlorothiazide f!D
Spironolactone ED
Indapamide tiD
In a hypertensive patient on an ACE- i an d calciu m channel blocker who requires a

t hird agent, t hiazide-type diu retics are next line
This patient is >55 yea rs old and is a lready on an ACE-i nhibitor (ra mip ril) a t the maximum
d ose a nd a calcium channel b locker (am lodipine) at the maximu m d ose.
Acco rding to the NICE gu idelines, th iazid e-like diu reti cs a re the next li ne therapy eg
chlortalid one (1 2.5-25.0 mg o nce daily) or ind apamide (1.5 mg modified -re lea se o nce
d a ily or 2.5 mg on ce d a ily). The refore, the co rrect a nswer here is 5, indapa mide.
NICE state that a thiazid e- li ke diu retic s hould be used in p reference to a conventional
m
thiazide diuretic su ch as bendroflumethiazi de o r hydrochlorothiazid e . Therefore, these
se
As
two a nswers a re wrong . Cand esa rta n is an an giotensin receptor b lo cker (ARB) a nd shoul d
not b e used in co njunction with a n ACE-inhibitor. Sp ironola ctone is used as a fourth
Dr
A 40-year-o ld woman who is being treated for refractory hypertensio n undergoes a
coro nary a ngiogram after develo ping non -specific chest pains. The ca rdio logist takes a
nu mber of measurements du ring the p roced ure:
Pressure (mmHg)
Right femoral artery 122/ 68
Left ventricle 202/104
Aorta 194/ 84
The blood p ressu re in her left arm taking du ring the procedu re was 188/74 mmHg. What
is the most li kely underlying diag nosis?
Left subclavian artery stenos is
Renal a rtery stenosis
Ao rtic stenosis
m
se
As
Resu lts consistent with essential hypertension
Dr
I Left subclavian a rtery stenosis
I Coarctation of the aorta
Aortic stenosis
Resu lts consistent with essential hypertension
The most commo n type of coarctation of the aorta seen in a dults is the postd ucta l va riety,
i.e. the aortic narrowing is dista l to the d uctus a rteriosus. This means that the upper limb
b lood pressu re is g reate r than that in the lower lim bs as the narrowing occurs a fte r the
left subclavian a rtery b ranches from the aorta.
Another a pp roach to a nswering this question is to look at the history. A young pe rson
with re fractory hypertensio n ra ises the possibility of secondary, rather tha n essentia l
(primary) hypertension. The on ly two diagnoses listed above which cause hypertension
m
se
are coarctation and renal artery stenosis. This narrows the diagn ositic possibilities and
As
makes the question easie r to answer.
Dr
A 35-yea r-o ld man who is an intravenous drug user is a dm itted to hos pital. He has had
three previous adm issions with infective endocarditis but presents on this occasion
feeling generally unwe ll, compla ining of upper abdom ina l discomfort and leg swelli ng. On
exam ination he has an e levated jugu lar venous pressu re, tender hepatomegaly and
periphera l oedema. A diagnosis of tricuspid regurgitation is suspected. Which one o f the
following a dd itional features wou ld b e most suppo rtive of this diagnosis?
Split first heart sound
Early diastolic murmur
Left parasternal heave
Wide pulse pressu re
m
se
As
Cannon ·a· waves
Dr
Split first heart sound GD
Early diastolic murmur CD
Left parasternal heave CD
Wide r ulse pressure CD
Cannon 'a' waves tiD
m
Left parasternal heave is a feature of tricuspid regu rgitation
se
As
Dr
Which part of the jug ular venous wavefo rm is associated with the closure o f the tricusp id
va lve?
a wave
cwave
x descent
y descent
m
se
As
vwave
Dr
a wave GD
r c wave ED
x descent CD
y descent GD
vwave GD
JVP: C wave - closu re of the tricuspid va lve

Important for me l ess imocrtc.nt
m
se
The c wave o f the jugular venous waveform is associated with the closure of the tricuspid
As
va lve
Dr
A patient d eve lo ps a broad complex tachycardia two days following a myoca rdial
infarctio n. Intravenous am io darone is g iven.
Which one o f the following best d escribes the primary mechan is m of actio n of
am iodaro ne?
Blocks voltage-gated potassium channels
Shortens QT interva l
Blocks voltage-gated sodium channels
Opens sodium channels
m
se
As
Blocks voltage-gated calcium channels
Dr
I Blocks voltage-gated potassium channels
Shortens QT interval
Blocks voltage-gated sodium channels
Opens sodium channels
Blocks voltage-gated calcium channels
m
se
Amiodarone - MOA: blocks potassium channels
As
lrrporrar : "or me _ess rr x -tart
Dr
A 70-y ea r-o ld man is ad mitted to t he Acute M ed icine Unit as he is pyrexial and feeling
g enerally unwell. He has a history o f ischaem ic hea rt d isease and had a myo cardial
infarction 5 y ea rs ago. An echoca rdiog ram is arranged wh ich shows a sm all veg etation
arou nd the m itral valve. Blood cu lt ures are taken w hich are repo rted as follows:
What is the m ost ap pro priate ant ib iotic therapy?
IV benzylpenicill in
IV benzylpenicill in + ceh riaxone
IV flucloxacillin + gentam icin
IV vancomycin + rifampicin + gentamicin
m
se
As
Dr
I IV benzylpenicillin
IV benzylpenicillin + ce ftriaxone
N flucloxacillin + gentamicin
N vancomycin + rifampicin + gentamicin
m
se
As
N vancomycin + benzylpenicillin
Dr
A 61-yea r-old ma n with a history of hypertension p resents with ce ntra l chest pa in. Acute
co rona ry synd ro me is diag nosed a nd conve ntio nal manageme nt is g iven. A few days late r
a dia gnostic corona ry a ngiog ram is p erfo rmed . The fo llowing wee k a dete rio rating of
re nal function is noted a ssociated with a purpuric rash o n his feet. What is the most like ly
diagn osis?
Aspirin-induced interstitia l nephritis
He parin-induced thrombocytopaenia
Re nal a rte ry stenosis
Cholesterol embolisatio n
m
se
As
Antiphosp holipid syndro me
Dr
m
se
As
Cholesterol embolisation is a well-documented complication of co ronary angiography
Dr
A patient with seve re aortic stenosis is noted to have a fo urth heart sound. Which pa rt o f
the ECG d oes this best co rrelate with?
U wave
QRS com plex
P wave
ST segment
m
se
As
T wave
Dr
U wave «ED
QRS comp lex GD
Pwave ED.
ST seg l ent tiD
m
se
Twave GD
As
Dr
Which one of the fo llowing statements regard ing prosthetic hea rt valves is correct?
Antibiotic prophylaxis is still recommended for patients with mechanica l valves who
have denta l p rocedures
The majority of mechan ical valves a re o f the ball-and -ca ge type
Bioprosthetic valves a re now usually o bta ined from human cadavers
The ta rget INR for patients with mechanica l a o rtic va lves is 3 .0-4.0
m
se
As
Mechanica l va lves have a lowe r failure rate tha n biop rosthetic va lves
Dr
Antibiotic prophylaxis is still recommended for patients with mechanical valves
who have dental procedures -
The majority of mechanical valves are of the ball-and-cage type
Bioprosthetic valves are now usually obtained from human cadavers

-
The target INR for patients with mechanical aortic valves is 3.0-4.0
m
se
As
Mechanical valves have a lower failure rate than bioprosthetic valves
Dr
A 23-year-old woman presents to the emergency department with palpitations. She is 26
weeks pregnant. Investigations are undertaken and she is treated for Supraventricular
Tachycardia (SVT). She exp la ins this is he r 3rd presentation of this.
Which anti-arrhythm ic should be used as p rophylaxis for SVT?
Metoprolo l
Am iodarone
Adenosine
Flecainide
m
se
As
Verapa mil
Dr
Metoprolol CD
Amioaarone CD
L
Adenosine fi!D
Flecainide tiD
Verapamil tiD
Although all of the ab ove could be consid ered as p rophylaxis, many are u nsuitable in
p regnancy.
Am iodarone is contra-i ndicated due to t he risk of teratogen icity and neonatal goitres.
Adenosine and Verapamil can cause d ecreased ut erine blood f low, particularly in higher
d oses, thus are often avoided. Flecainid e can be used, but is initiated in specialist care due
t o t he association w ith foet al t oxicity and hyperbilirubina emia. Metoprolol, although can
cause intra -ut erine growth restriction, is seen as t he safest as toxicity is usually associat ed
with higher d oses in t reat ment of gest ational hypertension.
Heart Disease and Pregnancy - (Management of Paroxysmal SVT) :

http://www.heartdi seasean dpreg n ancy.co m/ pdf/ phyarr.pdf
m
Heart BMJ, Managing palpit ations and arrhythmia du ring pregnancy - (Su pra-ventricular
se
As
Tachycardia section):
http://heartrhyth muk.org.uk/files/file/ Docs/ Guidelines/ Pa lpitations%20and%20Pregnancy'
Dr
A 25 -yea r-o ld wo man is broug ht to the Emergency Department by a frie nd . She
d eve lo ped palp itations around 30 minutes ago whilst drinking a cu p o f coffee. Her only
past med ical history of note is asthma an d menorrhag ia fo r which s he uses a sa lbuta mol
inhaler and takes tranexa mic a cid respectively. The a dmission ECG shows a
su praventricular tachyca rd ia at a rate of 160 b pm. Vaga l manoeuvres are unsuccessful.
What is the most ap pro priate next ste p in he r manageme nt?
Intrave nous ve rapa mil
Intrave nous am ioda rone
Electrica l card iove rsion
m
se
As
Intrave nous esmolo l
Dr
A 25-yea r-old woman is brought to the Emergency Department by a friend . She
d eveloped palpitations around 30 minutes ago whilst drinking a cup o f coffee. Her only
past med ica l history of note is asthma an d menorrhagia for which s he uses a salbuta mol
inhaler and takes tranexa mic acid respectively. The admission ECG s hows a
su praventricular tachyca rd ia at a rate of 160 b pm. Vaga l manoeuvres are unsuccessful.
What is the most appropriate next step in her management?
Intravenous ve rapa mil
Intravenous amioda rone
Electrica l cardioversion
Intravenous esmoiol
m
se
The adm inistration of adenosine is contrain dicated by her history of asthma. Verapami l
As
s hould therefore be given.
Dr
Dilated cardiomyopathy may be caused by deficiency of which one of the following:
Chromium
Magnesium
Pyridoxine
Molybdenum
m
se
As
Selenium
Dr
Dilated cardiomyopathy may be caused by deficiency of which one of the following:
Chromium m
Magnesium CD
Pyridoxine 6D
Molybdenum CD
m
se
As
Selenium 6D
Dr
A 57-yea r-o ld female p resents to the Emerge ncy Depa rtment with s hortness of b reath
a nd pleu ritic chest pa in. She has no past medical history of note and e njoys g ood hea lth.
Investigatio ns revea l a no n -massive pulmonary embolism. What is the recom me nd ed
length of wa rfarinisatio n fo r this patient?
6 weeks
3 months
6 months
12 months
m
se
As
Life-long
Dr
6 weeks CD
3 months ED
:-
6 months 6D
12 months m
Life-long CD
'Unprovoked ' pu lmonary embolisms are typically treated for 6 months

There are no tra nsient risk factors fo r venous thromboembolism t herefore the patient
should be anticoagu lat ed for 6 months.
Recent NICE guidelines advise to 'offer a VKA* beyon d 3 months to patient s with an
m
unpro voked PE'.
se
As
*vitam in K antagonsist, i.e. warfarin
Dr
A 25-year-old fema le patient with know n Bartter's disease presents to the Emergency
Department w ith severe muscle weakness. Wh ile awaiting a potassium result f rom the
laboratory, which of the following ECG f indings wou ld be the most consistent with severe
hypoka Ia em ia?
U waves, T -wave inversion, PR shorten ing
U waves, ST d epression, T-wave inversion
U waves, PR shortening, ST depressio n
T -wave inversion, PR shortening, ST depression
m
se
T -wave inversion, PR lengthening, ST elevation
As
Dr
U waves, T -wave inversion, PR shorten ing
I U waves, ST d epression, T-wave inversion
U waves, PR shortening, ST depress io n
T -wave inversion, PR shortening, ST d epression

-
~
T -wave inversion, PR lengthening, ST elevation
ECG cha nges in electro lyte abnormaliti es feature f requently in M RC P examinations.

-
~
m
se
In hypokalaemia, th e q uoted f igure is t hat ECG abnormalities begin to appear when K+
As
falls t o b el ow 2.7mmoi/L.
Dr
A 24-year-old male is diagnosed as having hypertrophic obstructive cardiomyopathy.
Which one of the following markers is most useful in assessing risk of sudden death?
Abnormal blood pressu re changes on exercise
Left ventricular out flow tract gradient
QT interva l
Right atrial diameter
m
se
As
QRS duration
Dr
A 24-year-old male is diagnosed as having hypertrophic obstructive cardiomyopathy.
Which one of the following markers is most useful in assessing risk of sudden death?
Abnormal blood pressu re changes on exercise
Left ventricular outflow tract gradient

-
~
QT interval
Right atrial diameter

-.....,
m
se
As
QRS duration
Dr
Yo u are reviewing a 56-year-old ma n who has recently been successfully ca rd iove rted
fo llowing a n e pisode of ve ntricula r tachyca rdia . He ha d recently been treated with a
cou rse of eryth romycin. You are interested to see if he has an und erlying p rolonged QT
inte rval. What is the most a pp ropriate way to mea su re the QT interva l o n the ECG?
Tim e betwe en the end of the Q wave a nd the start of the T wave
Tim e betwe en the start of the Q wave and the end of the T wave
Tim e betwe en the end of the QRS wavefo rm a nd the sta rt of the T wave
Tim e between the end of the Q wave a nd the end of the T wave
m
se
As
Tim e betwe en the start of the Q wave and the start of the T wave
Dr
Time between the end of the Q wave and the start of the T wave
Time between the start of the Q wave and the end of the T wave
-
~
Time between the end of the QRS waveform and the start of the T wave
Time between the end of the Q wave and the end of the T wave
Time between the start of the Q wave and the start of the T wave
m
se
As
QT interval: Time between the start of the Q wave a nd the e nd of the T wave
Dr
Which one o f the fo llowing is least recogn ised as a n adve rse effect of ta ki ng
Photosensitivity rash
Ag ra nulocytos is
Hypoka laem ia
Pancreatitis
m
se
As
Hirsutism
Dr
Which one o f the following is least recognised as an adverse effect of t aki ng
Photosensitivity rash CD
Ag ranulocytos is fllD
Hypoka laemia CD
-
Pancreat itis (!D
m
se
Hirsutism ED
As
Dr
A 74-year-o ld gentleman has been referred in by his GP with a one day history of
shortness of breath. He has had a dry cough for one week, but denies any sputum
production or fevers. His past medical history includes hypertension and a transurethral
resection of the prostate 3 weeks ago. He takes ramipril and tamsu losin. He previously
smoked 10 cigarettes per day for 20 years.
On exam ination his chest is clear but his respi ratory rate is 24/min and his oxygen
saturations are 91% on air. His heart rate is 105/min and blood pressure is 145/84mmHg.
His ECG shows a sinus tachycard ia. A chest x-ray is reported as normal. Blood resu lts
show:
Hb 129 g/1 Na+ 137 mmol/1
Platelet s 250 * 109 / 1 K+ 4.3 mmol/1
WBC 9.4 * 109/ 1 Urea 6.5 mmol/1
Neuts 6.8 * 109/ 1 Creati nine 84 IJmol/1
CRP 29 mg/1
Venous blood gases:
pH 7.41
pC02 5.8kPa
p02 6. 1kPa
Bicarbonate 23 mmol/1
Base excess -1.4 mEq/ 1
Lacta t e 1.8 mmol/1
What is the next most appropriate investigation?
Blood cultures
D Dimer
Pulmonary function tests
CT-Pulmonary Angiogram
0 Arterial Blood Gas

em
s
Submit answer
As
Dr
Blood cultures
D Dimer
Pulmonary function tests
CT -Pulmonary Angiogram
Arterial Blood Gas
Here the correct answer is CT -Pu lmonary Angiogram, as it is likely this gentleman has a
pu lmonary embolus (PE).
Given likelihood of PE, t achycard ia and recent surgery he wou ld have a high Wells score
of 6.
Due to the high Wells score it wou ld be inappropriate to perform a D Dimer, as a negative
result would not be enough to exclude PE.
Whilst an arterial blood gas would provide useful information about this gentleman's level
of hypoxia, you can already tell he is hypoxic via pulse oximetry. It may add to the weight
of evidence suggesting this man has aPE, but you already have enough to warrant aCT-
PA.
m
se
As
There is no sign ifi cant evidence here to suggest that this man is sept ic or has pneumonia
so blood cultures are unnecessary.
Dr
A 26-year-o ld male with a fall from height has arrived to the emergency department via
the air ambu lance. Following assessment and a trau ma CT scan he has bilateral
pneumothoraces and an intracran ial haemorrhage. Post CT scan he arrests and
defibrillat ion pads are placed on the patient and the rhythm shows pu lseless electrical
activity (PEA). Chest compressions are commenced immediately and IV access is already
ga ined.
What w ill you do next?
Continue chest compressions until a 2 minute cycle is complete then give

adrenal ine
Give 1 mg adrenaline immed iately
Give a shock at 200J
Need le decompression
Give three successive shocks
m
se
As
Submit answer
Dr
What w ill you do next?
Conti nue chest compressions until a 2 minute cycle is complete then give
adrenaline
Give 1mg adrenaline immediatj'y
Give a shock at 200J
Needle decompression
Give three successive shocks
ALS -g ive adrenaline in non-shockable rhythm as soon as possible

Importa nt fo r me Less important
This gentleman is in PEA chest compressions have already begun and following the ALS
algorithm 1 mg adrenaline must be g iven immediately. Thus option 2 is correct.
Option 1 is incorrect, adrenaline must be g iving immediately and then chest

compressions conti nue for 2 minutes until further adrenaline is given.
Option 3 is incorrect. PEA is a non-shockable rhythm.
Option 4 is also incorrect but will be part of your management of t his patient following
option 2, going through the reversible causes (4H's 4T's) of which needle decompressior
would be involved.
Option 5 is incorrect. The use of up t o three quick successive (stacked) shocks is now
recommended for ventricu lar fibrillation/pulseless ventricular tachycardia (VF/VT)
occurring in t he ca rdiac catheterisation laboratory or in the immediat e post -operative
period following cardiac su rgery.
[ .. Ia• tt Discuss (1) Improve
Adult advanced life support
The following is based on t he 2015 Resus Council gu idelines. Please see the link for mon
details, below is only a very brief summary of key points.
Maj or point s include:

• ratio of chest compressions to vent ilation is 30:2
• chest compressions are now continued while a defibrillator is charged
• during a VF!VT card iac arrest, adrenaline 1 mg is given once chest compressions
have restart ed after t he t hird shock and t hen every 3-5 minutes (during alternate
cycles of CPR).
• a sing le shock for VF/pulseless VT followed by 2 minutes of CPR, rat her t han a serie
of 3 shocks fol lowed by 1 minute of CPR
• if t he ca rdiac arrested is w itnessed in a mon itored pat ient (e.g. in a coronary care
unit) then the 2015 guidelines recommend 'up to three qu ick successive (stacked)
shocks', rat her than 1 shock followed by CPR
• asystole/pulseless-elect rical activity: a.c:f~~~a.l i _n.~ should be given as soon as possiblE
Shou ld be t reated w ith 2 m inutes of CPR prior to reassessmen t of t he rhyt hm
• atropine is no longer recommended for routine use in asystole o r pulseless electric
activity (PEA)
• delivery of drugs via a tracheal t ube is no longer recommended
• following successful resusci tat ion oxygen should be tit rated to achieve saturations
of 94-98%. This is to add ress the potential harm caused by hyperoxaemia
Reversible causes of card iac arrest:
The 'Hs' The 'Ts'
• Hypoxia • Thrombosis
• Hypovolaemia (coronary or
• Hyperkalaemia, hypokalaemia, hypoglycaem ia, pulmonary)
hypocalcaem ia, acidaemia and ot her metabolic • Tension
d isorders pneumothorax
• Hypot hermia • Tamponade -
cardiac
m
se
• Toxins
As
Dr
A 7-year-old male presents with generalised lymphadenopathy. Wh ich one of the
following is least likely to result in this presentation?
Kawasaki disease
Cytomegalovirus
Acute lymphoblastic leukaemia
Phenytoin therapy
m
se
Infectious mononucleosis
As
Dr
Kawasaki d isease
Cytomegalovirus
~enytoin therapy
m
se
As
Kawasaki d isease causes on ly cervical lymphadeno pathy
Dr
A 34-year-old man who is HIV positive is starting treatment for Burkitt 's lymphoma. His
chemotherapy regime includes cyclophos phamide, vincristine, methotrexat e and
prednisolone. Around 24 hou rs aher st arti ng chemotherapy he becomes con fused and
com plain s of muscle cra mps in his legs. Which one of the followi ng is most likely to have
occurred?
Prednisolone-induced psychosis
Hypercalcaem ia
Methotrexate pneumon itis leading to hypoxia
Haemorrhagic cystitis leading to acute renal failure
m
se
As
Tumou r lysi s syndrome
Dr
Prednisolone-induced psychosis
Hypercalcaemia
I Methotrexate pneumonitis leading to hypoxia
Haemorrhagic cystitis leading to acute renal failure
Tu mour lysis syndrome
Burkitt's lymphoma is a common cause of tumou r lysis syndrome

Tu mour lysis syndrome occurs as a result o f cell b reakdown following chemotherapy. This
m
se
releases a large quantity of intracellular component s such as pot assium, phosphate and
As
uric acid.
Dr
A patient is due to start chemothe ra py fo r metastatic colo rectal cancer. What is the main
advantage of using capecitabine instead of fluoro uracil?
Current data s hows increa sed survival
Less ca rdioto xic
Ora l a d ministration
Less nausea
m
se
Not re nally excreted the refore can be used in patie nts with chro nic kidney disease
As
Dr
Current data shows increa sed survival C!D
Less ca rdiotoxic GD
I Oral a d ministration
I ED.
Less nausea «fD
Not renally excreted therefore can be used in patie nts with chro nic kidney
disease
m
se
Capecitabine is an o ra lly adm inistered pro drug which is e nzymatica lly converted to 5-
As
fluorouracil in the t u mou r.
Dr
A 67 -yea r-old woma n is referred to the haematology clinic. Her GP has noted that her
platelet count is persistently elevated and no reactive cause can be found. Bloods taken a
week befo re clinic a re as follows:
Hb 15.4 g/dl
Plat elet s 784 * 109/1
JAK2 k inase (V617F mutation) Positiv e
What is the treatment of cho ice?
Imatinib
Stem-cell transplantation
Hydroxycarbam id e
Vincristin e
m
se
As
Venesection
Dr
Imatinib
Stem-cell transplantation
Hydroxycarbamide
Vincristine
Venesection
m
se
As
Dr
A 67 -year-old woman is reviewed 6 months aher she had a mastectomy following a
diagnosis of breast cancer. Which one of the following tumour markers is most useful in
monitoring her disease?
CA 125
CD34
CA 15-3
CA 19-9
m
se
As
CD 117
Dr
CA 125 GD
CD34 m
CA 15-3 GD
CA 19-9 CD
CD 117 CD
m
se
CA 15-3 is a tumou r ma rker in breast cancers
As
Dr
Burkitt's lymphoma is associated with a mutation in which one of the following genes?
Cyclin 01 gene
PML gene
BCR-ABL gene
RAR-alpha gene
m
se
As
MYC gene
Dr
Cyclin Dl gene CD
PMjl gene CD
BCR-ABl gene f!D
RAR-a lpha gene CD
m
se
As
MYC gene GD
Dr
Which one o f the followin g is least associated with eos inophilia?
Churg -Strauss syndrome
Nematode infection
Histoplasmosis
Allergic b ronchopu lmonary aspergillosis
m
se
As
Asthma
Dr
Churg-Strauss syndrome
Nematode infect ion
Hist oplasmosis
I
Allergic broncnopulmonary aspergillosis
-
~
m
se
As
Asthma ~
Dr
John, a 35-year-old gentleman on the ga strointestinal ward has been suffering from
melaena for a week. His haemoglobin level t oday is 60g/L and the co nsultant has
request ed that you transfuse John a unit of packed red blood cells. Within minutes of
starting the transfusi on, John co mplains o f itching and stinging sensations on his trunk.
On examination, you observe red raised welts over his abdomen and chest. His blood
pressure is unaltered from prior to the transfusion at 130/?0mmHg, his t emperature is
37°C and there are no signs of dyspnoea, w heezing, stridor or angioedema. Which one of
the following management options is the most appropriate?
Temporary tran sfusion termination and an anti histamine
Permanent transfusion t ermination, generous fluid resuscitation with saline solution

and inform the lab
Permanent transfusion t ermination, intra muscular adrenaline, antihistamines,

corticosteroids, bronchodilators and su pportive care
Temporary tran sfusion termination and an antipyretic
m
se
Permanent transfusion t ermination and high dose immune globulin therapy
As
Dr
Temporary transfusion termination and an anti histamine
Permanent transfusion te rmination, generous fluid resuscitation with saline

solution and info rm the lab
Permanent transfusion te rmination, intramuscular adrenaline, antihistamines,

corticosteroids, bronchodilators and supportive ca re
I Tem porary tra nsfusion termination and an antipyretic
Permanent transfusion te rmination and high dose immune globulin therapy
For urticarial blood transfusion reactions without anaphylaxis, an antihistamine

should be given and the transfusion te mpora rily stopped
This patient is suffering from an urticarial rash following blood transfu sion, hence the
transfusion should be stopped and an antihist amine given. Once the sym ptoms resolve,
the transfusion may be continued with no need for further workup.
Additiona l IM adrenaline, corticosteroids, bronchodilators and supportive care would only
m
se
be required for symptoms of anaphylaxis or severe allergic reaction. Th is patient does not
As
have angioedema or si gns of breathing difficu lties. Dr
A 66-year-old woman with lung cancer develops a deep vein thrombosis. She is reviewed
in the hospital clinic an d started on treatment dose low- molecular weight heparin
(LMWH). What is the most appropriate treatment plan?
Switch to warfarin, continue for 6 months
Switch to warfarin, continue for 3 months
Contin ue on LMWH for 6 month s
Continue on LMWH for 6 weeks
m
se
Contin ue on LMWH for 3 month s
As
Dr
Swit ch to warfarin, continue for 6 mont hs
Switch to warfar f"l, continue for 3 mont hs
Continue on LMWH for 6 montrs
Continue on LMWH for 6 weeks
Continue on LMWH for 3 month s
Cancer patients with VTE - 6 months of LMWH

Patients wit h active ca ncer are at cont inued risk of th rom bosis. For t his reason a 6 month
m
cou rse of anticoagulat ion is recommended. Lo w-molecular weight heparin has the
se
advanta ge of being more easy to reverse and stop if a cancer-relat ed bleed occurs, for
As
example massive haemoptysis in a patient with lung cancer.
Dr
A 69-year-old male patient of yours is found to have an elevated serum paraprotein level
of 35g/ L. Bone marrow aspirate reveals 32% monoclonal plasma cell infiltrate. He has no
evidence of anaemia, renal impairment, hypercalcaemia or lytic lesions. What is the next
step in management?
Observe and mon itor
Arra nge for autologous stem cel l transplantation
Commence th alidomide
Commence dexamethasone
m
se
Commence combined therapy with prednisolone and thalidomide I bortezomib
As
Dr
Observe and monitor
Arrange for autologous stem cel l transplantation
Commence th alidomide
Commence dexamethasone
Commence combined therapy with prednisolone and thalidomide I bortezomib 6D
This question is asking about the diagnostic crit eria for multiple myelom a and it's
su bsequent management. Here, because the pati ent is asympt omatic but has the criteria
for multiple myeloma, the underlying diagnos is of this stem is smoldering multiple
myelom a. The treatment of smoldering multiple myeloma is typically t o wat ch and wait.
This decision t o delay therapy in patient s with smoldering multiple myeloma is supported
by a 2003 Cochrane meta-analysis that com pared chemotherapy at diagnos is versus
m
deferral o f chemoth erapy until progression. Early treatment delayed progression o f the
se
disease but did not have significant effect s on mortality or response rat e, and early
As
treatment may have increased the risk o f acut e leukaemia.
Dr
A 4-year-old g irl with sickle cell anaem ia presents with abdomina l pain. On exa mination,
she is noted to have splenomegaly and is clinically anaemic. What is the most likely
diagnosis?
Liver cirrhosis
Parvovirus infection
Sequestration crisis
Salmonella infection
m
se
Th ro mbotic crisis
As
Dr
Liver cirrhosis
•
GD
I Sequestration crisis CD
Salmonella infectio n CD
Thrombotic crisis .
(D
During a sequestration crisis, the sickle cells cause the spleen to become grossly enlarged
causing the abdom ina l pain as present in this case. This is mo re co mmon in ea rly
childhood as repeated sequestration and infarction of the spleen during childhood
gradually results in an auto-splenectomy. A sequestration crisis may resu lt in severe
m
se
anaemia, marked pa llo r and cardiovascula r collapse due to loss of effective circulating
As
vo lume.
Dr
A 7-year-old boy who recently emigrated from Nigeria was seen in emergency
department with a 6 week history of progressive swelling of his jaw, fevers, nig ht sweats
and weight loss. He had no past med ical history but his mother describes a sore throat in
the past, which was treated with antibiotics, but unfortunately develo ped a rash
subsequently. On examination there was a pa inless 4x3cm mass that was fixed and ha rd .
The only other examination findi ngs of note was rubbery symmetrical cervical
lympha denopathy.
What translocation wou ld most likely to fou nd on biopsy karyotyping?
T9:22
T15:17
T8:14
T14:18
m
se
As
Tll:l4
Dr
I T8:14 6D
T14:18 fiD
Tll:l4 C!D
Burkitt's lymphoma is an uncommon, very high grad e non Hodgkin's lymphoma endemic
t o west Africa and th e mosquit o belt. There is a close associat ion with contraction of
Epstein Barr virus (EBV). Burkitt's lymphoma oh en presents wit h symmetrica l painless
lympha denopat hy, systemic B sympto ms (fever, sweat s and weight loss), central nervous
system involvement and bone marrow infiltration. Classica lly in the t extbooks t he patient
also d evelops a large j aw tumou r.
T9:22 - Chronic myeloid leukaemia - 9 ABL (oncogene - an aberrant tyrosine kinase) + 22

B cell receptor
T15:17 -Acute p ro-myelocytic leukaemia - 15 Promyelocytic gene + 17 Retinoid acid

recept or alpha (Fusion protein bind s retinoid acid receptor and promotes t ranscription).
T8:14 - Burkitt's Lymphoma - 8 c-myc (oncogene) + 14 Ig heavy const ant region
T14:18 - Foll icu lar Lymphoma - 14 Ig heavy constant region + 18 Bcl2 (ant i-apoptotic
m
g ene)
se
As
T11:14 - Mantle Ce ll Lymp homa - 11 - Cyclin D (oncogene) + 14 Ig heavy constant region
Dr
A 67-yea r-o ld man is diag nosed with myelofibrosis. What is the most common p resenting
sympto m of myelofibrosis?
Letha rgy
Ano rexi a a nd weight loss
Night sweats
Ea sy bruising
m
se
As
Spleno meg aly
Dr
I Lethargy ED
Anorexia and weig ht loss fl!D
I Night sweats (D
Easy bruising GD
Splenomegaly CD
Myelofibrosis - most common presenting symptom - lethargy

m
se
As
Whilst all the above may be seen in myelofibrosis letha rgy is the most common
Dr
Which of the follow ing is a cause of ext ravascu lar haemolysis?
Heredit ary spherocytosis
Paroxysma l nocturnal haemog lobinuria
Dissem inat ed intravascular coagu lation
Mismat ched blood t ransf usion
m
se
As
Haemolyt ic uraemic syndrome
Dr
Hereditary spherocytosis
Paroxysmal nocturnal haemoglobinuria
I Disseminated intravascular coagulation
Mismatched blood transfusion
Haemolytic uraemic syndrome
m
se
As
Extravascular haemolysis - hereditary spherocytosis
Dr
A 48-year-old man presents with a swollen, red and painfu l leh calf. Aher being referred
to the deep vein thrombosis (DVT) clinic he is diag nosed with having a proximal DVT and
commenced on low-molecular weight heparin whi lst awaiting review by the warfa rin
clinic.
There is no obvious precipitating factor for this such as recent su rgery o r a long haul
flight. He is generally fit and well and takes no regular med ication other than proprano lol
as migraine prophylaxis. There is no history of venous thromoboembolism in his family.
Other than commencing warfarin, what further action, if any, is required?
No further action is required
Investigate for underlying malignancy + check anti-phospholipid antibodies
Check anti-phospholipid antibodies + hereditary thrombophilia screen
Check anti-Xa levels
m
se
As
Perform an echocardiogram
Dr
No further act ion is required
Investigat e fo r underlyi ng malignancy + cheJ anti-phospho lipid antibodies
Check anti-phospholipid antibodi es + hered itary thrombophil ia screen
Check anti-Xa levels
Perform an echocardiog ram
NICE would recom mend doing a chest x-ray, b lood and urine tests initially to excl ude an
underlying malig nancy. If these are no rmal, aCT abdomen and pelvis shou ld be arranged
as t he patient is > 40 years. They also recom mend checking anti -phospholipid antibodies
m
for t he f irst u nprovoked DVT/PE. There is no history to support an inherited
se
As
thrombophilia.
Dr
A 30-year-old male with sickle cell disease p resents to the Emergency Department (ED)
with fever, tachypnoea and rib pain. On examination, they have a low g rade fever o f
37.9°(, oxygen saturations of 95% on air, and on auscu ltation there are bilateral vesicula r
b reath sounds. A chest X-ray shows opacification in the right midd le zone. Which o f these
statements most accu rately describes the management of this patient?
Bronchodilators are ind icated
The patient should undergo a simple transfusion to a target Hb > 8g/L
The patient should undergo an exchange transfusion to a target Hb > 8g/L
Incentive spirometry is indicated
m
se
As
Empirical antibiotic the rapy is not in dicated
Dr
I Incentive spirometry is indicated
Empirica l antibiotic therapy is not in dicated
This question requ ires the cand idate first of all to diagnose this p resentation as an acute
chest synd rom e. The British Committee fo r Standards in Haematology (BCSH) defines this
as 'an acute illness characterized by fever and/ or resp iratory symptoms, accompan ied by
a new pulmonary infiltrate on chest X-ray'.
The fundamentals of initial man agement are as follows:
• Oxygen therapy to ma intain satu rations > 95%

• Intravenous fluids to ensure euvolaemia
• Adequate pa in rel ief
• Incentive spirometry in a ll patients p resenting with rib or chest pain
• Antibiotics with cove r fo r atypica l organisms
• Early consultation with the critical care team and haemato logy
A senior haematologist wil l make a decision as to whether a sim ple or exchange

transfusion is necessary, and gui deli nes suggest an Hb target of 100-llOg/L in either
instance. On presentation, pati ents with acute chest synd rome should be fu lly cross
matched and a history of red cell antibod ies sought.
m
se
Bronchod ilators are ind icated if asthma co-exists with acute chest syndrome, o r if there is
As
evidence of acute b ronchospa sm on au scultati on.
Dr
A 24-year-old female present s to t he acute medica l t ake w ith severa l lumps in her neck
and under her arms, w eight loss, vomiting and low mood. She is found to have several
areas of suspicious lymphadenopathy, inclu ding in the neck, both axillae and
mediastinum. She also has mult iple lesions in her liver. All lesions are confirmed to be
manifest ations of Ho dgkin's lymphoma after biopsy and discussion at the oncology MDT.
Which stage of disease does she have?
II
Ill
IV
m
se
v
As
Dr
II
•m
III fiD
IV GD
v .
(D
Sprea d into the liver, bone marrow, lu ng s o r other organs would be classified as
stage IV on the Ann Arbor sta ging system fo r Hodgkin's lymphoma
This patient has stage IV disease as per the Ann Arbor scale. She has spread o f disease
beyond the lymph nodes into the liver.
Stage I co nsists of disease in one lymph node a rea only. Stage II consists of d isease in two
lymph node areas, bu t both on the sa me side o f the diaphragm. Stage III co nsists of
disease in two lymph node areas on d ifferent s ides of the d iaphragm. Stage IV cons ists of
the spread of disease beyond the lymph nodes, into the live r, lungs or bone marrow.
Stage Vis not included in the sca le.
m
Lym phoma Association: Staging of lymphoma. se
As
https://www.lymphomas.org.uk/about-lymphoma/what-is- lymphoma/stag ing - lymphoma
Dr
A blood film is reported as follows:
Howell-Jolly bodies, target cells and occasional Pappenheimer bodies are seen
What is the most likely underlying cause?
Iron -deficiency anaemia
Lead poisoning
Myelofibrosis
Sideroblastic anaemia
m
se
As
Post-splenectomy
Dr
Iron -deficiency anaemia f.D
R po isoni ng f.D
Myelofibrosis
Sideroblastic a naemia
•
GD
m
CD
se
Post-splenectomy
As
Dr
You a re reviewing a man who has metastatic small cell lung cancer. He has developed a
prog ressive ly severe headache ove r the past week. As pa rt of your differential dia gnosis
you consider supe rior vena cava obstruction. What is the most com mon featu re of th is
condition?
Nasal stuffiness
Visual distu rbance
Arm swell ing
Fa cial swelling
m
se
As
Dyspnoea
Dr
Nasal st uffi ness m
Visua l disturbance
Arm swelling
•CD
Facial swelling CiD

Dyspnoea fD
m
se
SVC obstruction - dyspnoea is the most common symptom
As
Dr
A 48-year-old man is diagnosed w it h acute myeloid leukaemia and cytogenics are
performed. Which one of the following is associated most w ith a poor prognosis?
Deletions of chromosome 5
Translocation between chromoso me 15 and 17
Deletions o f chromosome 15
Translocation between chromoso me 9 and 14
m
se
As
Deletions o f chromosome 8
Dr
Translocation betwee chromosome 15 and 17
Translocation between chromosome 9 and 14
-
~
m
se
Acute myeloi d leukaemia - poo r prognos is: d eletion of chromosome 5 or 7
As
Dr
What are t he most com mon types of t ransfo rmations seen in patients w ith polycythaem ia
vera?
M yelodysplasia + chronic myelo id leukaemia
Myelof ibrosis + ch ronic myeloid leukaem ia
M yelodysplasia + myelof ibrosis
Myelof ibrosis + acute myeloi d leukae mia
m
se
As
M yelodysplasia + acute myeloid leukaem ia
Dr
What are the most common types of transformations seen in patients w ith polycythaemia
vera?
Myelodysplasia + chronic myeloid leukaemia
Myelofibrosis + ch ron ic myeloid leukaemia
Myelodysplasia + myelofibrosis
r Myelofibrosis + acute myeloi d leukaemia
Myelodysplasia + acute myeloid leukaemia
m
Polycythaemia rubra vera - around 5-15% progress to myelo fibrosis o r AML
se
Important for me Less i m ::~c rtc.nt
As
Dr
Each one of the following is seen in Wiskott-Aid rich syndrome, except:
Th ro m bocytopen ia
Recu rrent chest infections
X- li nked recessive inheritance
Mutation in the WASP gene
m
se
As
Psoriasis
Dr
Thrombocytopenia
Recurrent chest infect ions
X- linked recessive inheritance

---
~
Mutation in the WASP gene
m
se
As
Psoriasis
Dr
Which of the following cytotoxic agents is most associated with ototoxicity?
Vincristine
Bleomycin
Cisplatin
Doxorubicin
m
se
As
Cyclophosphamide
Dr
Vincristine CD
Bleomycin CD
I Cisplatin eD
Doxorubicin fD
Cyclophosphamide .
(D
m
se
Cisplatin may cause otot oxicity
As
Dr
A 26-year-old female is diagnosed with an unprovoked DVT and a t hrombophilia screen is
performed.
What ab normality is most likely to be found?
Factor V Lei den
Lupus ant icoagu lant
Protein C def iciency
Protein S deficiency
m
se
As
Wald enstrom 's macroglobulinaemia
Dr
I Factor V Leide_n_ _ _ _ _ _ _ _ _ _ ____,
Lu pus ant icoagul ant
Protein C def iciency

-
~
Prot ein S d ef iciency
Waldenstrom 's macroglob ulinaemia
Factor V Lei den is t he commonest inherited t hrombophilia

Fa ctor V Lei den is the co mmonest inherited t hrombophilia in European populat ions
(approximately 5% prevalence of a het erozygous mutation).
Prot ein C and S deficiency are possible answers b ut both are less com mon than Factor V
Leid en. Lupus anticoagulant is another possible answer and features in ant i phos pholipid
syndrome but t his is again less common.
m
se
Waldenstrom 's macroglobulinaemia typically p resents in elderly males with symptoms of
As
hyperviscosity.
Dr
Each one of the fo llowing is associated with polycythaemia ve ra, except:
Sp le no megaly
Hyperviscosity
Ra ised ESR
Hypertension
m
se
As
Pru ritus
Dr
Splenomegaly GD
Hyperviscosity
Raised ESR
•
e:D
Hypertension fD
Pruritus .
(D
m
se
Polycythaemia rubra v era is associat ed with a low ESR
As
Dr
A 61-yea r-old man is re ferred by his fa mily physician to a hematologist a fter he p resented
with a right-sided painless neck lump. The lum p started sma ll and has been s lowly
increasing in size. More recently a second lum p has app eared which p rompted the fam ily
p hysician to refe r the patient.
The patient has a lso been co mpla ining of lethargy, night sweats and has lost sign ificant
we ight. Thyro id function tests are normal and the patient d oes not have a sign ificant
fam ily history. There is no recent trave l or contact history. Biopsy of the nodes and
cyto genetic ana lysis show a trans lo cation causing increased B-celllymphoma 2 (BCL-2)
transcription which confirms the diagnosis. Unfortunately, the patient's cond ition cannot
be treated with imatinib.
Which of the following translocation does this patient have?
t(14;18)
t(ll;l4)
t(15;17)
t(12;15)
m
se
As
t(11;22) Dr
I t(14;18) C!D
t(11;14) fD
t(15;17) CD
t(12;15) m
t(11;22) GD
The t(14;18) trans location causes increased BCL-2 t ranscri ption and causes follicular
lymphoma
This patient present ed with the signs and symptoms suggestive of non-Ho dgkin
lymphoma. This is supported by the signs and symptoms of weight loss, night sweats, and
painless lymphad enopathy. Non-Ho dgkin lymphoma is one class of lymphoma, w ith t he
o t her class b eing Hod gki n lymphoma. There are several types o f Hodgkin lymphoma
which are actually neoplasms o f mature B cells, and very rarely of T cell origin. In t his case,
a cytogeneti c analysis revea led a translocation causing increased BCL-2 t ranscript ion. This
is associat ed w ith t he t(14;18) translocation which causes follicular lymphoma.
(Fi rst Aid 2017, p407-410).
2: t(11;14) is associat ed with Mantle cell lymphoma, which is a type of non -Hodgkin
lymphoma. There is a t ranslocation of cycli n D1 on chro mosome 11 and heavy-cha in Ig
on chromoso me 14. Mantle cell lymp homa is cha ract eristic of being CDS p ositive. It is
known to be an aggressive t u mor with lat e presentation and therefore poor prognosis.
3: t(15;17) is associat ed with the acute p ro myelocytic leukemia (APL) su btype of acut e
myeloid leukemia (AM L). AML usually presents in patients ab ove 65 years of age. The
therap eutic importance of know ing the APL subtype is that it res ponds t o all-tra ns
retinoic acid (vit amin A) .
4: t(12;15) is associated with the development of breast cancer, more specifically secretory
b reast carcinoma. This type of breast cancer is know n t o be rare and the clin ical outcome
fo llowing is usually good.
5: t(11;22) is a translocation w hich o ccu rs in Ewi ng sarcoma. This is a malignant bone

tumor which often o ccu rs in individuals under 15 years o f age. The disease is known t o be
em
very aggressive and is associat ed with the develop ment o f early metast ases.
s
As
I •• I •• 9t Discuss Improve J
Dr
A 52-year-old woman with a history of hypot hyroid ism present s with let hargy and a sore
tongue. Blood tests are reported as follows:
Hb 10.7 g/dl
MCV 121 fl
Pit 177 * 109/1
WBC 5.4 * 109/ 1
Further tests are ordered:
Vitam in B12 64 ng/ 1( 200-900 ng/ 1)
Folic acid 7.2 nmolfl ( > 3.0 nmolfl)
1 mg of IM hyd roxocobalamin once every 3 months
0 1 mg of IM hyd roxocoba lamin 3 times each week for 2 weeks, then once every 3
mont hs
1 mg of IM hyd roxocobalamin once every 2 months + fol ic acid Smg od
Give fol ic acid Smg od one week the n recheck b loods
1 mg of IM hyd roxocoba lamin 3 times each week for 2 weeks, then once every 3
mont hs + folic acid Smg od
em
Submit answer
s
As
Dr
1 mg of IM hyd roxocobala min once every 3 months
1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 CD

months
1
1 mg of IM hyd roxocobala min once every 2 months + fol ic acid Smg od CD
Give fo lic acid Smg od one week then recheck b loods 8
1 mg of IM hyd roxocobalamin 3 times each week for 2 weeks, then once every 3 CD
months + folic a cid Smg od
m
se
If the patient was d eficient in fo lic acid it wou ld important to treat the B12 deficiency first
As
to avoid p recipitating subacute combined degeneration of the cord.
Dr
A patient with testicular cancer is started on cisplatin therapy. Wh ich of the following
side-effects is most cha racteristically associated with cisplatin?
Liver cirrhosis
Alopecia
Peripheral neuropathy
Haemorrhagic cystitis
m
se
As
Cardiomyopathy
Dr
Live r cirrhosis fD
Alopecia GD
r
Peripheral neuropathy CD
Haemorrhagic cyst it is CD
Cardiomyopathy fD
m
se
Cisplatin may cause perip heral neuropathy
As
Dr
A patient with lung cancer has a Positron Emission Tomogra phy (PET) scan to evaluate
possible metastatic disease. What d oes this type of scan d e monstrate?
Cellul ar p rolife ratio n
Apopto tic activity
Glu cose uptake
Vascular sup ply
m
se
As
Tyrosin e kinase a ctivity
Dr
Cellular pro liferation
Apoptotic activity
Glucose uptake
-
Vascular supply
m
se
As
Tyrosine kinase activity
Dr
A 71-year-old woman with no significant past medical history is investigated fo r
lymphocytosis. She has recently lost ?kg in weight and complains of letha rgy. The
following blood results are obta ined:
Hb 9 .8 g/dl
Pit 104 * 109/1
WBC 70.3 ~ 109/1
Blood film : Lymphocytosis. Smudge cells seen
Four months previously her white cell count was 30.5 • 109/1. What is the most
appropriate management?
Imatinib
Chlorambucil
No treatment, monitor full blood count
Fludarabine, cyclophospha mide and rituximab
m
se
Allogeneic stem cell transplantation
As
Dr
Imatinib
Chlorambucil
No treatme nt, monito r full blood cou nt
Fludarab ine, cyclophosphamide a nd rituximab
Allogeneic stem cell transplantation
CLL - treatment: Fluda ra bine, Cyclopho sp ha mide a nd Rituxima b (FCR)

This patient has chronic lymp hocytic leukaemia. The lymphocyte doub ling time is less
than 6 months, the patient has some evid ence of marrow failure and also has systemic
symptoms. She should therefore be treated and o f the options given a combination o f
flu darabine, cyclophosphamide and rituximab (FCR) is the most app ropriate treatment.
Chlorambucil used to be the first-line treatment o f choice but stu dies have shown it not
to be as effective as FCR.
m
se
As with many haematological cancers such patients are often entered into randomised
As
trial s
Dr
A 45-yea r-old man attends ambulatory care with a 2-month history of worsening fatigue.
On further questioning he states that whilst he has lost some we ight recently, he ha d
attributed this to reduced ap petite, stating that he has been feeling full after eating
relatively little. On direct questioning he states that on a few occasions over the last 2
weeks he has woken feeling sweaty with damp sheets. On exa mination the patient has
pa le conjunctiva and there is a la rge, firm mass in the left upp er quad rant of the
abdomen. He is haemodynam ically stable, afeb rile and there are no signs of respirato ry
distress.
Initial bloods show:
Hb 105 g/1
WBC SO * 109/ 1
The F1 clerking the patient requested an abdom inal CT wh ich has been reported by the
radiologist as s howing massive splenomegaly.
A bl ood film has been sent and th e patient has been d iscussed with the on-call
haematolog ist who has arranged a bone marrow biopsy and cytogenetics. However, the
results of these investigatio ns a re not yet availab le.
Which of the following findings would support a diagnosis of chronic myeloi d leukaemia
(CM L) rather tha n myelofibrosis?
t(15;17) tra nslocation
t(8;21) translocation
Low leucocyte alkaline phosphatase score
Ra ised leucocyte a lkalin e phosphatase score

sem
As
Massive splenomegaly
Dr
I t (l5;17) tra nslocation
t(8;21) t ranslocation
I Low leucocyte alkaline phosphatase score
Ra ised leucocyte alkaline phosphatase score
M assive splenom ega ly
Leucocyte alkaline phosp hat ase is low in CML but raised in myelofibrosis
The correct answer here is a low leucocyte alkaline phosphatase (LAP) score.
LAP is fou nd within mat ure whit e blood cells (WBCs).
Low LAP levels are found in conditions associat ed with immature/ undevelop ed WBCs (e.g.
CML), whereas patholog ies associated w ith mature WBCs (such as myelofibros is) cause
hi gh LAP levels.
t(lS; 18) t ranslo cation is associated wit h acut e promyelocytic leukaemia (APM L)
t(8;21) t ranslo cation is associated with acute myeloid leukaemia (AM L)
the Philadelphia chromosome t(9;22) creates a BCL-ABLl f usion gene t hat codes for a
constitut ively active tyrosin e kinase receptor. This is associated with 95% o f CML cases
and is the ta rget for imati nib (a tyros ine kinase i nhibitor).
s em
Massive splenomegaly is seen in b oth CML and myelofibrosis

As
Dr
A 15-yea r-old gi rl presents with abdominal pain. She is no rmally fit and well and currently
takes a combined o ra l co ntraceptive pill. The patient is accom pa nied by her mother, who
is known to have hered ita ry spherocytos is. The pai n is located in the upper abdomen and
is episodic in nature, bu t has become severe today. There has been no change to her
bowel habit and no nausea or vomiting. What is the most likely d iagnosis?
Inferior vena cava throm bosis
Acute pancreatitis
Renal vein throm bosis
Gastritis
m
se
As
Bilia ry colic
Dr
Inferior vena cava thrombosis
Acute pa ncreatitis
Renal vein thrombosis
Gastritis
Biliary colic
m
This patient has hereditary spherocytosis resulting in chronic haemolysis and gallsto ne
se
formation. An important differential in a poorly patient with hereditary spherocytosis
As
would be splenic rupture
Dr
A 42-year-old fema le is noted to have a Hb o f 17.8 g/ dl. Which one of t he followin g is
least likely to be t he cause?
Polycythaem ia ru bra vera
Chronic obstructive p ulmonary disease
Hypernephroma
Haemochromatosis
m
se
As
Dehydration
Dr
Polycythaemia rubra vera GD
Chronic obstructive pu lmonary disease fD
Hypernephroma tiD.
I Haemochromatosis CID
Dehydration GD
Haemochromatosis is not associated w ith polycythaem ia. Blood tests typically revea l a
m
se
raised ferritin and iron, associated with a transferrin saturation of greater than 60% and a
As
low tota l iron binding capacity
Dr
A 25-year-old female patient presents with massive haemorrha ge. You are working in the
hosp ital b lood bank and are asked to prepare 2 unit s each of Red cell s and Fresh Frozen
Pla sma (FFP) when the resu lt o f the group and save is availab le.
The patient's samp le is grouped as B RhD neg ative. You manag e to procu re some Group
B red cell s f rom the frid ge b ut the re is no Group B FFP available.
FFP from a d onor of which blood group wou ld be best t o give?
A RhD negative
A RhD pos it ive
AB RhD negative
AB RhD posit ive
m
se
0 RhD positive
As
Dr
A RhD negative .
(D
RhD posit ive
AB RhD negative
•
ED
AB RhD positive fi!D
0 RhD positive .
ED
The universal donor of fresh frozen p lasma is AB RhD negative blood

This p atient is blood group B RhD negative, meaning her red cells p ossess B antigens only
from t he ABO grou ping, and she nat u rally produces anti -A antigens in her plasma.
Therefore, she needs t o receive red cells with only B antigen or no antigens at all (i.e.
Groups B or 0 ) but need s to receive FFP t hat d oes not have anti-B in it. Group 0 donors
naturally p roduce anti-A and anti -B, Group A donors naturally produce on ly anti-B, so she
can only receive FFP from groups B o r AB.
Group AB is the universa l d onor for FFP because they p ro duce neither ant i-A or anti -B
and is therefore compatible with all ABO groups.
m
se
In many cases the RhD st at us woul d not matter for blood t ransfusion, however as this is a As
woman of childbearing age w ho is RhD negative, she should receive RhD negative b lood
Dr
in order t o avoid p rob lems with future pregnancies in w hich t he foet us is RhD positive.
A 54-yea r-old fema le is receiving a cou rse o f che mothe rapy fo r breast cancer. She is
expe rienci ng troublesome vom iting which has not been helped by d o mperid o ne. What is
the most a pp ropriate next ma nag ement step?
Add an antihistami ne
Add a 5HT2 a nta gonist
Add a phenoth iazi ne
Add a dopamine receptor antagonist
m
se
As
Dr
A 54-yea r-old female is receiving a course of che motherapy fo r breast cancer. She is
experiencing troublesome vomiting which has not been helped by d omp erid one. What is
the most a p propriate next ma nag e ment step?
Add an anti histam ine
Add a phe nothiazi ne
Add a ~ opa mine rece ptor antag onist
m
se
As
Add a 5HT3 antagonist
Dr
A 42-yea r-old wo ma n presented with sudde n o nset ga it ataxia, intention tremor an d
nysta g mus. CT head d emonstrated a 4cm leh cerebellar haematoma . She is discussed
with the local neu ro su rg ical unit and urgently transfe rred fo r inte rventio n. She is
repatriated a week later for furthe r rehabilitatio n. Routine blood tests are notab le for a
platelet cou nt o f 1,700 * 109/ l. Initia lly, you attribute this to a post-surgica l rise. However,
on closer examinatio n of her results yo u realise that on initial p resentation her platelet
co unt was 1,300 * 109/ 1. What gene mutation is like ly to be d iscovered in this lady?
JAK2
HFE
CFTR
WASP
m
se
As
BCR-AB L
Dr
JAK2 flD
HFE m
CFTR
WASP
•
f!D
BCR-ABL
•
This lady has presented with a stroke at a young age, on a background of raised platelets.
This is very suggestive of essential thrombocythaemia which is known to be a rare cause
of stroke and is associated with a mutatio n in the JAK2 gene.
HFE mutatio n is seen in haemoch romatosis, CFTR in cystic fibrosis and WASP in Wiskott-
m
se
Aidrich. Mutations in BCR-ABL are associated with chronic myeloid leukaemia, and is
As
known as the Philadelphia translocation.
Dr
A 62-year-old man presents w ith letharg y. A fu ll blood count is taken and is rep orted as
follows:
Hb 10.2 g/dl
Platelets 330 * 109/ 1
WBC 15.2 8
109/ 1
Film Leucoerythroblastic picture. Tear -drop poikilocytes seen
Myelodysplasia
Chronic lymphocytic leukaemia
Myelofibrosis
Chronic myeloid leukaemia
m
se
As
Post-splenectomy
Dr
M yelodysplasia
-
M yelof ibrosis
-
"""'
........
Post-splenectomy
-
........
Myelof ibrosis is associated with 't ear drop' poikilocytes on b lood film
Thro mbo cytopen ia and leucopenia are seen in progressive disease.
m
se
As
Blood film showing tear-drop poikilocytes
Dr
You are an SHO on a n acute oncology ward . You are asked to speak to a 56-year-old man
with colorectal ca ncer. He was d iagnosed 1 month ago a fter participating in screenin g.
Following a positive faecal occu lt b lood test, colonoscopy demo nstrated a malignant
lesion in the descending colon. CT staging showed lymph node invo lvement b ut no
distant metastases. He has undergone a left-hemicolectomy and is due to start adjuvant
chemotherapy with a combination o f 5-FU and oxa lip latin. During his work-up, his
consultant expla ined that he would need to be monitored for disease recurrence.
Which of the following has a role in monitoring disease activity in colo rectal cancer?
Alpha - Fetoprotein (AFP)
Meso recta l M RI
Ca-19-9
Carcinoembryonic Antigen (CEA)
m
se
As
Ca-15-3
Dr
Alpha-Fetoprotein (AFP)
Mesorecta l M RI
Ca- 9-9
Carcinoembryonic Antigen (CEA)
Ca-15-3
-
~
Carcinoembryonic Antigen (CEA) is a tumo ur marker in colorectal cancer and has a

role in monitoring disease activity
The correct answer is carcinoem bryon ic antigen (CEA). CEA is a known tumour marker for
colorectal cancer. It is not used diagnostically, b ut in patient 's with a known diagnosis o f
m
se
colorectal cancer associat ed with raised CEA levels, it can b e used to monit or disease
As
activity and help with early identification of disease recurrence.
Dr
A 72-year-old woman is found to have a marked lymphocytosis associated w ith smudge
cells on the blood film. A diagnosis o f chronic lym phocytic leukaemia is suspected. Which
one of the following is the investigation of choice?
Immunophenotyping
Bone marrow aspiration
Prot ein electrophoresis
Whit e cell scan
m
se
Bone marrow trephine
As
Dr
lmmunophenotyping
Prot ein electrophoresis
Whit e cell scan
Bone marrov trephine
CLL - immunophenotyping is investigation of choice

m
se
lmmunophenotyping will demonstrate the cells to be B-cells (CD19 p ositive). CDS and
As
CD23 are also characteristically positive in chronic lymphocytic leukaemia
Dr
A 67 -yea r-old g entleman presents with the blurring of his vis ion. This was sudden in onset
and associated with this was shortness of breath and headache wh ich came on g radually
following the blurry vision. His past medica l history includes treatment of squamous cell
ca rcinoma o f the lu ng wh ich has fa iled to shrink d espite the chemotherapy. On
exam ination, he is short of b reath with bu lgi ng veins on h is forehead. Fu ndoscopic
examination revea ls papilloedema. His face appears swo llen. Pemberton sign is positive.
You administer oxygen and called fo r help. What is the next immed iate step in manag ing
this?
Administer d exametha sone
IM ad rena line
Topica l latanoprost
Full b lood count
m
se
As
Mannitol
Dr
I Adm in ister dexamethasone
IM adrena line
(To pical latanoprost
Fu ll blood cou nt
Mann ito l
SVC obstruction can cause visual disturbances such as b lu rred vision

This is superio r vena cava obstruction. Due to the malignancy present, the su pe rior vena
cava has been compressed by a tumou r. Th is is confirmed by the bulg ing of the veins on
the forehead (back p ressu re due to compression), the papilloedema which is a s ig n of
ra ised intracra nia l p ressu re and Pemberton sign. This is when you ask a patient to raise
their a rms until they touch the s id e of their face. If they d evelop cya nosis o r worsening of
their shortness of b reath o r facial congestion, it is said to be positive. The next best step
wou ld be a ste ro id to dam pe n the inflammatory response to a tumou r and swell ing. Then
either a stent o r radiotherapy/ chemotherapy wou ld be given.
IM ad rena line would be useful if this was anaphylaxis. It wou ld not be appro priate here.
Latano prost is a treatment for glauco ma. It is a prostaglandi n analog ue and serves to
reduce ocula r p ressure. This would not be the next imme diate treatment in this condition.
A fu ll blood count will be taken, but it is not the main p rio rity.
em
Mann ito l would not be suitable here. It is g iven to reduce intracrania l pressure. However,
s
As
dexamethasone is mo re effective.
Dr
A 34-year-old female present s due t o the development of a purpuric rash on the back of
her legs. Her only regular medication is Microgynon 30. She also repo rts frequent nose
bleeds and menorrhagia. A full blood count is request ed:
Hb 11.7 gfdl
Plat elet s 62 8
10 9/1
wee 5.3 * 109/ 1
PT 11 sees
APTT 30 sees
Factor VIlle
Normal
activity
Drug-induced thrombocyto penia
Henoch-Schonlein purpura
Thrombotic thrombocytopenic purpura
Idiopathic thrombocytopenic purpura

m
se
As
Antiphospholipid syndrome
Dr
I Drug-induced thrombocyto penia
-
~
Thro mbotic thrombo cytopen ic purpura
~opathic thrombocytopenic pu rpura

Antiphosp holipid syndrome
m
se
The isolated thrombocytopenia in a we ll patient po ints to a diagnosis o f ITP. The
As
comb in ed o ra l contraceptive pill d oes not commonly cause blood dyscrasias
Dr
A 12-year-old boy is noted to bleed excessively duri ng an elective dental extraction.
Following the procedure, examination reveals petechial skin haemorrhages. Blood results
show:
Hb 12.3 g/dl
Pit 255 * 109/ 1
W BC 7.9 * 109/ 1
PT 13.3 sees
APTT 39 sees
Factor VJJJ
87%
activity
Disseminat ed intravascular coagulation
Von Willebrand's disease
Haemophilia A m
se
As
Haemophilia B
Dr
Disseminated intravascular coagulation
Idiopathic thrombocyto penic pu rpu ra
Von Wi llebrand's disease
Haemophilia A
Haemophilia B
m
se
The combination of a petechial skin rash combined with a slightly elevated APTT and
As
reduced factor Vlll activity make Von Willebrand's disease the most likely diagnosis
Dr
Which one of the following causes of primary immunodeficiency is due to a defect in
neutrophil function?
Wiskott-Aidrich syndrome
Common variable immunodeficiency
Bruton's congenital agammaglobulinaemia
Di George syndrome
m
se
As
Chronic granulomat ous disease
Dr
Wiskott-Aidrich syndrome GD
Common variable immunodeficiency GD
Bruton 's congenital agammaglobulinaemia CD
Di George syndrome CD
m
se
CD
As
Dr
A 75-year-old male patient presents to the urology clin ic with a 1-month hist ory of
passing frank haematuria. A flexible cystoscopy reveals a mass of the bladder wall and the
biopsy reveals transitional cell ca rcinoma.
Which industry was he likely t o have wo rked in?
Feed production
Milit ary p ersonnel
Rubber industry
Dyestuffs and pigment manufacture
m
se
As
Refrigerant production before 1974
Dr
Feed production
Milit ary personnel
Rubber industry
Dyestuffs and pigment manufacture
Refrigerant production before 1974
Exposure to aniline dyes is a risk factor for trans itional cell carcinoma
Important for me l ess :mocrtc.nt
Aniline dyes are used in dyestuffs and pigment manu facture. Exposure to aniline dyes is a
risk fact or for transitional cel l carcinoma.
Feed production may expose to aflatoxin.
The military may expose t o must ard gas.
m
Rubber industry may expose to nitrosa mines.
se
As
Refrigerant production before 1974 may expose to vinyl chloride. Dr
Which one of the following featu res is least associated with Waldenstrom's
macrog lobulinaemia?
Cryoglobulinaemia
Bone pain
Retinal vein thro mbosis
Hepatosplenomegaly
m
se
As
Monoclonal IgM paraproteinaemia
Dr
Cryog lobu linaem ia f!D
I Bone pain ED
Retinal vein thrombosis GD
Hepatosplenomegaly f!D
m
se
Monoclonal IgM paraproteinaemia GD
As
Dr
A 68-year-old man p resents to the acute med ical ward following a refe rral from his
g eneral practitio ner. The patient has experienced a 3 mo nth h istory o f weight loss,
lethargy and malaise, accompanied by headaches and blurred vision. On examination the
patient has mild s pleno megaly and some minor cervical lymphadenopathy.
Initial investigations a re as follows:
Hb 110 g/ 1
Platelet s 95 8
109/ 1
WBC 14 8
109/ 1
Bilirubin 11 IJffiOI/1
ALP 70 u/1
ALT 17 u/1
yGT 52 u/1
Albumin 20 g/1
Urinary Bence Jones protein Positiv e
Skelet al survey X-rays No lesions observed
Given these in itial results and the patient's presenting symptoms, what is the most likely
diagnosis?
Acute myeloid leukaemia
Multip le myeloma
Burkitt's lymphoma
Waldenstrom 's macroglobu linaemia

em
s
As
Myelodysplasia
Dr
Acute myeloi d leukaemia
Multiple myeloma
Burkitt's lymphoma
Waldenstrom 's macroglobulinaemia
Myelodysplasia
Waldenstrom 's macroglobulinaemia - Organomegaly with no bone lesions
Multiple myeloma - Bone lesions with no organomegaly

Differentiating between multip le myeloma and Wa ldenstrom's macrog lobulinaemia can

be difficu lt due to the considerable overlap seen in their presenting symptoms. However,
key differences do exist.
In cases of multiple myeloma, bone pain in the hips, back or shoul ders is present in the
maj ority of patients. This kind of pain is absent in Waldenstrom 's macroglobulinaem ia,
who usually w ill co mplain of pain secondary t o hyperviscosity e.g. persistent headaches
Organomegaly is also more commonly seen in Wa ldenstrom's macrog lobulinaemia.
Bence Jones protein, although classically associat ed with multiple myeloma, can be
em
present in patient s with Wa ldenstrom's macroglobulinaemia or patients with chronic B

s
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cell lymphocytic leukaemia.

Dr
Transmission o f which type of infection is most likely to occur following a platelet
transfusion?
Syphilis
Malaria
Hepatitis B
Bacterial
m
se
As
HN
Dr
Syphilis m.
Malaria tiD
Hepatitis B fD
Bacterial ED
HIV m.
m
se
As plat elet co ncentrates are g enerally stored at room temperature they p rovide a more
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favourable environment for bacterial co ntamination than other b lo od p rodu cts .
Dr
Which one o f the following causes of primary immunodeficiency is due to a defect in B-
cell function?
Di George syndrome
Chediak-Higashi syndrome
Chronic granulomatous disease
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Wiskott-Aid rich syndrome
Dr
Di George syndrome GD
Chediak-H igashi syndrome GD
I Common variable immunodeficiency crD
Chronic granulomatous disease (fD
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CD
As
Dr
A 60-year-old man is known to have renal cell carcinoma and is currently undergoing
treatment. He presents to the med ical take with a one month history of worsening central
lower back pain which he cannot manage with analgesia at home and which is worse at
night. He has no other new symptoms. Which investigation should be performed next?
X-ray who le spine
CT lu mbar spi ne
MRI whole spine
MRI lumbar spine
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X-ray lumba r and sacral spine
Dr
X-ray whole spine
CT lu mbar s pi ne
MRI who le sp ine
MRI lumbar spine
X-ray lu mbar a nd sacral spine
An MRI whole spine s houl d be perfo rmed in a patient s uspected of sp inal

metastases
Sp ina l metastases should be hig h on yo ur list o f differe ntia ls fo r this patie nt. He is known
to have a type of cancer which readily meta stasises to the bo ne, a nd has p rog ressive back
pa in. He, the refo re, need s urge nt imag ing of his sp ine . MRI who le spine is pre fe rable
because patients with spinal metastases often have metasta ses at multip le leve ls within
the spine . Pla in radiog rap hs and CT should not be performed as they have a lowe r
sensitivity for revea ling lesio ns and cannot exclud e co rd com pression.
Im ag ing should b e perfo rmed within 1 week if the re a re symptoms sus picious for spinal
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metasta ses but no neurolog ica l symptoms, and within 24 hours if there a re symptoms
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s uggestive of maligna nt sp ina l cord compression.
Dr
A 40-year-old female is referred to medical assessment unit by her physician for querying
t hro mbotic thro mbocytopenic purpura (TIP) after she presented with a temperature of
38.9°C. Her subsequent urea and electrolytes showed det eriorating renal function with a
creatinine 3 times greater than her baseline.
What is the underlying pathophysiology of TIP?
Autoimmune destruction o f red blood cells
Failure t o cleave von Willebrand factor normally
Anti-bodies against von Will ebrand facto r
Autoimmune destruct ion of platelets
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A deficiency of vo n Willebran d factor
Dr
Autoimmune d estruction o f red blood cells
I Failure t o cleave von Willebrand factor normally
Ant i-bodies ag ainst von Will eb rand fact or
Autoimmu ne d est ruction of p latelets
A d eficiency of von Willebran d factor
TIP is caused by the fa ilure to cleave vWF normally

Patients wit h TIP have unusually large multimers o f von Willeb rand fact or (vWF) in t heir
plasma. Patients wit h TIP lack a plasma p rot ease t hat is resp onsible f or t he breakdown o f
these ult ra-large vWF multimers. See notes below.
Autoimmune d estruction of red blood cells is a form of autoimmu ne hemolytic ana emia
and is not t he correct answer in this scenario.
Autoimmune d estruction of p latelet s is seen in idiopathic throm bo cytopenic p urp ura

(ITP).
A d eficiency of von Willebran d factor (vWF) is seen in von Willebrand disease, a genet ic
disorder. m
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Ant i-bodies against vWF is incorrect.

Dr
A 35-year-old woman who is 16 weeks p regnant has attended the acute medical un it
a fte r her first seizure. Her p regn ancy has been uncomplicated thus far. Her temperature is
39.4°(, pulse rate 86, blood pressu re 125/86 mmHg. Bloods are as follows:
Hb 69 gf l
Plat elet s 43 s 109/ 1
WBC 7.4 * 109/1
Na• 137 mmol/ 1
K• 4 .9 mmolfl
Urea 18 mmol/ 1
Urine di p was negative for p rotein and ketones. The la boratory p hone you to info rm you
schistocytes have been seen on the blood fil m.
Which of these best describes the pathogenesis of this condition?
Dysregu lation of coagulation and fibrino lysis, resu lting in widespread clotting
An acqu ired inhibition of ADAMTS13, preventing the cleavage of von Willebrand

Factor multimers
Bacteria l toxin initiation of apoptosis and throm bogenesis
Abnorma l placenta l pe rfusion and vascu larisation

sem
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Paras itic infiltration of re d blood cells

Dr
Dysregu lation of coagu lation and fibrino lysis, resulting in widespread clotting fl3
r:
I acquired inhibition of ADAMTS13, p reventing the cleavage of von Willebra nd
Factor multimers
C!!D
Bacterial toxin initiatio n of apoptosis and throm bogenesis
Abnort placenta l perfusion and vascularisation
Paras itic infiltration of red blood cells
Acquired inh ibition of the p rotein ADAMTS13 which cleaves vWF multimers is the
most co mm on cause of TIP
This woman has presented with the classical pentad of thrombotic thrombocytop enic
pu rpu ra - feve r, neu rological dysfunction, evidence of haemolys is (blood film), rena l injury
and thrombocytopenia.
Acquired inability to cleave vWF multimers is the most common cause of TIP. This can
occasiona lly be prompted by p reg nancy. Th is results in p latelet deposition a nd
widesp read coagu lation. ADAMTS13 is the p rotein responsible for th is cleavage and can
be inhib ited by numerous causes. A co ngenita l deficiency in this protein is a rare cause
(Upshaw-Schu lma n Syndrome).
1 - Describes disseminated intravascu la r coagulation. This has a similar haemolyti c

pictu re, but fever, neu ro logica l dysfu nction and AKI are less common.
3 - Describes haemo lytic-uraemic syndrome which is classically a ssociated with E co li

0 :157; however no p rodroma l history of diarrhoea is mentioned. The blood results woul d
however be rather sim ilar.
4 - Describes pre-ecla mps ia. This can cause both seizures (ecla mps ia) a nd a
microang iopathic haemolytic anaemia. However, it woul d be uncommon to occu r so ea rly
in p regnancy. a negative urine dip a lso suggests this is not the diagnosis.
5 - This is malaria . Whilst it can also cause haemolys is, it is uncommon for it to do so with
this history. For malaria to be seve re enough to cause seizures, one would expect the
b lood fil m to show some parasites and not just sch istocytes.
em
I•• I
s
'f • Discuss (3)

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Improve J
Dr
A 68-year-old man presents with lymphadeno pathy. On examination you note
splenomegaly. Investigatio ns reveal:
Hb 125 g/ 1
Ca2• 2.34 mmol/ 1
Further investigations reveal an IgM pa raprotein of 40 g/ Land skeletal survey shows no

bone lesions.
Monoclonal gammopathy of unknown significance
Chronic lym phocytic leukaemia
Waldenstrom's macroglobuli naemia
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Myeloma
Dr
Monoclonal gammopathy o f unknown significance

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Waldenstrom 's macroglobulinaemia
Myeloma
A paraproteinaemia is most often seen in myeloma, although a few other

-
........
lymphoproliferative disorders can be associated with this. In this case, the patient most
likely has a type of lymphoma (lymphoplasmacytic lymphoma) produci ng excess IgM.
Collectively the syndrome is called Wa ldenstrom's macroglobulinaemia, w hich usually also
present s w ith b one marrow infiltration, splenomegaly and sometimes lymphadenop athy.
In contrast to myeloma it does not cause lytic bone lesions o r hyperca lcaemia. Further
evidence against myeloma would b e the nat ure of the p araprotein. A true IgM myeloma is
very rare (lgG, IgA, and IgD being much more co mmon). To fulfill the diagnostic criteria
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for monoclonal gammop athy o f unknow n significance, patients must have a monoclonal
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paraprot ein band lesser than 30 g/L.
Dr
A 77 -year-old man with a history of chronic lymphocytic leukaemia is adm itted to the
Acute Medical Un it with pneu monia. This is his fourth adm ission for pneumonia in the
past six mo nths. Which one of the following factors is most likely to be responsible?
Hypersplenism
Decreased lymphocyte su rvival
Hypoga mmaglobulinaemia
Transformation to high -grade lymphoma
m
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Immature lymphocytes
Dr
A 77 -year-old man with a history of chronic lymphocytic leukaemia is admitt ed to the
Acute Medical Unit with pneumonia. This is his fourth admission for pneumonia i n the
past six months. Wh ich one of the follow ing fact ors is most likely to be res ponsible?
Hypersplenism
Decreased lymphocyte survival
Hypogammaglobulinaemia
Transformation t o high -grade lymphoma
m
Immature lymphocytes
se
As
Dr
Which one of the following is least associated with lead poisoning?
Acute glomerulonephritis
Blue lines on gum margin
Abdominal pain
m
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As
Microcytic anaemia
Dr
Which one of the following is least associated with lead poisoning?
Peripheral neu ropathy
Acute glomerulonephritis
Blue lines on gum ma rgin
Abdominal pain
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~
m
se
Microcytic anaemia
As
Dr
A 52-year-old man with a history of anaemia and abdominal discomfort is diagnosed as
having chronic myeloid leukaemia. What is the mechanism of actio n of imatinib?
EGF receptor antagonist
Tyrosine kinase inhibitor
Anti-CD52 monoclonal antibody
m
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p53 inhibitor
Dr
A 52-year-old man with a history o f anaemia and abdominal discomfort is diagnosed as
having chronic myeloid leukaemia. What is the mechanism of actio n of imatinib?
EGF receptor antagonist
I Tyrosine kinase inhibitor

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~
Chronic myeloid leukaemia - imatinib = tyrosine kinase inhibitor

m
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Imatinib is an inhibitor of the tyrosine kinase associated with the BCR-ABL defect
Dr
A 72-yea r-old woman is admitted with confusion and pa llor. Her daughter reports that
she has been getting more confused and tired fo r the past three months. Blood tests are
Hb 89 g/1
MCV 125 fl
Pit 148 * 109/1
WBC 4.4 * 109/ 1
In light of the macrocytic anaem ia some further tests a re ordered:
Intrinsic factor antibodies Negative
Vitamin B12 94 ng/ 1( 200-900 ng/ 1)
Folic acid 1.1 nmolfl ( > 3.0 nmolfl)
Ora l folic acid + blood transfusion
Ora l folic acid + start Intramuscular vitam in Bl 2 when folic acid levels are normal
Intra muscula r vita min Bl2 + start oral folic acid when vitamin Bl2 levels a re normal
Blood transfusio n
em
s
As
Ora l p redn isolone

Dr
Oral folic acid + blood transfusion
Oral fo lic acid + sta rt Intramuscu lar vitamin Bl2 when folic acid levels are no rmalfiB
Intramuscular vitamin Bl 2 + start ora l folic acid when vitamin Bl 2 levels are
normal
Blood transfusion
Oral prednisolone
It is important in a patient who is also deficient in both vitamin Bl2 and folic acid to treat
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the Bl2 deficiency first to avoid preci pitating subacute combined degeneration of the
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cord
Dr
A 56-year-old man is investigated for lethargy. A full blood count shows the following:
Hb 8.6 g/dl
Platelets 42 s 109/1
WBC 36.4 8
109/1
***Blood film shows 30% myeloid blasts with Auer rods - please liase with
haematologist** 8
Given th e likely diagnosis, w hich one of the following is associated with a good
prognosis?
25% blast following first course of chemotherapy
Deletion of chromosome 5
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Dr
25% bias following f irst course of chemoth erapy
Delet ion of chromosome 7
Acute myeloid leukaemia- good prognos is: t(15;17)

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A t ranslocation b etween chromosome 15 and 17 is seen in acut e promyelocytic.
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leukaemia, which is know n to carry a good prognos is.
Dr
A 74-year-old woman with a past history of chronic lymphocytic leukaemia presents with
lethargy. The following blood results are obtained:
Hb 7.9 g/ dl
Pit 158 * 109/ 1
wee 24 .0 8
10911
Blood film : normochromic, normocytic anaemia
What complication has most likely occurred?
Microangiopathic haemolytic anaemia
Warm autoimmune haemolytic anaemia
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Cold autoimmune haemolytic anaemia
Dr
Microangiopathic haemolytic anaemia

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Cold autoimmune haemolytic anaemia
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Warm autoimmune haemolytic anaemia occurs in around 10-15% of patients with chronic
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lymphocytic leukaemia
Dr
A patient with a history o f recurrent th romboembolic events develops a deep vein
thrombosis despite full anticoagu lation with heparin. Wh ich one of the following causes
o f thrombophilia is associat ed with resistance t o heparin?
Antithrombin III deficiency
Protein C deficiency
Lupus anticoagulant
m
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As
Activated protein C resistance
Dr
Prot ein S deficiency
Prot ein C deficiency
I Lupus anticoagulant
Activat ed protein C resistance
m
Heparin works by binding to antithrombin III, enhancing its anticoagu lant effect by
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inhibiting the formation of thrombin and other clotting fact ors. Patient s with antithrombin
As
Ill deficiency may therefore by resistant t o heparin treatment
Dr
A 28-year-old gentleman was diagnosed with Hodgkin's lymphoma after presenting to
his GP with painless lymphadenopathy. Following a staging pos itron emission
tomography (P ET) scan, nodes invo lving both sides of the d iaphragm were found. Which
stage of the Ann-Arbor classification does his presentation fall under?
Stage I
Stage II
Stage III
Stage IV
m
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As
Stage V
Dr
Stage I m
Stage II CD
~gelll GD
Stage N CD
Stage V m
Stage Ill of the Ann-Arbor clinical staging of lymphomas involve lymph nodes on
both sides of the diaphragm
The Ann -Arbor classification is used for Hodgkin's lym phoma and is split into 4 stages
according to the spread of the disease.
Stage I - involves a single regional lymph node
Stage II - involves two or more lymph nodes on one side o f the diaphragm
Stage N - distant spread involving one or more extra lymphatic organs
m
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Stage V - Not part of the Ann-Arbor classification
As
Dr
Which of the following is a good prognostic factor in chronic lymphocytic leukaemia?
Female sex
Lymphocyte doubling time < 12 months
CD38 expression positive
Age > 70 years
m
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Raised LDH
Dr
Female sex
Lymphocyte doubling time < 12 months
CD38 expression positive
I
Age> 70 years
m
Raised LDH
se
As
Dr
A 10-year-old boy is referred to you following his 7th course of antibiotics for lower
respirat ory tract infection in t he last 6 yea rs. He has difficult to co ntrol eczema for which
he is currently on a to pical steroid cream . His bloods are as follows
Hb 139 g/1
8
Plat elets 65 109/1
8
WBC 12.3 109/1
In which of t he following genes may you expect to see an abnormality?
WASP
PKDl
CFTR
HFEl
m
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As
RET
Dr
WASP CD
P~D l
CFTR
•
GD
HFEl m
RET m
The combination of frequent infections, eczema and thrombocytopenia are characteristic
of the Wiskott-Aidrich syndrome, which is caused by an abnormality in the WASP gene.
m
The PKDl gene is associated with polycystic ki dney disease, CFTR with cystic fibrosis,
se
HFEl with haemochromatosis and RET an oncogene associated with multiple endocri ne
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neoplasia and also Hirschsprung's disease.
Dr
Which electrolyte disturbance is cisplatin most associated with?
Hypocalcaemia
Hyponatraemia
Hypomagnesaemia
Hypokalaem ia
m
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As
Hypercalcaemia
Dr
Hypocalcaemia CfD
Hyponatraemia .
(D
Hypomagnesaemia CD
Hypokalaemia tiD
Hypercalcaemia tiD
m
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Cis platin is associated with hypomagnesaemia
As
Dr
A 29-year-old wo man who has a hist ory of recurrent pulmonary emboli is identified as
having factor V Leiden. How does this particular inherited thrombophilia increase her risk
of venous throm boembolic events?
Decreased levels of facto r V
Increased levels of factor V
Activated fact or V is inactivated much more slowly by activated prot ein C
Activated fact or V is inactivated much more quickly by activated protein C
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As
Decreased antithrombi n III levels
Dr
Decreased levels of facto r V
Increased levels of factor V
I Activated factor Vis inactivated much more slowly by activated prot ein C
Activated facto r V is inactivated much more quickly by activated protein C

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Decreased antithrombin III levels
m
In patient s with factor V Lei den, activated facto r V is inactivated 10 times more
se
slowly by activated p rotein C than normal
As
Dr
Which one o f the following trans locations is associated with acute p ro mye locytic
leukaemia?
t(15;17)
t(9;17)
t(9;22)
t(15;22)
m
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As
t(17;22)
Dr
t(15;17) CD
t(9;17) m
t(9;22) f!D
t(15;22) .
(D
t(17;22) CD
m
se
Acute promyelocytic leukaemia - t(15;17)
As
Dr
A 39-yea r-old woman presents with a strange collection of sym ptoms over the past six
months. She has been seen by mu ltiple specialists, none of whom have been a ble to find
a cause for her sym ptoms.
Her symptoms include wo rsening headaches, memory loss, low mood, lethargy,
a bdom inal pain causing paroxysms of intermittent genera lised pain, nausea, an unusual
taste in her mouth and pa raesthesia in her extre mities.
She is irrita ble during you r consultation and at times tea rful complaining that no one is
ta ki ng her seriously and confid ing that her Genera l Practitioner had referred her fo r
counselling.
Routine b lood tests show:

Hb 101g/ L
WBC 5.6 10*9/ l
Plat elet s 350 10*9/ l
MCV 77fl
Na 136mmol/l
K 4.3mmoi/L
Urea 18.2mmol/l
Creat inine 408umol/l
What is the likely cause of he r sym ptoms?
Pick's disease
Hepatic encephalopathy
Lead po ison ing
Early-onset Alzheimer's
em
s
Vira l e ncephalitis
As
Dr
Pick's disease
Hepatic e ncephalopathy
Lead po iso ni ng
Early-onset Alzheimer's
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r Viral e ncepha litis
Lead po isoni ng is o ften occupatio nal and com prises g astro intestina l an d
neu ro psychiatric symptoms and anae mia due to interruption to the hae m
b iosynthetic pathway.
It is impo rtant to keep lead poisoning in mind as a differentia l, particularly in someone for
whom routine investigations are not providing an answer and who clea rly has abnormal
pathology (demonstrated by her kidney fa ilure and microcytic anaemia).
It can cause a varied and often non-specific array of symptoms. Some more 'classical'
features include an unusual taste in the mouth and paraesthesia of the extremities.
m
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As
Questions may more obviously point to the route of exposu re through industrial exposure
or contact with lead-based products such as paint or contam inated water.
Dr
A 79-yea r-old fema le with a histo ry of CO PD a nd metastatic lung cancer is a dm itted with
increasing s hortness of b reath. Following d iscussion with fam ily it is decided to withdraw
a ctive treatment, inclu ding fluid s a nd a ntibiotics, as the adm issio n li kely represents a
terminal event. Two d ays after ad mission she b ecomes ag ita ted a nd restless. What is the
mo st app ropriate mana gement?
Subcuta neous midazo lam
Intramuscula r ha lo pe rido l
Ora l lormetazepam
Ora l haloperidol
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Re commence fluids and antibiotics
Dr
I Subcutaneous midazolam
Intra muscula r haloperidol

CD
mt
Oral lormetazepam CD
I Oral haloperidol GD
m
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Recommence fluids and antibiotics CD
As
Dr
A 64-year-o ld female is b ro ught to t he Emerg ency Department by her fam ily, w ho are
concerned about her increasing confusion over the past 2 days. On exami nati on she is
found to be pyrexial at 38°C. Blood t ests reveal:
Hb 9.6 g/ dl
Platelet s 65 8
109/ 1
wee 11.1 8
109/ 1
Urea 23 .1 mmol/ 1
What is the most likely d iag nosis?
Wegener's g ranu lom atosis
Thro mbotic thro mbo cyto penic purpura
Haemo lyt ic uraem ic syndrome
Idiopat hic t hro mbocyto penic pu rpu ra
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As
Ra pidly progressive g lomerulo nephritis
Dr
Wegener's granulomatosis CD
I Thrombotic thro mbocytopenic purpura CD

Haemolytic uraemic syndrome m
Idiopathic thrombocytopenic purpu ra
Rapi dly progressive glomerulonephritis

•m
HUS or TTP? Neuro signs point towards TTP
m
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The combination of neurological features, renal failure, pyrexia and thrombocytopaenia
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point towards a diagnosis of thrombotic thrombocyt openic purpu ra
Dr
A 21-yea r-old man attends the emergency depa rtment after noticing blood in his urine.
He has been feeli ng fatigued and generally unwell fo r the last two days and has been
finding himself getting out o f b reath easily. His housemates had commented yesterday
that he was 't urn ing yellow', but he had assumed they were teasing him for being unwell
and had igno red them .
He is normally fit and well and is not on any regular medications. He has however recently
started taking primaqu ine in preparation for a volunteering trip to Tanzan ia next week.
On exam ination, he is clea rly jaundiced and tachypnoeic. His urine sample is a dark b rown
and is pos itive for b lood and b il irubin. He is afebrile and normotensive, though is
requ iring some supplemental oxygen.
You a re awa iting the rest of his test resu lts but have received the following from the lab
so fa r:
Hb 115 g/ 1
MCV 90 fL
Haematocrit 0.3 L/L
Platelets 250 * 109/1

8
WBC 10.2 109/J
Reticulocyte count 2. 1%
Peripheral blood film Presence of schistocytes, spherocytes and bite cells noted
What is the most li kely reason for this p resentation?
Sickle cell crisis
Post-in fectious haemolytic anaemia
G6PD deficiency
sem
As
Pyruvate kinase deficiency

Dr
Sickle cell crisis m
Post-infectious haemolytic anaemia CD
I G6PD deficiency GD
Hereditary spherocytosis f!D
Pyruvate kinase deficiency m
Ma la ria prophylaxis (e .g. primaquine) can trigger haemolytic anaemia in those with
G6PD deficie ncy
This man is presenting with signs and sympto ms of a haemolytic anaemia, the most like ly
cause of which is G6PD deficiency. A number o f foods and med ications can trigger
haemo lysis in individ uals with G6PD deficiency, an important class o f which are qu inine -
based anti- malaria l medications. The tempora l li nk between starting mala ria prophylaxis
and developing signs of haemolys is makes this the most like ly cause.
While a sickle cell crisis can trigger haemolysis, there is nothin g to suggest this patient
has sickle cell disease, and no sickle cells are p resent on the blood film.
Post-infectious haemolysis can occur with atypical pneumonias such as Mycoplasma

(cold -agglutinin disease) and infections th at induce hypersp lenism such as
mononucleos is. There is nothing to suggest an infectious cause in this scena rio, however.
Congenital haemog lobin defects such as s pherocytosis can a lso cause haemolysis. Whi le
there are spherocytes on this man's b lood film, these are present to different degrees in
haemo lytic anaem ias o f any cause and as such a re not s pecific.
Pyruvate kinase deficiency is the next most common inhe rited metabolic disorder after
em
G6PD deficiency. Haemolysis in these patients tends to be triggered in times o f s ignificant

s
As
physio log ical stress.

Dr
Which of the following is deficient in patients with hereditary angioedema?
Cl -I NH
C3
Heat shock protein type 1
m
C6
se
As
Histamine degradation protein (HDP)
Dr
Cl-INH f.D
C3 GD
I
Heat shock protein type 1
C6
m
Histamine degradation protein (HOP) m
m
se
As
Hereditary angioedema- Cl-INH deficiency
ltrpor:a.r! "or me _ess r-oc-tart
Dr
A 67 -year-old man with lung cancer is cu rrently t aking MST 30mg bd for pain relief. What
dose of oral morphine solution shou ld he b e prescribed for breakthrough pain?
5 mg
10 mg
15 mg
20 mg
m
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As
30 mg
Dr
5 mg fD
10 mg CD
15 mg GD
20 mg fD
30 mg (D
Breakthrough dose = 1/6th of daily morphine dose

m
se
The tota l daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should
As
be one-sixth of this, 10 mg
Dr
A 18-year-old man who is known to have hereditary spherocytosis is admitted to hospital
with lethargy. Admission bloods show the following:
Hb 4. 7 g/ dl
Retics 0 .3%
What is the most likely explanation for these findings?
Haemolytic crisis
Recent ciprofloxacin therapy
Sequestrati on crises
m
se
As
Ang iodysplastic bowel lesions
Dr
Haemolytic crisis CD
Recent ciprofloxacin therapy CD
I Parvovirus infection
Sequestrati on crises
6D
(tD
Ang iodysplastic bowel lesions m
m
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As
This man has had an aplastic crisis secondary to parvovirus infection.
Dr
A 40-year-old female has been diagnosed with haemolytic uraemic syndrome aher an
episode o f severe diarrhoea. She has a haemoglobin o f 84 mg/dl. Which of the fo llowing
blood results is most likely to be found?
Low haptoglobin
Low bilirubin
El evated magnesium
Low urea
m
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As
Increased Hb F
Dr
Low haptoglobin flD
Low bilirubin CD
Elevated magnesium fi!D
Low urea CD
Increased Hb F GD
Low haptoglobin levels are foun d in haemolytic anaemias

The pat ient has an intravascular haemolytic anaemia secondary to haemolytic u raemic
syndrome. Haptoglob in levels are reduced in intravascular haemolysis b ecause t hey bind
t o free haemogl ob in released from lysed erythrocytes. The complexes are t hen removed
from the p las ma by t he hepat ic ret iculo -endo thelial cells. Hapto globin levels d ecrease if
the rat e o f haemolysis is great er t han t he rate of haptoglob in pro duction.
Bilirubin levels are likely t o be elevat ed b ecause of increased metabolism o f haem.

Magnesium may b e low because o f diarrhoea or unaffected. Urea wou ld be increased due
m
se
t o acut e kidney inj u ry. HbF is found in patients w ith in herited haemoglob inopat hies and
As
not in acqu ired haemolytic anaemias.
Dr
A 54-yea r-old man is investigated for a chronic cough. A chest x-ray arra nged by his GP
shows a suspicious lesion in the right lung. He has no past history of note and is a life-
long non -smoker. An urgent bronchoscopy is arra nged which is normal. What is the most
likely diagnosis?
Lung sa rco ma
Squamous cell lung cancer
Lung adenocarcinoma
Small cell lung cancer
m
se
As
Lung carcinoid
Dr
Lung sarcoma CD
Squamous cell lung cancer C!D
I Lung ad enocarcinoma e:D

Small cell lung cancer CD
Lung carcinoid G'D
Lung adenocarcinoma
• most common type in non-smokers
• peripheral lesion
m
se
The clues are the absence of a smoking history and normal bronchoscopy, which suggests
As
a p eripherally locat ed lesion.
Dr
Which one of the following is the most common cause o f recurrent first trimester
spontaneous miscarriage?
Factor V Lei den gene mutation
Polycystic ovarian syndrome
Hyperprolactinaemia
m
se
As
Anti phospholipid syndrome
Dr
Factor V Lei den gene mutation

-
"""
Hyperprolactinaemia
Anti phospholipid antibodies (aPL) are present in 15% of women with recurrent
-
~
m
se
miscarriage, but in compa rison, the prevalence of aPL in women w ith a low risk obstetric
As
history is less than 2%
Dr
A 54-yea r-old lady presents with shortness of b reath, distended neck veins, and a swollen
and red face. She ha d She undergoes a CT scan of her chest demonstrating obstruction of
the superior vena cava (SVC). What is the most li kely cause?
Fibrosing mediastinitis
Th rombosis
Syphi litic th oracic aortic aneurysm
Primary mal ignancy
m
se
As
Metastatic ma lignancy
Dr
Fibrosing mediastinitis CD
Th ro mbosis .
CD
Syphilitic thora cic a ortic aneu rysm CD
I Primary malignancy ED
Metastatic mal ignancy ED
The correct a nswer is a p rimary maligna ncy. Intratho racic malignancy is resp onsible fo r up
to 60-85% of SVC o bstruction cases. Most co mmon is non-sma ll cell lung cancer, small
cell lung cancer and non-Hodg kin lymp homa. Together these malignancies re present
95% of SVC syndromes caused by ma lignan cy. This can b e the presenti ng featu re o f a
undiagnosed tumour. Throm bosis can occur fo llowing pace ma ker wire insertion and
centra l line placement. Syphilitic thoracic aortic aneu rysm and fibros ing mediastinitis used
to be common causes p rio r to widespread a ntib io tic use.
Source:
m
se
As
'Sup erio r Vena Cava Synd ro me .' BMJ Best Practice. 20 July 2016.
Dr
Which one of the followin g stat ement s regarding t he aetiology o f venous
thro mboem bol ism (VTE) is correct?
Third g eneration co mbined oral contraceptive pill s are safer t han second
g eneration ones
VTE d evelops in around 5% of patient s with Goodpasture's syndrome
Female g ender is a risk fact or recurrent VTE
The second trimester of p reg nancy is associated with a greater risk t han t he
puerpenum
m
se
As
Ta moxifen t herapy increases t he risk of VTE
Dr
Third generation combined o ra l contraceptive pill s a re safe r than second
generation ones
VTE d evelo ps in a round 5% o f patie nts with Good pastu re 's syndro me
Female gend er is a risk facto r recu rrent VTE
The second trimester o f p reg nancy is associated with a g reater risk than the
puerp enum
m
se
As
Tamoxifen therapy increases the risk of VTE
Dr
Which one o f the following may be associated with an increased risk o f venous
thromboembolism?
Fluoxetine
Selegiline
Diazepa m
Am itriptyline
m
se
As
Olanzapine
Dr
Fluoxetine GD
Selegiline flD
Diazepa m fD
ll npty
Am1 · r1ne
•
m
se
As
Olanzapine GD
Dr
What is the most commo n inherited bleeding disorder?
Haemophilia A
Haemophilia B
m
se
As
von Willebrand's disease
Dr
Haemophilia A (fD
Activated protein C resistance (D
Haemophilia B m
Antithrombin III deficiency CD
m
se
I I
As
von Willebrand's disease CD
Dr
A 32-year-old male presents to you r clin ic for review. He has a history of hereditary
spherocytosis and recently und erwent splenectomy. Since t he operation he's noticed a
major improvement in his energy levels.
If a blood film was taken from the patient, what new histological finding wou ld be
observed which wou ld have been absent p rior to splenectomy?
Schistocytes
Bite cel ls
Heinz bodies
Spherocytes
m
se
As
Howell-Jolly bodies
Dr
Schisto cytes m
Bite cells CD
Heinz bodies CD
Sphe~ocytes .
(D
Howell-Jolly bodies f.D
Howell-Jolly bodies are present in hereditary spherocytosis post-splenectomy

Howell -Jolly bodies are rem nants of the red blood cell (RBC) nucleus which are normally
removed by t he spleen. Post -splenectomy these Howell-Jolly b od ies persist and can be
o bserved on histo lo gy.
Spherocytes would also b e present. However, they wou ld have been obse rved on
histology p rior to sp lenect omy.
Schistocytes are sheared RBCs seen in micro angiopat hic haemolytic anaemia.
m
se
Heinz b odies and bite cells are ch aracteristic of glucose- 6-phosp hat e d ehydrogen ase
As
(G 6PD) d eficiency.
Dr
A 68-yea r-o ld ma n who takes warfa rin fo r atrial fibrillatio n is taken to the emerge ncy
d e partment ah er be in g invo lved in a road tra ffic accid ent. His GCS is red uced a nd a CT
head shows an intracrania l haemo rrhage . Bloods o n admission show the following:
Hb 13 .2 g/1
Plat elet s 222 * 109/1

8
W BC 11.2 109/ 1
INR 3 .1
In ad ditio n to vita mi n K, which o ne of the fo llowing blood p rod ucts should be g iven?
Cryo pre cipitate
Plate let tra nsfus io n
Prothromb in co mplex co ncentrate
Packed red cells
m
se
As
Fresh frozen plasma (FFP)
Dr
Cryoprecipitate
Plate let transfus ion

-
~
Prothrom b in complex concentrate
Packed red cells
Fresh frozen plasma (FFP)
m
Prothrombin complex concentrate is used for the emergency reversal of
se
As
anticoagu lation in patients with severe bleeding or a head injury
Dr
A 64-yea r-old man is reviewed in the haemato logy clinic. Which one of the following
features wou ld suggest th at a diagnos is mo noclo nal gammopathy of undeterm ined
significance is more likely than myeloma?
Bone pain
IgG pa raprote in band = 18g/l
Creatinine = 160 IJmol/1
Raised beta-2 microg lobulin
m
se
As
Lytic lesions on x-ray
Dr
Bone pain
IgG paraprote in band = 18g/l
Creatinine = 160 ).J mol/1
Ra ised beta-2 micrf globulin
Lytic lesions on x-ray
m
Paraproteinaemia is seen in both myeloma and monoclonal gammopathy of
se
undet ermined significance (MGUS) - at this level a diagnosis of MGUS is more likely. The
As
other features indicat e myeloma
Dr
A 51-year-old female is referred to t he haematology clin ic with a haemoglobin of 19.2
g/dl. She is a non-smoker. Her oxygen saturations on roo m air are 98% and she is noted
to have mass in the leh upper quadrant. What is t he most useful test to establish whet her
she has po lycythaemia vera?
Blood film
Red cell mass
Transferrin saturation
m
se
JAK2 mutation screen
As
Dr
Blood film
Red cell mass
Transferrin saturation
JAK2 mutation screen
Polycythaemia rubra vera - JAK2 mutation

m
se
The discovery of t he JAK2 mutation has made red cell mass a second- line investigation
As
for patients w ith suspected JAK2-negat ive po lycythaemia vera
Dr
A 60-year-old woman develops a d eep vein thrombosis (DVT) 10 days after having a hip
replacement despite taking prophyla ctic dose low-molecular weight heparin (LMWH). She
has no significant past medical history of note other than osteoarthritis. After being
diagnosed she is started on t reatment dose LMWH. What is t he most appropriate
anticoagulation strategy?
Continue on t reatment dose LMWH for 6 weeks
Continue on t reatment dose LMWH for 3 months
Switch to warfa rin for 3 months
m
se
As
Dr
Continue on t reatment dose LMWH for 6 weeks
Continue on t reatment dose LMWH fo r 3 months
Switch to warfarin for 6 months

-
~
Venous thro moboem bolism - length of warfarin t reatment

• p rovoked (e.g. recent su rgery): 3 months
• unp ro voked: 6 months
m
se
The recent su rgery is an obvious 'provoking' factor for the DVT. She should therefore be
As
anticoagulated for 3 months.
Dr
A 4 -yea r-o ld child with a d efo rming mandibula r neck swe lling . Biopsy of the lesio n reveals
a 'sta rry sky' a ppea ra nce und e r microscopy.
Infection with which virus is an essential ste p in the pathogenesis of this di sea se?
HTLV-1
EBV
HPV
HIV
m
se
As
HSV-2
Dr
HTLV-1 C!D
EBV f%D
HPV a
HIV CD
HSV-2 a
EBV infection is imp licated in the pathogenesis of Burkitt's lymphoma
EBV is id entif iable in nearly all cases of Burkitt's lymphoma.
HTLV- 1 is associated with adu lt T cel l lymphoma
HPV is associated with cervical an d anal cancers
HIV inf ect ion is important in the pathogenesis of immuno deficiency-associated Burkitt's
lymphoma. However, in the endemic variant clearly d escribed here the disease may occur
in HIV negative children.
m
se
As
HSV-2 causes genital herpes
Dr
A 46-yea r-old woman presents to her GP with a 2-month history o f increasin g tiredness
and fatigue. She has also noticed that she ha s been getting more short o f breath recently.
Her past medica l history includes two urina ry tract infections in the past yea r and lower
back pa in fo r which she takes paracetamol. She does not take any othe r med ications. On
examination, she is pa le. The GP orders some basel ine blood tests:
Hb 101 g/ 1 (115-165 g/ L)
MCV 88 .1 fl (80- 100 fl)
Platelet s 129 * 109/1 (140-400 * 109/1)
ESR 114 mm/h (3-9 mm/h)
WBC 3.2 * 109/ 1 {4.0- 11.0 * 109/1)
Na• 137 mmol/ 1 (1 35- 14Smmol/l)
K• 4 .9 mmol/1 (3. 5-Smmol/ 1)
Urea 10 mmol/ 1 (2.5-6 .7mmol/ l)
Creatinine 108 ~mol/1 ( 45-90J,Jmol/ l)
eGFR SO ml/min/1. 73m2 ( >90 ml/min/1. 73m2)
Ca 2 + 2.9 mmoi/L (2.1 2-2.6Smmoi/L)
What is the next most appropriate investigation?
Renal ultrasound scan
Cervical lymph node b iopsy
PTH levels
CT KUB
em
s
As
Seru m e lectrophoresis
Dr
Renal ultrasound scan f.D
Cervica l lymph node biopsy f.D
PTH levels GD
CT KUB m.
I Serum electrophoresis CD
'CRAB' features of multiple myeloma = hyperCalcaemia, Renal fa ilure, Anaemia (and

thrombocytopenia) and Bone fractures/ lytic lesions
The combination of the hist ory, examination findings an d blood test results point towards
a diagnosis of multiple myeloma. This patient is demonstrating evidence of all four
f eatures of multiple myeloma:
• C - hypercalcaemia
• R- rena l insu fficiency (suggested by the U&Es and com plicated by the recurrent
UTis - patients are susceptible t o infections as the production of antibodies by
normal plasma ce lls is impaired)
• A -this patient is short of breath due t o her anaemia (and the FBC shows evidence
of pancytopenia - typically due to plasma cells infiltrating the bone marrow)
• B - bone pain (albeit subtle in the form of a vague hist ory of lower back pain)
The immunoglobulin produced by dysplastic plasma cells shows up as a monoclonal band

on serum electrophoresis.
Renal ultrasound scan will not aid diagnosis of multiple myeloma.
Cervical lym ph node biopsy may be helpful in lymphoma but not myeloma (a bone
marrow biopsy would be more helpful in multiple myeloma).
PTH levels can help identify the cause of hypercalcaemia but this patient has enough
f eatures suggestive of multiple myeloma t o j ustify investigating fo r myeloma first.
em
CT scan of the kidneys, ureters and bladder is unlikely to be helpful in identifying multip le
s
As
myeloma (although whole-body CT scanning is often used to detect osteolytic lesions).

Dr
A 54-yea r-old ma n who has developed d isseminated intravascula r coagulation secondary
to sepsis is reviewed . Twenty minutes ago he started to bleed per rectum. Blood products
includi ng pa cked red cel ls and fres h frozen plasma have been orde red. What is the single
most important facto r in determining whether cryoprecipitate should be given?
A low fibrinogen level
A high prothrom bin time
A high activated partial thrombo pla stin time
A low platelet count
m
se
As
A low haemog lobin
Dr
A low fibrinogen level
A high prothrombin time
A high activated partial thromboplastin time
A low platelet count
m
A low fibrinogen level is the major criteria determining the use of cryoprecipit ate in
se
As
bleeding
Dr
A 4-yea r-old boy is admitted after developing a haem arthrosis in his right knee whilst
playing in the garden. The following blood results are obtained:
Plat elets
PT 11 sees
APTT 76 sees
Factor VIlle
Normal
activity
Haemophilia A
m
se
As
Haemophilia B Dr
Antithrombin III deficiency CD
Von Willebrand's disease 6D
ntiphospholipid syndrome m
Haemophilia A tiD
I Haemophilia B CD
m
A grossly elevated APIT may be caused by heparin therapy, haemophilia or
se
antiphospholipid syndrome. A normal factor VIlle activity point s to a diagnosis of
As
haemophilia B (lack of factor IX). Antiphospholipid syndrome is a proth rombotic condition
Dr
A 17-year-old man is reviewed in the haemato-oncology multi-d isciplinary meeting with a
diagnosis of Acute lymphoblastic leukaemia, (ALL). The results of bone marrow testing,
immunophenotyping, and chromosomal analysis are reviewed.
Which of the following features is associated with a poor prognosis?
Hypodiploidy
Translocation t(12:21)
Precursor B ALL
Translocation t(1:19)
m
se
As
Trisomy 4
Dr
I Hypodiplo idy fD
Translocation t(12:21) fiD
Precursor B ALL f!D.
Translocation t(1:19) CD
Trisorr y 4 CD
Hypodiplo idy is seen as a n unfavou ra ble feature in ALL, with th e opp osite, hyper diplo idy
associated with a g ood prog nostic o utco me.
Trisomy 4, 10 a nd 17 is associated with a g ood p ro gnostic outcome in ALL.
The t(12;21) tra nslocation associated with a fusion pro te in fo rmerly known as TE L-AM Ll is
associated with a g ood prog nostic o utco me in ALL, The t(1:19) tra nslocation is associated
with low leve ls o f resistance to chemothe ra py inte rve ntion in ALL, and thus a good
p rog nostic outcome. The t(9:22) o r Phila de lp hia translocatio n, is associated with a poor
p rog nos1s.
m
se
Precursor B-ALL is more res ponsive to chemothera py than that invo lving mo re mature B
As
lymphocytes. Dr
A patient presents as she has a stro ng fam ily history of cancer. Which one of the following
cancers is least li kely to be inherited?
Colorectal cancer
Breast cancer
Gastric cancer
Endometria l cancer
m
se
As
Ovarian cancer
Dr
Colorecta l cancer fD
Breast cancer fD
Gastric cancer ED.
Endometrial cancer fD
Ovarian cancer fiD
Between 5 and 10% of all breast cancers are thou ght to be hereditary. Mutation in the
BRCAl and BRCA2 g enes also increase t he risk of ovarian cancer. For colorect al cancer
around 5% o f cases are caused by heredit ary non -polyposis colorecta l ca rcinoma
m
(HNPCC) and 1% are due to fam ilial adenomatous polyposis. Women who have HNPCC
se
also have a markedly increased risk for develop ing endometrial cancer - around 5% of
As
endometrial cancers occur in women with this risk factor.
Dr
A 59-year-old female patient presents with headache, lethargy, and a purpuric rash on her
shin s.
Hb 89 g/1
Platelets 68 s 109/1
WBC 2.6 * 109/ 1
Protein Electrophoresis paraprotein 2g/L
lmmunoprotein Electrophoresis monoclonal lgM
C4 low limit of normal
Rheumatoid Factor elevated
Hepatitis C infection
Rheumat oid arthritis
Sj ogren syndrome
Waldenstrom's macroglobulinaemia
m
se
Monoclonal gammopathy of unclear significance As
Dr
Rheumatoid arth ritis
Sjo ~ren synd rome
-
Monoclonal gam mopathy of unclea r significance
Waldenstrom macrog lobulinaemia is a lymphoplasmacytic lymphoma (lymphoplasmacytic

infiltration in the bone ma rrow or lymphatic tissue) associated with an IgM monoclonal
p rotein in the serum. It is essentially a bone marrow-based d isease. Patients may develop
m
constitutional symptoms, pancytopen ia (especially anaem ia and th rombocytopen ia),
se
o rganomega ly, neuropathy, and symptoms associated with immunoglobu li n depos ition
As
o r hyperviscosity.
Dr
A 22-year-old fema le present s to the emergency department with angioedema on 5
occasions i n a six month period. No obvious trigger was identified and she does not
improve significantly w hen given IM adrenaline.
Her symptoms are caused by a deficiency of which substance?
Bradykinin
Cl est erase inhibitor
Eosinophil peroxidase
m
Kallikrien
se
As
Neutrophil elastase
Dr
A 22-year-old fema le presents to the emergency department with angioedema on 5
occasions in a six month period. No obvious trigger was identified and she does not
improve significantly when given IM adrenaline.
Her sym ptoms are caused by a deficiency o f which substance?
Bradykinin «ED
Cl esterase inhibitor fD
Eosinophil peroxidase m
Kallikrien CD
Neutrophil elastase
•
Heredit ary angioedema is caused by deficiency o f Cl esterase inhibitor
m
se
As
Heredit ary angioedema is caused by a deficiency o f Cl esterase inhibitor.
Dr
A 52-yea r-old wo man presents with a pa inless, en la rged lymph node in her neck. She has
no other sympto ms. Cytogenetic stu dies revea l a translocation which confirms a dia g nos is
o f fo ll icular lymp homa.
Which translocatio n was obse rved in the patient's cytogenetic stud ies?
t(9;22)
t(8;14)
t(ll;l4)
t(14;18)
m
se
As
t(15;17)
Dr
t(9;22) f!D
t(8;14) CD
t(11;14) tiD
t (14;18) CD
t(15;17) f!D
Follicular lymphoma is characterised by a t(l4:18) t ranslocation

Follicular lymphoma is driven by a translocation involving Ig heavy chain on ch romosome

14 and BCL2 on chromosome 18.
t(9;22) is associated with ch ron ic myeloid leukaemia
t(8;14) is associated with Burkitt lymphoma
t(11;14) is associated with mantle cell lymphoma
m
se
t(15;17) is associated with acute promyelocytic leukaemia As
Dr
A 67 -year-o ld with chronic kidney disease stage 4 and metastatic prostate cancer
presents as his pain is not contro lled with co-codamol. Which one of the following
opio ids is it most appropriate to use given his impa ired rena l function?
Buprenorphine
Morphine
Hydromorphone
Diamorphine
m
se
As
Trama dol
Dr
Buprenorphine C!D
Morphine fiB
Hydromorphone CD
Diamorphine «D
Trama dol crD.
m
se
Alfentanil, buprenorphine and fenta nyl are the preferred opioids in patient s with chronic
As
kidney disease.
Dr
Which one of the following haematological malignancies is most commonly associated
with the t(ll; l 4) translocation?
Acute promyelocytic leukaemia
Burkitt's lymphoma
Mantle cell lymphoma
m
se
As
Dr
Burkitt's lymphoma

-
~
m
se
As
Chronic myeloid leukaemia ~
Dr
A 17-year-old man is investigat ed fo r recu rrent infectio ns and easy bruising. In the past
year he has had four episodes of pneumonia. Other tha n the bruising he is noted to have
severe eczema on his trunk and arms. A full blood count is ordered and reported as
follows:
Hb 14 .1 g/dl
8
Pit 82 109/1
WBC 5.9 * 109/ 1
Neuts 4.4 * 109/ 1
Further bloods show low immunoglobulin M levels. What is the most likely diagnosis?
Ataxic telangiectasia
Chediak-H igashi syndrome
m
se
As
DiGeorge syndrome
Dr
Bruton's congenital aga mmag lobulinaem ia
I
Chediak-Higash i syndrome
DiGeorge synd rome
• recu rrent bacterial infections (e.g. Chest)
• eczema
m
se
• t hro mbocytopaenia
As
Dr
A 72-year-old man is referred to haematology with a ra ised haemoglobin. A diagnosis of
polycythaemia vera is suspected. Wh ich other abnormality of the blood wou ld be most
cons istent with this diagnosis?
Ra ised alkaline phosphatase
Hypokalaemia
Thrombocytopaenia
Ra ised ferritin level
m
se
As
Neutrophilia
Dr
Ra ised alkaline phosphatase ED
Hypokalaemia CD
Thrombocytopaen ia GD
Ra ised ferritin level QD
m
se
I 6D
As
Neutrophilia
Dr
Which one o f the following causes of primary immunodeficiency is due to a defect in both
B-cell and T-cell function?
Common va riable immunodeficiency
Chediak-H igashi syndrome
m
se
As
Di George syndrome
Dr
Common variable immunodeficiency fD
Chronic granulomatous disease m
I Wiskott-Aidrich syndrome &3
Di George syndrome
•
GD
Combined B-and T-cell disorders: SOD WAS ataxic (SOD, Wiskott-Aidrich

syndrome, ataxic te langiectasia)
Wiskott-Aidrich syndrome causes primary immunodeficiency due to a combined B- and

T -cell dysfunction. It is inherited in aX-linked recessive fashion and is thou ght to be
m
se
caused by mutation in the WASP gene. Features include recurrent bacterial infections (e.g.
As
chest), eczema and thrombocytopenia
Dr
A 54-year-old woman presents to the Emergency Department wit h a five day history of
back pain. Her past medical history includes b reast cancer and osteoarthritis. The back
pa in is located in the lower thoracic region and is made wo rse by cough ing and sneezing.
There has been no change in bowel habit or urinary symptoms. On examination there is
diffuse tenderness in t he lower thoraci c reg ion. Peri-a nal sensation is normal and lower
limb reflexes are brisk. Which one of the following is the most ap propriate management
plan?
Organise outpatient MRI
Oral pa raceta mol + urgent MRI
Oral pa raceta mol + urgent t horacic/lumbar spine x- ray
Oral dexamethasone + urgent tho racic/ lumbar spine x- ray
m
se
As
Oral dexamethasone + urgent MRI
Dr
Organise outpatient MRI
Oral pa raceta mol + urgent MRI
Ora l pa raceta mol + urgent tho racic/ lumbar spine x-ray

-
I
Ora l d examethasone + urgent tho racic/ lumbar sp ine x-ray
Oral dexamethasone + urgent MRI

-
"""
"""
This woman has spinal co rd co mpression until proven otherwise and should have urgent
assessment.
Recent NICE guidelines suggest contacting the local metastatic spina l cord compression
m
se
coordinator in th is s ituation. This should hopefully prevent delays in treatment by
As
ensuring the patient is admitted to the most appropriate p lace
Dr
A 31-year-old woman who is 25-weeks pregnant is brought t o the Emergency
Department by her husband. Over the past two days she has become increasingly
confused. Her t emperature is 37.8°C and blood pressure is 104/62 mmHg. Blood t ests
show:
Hb 8.3 g/dl
Platelets 88 8
109/1
WBC 15.1 8
109/1
Blood film Fragmented red blood cells
Sodium 139 mmol/ 1
Potassium 5.2 mmol/1
Urea 19.4 mmol/ 1
Creatinine 296 J,Jmol/ 1
What is the most appropriate treatment?
Rituximab
Intravenous immunoglobulin
Methyl prednisolone
Ceftriaxone + vancomycin m
se
As
Pla sma exchange

Dr
1- :tuximab
Intravenous immunog lobulin
Methyl predn iso lone
Ceftriaxone + vancomycin
Plasma exchange
TIP- plasma exchange is fi rst-line

important for me l ess im:>crtc.nt
m
se
This patient has thrombotic thrombocytopenic pu rpu ra, a co nditio n associated with
As
preg nancy
Dr
Which one of the following wou ld most suggest a leukaemoid reaction rather than
chronic myeloid leukaemia?
Ra ised packed cell volume
Right shih of neutrophils
A low leucocyte alkaline phosphatase score
Dohle bodies in the white cells
m
se
As
Positive osmotic fragility test
Dr
Ra ised packed cell volu me
Right sh ih of neutrophils
A low leucocyte alkaljne phos phatase score
Dohle bodies in the white cells

-
~
m
se
As
Positive osmotic fragility test
Dr
A 77 -yea r-old lady is adm itted by the e me rgency d epartment comp la ining of d ifficu lty
coping at hom e. She is unable to mobilise ind e pendently and has a poo r appetite due to
difficu lty swallowing. She ha s a d iagnos is o f oesophageal cancer b ut is not thou ght to be
a candidate for chemotherapy. Her GP recently started her on nitrofura nto in for a urina ry
tract infection.
On examinatio n she is a thin, frail lady who is a lert and o rie nted . There is no neuro log ica l
d eficit in the upper lim bs. She has weakness o f hip flexion and knee extension in both
legs, b ut marked ly more so on the right. You are ab le to e licit some loss o f p inprick
se nsation on the a nterio r thigh. Her reflexes a re bris k with an upgo ing planta r on the
right.
Her bl ood results are as fol lows:
Hb 101 g/ 1
Plat elet s 440 * 109/1
WBC 8.4 * 109/ 1
MCV 99 fL
Na• 136 mmol/ 1
K• 4 .8 mmol/1
Urea 3 .7 mmol/1
Creatinine 52 IJmol/1
What is the next most app ropriate step in th is patie nt's manageme nt?
Transfer to hos pi ce
Refer fo r physiotherapy
MRI imaging of th e sp inal cord
Check B12 a nd folate levels

sem
As
Stop nitrofuranto in
Dr
Transfer to hos pi ce CD
Refer for physiotherapy m
I MRI imaging of the spinal cord ED.
Check B12 and folate levels fD
Stop nitro furantoin GD
A patient with new lower lim b neurology and a h istory of cancer should raise the
suspicion o f metastatic spinal cord compression, which is best d emonstrated on MRI.
m
se
Although nitrofurantoin and B12 d eficiency could cause a peripheral neuropathy, both are
As
less urgent p roblems than cord com pression.
Dr
A 67-year-old man present s f eeling 'generally unwell' and co mplaining of pain in his back
and legs. His wife also reports that he has been slight ly confused for the past two weeks.
Basi c blood tests are ordered:
Hb 12.1 g/dl
WBC 7.6 * 109/ 1
Na• 143 mmol/ 1
K• 5.3 mmol/1
Urea 15.7 mmol/ 1
Bilirubin 20 j.Jmol/1
ALP 110 u/1
ALT 55 u/1
yGT 67 u/1
Albumin 31 gfl
Total protein 84 g/1
Calcium 3.10 mmol/ 1
Phosphate 0 . 79 mmol/ 1
What is the most likely underlying diagnosis?
Multiple myeloma
Renal ca ncer with bony met astases
Sarcoidosis
sem
As
Prostate ca ncer with bony met astases

Dr
I Multiple myeloma
Renal cancer with bony metastases
Sarcoidosis
Prima hyperparathyroidism
Prostate cancer with bony metastases

-
~
Hypercalcaemia, renal failure, high tot al pro tei n = myeloma

One of t he stand out resu lts is t he high calcium level. This immediately narrows t he
different ial diagnosis considerably. Remember the two most common causes of
hypercalcaemia are malignancy and primary hyperparathyroidism. Neither of these alone
m
se
wou ld however explain t he renal failure and high total protein, bot h common features of
As
untreated myeloma.
Dr
A 38-year-old Pakistani female was admitted with shortness of breath and a syncopa l
episode. She describes a 2 week history of lethargy, ma laise and dizziness. The patient
had recently started anti-tubercu lous therapy. History revealed she was not a vegetarian .
Hb 8.Sg/dl
MCV 72fl
wee 11 8
1QA9/ I
Platelets 225 * 1QA9/ I
TSAT 33%
Ferritin 600ng/ml
Haemoglobin electrophoresis normal
Which stain should be applied to a blood fi lm?
Giemsa
Gram
Ziehl Neelsen
m
Peri's
se
As
Ind ia ink
Dr
Giemsa 6D
Gram CD
Ziehl Neelsen 6D
Peri's CID
India ink 6D
This 38 year o ld Pa kistani female has p rese nted with sym ptomatic anae mia. Blood tests
reveal a microcytic anaem ia, th e causes of which can be broadly categorised into : 1, iron
d eficiency, 2, thalassaemia trait 3, sid ero blasti c a na emia.
Inte rpreting the iro n studies shows a no rmal transfe rrin satu ration a nd normal fe rritin,
ru ling out iro n d eficiency anaem ia . Normal haemoglobin electrophoresis rules out
tha lassaem ia, there fore the li kely ca use is side ro blastic anaem ia. This is a lso hinte d at by
the recent co mmencement of Ison iazid (anti tu berculous the rapy) a cause of side ro blastic
a naemia.
Side ro blastic a nae mia when sta ined with Peri's sta in shows ring s id e ro b la sts. The disease
m
is characterised by ineffective erythro po iesis leadin g to poor in co rpo ration o f iron into the
se
As
nu cleus o f e rythro blasts. Dr
A 34-year-old man who is known to have glucose-6-phosphate dehydroge nase deficiency
presents w ith symptoms of a urinary tract infection. He is prescribed an antibiotic. A few
days later he becomes unwell and is noticed by his partner t o be pale and j aundiced .
What drug is mostly likely to have been prescribed?
Co -amoxiclav
Trimethoprim
Ciprofloxacin
Cefalexin
m
se
As
Erythromyci n
Dr
Co -amoxiclav CD
Trimethoprim aD
I Ciprofloxacin ED
Cefalexin CD
Erythromycin fD
The sulfamethoxazole in co-trimoxazole causes haemolysis in G6PD, not the
m
se
trimet hoprim
As
Dr
A 72-year-old man with longstanding Wa ldenstrom's macroglobulinemia presents t o
rheumat ology cl inic with joint pains and generalised weakness.
Which of the follow ing would be most indicative of Type I cryog lobulinaemia?
Livedo reticularis
Raynaud's phenomenon
Arthralgia
Membranop roliferative glomerulonephritis
m
se
As
Low C4 levels
Dr
Livedo reticularis GD
I Raynaud's phenomenon CD
Arthralgia m
Membranoproliferative glomerulonephritis G'D
Low C4 levels fD
Raynaud's - Type I cryoglobulinaemia

Cryoglobulinaemia can be caused by paraprotein bands such as those in Waldenstrom's

macroglobulinemia and multiple myeloma. Meltzer's triad of arthralgia, weakness and
palpable purpura are commo n to all types of cryoglobul inaemia - as are
membranoproliferative glomerulonephritis and low C4 levels.
m
se
Raynaud's occurs most co mmonly in type 1 cryoglobulinaemia and its presence can be
As
helpful in ascertaining the underlying cause.
Dr
A 60-yea r-o ld woman is inve stigated for painful fingers a nd toe s in cold weather. She has
p reviously been d iagnosed with Raynau d's phe nomenon b ut she is now experiencing
s ignifica nt p urp lish d iscolou ration of her peripheries a nd no se a s well as g enerally feeling
tired and lethargic. Blood te sts shows the following:
Hb 99 g/1
WBC 5.9 * 109/1
Blood film Spherocytes seen
What is the next best inve stigation?
Com pleme nt levels
Osmotic fragility test
Anti-nuclea r antibody
Flow c.ytometry of blood
m
se
As
Direct antiglobu li n test
Dr
m
se
This lady is likely to have co ld agglutinin disease, a form of autoimmune hemolytic
As
anemia.
Dr
A 48 year old nurse presents with a short history of epistaxis and bleeding gums. You
request urgent bloods, the results of which are shown in the table below:
Haemoglobin 86 g/L
White cells 2.3 x lOA9/ L
Platelets 18 x 1QA9/ L
Clotting deranged
Blood film bilobed large mononuclear cells
Lym phoma
m
se
As
Surreptitious warfari n overdose
Dr

-
~
Lymphoma
~ute myeloid leukaemia

Surreptitious warfari n overdose
This is a picture of bone marrow fa ilure secondary to acute myeloid leukaemia.
In acute leukaemia a malignant expansion abnormal white cells accumulate in the bone
marrow, replacing normal haemopoietic cells.
Acute expansion of the myeloid stem line (acute myeloid leukaemia) is more common
over the age of 45, in comparison with acute lymphoblastic leukaemia which is mostly
seen in ch ildren.
Lym phoma does not tend to present in th is way, but more so with rubbery enlargement
of lymph nodes.
m
se
Von Wi llebrand's disease may present with epistaxis and bleeding gums in severe cases,
but it is ra re that there are abnormalities on blood results. As
Dr
A 38-yea r-old female patient presents to the e mergency de pa rtment with seve re
a bd om inal pain, nausea an d vo miting. She also re ports red uced sensation in the bilateral
lowe r limb extre mities. She a pp ears highly agitated and labile in mood . Her partne r
re ports that this has ha ppened about 6 times befo re and va rious suspected diagnoses
we re made for these past ep isodes but no d efinite diagnosis was eve r made. She repo rts
that he r mothe r a lso gets such e pisodes. These past suspected d ia gnoses include acute
a ppend icitis, rena l ca lculi, acute intestina l o bstruction. They we re all fo und to b e negative.
What is the likely diagnosis to account fo r this cl inical presentation?
Acute intermittent porp hyria
Porphyria cutanea ta rda
Lead po isoni ng
Neurotic disorder
m
se
As
Multip le scle ros is
Dr
I Acut e intermittent porphyria f.ZD
Porphyria cutanea t arda fD
Lead poisoning G'D
Neurotic disorder CD
Multiple sclerosis CD
Acute intermittent porphyria typica lly presents with abdominal, neurological and
psychiatric sympto ms
Acut e intermittent porphyria (AlP) typica lly presents with abdominal, neurologica l and
psychiatric sympt oms.
Porphyria cutanea t arda presents w ith photosensitive bullae.
Lead poisoning is possible t o account for this presentation but it doesn't account for the
family history. Al P is more likely g iven the family history.
Neuro tic disorder may be possible but physical causes need t o b e ruled out b efo re
m
se
considering a psychiatric diagnosis. As
Dr
Multiple sclerosis doesn't usually present with gastroint esti nal symptoms.
A 34-year-old man who is known to have type 1 von Willebrand 's disease asks for advice.
He is due to have a tooth extracted at the dentist next week. Which one of the following
is the most appropriate management to reduce the risk of b leed ing?
Mefanam ic aci d
Vitamin K
Desmopressin
Factor Vlll concentrate
m
se
As
Factor VII concentrate
Dr
Mefanamic aci d mt
Vitamin K f.D
I Desmopressin CD
Factor Vlll concentrate fD
Factor VII concentrate CiD
m
se
Blood products such as facto r VIII concentrate should be avoided when possible to
As
minimise the risk of transfusion acquired vira l ill nesses.
Dr
An 80-year-old man is reviewed in the haematology cl inic. He has been referred due to
weight loss, lethargy and a significantly elevated IgM level. Recent bloods show the
following:
Hb 13.8 g/dl
IgM 2150 mg/dl (range 50-330 mg/ dl )
ESR 45 mm/hr
Given the likely diagnosis, w hich one of the follow ing complications is he most likely to
develop?
Renal fa ilure
Anaemia
Hyperviscosity syndrome
m
se
As
Hyperca lcemia
Dr
Renal fa ilure
Anaemia
Hyperviscosity syndrome
Hypercalcemia
IgM paraproteinaemia - ?Waldenstrom's macrog lobulinaemia

m
se
Th is patient has Wa ldenstrom's macroglobu linaemia. Hyperviscosity syndrome is p resent
As
in around 10 -15% of patients. Other common complicatio ns include hepatosplenomega ly.
Dr
A 38-year-old woman presents with a 2-month history of symptoms of fatigue, pa llor and
palpitations. She also compla ins of b reathlessness at rest as well as during exertion. She
has an established diag nosis of systemic lupus erythematosus (SLE). On abdominal
exam ination you notice the spleen is s lightly enla rged. Blood tests reveal:
Hb 90 g/1 {115- 160 g/1)
MCV 90 fl (82-100 fl)
D-dimer 150 ng/ml ( <400 ng/ml)
Direct Coombs test Pos
What is the most likely diag nosis?
IgM-mediated autoimm une haemo lytic anaemia
IgG-med iated autoimmune haemolytic anaemia
Immune thrombocytopenic purpura
m
se
As
G6P D deficiency
Dr
IgM- mediated autoimmune haemolytic anaemia
I IgG-mediated autoimmune haemolytic anaemia
Immune thrombocyt openic purpura
G6PD deficiency
SLE is a risk factor for warm aut oimmune haemolytic anaemia

SLE is an important risk f actor for IgG-mediated, warm aut oimmune haemolytic anaemia.
This is associated with extravascular haemolysis which can lead to a hypertrophic spleen.
IgM- mediated aut oimmune haemolytic anaemia is not sp ecifica lly linked to SLE and
would also present with cold-induced sympt oms involving the hands and t oes.
Paroxysmal nocturnal haemoglobinuria is a deficiency of GPI protei n on red blood cells

leaving them susceptible t o complement-mediat ed destruction.
Immune thrombocyto penic purpura is an autoimmune condition characterised by

thrombocytopaenia.
m
se
G6PD deficiency is an enzymatic deficiency with in red blood ce lls rendering them prone
As
t o oxidative stress.
Dr
A 30-year-old female p resents to the Emergency Department with e pistaxis, which has
now terminated. Her boyfriend reports she has a recent history of mucosa l bleed ing and
has at times been very diso rientated. On examination, she has a low-grade fever and
appears confused and jaund iced. There is bru ising over her legs and a rms. A urine
p regnancy test is negative. You receive the following blood resu lts from the laboratory:
Hb 85 g/1
Plat elet s 8 * 109/ 1
WBC 4 .5 * 109/ 1
MCV 92 fl
Na• 138 mmol/ 1
K• 4 .9 mmol/1
urea 10.2 mmol/ 1
Creatinine 182 IJmOI/ 1
Clotting stud ies are no rmal. Given the most likely diagnosis, what is the most appropriate
ma nagement o f this patient?
Plate let transfus ion
Intravenous immunoglo bulin
Plasma exchange
Intravenous methylprednisolone
em
s
Intravenous argatro ban

As
Dr
Platelet tra nsfusion
Intrave nous immunoglobulin
Plasma exchange
Intravenous methylprednisolone
Intravenous argatroban
This questio n requ ires you to ide ntify correctly the ha ematological emerg ency and be
aware of the correct ma nag eme nt.
Thro mbotic thro mbo cytopen ic p urp ura (ITP) is classically characterised as a penta d of:
thro mbo cytopen ia, microvascular haemolys is, fluctua ting neuro lo gica l signs, renal
impairment and fever.
Also in the diffe re ntia l d iagnosis fo r severe thrombocytop enia is immune

thro mbo cytopen ic p urp ura (ITP). ITP is mo re com mo n than ITP however wo uld not
p resent with the ra nge of symptoms seen in th is scena rio.
ITP has a n untreated morta lity o f u p to 90% a nd there fo re rap id pla sma excha nge (PEX)
may be a life saving interventio n. Platelet tra nsfusion in ITP is on ly indicated if there is an
o n-g oi ng life-threate ning b leed. Intravenous methylprednisolone is indicated a fte r
treatment with PEX has been com pleted .
There is no current role fo r intravenous immunoglobulin in the ro utine management of

ITP, however the re have been re po rts of its successful use in PEX- and steroid -refracto ry
cases.
Intravenous argatro ban is indicated in he pa rin-induced th rom bocytopenia (HIT), however

em
the re is no history of recent hepa rin admi nistration or hospitalisati on in this patient, nor
s
As
a re the clinical signs cons istent with HIT.

Dr
A 78-yea r-old male is adm itted to the wa rd with suspected sepsis. He is receiving IV
a ntibiotics. The nurse info rms you the p atient is deterio rati ng with tachyca rdia,
hypotension and bleeding from the IV site. You susp ect the patient has d isseminated
intravascu la r coa gulation (DIC) seconda ry to sepsis.
If a blood fil m was taken from the patient, which of the fo llowing wou ld most likely be
o bserved on histo lo gy?
Schisto cytes
Bite cel ls
Howe ll -Jo lly bod ies
Hei nz bo dies
m
se
As
Ta rget cells
Dr
I Schistocytes
Bite cells
CD
«ED
I Howell-Jolly bodies CD
Heinz bodies .
CD
Ta rget cells .
CD
DIC is associated with sc histo cytes d ue to microangiopathic hae mo lytic anaem ia

DIC can trig ger microangiopathic haemolytic anaemia. Red blood cells a re sheared by
microthrombi as they pass throu gh the circulation producing schistocytes which can be
visualised on histo logy.
Heinz bodies and bite cells are characteristic of glucose -6-phosp hate d ehyd rogenase
(G6PD) deficiency.
Howell-Jol ly bodies a re seen in asp len ic patients.
m
se
As
Ta rget cells can be seen in conditions such as tha lassae mia.
Dr
A 21-yea r-old man comes for review. He recently had an abdomina l ultrasound for
episodic right upper quadrant pain which demonstrated g allstones. A fu ll blood count
was a lso o rd ered which was reported as follows:
Hb 9 .8 g/dl
MCV 91 fl
Pit 177 * 109/1
WBC 5.3 * 109/ 1
The patient also mentions that his fathe r had a splenectomy at the age of 30 years.
Which one of the followin g tests is most likely to be diagnostic?
Ham's test
PAS staining of erythrocytes
Glucose-6-phoshate dehydrogenase levels
EMA binding test
m
se
As
Direct Coombs' test Dr
Ha m's test
PAS staining of erythro cytes
Gl ucose-6-phosha~e de hydrogenase leve ls
EMA b inding test
Direct Coombs' test
This patient likely has hereditary spherocytosis (HS) as evidenced by the normocytic
a naemia, gallstones and family history. The British Journa l o f Hae matology guide li nes
state that a clin ical diagnosis of HS can so metimes b e made for classical histories.
However, if the case is more eq uivocal then a dia g nostic test is recommend ed, such as the
EMA bi nding test.
The EMA b ind ing test uses flow cyto metry to dete rmine the amount of fluorescence
m
se
(reflect ing EMA bound to sp ecific tra nsmem brane pro teins) d e rived from individual red
As
cells.
Dr
Whi ch of the following may be used in the treatment of hereditary angioedema?
Anabolic ste roids
Oral contraceptive pill
ACE inhibitors
Beta-blockers
m
se
As
Aspirin
Dr
Anab olic steroids ED
Oral contraceptive pill m
I ACE inhibitors tiD
Beta-blockers CD
m
f!D
se
Aspirin
As
Dr
A 62-year-old woman presents after being advised by the chemothera py helpli ne to come
to a hospital. She has a past medical history of neuroendocrine cancer of the cervix
treated with ca rboplatin and etoposide. Her last treatment was eight days ago. She has
been feeling genera lly unwell with tem peratu res measured at home at 38.1C. Blood
cultu res are taken and she is started on neutropenic sepsis p rotocol. What is gram-
staining of the b lood cultu res most likely to show?
Gram-negative cocci
Gram-positive cocci
Gram-negative rods
Anaerobic bacteria
m
se
As
Spores
Dr
Gram-negative co cci GD
Gram-pos itive cocci GD
Gram-negative rod s ED
Anaerobic bacteria fD
Spores
•
The correct answe r is g ram- positive cocci. Gram-nega tive bacilli used to be the most
com mon pathogen isolated in neutropenic seps is, but ove r time the most common
pathogens a re now g ram-positive o rganisms. These accou nts fo r a majo rity of the
identified o rga nisms, an d are most com mo nly e ndo genous o rgan isms. The most frequent
cause is Staphylococcus epide rmidis, and following this a re other stap hylococci and
stre ptococci species.
Source:
m
se
As
'Febrile Neutropen ia.' BMJ Best Practice. 15 Sept. 2016.
Dr
Interferon alpha is a recognised treatment for w hich one o f the follow ing haemat ologica l
disorders?
Myelofibrosis
Burkitt's lymphoma
Hairy cell leukaemia
m
se
As
Dr
Mye lofibrosis
Burkitt's lympho ma
r :ry cell leukaemia
Acute myeloi d leuka e mia

J
Interfe ro ns (IFN) a re cytokines re leased by the body in resp onse to viral infectio ns and
neoplasia . They are classified acco rding to cell ular o rigin a nd th e type o f receptor they
b ind to. IFN-alpha and IFN-beta b ind to type 1 receptors whilst IFN-g a mma bi nds o nly to
type 2 recepto rs.
IFN-a lpha is p roduced by leucocytes and has an antiviral action. It has been shown to be
m
se
useful in the ma nagement of hepatitis B & C, Ka posi's sa rcoma, metastatic renal cell
As
ca ncer and hairy ce ll le ukaem ia
Dr
You are working on a geriatric post when you not ice t hat a 93-year-ol d man on your ward
has had consistent ly high white b lood cells, despite several courses of antibiotics . His
b loods today show:
Hb 91 gf l
Plat elet s 250 * 109/ 1
8
WBC 32 .2 109/ 1
8
Neutrophils 28. 1 109/ 1
Despite t his he has at no point shown signs of any infection. You r co nsulta nt suggests
contacting haematology wit h rega rds to ascertaining the leucocyte alkaline phosphatase
score.
Which of t he follow ing conditions would have a high leucocyte alkaline phosphatase
score?
Chronic myeloid leukaemia (CML)
Acute myeloid leukaemia (AML)
Paroxysma l nocturnal haemoglobinuria (PNH)
m
Leukemoid reaction
se
As
Pregnancy
Dr
Chronic myeloid leukaemia (CM L)
Acute myeloid leukaemia (AML)
Paroxysma l nocturnal haemo globinuria (PNH)
Leukemo id reaction
Pregnancy
Leukemo id reaction has a high leucocyte alka line phosphatase score

The answer is leukemoid reaction. Leucocyte ALP is one of types of alka line p hosphatase.
It has a diagnostic value in differentiating causes o f high numb er of white blood cells,
seen on manual differentials.
The leukemoid reaction refers to the 'leh-shih' of immature white blood cel ls that occurs
in underlying infections. On a blood f ilm, th is cou ld mist akenly be thought to b e a
malignant process (like CML). Leukocyte ALP can different iate the two - a low score
indicat es und eveloped leukocytes, like those fou nd in CM L and AM L. PNH also causes a
low score.
m
se
Pla cent al ALP found in p regnancy is a di stract or. As
Dr
A 27 -year-old woman prese nt s to the Emergency Department with a sudden onset of
swell ing of the hands and face. She describes multiple similar episodes over the past few
years, but t his episode is the most severe. She cannot reca ll any obvious precipitant. On
previous occasions, t he symptoms have subsided w ithin t hirty minutes but on t his
occasion t hey have worsened over t he cou rse of an hour. On examination, t here is
significant swelling of the lips which are dry and sh iny. The tongue is not enlarg ed. There
is no strid or and the chest is clear. Respiratory rate is 22 and oxygen saturations are 96%
on air. The hands are swollen and slightly erythematous but there is no pain or itching
and no lymphadenopathy. Heart rate is 106bpm and blood p ressure is 118/79mmH g.
Tym panic tem perature is 36.7"C. A diagnosis o f heredita ry angioedema is suspected.
Which one o f t he followin g is not implicated in the pathogenesis o f hereditary

angioedema?
Cl-esterase inhibitor
Bradykinin
Hist amine
Kallikrei n
m
se
High molecular weight kin inogen As
Dr
Cl-esterase inhibitor
Bradykinin
r-::t amine
Kallikrein
High molecular weight kininogen
Heredit ary angioedema (HAE) is pathophysiologically separate from anaphylaxis

and is treated differently. Therapeutic options are: intravenous infusion of human
Cl-esterase inhibitor o r su bcut aneous injection of the bradykinin recepto r inhibitor
icatibant
Important for me Less :mocrtant
Heredit ary angioedema (HAE) is an au tosomal dominantly inherited immune condition

characte rised by episodic swelling of the extremities, intra-abdominal viscera and mucous
membranes. Often att acks are unprecipitated although sometimes exogenous oestrogens
in the form of contraception can be traced, as well as exposure to angiotensin-converting
enzyme inhibitors. The primary pathophysiological defect is in the complement cascade
and deficiencies in factors C4 and Cl-esterase inhibito r are seen in type !.In type II HAE
Cl -esterase inhibitor levels are normal but the enzyme is dysfunctional and activity is low.
An acquired form of HAE is described in which all complement levels are low. In type III
HAE the cli nical features of angioedema are present but immunological testing reveals
normal levels and activity of complement fact ors. Ultimat ely, fa ilure of Cl-esterase
inhibitor leads to upregulation o f the rest of the comp lement syst em and membrane
attack complex, but also it leads to act ivation of the signalling protein kallikrein which acts
directly on the vascular wa ll t o increase permeability, an d it cleaves high molecular weight
kininogen to release bradykinin, again a potent peripheral vasodilator giving rise t o the
sympto ms of HAE.
HAE should be recognised as a separate entity from anaphylaxis since the clinical signs
are different, as is the pathophysiology of the condition and its treatment. Anaphylaxis is
an lgE mediated immune phenomenon related t o a specific allergen caus ing massive
ma st cell degranulation and hista mine release. HAE is driven by complement
dysregulation and consequent release o f the inflammatory cytokines bradyki nin and
kallikrein. Anaphylaxis is characterised by rapidly progressive, itchy, erythematous,
oedematous rash, swelling o f the lips, tongue and airways w ith accompanying
hypovolaemic hypotension and ca rdiovascular collapse due t o increased t issue
permeability. Anaphylaxis is a medical emergency and death can ensue in minutes unless
treated properly. HAE in compa rison may present recurrently and often w ith no obvious
precipitant. Usually, it s cou rse is more insidious with the evolution of symptoms over
minutes to hours. Swelling will o ften only affect an isolated limb and it is not itchy or
painful and minimally erythematous. Hypot ension is rarely seen and cardiovascu lar
inst ability is extremely unlikely. HAE can be fata l however if swelling o f the upp er airways
causes obstruction, and in some cases, prophylactic intubation and mecha nical ventilation
may be appropriate. Since the driving mechanism is not hista mine in HAE, steroids and
antihista mines are of no value. Where there is no haemodynamic compromise, adrenaline
is not warranted and may even wo rsen the situation due to increased plasma glucose
load and risk o f cap illary rupture.
Knowledge o f the cytokine cascade in HAE allows fo r knowledge of it s management.

Since the initiating pathophysiologica l hallmark is a deficiency or reduced effectiveness of
Cl -esterase inhibitor, exogenous administration of synthetic or reconstitut ed inhibitor
should be effective.
National guidelines released in 2013 recommend treatment of episodes of HAE with the
administration of reco nstituted human Cl-esterase inhibitor. In the UK two brands are
available; either Cinryze which is dosed at 1000 unit administration or Berinert at 20
unit s/kg. Bo th are administered as slow int ravenous infusions. Interestingly, a good
clinical response is o ften seen to these drugs even in HAE type Ill where Cl -est erase levels
are normal.
An alternative t o exogenous Cl -esterase inhibitor is icatibant which is a specific

antagonist at B2 bradykinin recepto rs in vascular smooth muscle. The 30mg dose may b e
repeated up to three times in 24 hours but a rapid resolution o f symptoms is often seen.
Many patient s with HAE are supplied with their own icatibant auto inject ors for use in the
pre -hospita l setting at the onset of sympto ms.
Ecallantide is a selective inactivator of the cytokine kallikrein. It is highly effective in the

treatment o f HAE in the United Stat es but has no European licence at this current time.
m
se
I •• I ••
As
tt Discuss (2) Improve J

Dr
Which one o f the following is least likely t o precipitate haemolysis in a patient with G6PD
deficiency?
Broad beans
Sepsis
Ciprofloxacin
Primaquine
m
se
As
Penicillin
Dr
Broad beans CD
Sepsis fD
I Ciprofloxacin GD
Primaquine (fD
m
se
As
Penicillin CD
Dr
A 69-year-old male patient presents to the oncology clinic w ith a 3-months history of
right upper quadrant discomfort, weight loss and anorexia. Ultrasound liver raises the
suspicion o f a hepatocellular carcinoma.
Which carcinogen ha d he likely been exposed to?
Nitrosamine
Aflatoxin
Aniline dye
Arsenic
m
se
As
Benzene
Dr
Nitrosam ine fD
I Aflatoxin fZD
An iline dye CD
Arsenic CD
Benzene fD
Exposure to af latoxin is a risk facto r for hepatocellular ca rci noma

Exposu re to af latoxin is a risk factor for hepatocellular ca rcinoma.
Exposu re to nit rosamine is a risk factor for gastric and oesophag ea l carcinoma.
Exposu re to aniline dye is a risk factor for t ransit ional cell carcinoma.
Exposu re to arsenic is a risk fact or for lung malignancy and liver angiosarcoma.
m
se
As
Exposu re to benzene is a risk factor for leukaemia.
Dr
A 31-year-old man is referred to the acut e medica l unit with a painful swollen left leg. The
patient reports that he has the 'Fact or V Leiden mutation'. Which one of the following
best describes the pathophysiology of his condition?
Activated protein C excess
Antithrombin deficiency
Resistance to action o f prot ein C
m
se
As
Activated protein C deficiency
Dr
Activated protein C excess
Antithrombin deficiency
Resistance to action of prote in C
Activated protein C deficiency
m
se
Factor V Leiden mutation resu lts in activated prote in C resistance
As
Important for me l ess ' m::~c rtont
Dr
A 73-year-old woman is reviewed in the pre-op clinic prior t o an elective hip replacement.
Her past medical histo ry includes p olymyalgia rheumatica and ischaemic heart disease.
Screening blood tests are ordered and the full blood count is repo rted as follows:
Hb 12.9 g/dl
Pit 158 * 109/1

8
WBC 19.0 109/1
Neuts 4.2 * 109/ 1

8
Lymphs 14.1 109/1
Lym phoma
Nicorandil-related lymphocytosis
Transient viral illness
m
se
As
Secondary to steroid use
Dr
Lymphoma
I Nicoran! il -related lymphocytos is
Transient viral illness
F onic lymphocytic leukaem ia

I
Second ary to steroid use
Such a lymphocytosis in an e lde rly patient is very likely to be caused by chronic
m
se
lymphocytic leukaem ia. Stero id s tend to cause a neutro philia. It wou ld be unusua l for a
As
viral illness to cause such a ma rked lymphocytosis in an e ld e rly person.
Dr
A 71-yea r-old woman who is known to have multip le myeloma is ad mitted with
confusion. Blood tests show the fo llowing:
Corrected calcium 2. 9 1 mmol/ 1
Which one of the fo llowin g is the most s ignificant cause of the ra ised calcium level?
Adverse effects of stand ard trea tment
Increased o steoclastic activation
Impa ired re nal fu nction
Increased rena l tubula r ca lcium reabsorption
m
se
As
Elevated PTH- rP levels
Dr
Adverse effects of stand ard treatment CD
I Increased osteoclastic activation CD
Impa ired re nal function CD
r :crj ased rena l tubular calcium reabso rption fD
m
se
Elevated PTH- rP levels GD
As
Dr
A 65-yea r-old female with metastatic breast cancer is reviewed in cl inic. Her husband
reports that she is increasingly confused and occasionally app ears to ta lk to relatives that
are not in the roo m. She undergoes investigations for reversible causes, of which none are
found. If conservative measu res fail and s he continues to be confused/agitated, what is
the most appropriate ma nagement?
Su bcuta neous midazolam
Ora l lithium
Ora l haloperidol
Ora l diazepa m
m
se
As
Ora l quetiapine
Dr
Subcutaneous midazolam
Ora l lithium
Ora l haloperidol
Ora l diazepa m
Ora l quetiap ine

-
"""
m
se
Oral haloperidol is the most appropriate treatment here . If the patient was in the termina l
As
phase and ag itated then subcutaneous midazolam would be ind icated
Dr
A 34-year-old man is reviewed four years after having an orchidectomy for a t esticular
t eratoma. What are the most useful follow-u p investigation(s) to d etect disease
recurrence?
CRP + beta -HCG
Testosterone + beta-H CG
ESR + alpha -fetop rotein
Alpha-fetoprotein + beta -HCG
m
se
As
LDH + ESR
Dr
CRP + bet a-HCG a
Testosterone + beta-HCG @D
ESR + alpha- fetop rotein
Alpha-fetoprotein + beta-HCG
•
CD
m
se
LDH + ESR a
As
Dr
A 65-year-old woman is reviewed . She is on the waiting list fo r a varicose ve in o peration
but during the p reoperative assessment was noted to have a ra ised lymphocyte count.
She re ports feeli ng well cu rrently and clinica l exam ination is normal. He r bloods we re as
follows:
Hb 11.8 gfdl
Pit 184 * 109/ 1

8
WBC 21.2 109/ 1
The re are no previous bloods to compa re these results with. Fo llowing re ferra l to
haemato logy a d iagnosis of chronic lymphocytic leukaem ia was mad e. What is the most
No treatment + cancel operation
No treatment + go ahead with operation
Chlora mbu cil + ca ncel operation
Fludara bine + go ahead with operation b ut with quinolone prophylaxis
m
se
As
Alemtuzuma b + cancel operati on
Dr
No treatment + cancel operation
I No treatment + go ahead with operation
Chlorambucil + cancel operation
Fludarabine + go ahead w ith operation but with quinolone prophylaxis
Alemtuzumab + cancel operation
m
se
There is no indication for treating this patient at the current time or not going ahead with
As
surgery
Dr
A 40-year-o ld male patient is adm itted with recurrent pancreatitis. ACT scan reveals no
pancreatic mass, but evidence of widesprea d lymphadenopathy. Ded icated liver imaging
reveals a stricture in the commo n bile duct but no stones. He a lso has a history of
parotiditis. What is the most li kely diag nosis?
Lym phoma
IgG4 d isease
Pancreatic cancer
Biliary ma lignancy
m
se
As
Primary sclerosing cho langitis
Dr
lgG4 disease
Pt eatic cancer
Bilia ry maligna ncy
Primary scle rosing cho langitis

-
~
lgG4- related disease has been described in virtually every o rga n system: the biliary tree,
sa liva ry gland s, pe riorbita l tissues, kidneys, lungs, lymp h nod es, meninges, aorta, breast,
p rostate, thyro id, perica rdium, and skin. The histopatho logica l features a re similar across
o rgans, rega rdless o f the s ite. lgG4-re lated d isease is a na logous to sarco id osis, in which
diverse o rgan manifestations are linked by s imila r histo patho log ical characte ristics. Raised
co ncentrations of lgG4 in tissue a nd serum can be he lpful in dia gnosing lgG4 disease, but
neither is a sp ecific d iag nostic marker.
Exa mples includ e:

• Ried el's Thyro iditis
• Autoimmu ne pancreatitis
• Mediastina l a nd Retroperitonea l Fib rosis
• Periaortitis/peria rte ritis/Inflammatory aortic a neurysm
• Kuttne r's Tu mou r (submand ibula r gla nds) & Miku licz Syndrome (sa liva ry a nd
m
se
lacrima l gland s) As
• Possibly sjog ren 's a nd primary bilia ry cirrhosis
Dr
A 24-year-old man is diagnosed w ith a deep vein thromb osis of his right leg. He is initially
treated w ith low -molecular weight heparin but is switched after three days to warfarin. He
then develops necrotic skin lesions on his lower limbs and forearms. Which one of the
fo llowing co nditions is characteristically associated w ith this complication?
m
se
As
Dr
Protein S deficiency (ID
Anti phospholipid syndrome CD

Antithrombin III deficiency f1D
Activated protein f resistance f.D
m
se
Protein C deficiency CJD
As
Dr
What is the mechanism of action of cisplatin?
Stabilises DNA-topoisomerase II complex
Causes cross-linking in DNA
Inhibits ribonucleotide reductase
Inhibits purine synthesis
m
se
Inhibits formatio n of microtubu les
As
Dr
Stabilises DNA-topoisomerase II complex
I Causes cross -l inking in DNA
Inhibits ri bonucleotide reduct ase
Inhibits purine synthesis
Inhibits formation of microtubules

-
~
m
se
Cisplatin - causes cross-l inking in DNA
As
Dr
A 54-yea r-old man who is about to start chemothera py fo r a high -grade lymphoma is
given intravenous rasbu ricase to help lowe r the risk of tumour lysis syndrome. What is the
mechanis m of action o f this drug?
Inhibits urate oxidase
Converts uric acid to allantoin
Inhibits xanthine oxidase
Converts uric acid to hypoxanth ine
m
se
As
Guanylic oxidase inhib itor
Dr
Inhibits urate oxidase
Converts uric acid to allantoin
Converts uric acid to hypoxanth ine
Guanylic oxidase inhibitor

-"""'
m
Ras buricase - a reco mbinant version of urate oxidase, an enzyme t hat metabolizes
se
As
uric acid to allanto in
Dr
A 62-year-old male presents with a 2-month history of symptoms of fatigue and
dyspnoea. The patient is visibly jaundiced and on abdominal examinatio n you notice the
spleen is palpable. Blood tests reveal:
Hb 98 gfl
MCV 88 fl
Direct Coombs test Pos
An antibody specificity test is requested an d a diagnosis of wa rm autoimm une haemolytic

anaemia is made.
Which immunoglobuli n is most likely med iating this?
Ig M
IgG
IgA
IgE
m
se
As
Ig D Dr
IgM GD
IgG fD
IgA m
IgE m
IgD m
Warm aut oimmune haemolytic anaemia involves IgG- mediat ed haemolysis
Warm aut oimmune haemolytic anaemia involves IgG-mediated red blood cell destruction
at body temperature with work-induced splenomegaly due t o extravascular haemolysis.
Episodes of IgM -mediated haemolysis are precipitat ed by the cold and characteristically
present with symptoms involving the hands and feet.
m
se
IgA. Ig E and IgD are not common antibody mediators of aut oimmune haemolytic
As
anaemia.
Dr
A 32-year-old demolit ions worker comes t o th e haemat ology clin ic for review. He has
suffered from abdominal pain and lethargy for the past few months, and his GP has not ed
a microcytic anaemia. Over the past few weeks he has begun tripp ing over because o f
weakness of both lower legs. His bl ood pressu re is 123/ 82 mmHg, pulse is 82 b eats per
minute and regular. The abdomen is soft and non -tend er, t he body mass index is 23
kg/m 2 and there is bilateral weakness of ankle d orsif lexion.
Investigations show the fo llowing:
Hb 98 g/1
MCV 77 fL
Blood film Basophilic stippl ing
WBC 7.1 * 109/ 1
Iron d ef iciency anaemia
Lead poisoni ng
Porphyria cutanea t arda
Thalassaemia t rait em
s
Wilson's disease
As
Dr
Iron deficiency anaemia D
I Lead po iso ning .

GD
Thalassaem ia trait
•m
D
The picture here with microcytic a naemia, basophilic stippl ing on the b lood film, and
peripheral motor neuropathy is consistent with lead poison ing . It's like ly this patient was
exposed during their work as a demolitions operative. Chelation therapy is the
intervention of choice, with EDTA, DMSA and penicillamine al l potential options.
The othe r cond itions a ren't associated with basophilic stipp li ng. In ad d ition, porp hyria is
associated with a photosensitive skin rash, and thalassaem ia tra it isn't associated with
m
se
clinica l symptoms. Wilson 's tends to present earl ier with either movement d isorder or
As
psychiatric sympto ms.
Dr
A 25 -year-old female presents with recurrent sinopulmonary infect ions. What test is most
likely to confirm a primary immunodeficiency?
IgG level
B cell level
T cell level
m
Complement (CHSO) assay
se
As
IgM level
Dr
I IgG level ED
B cell level fD
Tcell leveL (D
Complement (CHSO) assay (D.
IgM level GD
The most common clinica lly significant primary immunodeficiency is common variable
immunodeficiency or CVID. IgA deficiency is more common, but most are asymptomatic.
CVID is characterized by reduced serum immunoglobulins and het erogeneous cl inical
f eatures. A well -accept ed definition of CVID includes three key features: the presence of
hypogammaglobulinaemia of two or more immunoglobulin isotypes (low IgG, IgA, or
IgM), recurrent sinopulmonary infections, and impaired functional antibody responses.
However, IgG is more likely to be deficient than IgM.
The criteria for impaired functional antibody responses include absent isohaemagglutinins
(eg. antibodies associat ed with blood transfusion reactions), poor responses t o protein
(diphthe ria, tetanus) or polysaccharide vaccines (S pneumoniae), or both.
m
se
Mature B-cells are more likely to be absent in X-linked Bruton's agammaglobulinemia.
As
Good reference: doi:10.1016/ S0140-6736(08)61199-X
Dr
A 40-yea r-old lady presents with fatigue, s hortness of breath and palpitations. She has a
history of hypothyroid ism and migraine. On examination, she is comfortable at rest with
normal cardiovascu lar, respiratory and abdominal exa mi nation although her conjunctiva
appea rs pale.
Her full blood count resu lts are shown b elow:
Hb 98 g/1
WBC 3.5 * 109/1
On further testing, her MCV is 101 fl and her bl ood film dis plays hypersegmented
polymorphs.
What would be the most app ropriate next set of investigations?
Folate levels an d anti-gastric parieta l cell antibo dies
Schilling test
Iron stu dies
Folate levels an d LDH

m
se
As
Colonoscopy
Dr
I Folate levels and anti-gastric p arietal cell antibodies
Schi ll ing test
~on studies
Folate levels an d LDH
Colonoscopy
-
~
This patient has a macrocytic anaemia due to B12 d eficiency d emonstrated by the low
B12 levels and hypersegmented polymorphs on blood film. The next step is to id entify the
cause of the B12 d eficiency by investigating for pernicious anaemia and checking fo late
levels (combi ned B12 and folate deficiency a re common). Anti-gastric parietal cell
antibodies are present in 90% patients with PA (but also 5-10% patients without PA).
Other tests for PA are anti-intrinsic factor antibod ies wh ich a re more specific but less
sensitive than anti-parietal ce ll antibodies (present in 50%). In the past, Schilling tests
using rad ioisotope labelled B12 were used.
Explanatio n for other options:

• 2. Schilling test no longer used in cl inical practice due to shortage o f B12
radioisotope and less invasive means o f testing available
• 3. Fo late leve ls are useful and LDH wou ld b e raised in p ern icious anaemia b ut this is
a non-specific finding and d oes not aid d iagnos is
• 4 . Colonoscopy not ind icated at this stage and woul d be more usefu l in a microcytic
anaemia when GI blood loss would be a possib le cause
• 5. This patient has a macrocytic rather than microcytic anaemia (which would fit with
em
iron deficiency)
s
As
Dr
A patient is started o n cyclophos pham id e fo r vasculitis associated with Wegene r's
granulo matosis. Which of the following is most cha racteristically associated with
cyclo phos pha mid e?
Haemo rrhag ic cystitis
Card iomyo pathy
Ototoxicity
Alop ecia
m
se
As
Weig ht g ain
Dr
I Haemorrhagic cystitis CD.
Cardiomyopathy CD
Ototoxicity CD
( 1opecia CD
Weight gain
•
m
se
Cyclophosphamide may cause haemorrhagic cystitis
As
Important for me Less imoc rtc.nt
Dr
A 48-year-old who was initially investigat ed for having an abdominal mass is diagnosed
as having Burkitt's lymphoma. He is due to start chemotherapy today. Wh ich one of the
following should be given to prior to his chemo therapy to reduce the risk o f tumour lysis
syndrome?
Rasbu ricase
Allopurinol
Sodium bicarbonate
Albumin
m
se
As
Calcium gluconate
Dr
I Rasburicase GD
Allopu rinol ED.
r rdium bicarbonate CD
Albumin m
m
se
As
Calcium gl uco nate CD
Dr
Each one of t he fo llowing is associated with iro n -d eficiency anaem ia, except:
Atro phic glossitis
Onycho lysis
Post-crico id we bs
Ko ilo nychia
m
se
As
Angu la r sto matitis
Dr
Atrophic glossitis CD
I Onycholysis
Post-cricoid webs
ED
(fD
Koilonychia fD
m
se
f!D
As
Angu lar stomatitis
Dr
A 64-year-old man is referred to t he oncology clinic with prog ressively worsening lower
back pain over t he last 3 months. He also reports an 8-month history of weight loss. MRI
lumbar spine confirms the suspicion of bone metastasis.
What is the most likely p rimary tumour?
Leukae mia
Breast carcinoma
Colorectal carcinoma
Prostate carcinoma
m
se
As
Lung carcinoma
Dr
Leukaemia m
Breast carcinoma m
Colorectal carcinoma m
Prostate carcinoma fZD.
Lung ca rcinoma f!D
Prostate cancer is the most common primary tumour that metastasises to the bone
Prosta te ca ncer is the mo st common prima ry tumour that metastasises to the bo ne
It is unusual to have bone metasta sis in leukaemia.
Brea st, co lorectal a nd lung cance rs can all lea d to bo ne meta stasis b ut the question is
m
se
a sking fo r the most likely tumo ur and statistical ly s peaking, prostate cance r is the mo st
As
co mmo n prima ry tumour that metastas ises to the bone.
Dr
A 66-year-old woman is referred by her GP with anaemia. She has been feeling generally
unwell for the past 3 weeks. Bloods on admission show:
Hb 8.7 g/dl
MCV 87 fl
Pit 198 * 109/1
WBC 5.3 * 109/1
Further tests were then ordered:
Reticulocytes 5. 2%1
Direct antiglobulin test Positiv e, IgG onl y
Film Spherocytes and reticulocytes
Which one o f the following is the most likely underlying cause?
Non-Hodgkin's lymphoma
Mycoplasma pneumonia
Acute myeloid leukaemia subtype M3

m
se
Cyto megalovirus infection

As
Dr
I Non-Hodgkin's lymphoma ED
Mycoplasma pneumonia eD '
Chronic myeloid leukaemia fD

Acute myeloi d leukaemia subtype M3 «D
Cytomegalovirus infection GD
m
The blood resu lts suggest wa rm autoimmune haemolytic anaemia (AIHA) which may be
se
caused by non-Hodgkin's lymphoma. Mycoplasma pneumonia is associated w ith cold
As
AIHA. The other three listed conditions are not commonly associated w ith AI HA.
Dr
A 65-year-old male patient presents to the oncology clinic with 6-months history o f
weight loss and anorexia. A tumour marker pro file shows an elevat ed level of bombesin.
What is the most likely cancer to account for this result?
Recta l carcinoma
Prostate carcinoma
Breast carcinoma
Small cell lung ca rci noma
m
se
As
Lym phoma
Dr
Recta l ca rcinoma
Prostate ca rcinom a
-
"""'
Breast carcinoma
Small cell lung carcinoma
Lymphoma
Bombesin is a t umou r marker in small cell lung ca rcinomas

Small cell lung ca rci noma s are t he only option w hich could cause a raised level o f
bom besin. Bombesin is a t umour marker in small cell lung ca rcinomas, along with gastric
carcinomas and ret inoblast omas.
Carcinoembryonic antigen(CEA) is a t umour marker o f colo rect al cancer.
Prostate-sp ecific antigen(PSA) is a t umour marker o f prost at e carcinomas.
CA 15-3 is a t umour marker for breast cancer.
m
se
As
There is no specif ic t umou r marker for lymphoma.
Dr
A 28-year-old female patient presents to the emergency department with abdominal
pain, diarrhoea and progressive weakness and pain in the limbs. She looks low in mood
and tea rful at times. You ask for a urine sample and leaves it standing near the window.
20 minutes later, you notice that the urine has become darker.
Lead poisoning
Acute intermittent porphyria
Polymyalgia rheumatica
m
se
As
Guillain- Barre syn drome
Dr
Lead po ison ing C!D
I Acute intermittent porp hyria GD

Polymyalg ia rheum atica m
Gu illa in-Ba rre syndrome
-
In acute intermittent porphyria, the urine classically turns deep red on stand ing
This patient has recurre nt gastrointestinal symptoms associated with neu ro psychiatric
feat ures. This ra ises the suspicio n of acute intermittent porphyria (AlP). In AlP, the u rine
classically t urns d eep red on standing fo llowing sun exposu re .
Lead po iso ni ng can present with s imilar p resentation but the da rkening of uri ne o n sun
exposure is only found in AlP.
Porphyria cutanea tarda presents with photosensitive skin bullae.
Po lymyalgia rheumatica may p resent with proxima l li mb weakness but does not result in
the urinary phenomenon described.
m
se
Gu illa in -ba rre synd rome can develop following gastrointestinal symptoms, however, it As
does not cause the urine to turn red.
Dr
What is the underlying problem in methaemoglobinaemia?
The oxidation of Fe2+ in haemoglobin to Fe3 +
The reduction of Fe2 + in haemoglobin to Fe+
The oxidation of Fe3+ in haemoglobin to Fe2+
The reduction of Fe2 + in haemoglobin to Fe3+
m
se
As
Dr
What is the underlying problem in methaemoglobinaemia?
The oxidation of Fe2+ in haemoglobin to Fe3+
The reductio n of Fe2 + in haemoglobin to Fe+
I The oxjdation of Fe3+ in haemoglobin to Fe2+
The reductio n of Fe3 + in haemoglobin to Fe2+

-
~
m
se
Methaemoglobinaemia = oxidation of Fe2 + in haemoglobin to Fe3+
As
Dr
A 69-year-old man with metastatic p rostate cancer presents with worsen ing pa in. He
currently takes o ral mod ified-release morphine su lphate 60mg bd but it is decided to
convert this to subcutaneous administration as he is frequently vomiting. What is the
most appropriate dose of morphine to give over a 24 hou r period using a continuous
subcutaneous infusion?
20mg
30mg
40mg
60mg
m
se
As
120mg
Dr
20mg «fD
30mg GD
40mg flD
60mg CD
120mg f!D
The BNF recom mend half the oral dose of morphine in this situation:
The equivalent parenteral dose of morphine (subcutaneous, intramuscular, or intravenous)

is about half of the oral dose. If the patient becomes unable to swallow, generally morphine
is administered as a continuous subcutaneous infusion
m
se
As
This patient is on 60mg bd = 120mg. Divided by 2 = 60mg of subcutan eous morphine.
Dr
A 61-yea r-o ld presents for review. She has been having atypical lower back pain for the
past two months. An x-ray of her lumba r spine reported raised the possi bil ity of spinal
metastases but there is no cu rrent evidence of a primary tumou r. A series o f tumour
markers were sent. Which one of the following is most associated with ra ised levels of CA
15-3?
Pancreatic cancer
Colorectal cancer
Breast cancer
Ova rian cancer
m
se
As
Hepatocellu lar carcinoma
Dr
Pancreatic cancer
G:o lo recta l cancer
Breast cancer
Ovarian cancer
-
......,
Hepatocellu lar carcinoma
m
CA 15-3 is a t umour marker in breast cancers
se
As
Dr
A 54-year-old gentleman is diagnosed with diffuse large B-cell lymphoma and is started
on chemotherapy. Two days fol lowi ng his first treatment, he presents to the emergency
department with nausea, vomiting, and myal gia. On examination, he app ears clinically
dehydrat ed. A diagnosis of tumou r lysis syndro me (TLS) is suspected. Which of the
fo llowing would be in keeping with this diagnosis?
Low phosphate
Low uric acid
Low lactate dehydrogena se (LDH)
Low creatinine
m
se
As
Low co rrected calcium
Dr
Low phosphate
Low uric acid
Low lactate d ehydrogenase (LDH )
Low creatinine
-
"""
Low co rrected calcium
Of the choice s, low co rrected calci um is the on ly biochemistry result which would be in
keeping with TLS. All o f the o th er biochemistry markers a re e levated in TLS. TLS can occu r
when a large amount o f cancer cells a re destroyed, causing a release of their intra-cellular
content into the bloodstrea m. This occur due to chemo thera py, but can a lso occu r
with out chemotherapy. Potassium and p hosphate are releasfed from the cells, causing
both to be high. As phosphate precipitates calcium, the serum concentration o f calcium
becomes low.
Source:
m
se
La rson, Richard A., and Ching -Hon Pui. 'Tumor Lysis Syndrome: Prevention and
As
Treatment.' UpToDate. 4 Oct. 2016. 5
Dr
A woman is p rescribed d ocetaxel as part o f her chemotherapy for breast cancer. What is
the mechanism o f actio n of docetaxel?
Inhibits RNA synthes is
Stab ilizes DNA-to poiso merase II co mplex
Prevents microtubule disassembly
Inhibits fo rmation o f microtub ules
m
se
Causes cross- linking in DNA
As
Dr
Inhibits RNA synthesis
Stabilizes DNA-to poiso merase II complex

-
' UI;IIl'
I Prevents microtubule disassembly
Inhibits formation of microtubules
Causes cross-linking in DNA
Taxanes such as docetaxe l - prevents microtubule depolymerisation & disassembly,

decreasing free tubu lin
m
se
Like other taxanes the principa l mechan ism of action is the prevention of microtubule
As
disassembly.
Dr
A 27-year-old male is receiving cyclophospham ide as pa rt of his chemotherapy fo r non-
Hodgkin' lymphoma. What is the most appropriate management to reduce the like lihood
o f haemo rrhagic cystitis?
Hydration + tranexam ic acid
Hydration + twice-daily b lad der washouts
Hydration + prophylactic antibiotics
Hydration + twice-daily blad der washouts + prophylactic antib iotics
m
se
As
Hydration + mesna
Dr
Hydration + tranexa mic acid
Hydration + twice-daily blad der washouts
Hydration + pro phylactic antibiotics
Hydration + twice-daily blad der washouts + prophylactic a ntibiotics

-
~
I Hydration + mesna
Cyclop hospha mide - haemorrhag ic cystitis - preve nt with mesna

Cyclophospha mide may be converted to urotoxic metabolites such as acrolein. Mesna
m
se
binds to these metabolites throug h its sulfhydryl-moieties and reduces the incidence o f
As
haemo rrhagic cystitis
Dr
Rega rding the Ann-Arbor classification of Hodgkin's lymphoma, which one of the
following wou ld be staged as IllB?
Nodes on both s ides of d iaphragm with pruritus
Two or more lymph nodes on the same s ide of the diaphragm with pruritus
Nodes on both s ides of d ia phragm with night sweats
Two or more lymph nodes on the same s ide of the diaphragm with night sweats
m
se
Two or more lymph nodes on the same side of the diaphragm with no system ic
As
symptoms
Dr
Nodes on both sides of diaphragm with pruritus
Two or more lymph nodes on the same side of the diaphragm with pruritus
Nodes on both sides of diaphragm with night sweats
Two or more lymph nodes on the same side of the diaphragm with night sweat s CD
m
se
Two or more lymph nodes on the same side of the diaphragm with no syst emic
As
Dr
A 35-year-old female who is 34 weeks pregnant presents with a swollen, painful right calf.
A deep vein thrombosis is co nfirmed on Doppler scan. What is the preferred
anticoagulant?
Clopidogrel
Aspirin
Intravenous hepari n
Warfarin
m
se
Subcuta neous low molecular weight heparin
As
Dr
Clopidog rel
ll spirin
Intravenous hepari n
Warfarin
Subcutaneous low molecular weight heparin

-
~
Although teratogenic effects of wa rfa rin are greater in the first trimeste r most clinicians
wou ld use low molecular weight heparin in this situation. Another factor to co ns ider is the
m
se
risk of peri partum haemorrhage and potential problems reversing the effects of warfa rin if
As
this occu rred
Dr
A 69-yea r-o ld man with termina l lu ng cance r is reviewed . He cu rrently takes MST 60mg
bd for pain. He has b ecome una ble to take ora l med ications and a d ecision is made to
set-up a syringe driver. What d ose of diamo rphi ne should be p rescribed fo r the syringe
driver?
60 mg
40 mg
120 mg
30 mg
m
se
As
20 mg
Dr
60 mg fD
~mg .,
120 mg m.
30 mg CD
20 mg GD
m
se
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 =
As
120mg) should be divided by 3 (120 I 3 = 40mg)
Dr
A 45-year-old woman is diagn osed w ith non-Hodgkin's lym phoma. She is a recovering
alcoholic and has been left with significant alcohol -related peri pheral neuropathy. Wh ich
one of the following chemotherapy agents should be avoided if possible, given her past
hist ory?
Doxorubicin
Vincristine
Chlorambucil
Docetaxel
m
se
Cyclophosphamide
As
Dr
Doxorubicin
•
I Vincristine f1'D
Chlorambu cil CD
Docetaxel CD
Cyclophosphamide m
m
se
Vincristine - p eripheral neuropathy
As
Dr
Which one o f the following therap eutic options is least recognised in the treatment of
aplastic anaemia?
Interferon-alpha
Stem cell transplantation
Anti-lymphocyte globulin
Anti-thym ocyte globulin
m
se
Plat elet transf usion
As
Dr
Interferon-a lpha
Sl em cell transplantation
Anti-lymphocyte globulin
Anti-thymocyte globulin
-
"""'
m
se
Platelet transfus ion
As
Dr
Which one o f the following is the most common inherited thrombophilia?
m
se
As
Dr
Activated protein C resistance (Factor V Le iden) is the most common inherited
t hro mboph ilia
Activated p rotein C resistance is due a point mutation in the Factor V g ene, e ncod ing for
the Le iden allele. Heterozygotes have a 5-fold risk of ve nous thrombosis whilst
homozyg otes have a 50 -fold increased risk
m
se
As
Von Willebrand's d isease is the most common inherited bleeding disorder
Dr
A patient is diag nosed with acute lymphoblastic leukaemia after presenting with lethargy
and easy bruising. Which one of the following is a marker of a bad prog nosis in acute
lymphoblastic leukaem ia?
Pre- B phenotype
Presentation in childhood
Initia l white cell count of 18 * 109/I
Female sex
m
se
As
Philadelphia chromosome positive
Dr
Pre-B phenotype GD
Present ation in childhood m
I
Initial wh ite cell count of 18 * 10 9
/I tiD
Female sex m
I Philadelphia chromosome positive CD
Phila delphia trans location, t (9;22) - good p rognosis in CML, poor prognosis in AM L
m
se
+ALL
As
Dr
A 14-yea r-o ld gi rl is a dmitted to the Eme rgency Depa rtment. Ove r the past hou r s he has
d eve loped a pa inless, no n-pruritic e rythematous rash associated with seve re a ng ioedema.
She has a past medical history o f recu rrent a bdo minal pain. Her symptoms fail to respo nd
to adre na li ne and she is the refo re intubated to p rotect the a irway. She is discha rged fro m
ITU after three d ays. During outpatie nt fo llow-up two weeks late r a diagnosis of
heredita ry angioedema is suspected . What is the most a p prop riate screeni ng test to
perfo rm?
Serum IgE levels
Serum C3 leve ls
Serum tryptase leve ls
Serum C4 leve ls
m
se
As
Serum Cl -INH leve ls
Dr
Serum IgE levels
Serum C3 levels
Seru t ryptase levels
Serum C4 levels
-
.......,
Serum Cl-INH levels
m
se
Hereditary angioedema - C4 is the best screen ing test inbetween attacks
As
Dr
A 45-year-old woman who is b eing t reated for Ho dgkin's lymphoma w ith ABVD
chemotherapy is reviewed on the haematology ward.
Six d ays ago she was admitted with a fever of 38.9°C. After admission she was
immediately st arted on p iperacillin with tazobact am (Tazocin). Her blood count on arrival
was as follows:
Hb 10.1 gfdl
Platelet s 3 11 * 109/1
WBC 0 .8 * 109/ 1
8
Neutrophils 0.35 109/1
8
Lymphocy tes 0 .35 109/1
After 48 hours she remained febrile and tachycardic, Tazocin was stopped and
meropenem + vancomycin prescribed.
Tod ay, six days after being admitted she remains unwell w ith a t emperature o f 38.4°C.
Blood pressure is 102/ 66 mmHg and the heart rate is 96/ min. Resp iratory examination
remains unremarkable and b lood/ urine cu ltures have failed to show any cause for the
fever. What is t he most app ro priate next step?
Add amphotericin B
Add G-CSF
Add gentam ici n
Add aci clovir

em
Refer for a stem cell t ran spl ant

s
As
Dr
I Add amphotericin B ED
.
Add G-CSF CD
Add gentam ici n CD
Add aciclovir GD
Refer for a stem cell transplant CD
This patient meets the diagnostic crite ria fo r neutropen ic sep sis. Ah er failing to respond
to standard empirical treatme nt the q uestions is what to d o next.
There a re no g uid e lines that can fit every patient & scenario . The d ecision to use
a ntifunga ls is now o h en taken aher risk stratifying patients and ord ering investigations
such as HRCT, Aspergillus PCR etc to determine the likelihood of syste mic fungal
infection. Fo r the purposes o f the exa m howeve r the answer is often to g ive antifunga ls
em pirica lly.
m
se
As
G-CSF is not used routinely in neutro penic sepsis.
Dr
Of the following options, which one is the best diagnostic test for paroxysmal nocturnal
haemoglobinuria?
FMC-7 staining
PAS st aining of erythrocytes
Flow cytometry fo r CD 59 and CD 55
m
se
As
Immunophenotyping for CD19 and CD20
Dr
Prc-7 staining
PAS staining of erythrocytes
I Flow cytometry fo r CD 59 and CDSS
Immunophenotyping for CD19 and CD20
m
se
Flow cytometry of blood to det ect low levels of CD59 and CDSS has now replaced Ham's
As
test as t he gold standard invest igation in paroxysmal nocturnal haemoglob inuria
Dr
Which one of the following is the most co mmon type of Hodgkin's lymphoma?
Lymphocyte predominant
Nodular sclerosing
Lymphocyte depleted
Mixed cellularity
m
se
Hairy cell
As
Dr
Lymphocyte predominant 6D
I Nod uIa r sclerosing ED

Lymphocyte depleted fD
Mixed cellularity fD
Hairy cell CD
m
se
Hodgkin's lymphoma - most common type = nodular sclerosing
As
Dr
What chemica l mediator is mainly responsible for the tissue oedema seen in patients in
hereditary angioedema?
Hist amine
Serotonin
Neurokinin A
Bradykinin
m
se
As
Nitric oxide
Dr
Histamine CD
Serot on in m
Neurokinin A m.
I Bradykinin GD
m
se
Nitric oxide CD
As
Dr
A 71-yea r-old woman with metastatic b reast cancer co mes to surgery with her husband.
She is known to have bone metastases in her pelvis and ribs but her pa in is not contro lled
with a co mbination o f paracetamo l, d iclofenac and MST 30mg bd. Her husband reports
she is us ing lOmg o f o ra l morphine solution around 6-7 times a day for breakthrough
pa in. The palliative care team at the hospice tried using a bisphosphonate but this
unfortunately resulted in persistent myalgia and arthra lg ia. What is the most appropriate
next step?
Switch to oxycodone
Increase MST
Increase MST + add dexamethasone
Increase MST + suggest cou rse of complimenta ry therapies
m
se
As
Increase MST + refer fo r radiotherapy
Dr
Switch to oxycodone
Increase MST
Increase MST + add dexamethasone
Increr se MST + su ggest course o f co mplimentary the rap ies
Increase MST ~ refer for radiotherapy

-
~
Metastatic bone pa in may respond to analges ia, bisphosphonates or radiothe rapy

m
se
Dexamethasone shou ld be co nsidered if the metastatic spina l cord compression, but this
As
is not a feature given the location o f the lesions.
Dr
A 58-yea r-old man is reviewed in clinic. Six months ago he had a Wh ipple procedure fo r
pancreatic cancer and is currently unde rgoing chemothe rapy. Which one of the following
blood tests is most useful in monito ring his disease?
CA 15-3 leve ls
Faecal elastase
CA 125 leve ls
Amylase levels
m
se
As
CA 19-9 levels
Dr
CA 15-3 levels m
Faeca l elastase CD
n A 125 levels m
Amylase levels m
I CA 19-9 levels (D.
m
se
Pancreatic cancer - CA 19-9
As
Dr
A 75-year-old ma le patient has metastatic colo recta l cancer. He spend s most of his day
resting in bed or in his chair and requires assistance with his activities o f daily living. What
is his Eastern Cooperative Onco logy Group (ECOG) score?
m
se
4
As
Dr
0
-
1
•.
(D
2 (CD
I 3 6D
m
se
GD.
As
4
Dr
A fu ll blood count for a 38-year-old man is reported as follows:
Hb 12.9 g/dl
WBC 6 .2 * 109/ 1
Film Numerous Howell-Jolly bodies and pencil cells seen
Which one of the following conditions is most likely to produce these results?
Coeliac disease
HIV inf ection
Sickle-cell tra it
Autoimmune hemolytic anaemia
m
se
As
Liver disease
Dr
Coeliac disease
HN infection
Sickle-cell t rait
Autoimmune hemolytic anaemia

-
~
Liver disease
-
~
m
se
Howell-Jolly bodies are seen in hyposplenism and pencil cell s are a f eature of iron-
As
d ef iciency. Both o f these are seen in coeliac disease.
Dr
Yo u review a 65-yea r-o ld wo man in on co lo gy cli nic. She has known metastatic b reast
ca ncer, a nd has received a mastecto my, chemothe rapy and radiotherapy.
She has co mplai ned o f headaches and nausea for the la st 7 d ays, which are wo rse in the
morning s. ACT head showed multiple brain metastases, with co mpression of the
ve ntricles and sulci.
Yo ur patie nt declines further chemothe ra py or radiothe rapy. She is currently ta king o pioid
painkille rs.
Which of the following med ications ca n b e used as an adj unct to further rel ieve her
symptoms?
Ondansetron
Cyclizi ne
Dexamethasone
Ha lo perido l
m
se
As
Sumatriptan
Dr
Ondansetron fD
Cyclizine CD
Dexamethasone CD
Haloperidol m
Sumatriptan CD
Headache caused by ra ised intracran ia l pressu re due to bra in cancer (or metastases)
can be palliated with dexamethasone
Dexamethasone is used to reduce oedema a round bra in metastases, to pa lliate symptoms

of ra ised intracran ial pressu re.
Ondansetron, cyclizine and haloperidol are a ll effective agents fo r nausea, but would not
treat the root cause.
m
se
As
Su matriptan is a treatment fo r mig raines and has no role here.
Dr
Yo u are the haematology reg istra r. A 42-yea r-old lady has been referred by he r GP with a
pe rsistently elevated p latelet cou nt. It was incid entally fo und on a b lood test orig in ally s ix
months a go at 632 x10 " 9/ L. The latest reading was 848 x10"9/ L which was the highest it
has b een yet. She is otherwise well b ut d oes su ffer with regular headaches wh ich she
takes s imp le analg esia fo r. You suspect a diagnosis of essential thromb ocytosis and
arra nge a JAK-2 test which is neg ative (including an exon 12 test). Which is the most likely
other gene muta tion respons ible for this cond ition?
BCR-AB L
MPL
CMYC
Plate let fa ctor 4
m
se
As
CALR
Dr
BCR-ABL tiD
MPL GD
CMYC CD
Plat elet factor 4 6D
I CALR ED
CALR (cal reticu lin) is a more co mmonly foun d gene mutation in ET in around 20% of JAK-
2 negative patient s.
MPL (myeloproliferative leukaemia p rotein) is less common at less t hen 10%.
BCR-ABL is associat ed with the myelop roliferative disorder chronic myeloid leukaemia.
CMYC is a proto-oncogene associated with many malignancies including Burkitt's

lymphoma.
m
se
Plat elet factor 4 (PF4 complex) is the antigen found in heparin-induced
As
thrombo cytopen ia.
Dr
Which of the following is a cause of intravascular haemolysis?
Heredit ary sp herocytosis
Sickle cell anaemia
Haemolytic disease of the new born
m
se
As
Dr
Sickle cell anaemia
Haem0lyt ic disease o f the newborn
m
se
Intravascular haemolysis - paroxysma l noct urnal haemoglobinuria
As
Dr
A patient d evelops methaemoglo bina em ia aher being prescribed isosorb ide mononitrate.
Which substance is most likely to be d e pleted?
Pyruvate kinase
Hyponitrite reducta se
Pyridoxine 5-dehydrogenase
Glucose-6-p hosphate d ehydroge nase
m
se
As
NADH
Dr
Dr
As
se
m
Which one of t he followin g is not a recogn ised feature of met haemoglobinaemia?
Dyspnoea
'Chocolate' cyanosis
Anxiety
Reduced p02 but normal oxygen saturation on pu lse oximetry
m
se
As
Acidosis
Dr
Dyspnoea
'Chocolate' cyanosis
- ~
Anxiety
Reduced p02 but normal oxygen sat ration on pu lse oximetry

-
~
Acidosis
m
Normal p02 but d ecreased oxygen saturation is characteristic of
se
methaemoglobinaemia
As
Important for me l ess i m ::~c rtant
Dr
A 48-yea r-o ld fe male presents to her fa mily p hysician co mplai ning of post-coital pa in.
She initia lly thoug ht that this was relate d to he r age but recently she has b een feeling a
consta nt d ull pain in her pe lvis. She also re ports havi ng a fo ul-smelling discha rge from
her vag ina. Her past medical a nd surgica l histo ry reveal nothi ng significa nt a long but s he
says that she has had seve ra l sexual partn ers in he r early teenage yea rs and twe nties. She
cu rrently smokes a bout 10 ciga rettes a d ay fo r the past 10 years and d oes not consume
a lco ho l. On exam inatio n, the d octor find s an irregu lar mass on he r cervix. Which of th e
fo llowing best describes the mechan ism fo r the strongest risk facto r fo r this patient's
conditio n?
Human pap illoma virus 16 and 18 produces oncop rote ins which causes inhibition
o f the tumor suppressor g enes causing cervica l carcinoma
Cig arette smoking produces dysplasia of the squ amocolumn ar junct io n leading to
ce rvical cancer
Having mu ltiple sexua l pa rtners increase the risk of g etting HIV which the n
expresses vira l prote ins lead ing to ce rvica l dysp las ia a nd carcino ma
Human pap illoma virus 16 and 18 pro duces oncop rote ins which the n activate
oncogenes ca using ce rvica l carcinoma
m
se
The patients a ge is the strong est risk fa ctor a s the cervica l cells lose their repa ir
ca pacity and then prog ress o n to dysplasia a nd ca rcinoma As
Dr
Human papilloma virus 16 and 18 produces onco prote ins which causes
inhibition of the tumor suppressor genes causi ng cervical ca rcinoma
Cig arette smoking produces dysplas ia o f the squ amocolumn ar junction leading
to cervical cancer
Having mu ltiple sexual pa rtners increase the risk of g etti ng HIV which the n
expre sses viral proteins leadi ng to ce rvical dysp lasia a nd carcinoma
Human pap illoma virus 16 and 18 pro duces onco prote ins which the n activate
o ncogenes ca using ce rvica l carcinoma
~he patients a ge is the strong est ris k fa cto r a s the cervica l cells lo se their repa ir
<!apacity and then prog ress on to dysplasia a nd carcinoma
This patie nt has prese nted with the s ig ns and sympto ms typical of a ce rvical ca rci nom a.
The o nset of a co nstant dull p elvic pain ind icates a possible invasio n o f pelvic structu res
and nerves. The strongest risk factor in this patient is having seve ra l sexua l pa rtne rs at a
ve ry you ng a ge, which the n puts her at risk of be ing infected with the human papillo ma
v1rus.
1: Having multiple sexu al partners is the stro ngest risk facto r fo r the deve lo pment of
ce rvica l carcino ma. Th is is beca use having multiple sexual pa rtners greatly increa ses the
cha nce o f b eing infected with the huma n papill oma virus. The 16 and 18 viral strain the n
trig gers the ca rcinog e nesis by inhibitin g the tumo r suppressor g e ne p 53 a nd RB.
2: Although cig arette s moking will have a n o ncogenic e ffect, it is not the strongest risk
factor here.
3 : HIV is a risk facto r fo r cervica l carcino ma. Howeve r, it is a lesser risk factor than the
hu man pap illo ma virus wh ich is much more common.
4 : Although the huma n papilloma virus d oes rep rese nt the stro ng risk facto r, it d oes not
cause the activatio n o f o ncoge nes. Instea d, it causes the inhibitio n of tumor su ppressor
g e nes.
5: Ag e in itself has not b een reported to b e a risk facto r fo r the deve lop ment of cervical
ca rcinoma. An o lder p erson is mo re li ke ly to d eve lop cervical ca rcinom a if that p erson has
fo r insta nce been exposed to the human papilloma virus, which the n has more time to
em
induce the pro cess of carcinoge nes is via the inhib itio n o f t umor su ppressor g e nes.
s
As
Dr
Acut e intermittent porp hyria is due t o a defect in:
ALA synthet ase
PPG oxidase
Uropo rp hyrinogen d ecarb oxylase
Ferrochelatase
m
se
As
Porphobilinogen deaminase
Dr
ALA synthet ase
PPG oxidase
Uroporphyrinogen decarb oxylase
~errochelatase
Porphobilinogen deaminase
m
se
As
AlP - porphobilinogen deAminase; PCT - uroporphyrinogen deCarboxylase
Dr
A patient with glucose-6-phosphat e dehydrogenase (G6PD) deficiency present s for advice
about malaria prophylaxis. He is about t o go on a 'gap year' duri ng which he will be
travelling abroad for 12 months. Which one of the following medications is it most
important that he avoids?
Artemether with lumefantrine
Mefloquine
Proguanil
Doxycyline
m
se
As
Primaquine
Dr
Artemether with lumefantrine
Mefloquine
Proguanil
Doxycyline
Primaquine
-
~
Malaria prophylaxis (e.g. primaquine) can trigger haemolytic anaemia in those w ith
m
se
G6PD deficiency
As
Dr
You are arra ng in g a b lood transfusion for a patient who has been ad mitted with an upper
gastro intestina l haemorrhage as their haemoglobin is 59 g/1. They a re concerned about
the risks of contracting diseases from the transfusion and ask specifically about the risk of
variant Creutzfeldt-Jakob Disease (vOD) transm ission. What is the most appropriate
a dvice with respect to vCJD?
There was never any risk of vO D being tra nsmitted via blood transfusion
There had p reviously been a small risk of vCJD transmiss ion b ut the risk has now
been elim inated through screening
Measu res are taken to reduce the risk o f vCJD transm ission but there remains a
very s mall risk of transmission
There is a significant chance of vCJD trans mission to patients who are between the
ages o f 40-60 yea rs
m
se
There is a s ignificant chance of vCJD trans miss ion to patients who are between the
As
ages o f 60-90 yea rs
Dr
There was never any risk of vCJ D being t ransmitted via blood transfusion
There had p reviously been a small risk of vCJD t ransmission b ut the risk has now QD
been eliminated through screening
I
[ " :asures are taken to reduce the risk of vCJD transmission but there remains a
very small risk of transm ission
There is a signif icant chance o f vCJD t rans miss ion to patients w ho are between
the ages of 40-60 years
m
se
There is a significant chance o f vCJD t ransmiss ion to p atients w ho are between
As
the ages of 60-90 years
Dr
A man is investigated for ana emia. A bl ood film is ordered and reported as follows:
Ring sideroblast s
Which one o f the following is least likely t o g ive this picture?
Anti-tuberculosis medication
Alcoho l
Pyridoxine
Lead
m
se
As
Myelodysplasia
Dr
Anti-tuberculosis medication
Alcohol
Pyridoxine
Lead
Myelodysplasia
m
se
Pyridoxine is actually a treatment for sideroblastic anaemia. Ra rely pyridoxine deficiency
As
may be the cause
Dr
Which one o f the following is not a featu re o f paroxysmal nocturnal haemoglobinuria?
Haemolyt ic anaemia
Positive Ham test
Haemoglobinuria
Ap lastic anaemia
m
se
As
Haemarthros is
Dr
Haemolytic anae mia CD
Positive Ham test
Haemoglobinuria
•
CD
Aplastic anaej ia tiD.
m
se
As
Haemarthros is CD
Dr
A 50-yea r-old woman is investigated for weight loss and anaemia. She has no past
med ica l history of note. Clinical examination revea ls sp lenomegaly associated with pale
conjunctivae. A full blood count is re ported as follows:
Hb 10.9 g/dl
wee 56 .6 8
10911
Film Leucocytosis noted . All stages of granulocyte maturation seen
Given the like ly d iagnosis, what is the most appro priate treatment?
Chlora mbuci l
Rit uximab
Repeat full blood count in 3 months
m
se
As
Imatinib
Dr
Chlorambu cil
Rituximab
-
~
Repej t full blood cou nt in 3 months

-
~
m
se
Imatinib
As
Dr
A 68-year-old man who has s mall cell lung cancer is adm itted onto the ward for
chemothera py. He has experienced severe nausea and vomiting due to the chemotherapy
in the past. The consultant asks you to prescribe a neurokinin 1 (NKl) receptor blocker.
What agent will you choose?
Aprepitant
Dexamethasone
Metoclopram ide
Domperidone
m
se
As
Haloperidol
Dr
Aprepitant GD
Dexamethasone m
Metoclopramide CfD
Domperidone GD
Haloperidol CD
Aprepitant is an ant i-emetic which blocks the neurokinin 1 (NK1) receptor

Aprepitant is an anti -emetic which blocks the neurokinin 1 (NK1) receptor. It is a

substance P antagonists (SPA). It is licensed for chemotherapy-induced nausea and
vom it ing (ONV) and for p revention of postoperative nausea and vomiting. It is also been
shown to be effective in t reating cli nical depression.
Dexamethasone is a glucocorticoid. It is useful for p reventing the delayed emesis phase of

CINV.
m
se
Metoclopramide, domperidone, and haloperidol can all be used as anti-emetics due to
As
their dopamine b locking effects.
Dr
A 48-year-old female who has just completed a cou rse o f chemotherapy complain s o f
difficu lty using her hands associated with 'pins and needles'. She has also experienced
urinary hesitancy. Which cytotoxic drug is most likely to be responsible?
Doxorubicin
Cyclophosphamide
Methotrexate
Vincristine
m
se
Bleomycin
As
Dr
Doxorubicin CD
Cyclophosphamide CD
Methotrexate CD
Vincristine GD
Bleomycin m
Vincristine - p eripheral neuropathy

Important for me l ess · m ::~c rtont
m
se
Vincristine is associated with peripheral neuropathy. Urinary hesitancy may develop
As
secondary to bladder atony.
Dr
A 65-yea r-old man who is undergo ing b one marrow transp lant requires a blood
tra nsfusion. Irrad iated p acked red cells a re requested . What is the p urpose of requesting
irrad iated blood p roducts in this situation?
Dep letes the pa cked cell s of platelets reducing the risk of thrombotic complications
Ensures the b lood produ cts a re free of viruses a nd organisms
Destroys HLA markers reducing the risk o f blood transfusion reaction
Reduces the HbA2/ Hb ratio
m
se
Dep leted T-lymphocyte numbers redu ce the ris k o f transfus ion g raft ve rsus host
As
disease
Dr
Dep letes the pa cked cell s of plate lets reducing the risk of thro mbotic
com plications
Ensures t he blood produ cts a re free of viruses a nd o rgan is ms
Destroys HLA markers reducing the risk of blood transfusion reaction
Reduces the HbA2/ Hb ratio
Dep leted T-lymp hocyte numbers reduce the ris k of transfusion g raft ve rsus host ED
d isease
Irradiated blood products are used as they a re depleted in T-lymphocytes

m
se
The most co mmon indications for irrad iated blood p roducts are cond itions where the
As
immune system is co mpromised.
Dr
What is t he mechanism o f action of DDAVP in von Willebrand's disease?
Prevents renal excretion o f von Will eb rand's factor
Induces release of fact or VIII from endothelial cells
Induces release o f vo n Willebran d's factor f rom endothelial cells
Inhibits breakd own of von Willeb rand's fact or
m
se
As
Acts as substit ute carrier molecule for facto r VIII
Dr
Prevent s rena l excretion o f von Willeb rand 's factor
Induces release o f fact or VIII f rom endothelial cells
I Induces release of von Willebran d's facto{ f ro m endothelial cells
Inhib its b reakdow n of von Willebrand 's fact or
Acts as substit ute carrier molecule for factor VIII
m
se
Desmopressiin - induces release of von Willebrand's facto r from endothelial cells
As
Dr
What is the main mechanism by which vitam in B12 is absorbed?
Passive abso rption in the terminal ileum
Active absorption in the middle to terminal part of jejunum
Active absorption by the parietal cells of the stomach
Active absorption in the termina l ileum
m
se
As
Passive abso rption in the proximal ileum
Dr
Passive absorption in the terminal ileum
Active absorption in the middle to terminal part of jejunum
Active absorption by the parietal cells of the stomach
Active absorption in the terminal ileum
Passive absorption in the proximal ileum
Vitamin 812 is actively absorbed in the terminal ileum

m
se
A small amount of vitamin 812 is passively absorbed without being bound to intrinsic
As
factor.
Dr
A 72-year-old man is admitted with a deep vein th rombosis. He is normally fit and well
but has recently lost weight. Blood tests reveal the following:
IgG 889 mg/dl ( range 600- 1300 mg/dl)
IgM 1674 mg/dl (range 50-330 mg/dl)
IgA 131 mg/dl ( range 60-300 mg/dl)
Monoclonal gammopathy of undetermined significance
m
se
As
Multiple myeloma
Dr
Monoclonal gammopathy of undet ermined significance
Acut e promyelocytic leukaemia
Multi ple myeloma
IgM paraprot einaemia - ?Waldenstrom's macroglobulinaemia

Waldenstrom's macroglobulinaemia is more likely than monoclonal gammopathy of

undet ermined significance given the weight loss and deep vein thrombosis (evidence of
hyperviscosity).
m
se
As
IgG and IgA and the most common type of immunoglobulins produced in myeloma.
Dr
You are asked to review a 60-yea r-old Greek man with known glucose-6-phosphate
dehydrogenase (G6PD) deficiency who was adm itted with mala ria and a chest infection.
He has developed jaundice an d haemolytic anaemia after starting some medications this
morning.
Which of these medications are most likely to have precipitated his crisis?
Clarith romycin
Amoxicil li n
Artesunate
Primaquine
m
se
As
Salbutamol
Dr
Clarithromycin CD
(l1 oxicillin CD
Artesunate m
I Primaquine GD.
~
Salbut amol m
Malaria prophylaxis (e.g. primaquine) can trigger haemolytic anaemia in t hose w ith
G6PD deficiency
Primaquine is a wel l known cause of haemolysis in G6PD d eficiency and is used in the
treatment of malaria. Artesunat e is generally considered safe to use in G6PD d eficiency.
m
Penicillins and macrolides are safe antibiotics to use in G6PD d eficiency.
se
As
Source: BNF
Dr
A 54-year-old man is investigated for recurrent episodes of abdominal pain associated
with weakness of his arms and legs. Wh ich one of the following urine t ests wou ld best
indicate lead toxicity?
Haemoglobinuria
Coproporphyrin
Porphobilinogen
Uroporphyrin
m
se
As
Ham's test
Dr
Haemoglobinuria CD
Coproporphyrin ED
Porphobilinogen fD
Uroporphyrin tiD.
m
se
Ham's test f!D
As
Dr
A 74-yea r-old ma le is seen on the acute medical ward with a histo ry of persistent frontal
headaches associated with blurred vision fo r the past week. On fu rther questio ning, the
patient reports a history of wo rsening fatigue and shortness of breath ove r the preceding
2 months.
The results of preliminary investig ations a re as fo llows:
Hb 98 g/1
Plat elet s 100 * 109/ 1
WBC 6 * 109/ 1
Erythrocyte Sedimentation Rate SOmm/hr
On exam ination you note that the patient has enla rged cervical lymph nodes and
pa lpa ble sple nomeg a ly.
Which o f the fo llowing conditions is most likely to b e the cause of the patient's
symptoms?
Hod g kin's lymphoma
Multip le myeloma
Acute myeloid leuka e mia
Waldenstrom's macroglo bulinaemia
Acute lympho blastic leukaemia

em
s
As
Dr
Submit answer
Hodgkin's lymphoma
Multiple myeloma
Acute myelo id leukaemia
Wald enstrom 's macroglo bulinaemia

-
~
Patients with Wa ld enstrom's macroglobu linaem ia ohen present with issues

secondary to hyperviscosity
Wald enstrom 's macroglobulinaemia is a form of lymphoplasmacytoid lymphoma (LPL),

cha racterised by a monoclonallgM pa raproteinaemia. This pa raproteinaemia leads to
systemic symptoms of hyperviscosity such as headaches, visual disturbances and in rarer
cases, strokes and ischaemic orga n d a mage.
Many patients ohen present with issues secondary to th is hyperviscosity, as well as the
more genera lised systemic symptoms and signs common to many haematolo gical
diseases.
1) Hodgkin's lymphoma, although likely to cause cervica l lympha denopathy and

splenomega ly, is not usually associated with thrombocyto paenia or issues secondary to
hyperviscosity
2) Multiple myeloma ohen ca uses bony pa in in areas o f lesions and isn't ohen associated
with lymphadenopathy or organomeg aly
3) AML doesn't usual ly cause lympha denopathy o r splenomegaly.

em
5) ALL is less common in adults, and although capable of ca using lym phadenopathy and
s
As
splenomega ly, would not usually be associated with symptoms o f hyperviscosity

Dr
A 54-yea r-old man is diagnosed as having acute mye loid leukaemia. What is the single
most imp ortant test in d etermin ing his prognosis?
Gene-expression p rofil ing
White cell count at dia gnosis
Immu nophenotyping
Lactate d ehydrog e nase
m
se
As
Cyto geneti cs
Dr
Gene-expression p rof iling CD
I White cell cou nt at diagnosis CD
Immunophenotyping ED
Lactate dehydrogenase CD
I Cytogenetics
I
C!D
m
se
All of the above may be important but chromosomal abnormalities detected by
As
cytogenetics are t he single most important prognosti c factor.
Dr
What is the most useful marker of p rognosis in myeloma?
Calcium level
Urine Bence-Jones protein levels
Alkaline phosphatase
ESR
m
se
As
B2-microg lobulin
Dr
Calcium level GD
Urine Bence-Jones protein levels G'D
Alkaline phosphatase .
CD
ESR CD
m
se
I
As
B2-microg lobulin ED
Dr
Which one of the following is associated with a high leucocyte alka line phosphatase
score?
Myelofibrosis
Pernicious anae mia
Paroxysmal nocturnal haemog lobinuria
m
se
As
Dr
I M yelofib rosis CID
Pernicious anaemia m
Infectious mononucleosis (fD
Paroxysmal nocturnal haemoglobinuria f!D
m
se
As
Chronic myeloid leukaemia QD
Dr
A 45-year-old woman attends the acute medical unit with her second DVT this year. Her
background is notable fo r COPD, hypertension and chronic kidney disease stage 4
secondary to membra nous glomerulonephritis.
In chronic kidney disease, w hich of the following contributes most to the increased risk of
VTE?
Immobility
Loss o f protein C
Loss o f antithrombin III
Concurrent cancer
m
se
As
Lupus anticoagu lant
Dr
Immobility m
Loss of protein C ED
I Loss of antithrombin III ED.

Concu rrent cancer CD
Lu pus anticoagulant .
(D
CKD is the most common cause of antith rombin III deficiency

Important for me l ess ' m::~c rtant
Antithrombin III is an im portant regulatory molecu le that reduces the activity of the
intrinsic pathway of the clotting cascade. Loss of antithrombin III, thus, increases
coagulability.
Whilst there are hered itary causes of antithrombin III, it is a particularly small protein and
is easily lost through the nephron in CKD.
CKD does also increase the risk of concu rrent cancers, but not as significantly as the
m
se
protein loss. Lu pus anticoagulant is indeed highly prothrom botic and is associated with
As
antiphospholipid syndrome.
Dr
A 28-yea r-old man is investigated for cervical lymphadenopathy. A biopsy shows nodular
sclerosing Hod gkin's lymphoma. Which one o f the following factors is associated with a
poor prognosis?
History of Epstein Ba rr virus infection
Mediastinal invo lvement
Female sex
Night sweats
m
se
As
Lym phocytes 20% of tota l white blood cells
Dr
History of Epstein Barr virus infection
Mediastinal involvement
Female sex
Night sweats
Lymphocytes 20% of tota l wh ite blood cells

-
~
m
se
As
Night sweats are a ' B' sym ptom and imply a poor prognosis
Dr
A 72-year-old man with metastatic small cell lung cancer is admitt ed to the loca l hospice
fo r sympt om cont rol. His main problem at t he moment is intractable hiccups. What is the
most app ropriat e mana gement?
Chlorpromazine
Co deine phos phat e
Diazepa m
Methadone
m
se
As
Phenytoin
Dr
Chlorpromazine GD
Codeine phosphat e f!D
Diazepam f!D
Methadone
•
Phenytoin
•
Hiccups in palliative ca re - chlorpromazine o r haloperidol
m
se
As
Haloperidol may also be used
Dr
A 64-yea r-old wo man with meta static b reast ca nce r is brought in by her husband. Over
the past two d ays she has develo ped increasing ly severe back pain. Her hus ba nd reports
that he r leg s are weak and she is havin g difficulty walking . On e xam ination she has
reduced power in both leg s a nd increased tone asso ciated with brisk knee a nd a nkl e
reflexe s. There is some sensory loss in the lower limbs a nd feet but p eria na l se nsation is
normal. What is the most like ly d iagnos is?
Spina l cord com pression at TlO
Cauda eq uina syndrome
Guillain Barre syndrome
Hype rcalcaemia
m
se
As
Pa ra neoplastic pe rip hera l neuropathy
Dr
Spinal cord compression at TlO
Cauda equina syndrom e
Guillain Barre syndrome
Hypercalcaemia
-
Para neoplastic peripheral neuropathy
m
se
As
The upper motor neuron signs point t owards a diagnosis of spinal cord co mpression
above ll, rather than cauda equina syndrome.
Dr
A 30-year-old man is investigated for enlarged, painless cervica l lymph nodes. A biopsy is
t aken and a diagnosis o f Hodgkin's lymphoma is made. Which one o f the following types
o f Hodgkin's lymphoma carries the best prognosis?
Lym phocyte predominant
Mixed cellularity
Nodular sclerosing
Hairy cell
m
se
As
Lym phocyte depleted
Dr
Lymphocyte predominant
Mixed cellularity
Nodular sclerosing
Hairy cell
Lymphocyte depleted
m
se
Hodgkin's lymphoma - best prognosis = lymphocyte predominant
As
Dr
Which one of t he followin g malignancies may be associat ed w ith HTLV-1?
Adu lt T-cell leukaemia
Colorectal cancer
Burkitt's lymphoma
Medullary t hyroid cancer
m
se
As
Breast cancer
Dr
Adult T-cell leukaemia GD
Colorectal cancer CD
Burkitt's lymphoma CD
M eaullary t hyroid cancer CD
m
se
Breast cancer D
As
Dr
Each one of the following is associated with hyposplenism, except:
Sickle -cell a naem ia
Liver cirrhosis
System ic lupus e rythem atous
Co e liac d isease
m
se
As
Sp lenectomy
Dr
Sickle-cell anaemia GD
I Live r cirrhosis CiD

Systemic lupus erythematous GD
~eli a c disease f!D
m
se
As
Splenectomy m
Dr
A 65-yea r-o ld man comes fo r review. He has a history o f s mall cell lung ca nce r and
ischaemic heart disease. His cancer was d iag nosed five months ago and he has recently
com pleted a cou rse of c hemothe ra py. From a ca rdiac po int o f view he had a myocardia l
infa rctio n two years ago following which he had p rimary a ng io plasty with stent
placement. He has had no ang ina s ince.
Fo r the past week he has b ecome increasingly s hort-of-b reath. This is wo rse at n ight and
is associated with an occasional no n -pro ductive cough. He has a lso noticed that his
wed d ing ring feels tight. Clinica l exam ination is o f his chest is unremarka ble. He does
howeve r have diste nded neck ve ins and pe riorbita l oed e ma. What is the most likely
diag nosis?
Heart fa ilure secondary to chemothe rapy
Tu mou r lysis syndrome
Nep hrotic synd rome seconda ry to chemotherapy
Sup erior ve na cava obstruct io n
m
se
As
Hypercalcaemia
Dr
Heart failure secondary to chemothera py
( lmour lysis synd rome
Nep hrotic syndrome secondary to chemothera py
Superior vena cava obstruction

-
~
m
se
As
Hypercalcaemia
Dr
A 22-year-old man with sickle cell anaemia presents with pallor, lethargy and a hea dache.
Blood results are as follows:
Hb 4 .6 g/dl
Reticulocytes 3%
Infection with a parvovirus is suspected. What is the like ly d iagnosis?
Th rombotic cris is
Transformation to myelodysplasia
Haemolytic crisis
m
se
As
Aplastic crisis
Dr
Thrombotic crisis
r : ransformation to myelo dysplas ia
Haemo lyti c crisis
~astic crisis
m
se
The su dd en fa ll in haemoglobi n witho ut an approp riate reticu lo cytosis (3% is just above
As
the no rmal range) is typical of an aplastic crisis, usually seconda ry to parvovirus infectio n
Dr
Which one o f the followin g featu res is charact eristic of acute intermittent po rphyria?
Photosensitivity
Increased urinary po rp hobilinogen between acute attacks
Hypernatraem ia d uring a ttacks
Autosomal recessive inheritance
m
se
As
Increased faeca l p rotoporphyrin excretion
Dr
fD
..
Photosensitivity
rIncreased urinary porphobi linogen between acute attacks
Hypernatraemia du ring a ttacks CD

IAutosom~l recessive inherita nce f!D
m
se
As
Increased faeca l p rotoporphyrin excretion fD
Dr
In idiopathic throm bocytopenic pu rp ura what a re the autoantibod ies most common ly
directed at?
Platelet activating factor
Glycoprotein lib/lila complex
ATP receptor
Anti-thrombin Ill receptor
m
se
As
ADP receptor
Dr
Platelet activating factor GD
I Glycoprotein lib/lila complex
ATP receptor
CD
CD
I
Anti-thrombin mreceptor m
m
se
As
ADP receptor
Dr
A 23-year-old woman presents with lethargy. The following blood results are obtained:
Hb 10.4 g/dl
Pit 278 * 109/1
wee 6 .3 * 109/ 1
MeV 68 fl
Blood film Microcytic hypochromic RBes, marked anisocyt osis and basophilic stippling noted
HbA2 3.9%
Lead poisoning
Sickle cell anaemia
Beta-thalassaemia tra it
m
se
As
Siderob lastic anaemia
Dr
Lead poison ing
Sickle cell anaem ia
I Beta-thalassaemia tra it
Hered ita ry spherocytos is
Sid erob lastic anaem ia
Disproportionate microcytic anaemia -think beta-tha lassaem ia trait

A microcytic anaemia in a female shou ld raise the possibility of e ither gastrointestinal

b lood loss or menorrhag ia . However, there is no history to suggest this and the
microcytosis is disproportionately low fo r the haemoglobin level. This comb ined with a
raised HbA2 po ints to a d iagnosis of beta-tha lassaem ia trait.
m
se
Baso philic stippling is also seen in lead poison ing but wou ld not expla in the raised HbA2
As
levels.
Dr
A 17-year-old man is invest igated after he bled excessively following a toot h extraction.
The following results are obtained:
Pit 173 * 109/ 1
PT 12.9 sees
APTT 84 sees
Which clotting factor is he most likely to be deficient in?
Factor VI
Factor VII
Factor VIII
Factor IX
m
se
As
Factor X
Dr
Factor VI fD
Factor VII m
I Factor VIII fZD.
Factor IX CD
Fac or X CD
m
se
As
This man is most likely to have haemophilia A, which accounts for 90% of cases o f
haemophilia.
Dr
Which one of the following is least likely to cause a warm autoimmune haemolytic
anaemia?
Mycoplasma infection
Methyldopa
Lymphoma
m
se
As
Dr
Methyldopa
~ronic lyT phocytic leukaemia

Lym phoma
System ic lupus erythematous
Mycoplasma infectio n causes a cold autoimmune haemolytic anaemia. System ic lupus
m
se
erythematous can rare ly be associated with a mixed-type auto imm une haemo lytic
As
anaemia
Dr
A 62-year-o ld woman who is known to have metastatic breast cancer presents with
increasing s hortness of b reath. She is cu rrently receiving a chemotherapy reg ime. On
exam ination she has a third heart sound and the apex beat is d isplaced to the 6th
intercosta l space, a nte rior axillary line. Which one of the fo llowing chemotherapeutic
agents is most like ly to be responsible?
P ,clitaxel
Docetaxel
•
CD
Bleomycin (D
Dactinomycin m
m
se
I
As
Doxorubicin fD
Dr
~~clitaxel CD
Docetaxel m
Bleomycin GD
Dactinomycin m
Doxorubicin fD
m
se
Doxorubici n may cause ca rdiomyopathy
As
Dr
A 52-year-old is found t o have chronic myeloid leukaemia following investigation for
splenomegaly. Which one of the following best descri bes the function of the BCR-ABL
fusion prot ein?
Epidermal growth factor recept or
Phospholipase C
CD52 co-receptor
Tyrosine kinase
m
se
As
Fibroblast growth factor receptor
Dr
Ep idermal growt h factor recept or
Phospholipase C
CD52 co-receptor
Tyrosine kinase
Fibroblast growth factor receptor
m
Chronic myeloid leukaemia - imatinib = tyrosine kinase inhibitor
se
As
Dr
A 49-yea r-old female is adm itted to hospital d ue to shortness of b reath a nd pleuritic
chest pain. She also com pla ins of a marked decrease in app etite for the past 4 months . An
a d mission chest x-ray shows a right-s ided pleu ral effusion. An underlying malignan cy is
suspected a nd a series of tumour markers are requested:
CA 19-9 55 u/ml ( < 40)

CA 125 654 u/ml ( < 30)
CA 15-3 9 u/ml ( <40)
Ova rian fibroma
Pancreati c carcinoma
Hepatocellu la r cancer
m
se
As
Breast carcinoma
Dr
Ovarian fibroma f%!D
Small cell lung cancer CD
Pancreatic carcinoma GD
Hepatocellular cancer
Breast carcinoma
•.
(D
m
se
This patient has Meig's synd rome - an ova rian fibroma associated with a pleu ral effusion
As
and ascites
Dr
Which one of the following cyt otoxic ag ents act s by inhibiting dihydrofolate reduct ase
and thym idylate synthesis?
Methotrexate
Vincristine
Bleomycin
Cyclophosphamide
m
se
As
Doxorubicin
Dr
Methotrexate CD
Vincristine CD
Bleomycin m
Cyclophosphamide fD
Doxorubici n CD
m
se
Methotrexate - inhibits dihydrofolate reductase and thym idylate synthesis
As
Important for me Less : m ::~c rte;nt
Dr
A 32-year-old fema le is not ed to have a mild microcytic anaemia on routine blood t ests.
She is otherwise well with no maj or past medical history. She is originally from Tu rkey.
You suspect that she might have a haemoglobin abnormality. Wh ich of the following
blood results is most likely t o be elevat ed above the normal range?
Total haemoglobin
Haemoglobin A2
Haemoglobin H
Haptoglobin
m
se
As
Whit e cell count
Dr
Total haemog lobin CD
I Haemog lobin A2 GD
Haemoglobin H CD
Haptoglobin CD
White ce ll co unt m
HbA2 is ra ised in patients with beta tha lassae mia major

The correct answe r is HbA2. This patient is most like ly to have b eta tha lassaemia minor.
She has no symptoms of disease other than a mild asymptomatic anaemia and is from an
area of higher prevalence for this genetic condition. HbA2 leve ls a re e levated in beta
thalassaemia majo r and minor. It is a variant of haemoglob in A with two d e lta chains
replacing the normal two beta chains. It is found in sma ll amounts in healthy adults at
around 1.5- 3% o f total haemoglobin. It is increased in b eta thalassaemia because o f
reduced p roduction of haemoglobin beta chains.
Total haemoglobin wou ld b e reduced because of low leve l haemolysis, lea ding to a mild
anaemia. Haptoglobin would be no rmal or mild ly red uced, as it binds to free
haemoglobin released from eryth rocytes after haemolysis. Haemoglobin H is foun d in
severe al pha thalassaemia and consists of four b eta cha ins. The white cell count wo uld
not b e affected in thalassaemia.
em
Beta thalassaemia. Genetics home reference

s
As
https:/ /ghr.nlm.n ih.gov/co nd ition/ beta-thalassemia

1----.----.------.-------.
Dr
orer
A 56 year old man is treated w ith doxorubicin for transition cell carcinoma of the bladder.
Which one of the following adverse effects is most characteristically associated with this
drug?
Ot otoxi city
Pulmonary fibrosis
Cardiomyopathy
m
se
As
Haemorrhagic cystitis
Dr
Ototoxicity CD
Pulmonary fibrosis GD
Peripheral neuropathy CD
Cardiomyopathy CD
Haemorrhagic cystitis .
(D
m
se
Doxorubicin may cause ca rdiomyopathy
As
Dr
A 54-year-old man presents t o his GP with a one-month history o f fever, malaise and
weight loss. He also complains o f abdominal fullness and early satiety. His past medical
history and travel history is unremarkable and he is not on any regular medications. On
examination, the GP detects splenomegaly.
The results of his full blood cou nt and wh ite cell differential are present ed below:
Hb 123 g/1 (1 30- 180 g/ 1)
MCV 85.6 fL (80 - 100 fL)
Platelet s 420 * 109/1 (140-400 * 109/1)
WBC 102 * 109/1 ( 4- 11 * 109/1)
Neutrophils 51.0% (50-70%)
Bands 23 .0% (0-4%)
Lymphocytes 2.0% (20-40%)
Monocytes 2.0% (2-8%)
Eosinophils 1.0 % (0-5%)
Basophils 3.0% (0-2%)
Acute lymphocytic leukaemia

em
s
As
Essential thrombocytosis
Dr
lorer
Acute lymphocytic leu kaemia
Essential t hrombocytosis
In chronic myeloid leukaemia the re is an increase in granulocytes at different sta ges

of maturation +/- thrombocytos is
Acute myeloid leukaemia - blood test s will reveal immature blood ce lls (blasts).
Acute lympho cytic leu kaemia - far more co mm on in children and blood t ests w ill revea l
immature b lasts.
Chronic lymp hocytic leukaemia - a malignancy of the lymphoid lineage so there w ill be a
raised lymphocyte cou nt.
Essential t hrombocytosis - although patients with essent ial throm bocytosis can have a
raised white cell cou nt, these patient s tend to have much higher p latelet counts (typ ica lly
>450. 10 9/1).
The w hite cell different ial in th is case d emonst rat es granulocytes at different stages of
em
maturation (immature band forms an d mat ure neutrop hils) which is suggestive of chronic
s
As
myeloid leukaemia. The platelet count may also be raised in these patients.
Dr
Which one of the following is least recogni sed as a treatment modality in idiopathic
thrombocytopenic purpura?
Plasma exchange
Splenect omy
IV immunoglobulin
Cyclophosphamide
m
se
As
Ora l prednisolone
Dr
Plasma exchange CED
Splenectomy .
(!'D
IV immunoglobulin CD
Cyclophosphamide f.D
m
se
As
Oral prednisolone CD
Dr
Which one o f the following is least associated with thymomas?
Syndrome inappropriate ADH
Myasthenia gravis
Red cell aplasia
Dermatomyos itis
m
se
As
Motor neurone disease
Dr
Syndrome inapprop riate AD H
Myasthenia gravis
I Red cell aplasia
Dermatomyositis
m
se
As
Dr
A 30 yea r-old ma n presents with recurrent abdo minal pain. This is not associated with
food, hea rtburn, indig estion or dysphagia. He has had no weig ht loss. His b lood tests
have b een no rmal a nd he has b een given a diagnos is of irritable bowe l syndrome. Desp ite
lifestyle modifications a nd laxatives, he has still had recurre nt pa in. He then presents with
swe lling of his lips a nd tongue. This is not itchy and he is systemica lly well, but does have
a stridor.
What would be the most successful ma nag e ment out of the fo ll owing optio ns?
Supportive ca re
Adrena li ne
Prednisolone
Fresh frozen plasma
m
se
As
Chlorphena mine
Dr
Suppo rtive ca re GD
Ad renali ne 6D
Prednisolone fD
~sh frozen plasma ED
Chlorphena mine tiD
This patient has a history and acute p resentation in keepi ng with he red itary ang ioedema.
This is ca used by a deficiency o f Cl-esterase inhibitor. It is normally treated with Cl-INH
concentrate, however when th is is unavailable, fre sh frozen p lasma is the next best
treatment. The lack of itch ing in this case a nd the fact that he is systemica lly well point
away from anap hylaxis a s a cause. Heredita ry angioed ema rarely responds to treatment
with adrenaline or a ntihistamines. In a rea l life situati on this patient would probably be
m
se
treated a s a naphylaxis, but the q uestion a sks what the most successful treatme nt would
As
be, and in this case it would be FFP.
Dr
Which one of the following causes of primary immunodeficiency is due to a defect in both
Di George syndrome
Chronic granu lomatous disease
Bruton 's congenital aga mmag lobulinaem ia
Leukocyte adhesion deficiency
m
se
As
Dr
Which one o f the following causes of primary immunodeficiency is due t o a defect in both
Di George syndrome

-
~
Leukocyte adhesion deficiency
Ataxic telangiect asia

-"""'
m
Combined B-and T-cell disorders: SOD WAS ataxic (SOD, Wiskott-Aidrich
se
As
syndrome, at axic te langiectasia)
Dr
A 34-yea r-old intravenous d rug user is admitted with a pu rpuric rash a ffecting her legs.
Blood tests revea l the fo llowing:
Hb 11.4g/dl
wee 12.3 8
10911
Hev PeR positive
HBsAg negative
Rheumatoid factor positive
e3/ e4 reduced
Polyarte ritis nodosa
Henoch-Schon le in pu rpu ra
Wegener's granulomatosis
m
Cryog lobu linaem ia se
As
Dr

Polyarteritis nod osa
Henoch -Schonle in purpura
Wegener's g ranu lomatosis
Cryog lobu linaem ia
Syste ic lupus erythematous
m
se
As
He patitis C infectio n is associated with type II (mixed) cryoglobu li na em ia, suggested by
the pu rpu ric rash, positive rheu mato id facto r and re duced compl ement levels
Dr
Burkitt's lymphoma is associated with wh ich one o f the following genetic changes:
Cyclin 01-IG H gene translocation
TEL-JAK2 gene translocation
Bel -2 gene translocation
C-myc gene translocation
m
se
As
BCR-Ab ll gene translocation
Dr
Cyclin Dl-IG H gene translocation
TEL-JAK2 gene translocation
Bel-2 gene tra nslocation

- ........
C-myc gene translocation
-
......,
BCR-Abll gene translocatio n
- ........
m
Burkitt's lympho ma - c- myc gene translocation
se
As
Dr
Chronic lymphocytic leukaemia is mostly due to a:
Polyclonal proliferation of B-celllymphocytes
Monoclonal proliferation of B-celllymphocytes
Monoclonal pro liferation of large granular lymphocytes
Monoclonal proliferation ofT -cell lymphocytes
m
se
As
Polyclonal proliferation ofT -cell lymphocytes
Dr
Polyclonal proliferation of B-celllymphocytes
Monoclonal proliferation of B-cell lymphocytes
Mof oclonal proliferation of large granular lymphocytes
Monoclonal proliferation ofT -cell lymphocytes
Polyclonal proliferation ofT -cell lymphocytes
m
se
CLL is caused by a monoclonal proliferation of B-cell lymphocytes
As
Dr
A 25-yea r-old woman with prima ry antiphospholipid syndrome is reviewed. She has just
had a booking ultrasou nd at 11 weeks gestation which confirms a viable pregnancy. This
is her first pregnancy and she is otherwise fit and well. Which one of the following is the
reco mmend treatment?
Aspirin + prednisolone
Low-molecular weight heparin
Prednisolo ne+ low-molecular weight hepa rin
Aspirin + low-molecular weight heparin
m
se
As
Aspirin
Dr
Asp irin + prednisolone
Low -molecu lar weight heparin
Prednisolone+ low-molecular weight heparin
I Asp irin + low-molecular weight heparin
Asp irin
Anti phospholipid syndrome in pregnancy: aspirin + LMWH

The ultrasound at 11 weeks gest ation would show a fetal heart if the pregnancy was
m
se
viable. This patient should therefore be taking both aspirin and low-molecular weight
As
heparin.
Dr
A 15-yea r-old g irl is referred to haematology. She sta rted having periods three years ago
which have a lways been heavy and prolonged. Unfortunately the menorrhagia has
responded poorly to trials o f tranexa mic acid and the combined ora l contraceptive pill.
Blood tests show the following:
Hb 10.3 g/dl
Pit 239 * 109/ 1
WBC 6 .5 * 109/ 1
PT 12.9 sees
APTT 37 sees
Haemoph ilia B
Disseminated intravascu la r coagulation
Haemoph ilia A
Id iopathic thrombocytopenic pu rpu ra
m
se
Von Willebrand's d isease
As
Dr
Haemop hilia B
Disseminated intravascular coagulation

-~
Haemophilia A
Idiopathic thrombocyto penic pu rpura
I Von Wi llebrand's disease
Von Willebrand's disease is the most likely diagnos is as it is the most common inheritied
m
bleeding disorder. The mildy elevated APTI is consistent with this diagnosis.
se
As
The mild anaemia is consistent with the long history of menorrha gia.
Dr
An 80-yea r-old man has spent his whole workin g life as a loft insu lator and is concerned
that he may have been exposed to asbestos. He has been informed o f the risk of
mesothelioma but wants to know if there are any other conditions for which he is at
higher risk than the genera l popu lation. Which of the fo llowing is a lso proven to have a
causal li nk with asbestos exposure?
Bronch iectasis
Type D d iab etes
Bronch ial carcinoma
Basal cell carcinoma of the skin
m
se
As
Ischaem ic heart disease
Dr
Bronchiectasis
Type ll d ia betes
-
~
Bronchial carcinoma
Basal cell carcinoma of the skin
Exposure to as bestos is a risk facto r for bro nchia l ca rcinoma a s we ll as

mesotheliom a
Answer 3 is correct. Asbestos is well known to increase the risk o f mesothel ioma, but also
increases the risk of bronchial carcinoma, la ryngeal cancer and ovarian cancer. The re is
also some limited evidence that asbestos may increase the ris k of cancer of the stomach,
p harynx an d bowel.
Exposure to asbestos also increases the risk o f some benign diseases, including pleu ral
plaques, diffuse pleu ral thicken ing, a sbestos re lated ben ign p leura l effusions an d
asbestosis.
BMJ Clinical Review:

http://www.bmj.com/ content/339/bmj.b3209.fu ll
National Cancer Institute:

em
https:/ /www.ca ncer.gov/about -cancer/causes-

s
As
p reve ntion/ris k/substances/ asbestos/ asbestos-fact-sheet#q3

Dr
A 29-yea r-old man p resented to the hospita l a fte r he had two episodes of bright red
urine in the morn ing. He is very worried and tells the attend ing doctor that he has never
had such an ep isode b efo re. He has just sta rted working at an engineering firm and is
plann ing to get married in a few months. He reports feeling tired fo r the past few months
but thoug ht this was due to his job which req uired him to trave l to construction s ites
every d ay. He has no sign ificant fam ily history. He had an a ppendectomy when he was a
child but other than that he has neve r been ad mitted to the hospital. A blood test reveals
a hemoglobin concentration of 11.5 g/ dl and a reticulocyte o f 14% of red b lood cell s.
Which of the find ings is the most like ly to be reported upon flow cytometry o f a blood
sample from this patient?
C3 negative cells
CDSS negative cell s
CD59 negative cells
CS to C9 negative cells
m
se
As
CDSS a nd CD59 neg ative cel ls
Dr
C3 negative cells
CDSS negative cell s
CD59 negative cell s
CS t o C9 negative cells
CDSS and CD59 negative cells
This patient p resent ed with t he signs and symptoms cons istent with a diagnosis of
paroxysmal nocturnal hemoglob inuria (PN H). This condition is an acqu ired and ch ron ic
fo rm o f int rinsic hemolytic anemia. Pat ients can present w ith hemat u ria, or even simply
sympt oms of anemia. Venous throm bosis is also a common occurrence. The classic t riad
is hemolytic anemia, pancytopenia, and venous thrombosis. Flow cyt ometry is the gold
standard lab oratory investigations and shows CDSS and CD59 negative red an d blood
cells.
1: A def iciency o f C3 is a complement d eficiency disorder. Since C3 p lays an important

role in the act ivation of both the classica l and alternative complement pathways, a C3
d eficiency confers a higher risk of acquiring recurrent bacterial infections.
2: It is true that t his w ill be p resent in t his pat ient's cells. However, PNH patient s will also
have a deficiency of CD59.
3: It is true that t his w ill be p resent in t his pat ients' cells. However, PNH patient s will also
have a deficiency of CDSS.
4: Th is would indicate terminal com plement def iciency. This con dition involves a
d ef iciency of t he com plements forming the membrane att ack membrane. CS to C9
d eficiency confers a high risk of infection w ith Neisseria organisms.
5: The gold st andard in t he diagnosis of PNH is f low cytometry, and patient s usually have
a d eficien cy of both CDSS and CD59 on their red as well as their white b lood cell s.
Ecu lizu mab is a humanized monoclona l antibody which has b een approved for the
sem
treatment of PNH. It works mainly via the inhib ition of the t erminal complement cascade.
As
Dr
A 49-year-old wo man is referred to t he haematology clinic with easy bruising and
recurrent epistaxis. She is otherwise well. Blood tests reveal t he follow ing:
Hb 12.9 gfdl
8
Platelets 19 109/ 1
wee 6 .6 * 10911
The patient refuses consent for a b one marrow examination. What is t he most
appropriat e init ial management?
Plat elet t ransf usion
Oral prednisolone
No t reatment
A BVD chemotherapy
m
se
As
Splenect omy
Dr
Plat elet t ransf usion fD
I Oral prednisolone eD
No t reatment CD
A BVD chemotherapy
•
G lenect omy
•
ITP- give oral prednisolone
The likely diagnosis in this patient is idiopathic t hrombocyto penic purpura. The first line
m
se
treatment in such pati ents is high -dose prednisolone. Bone marrow examination wou ld
As
d emonstrat e increased megakaryo cytes
Dr
A 52-year-old female patient presents t o the oncology clinic with an 8-months history o f
poor appetite and weight loss. She also com plains of a right upper quadrant discomfort
which has been present for the last 3 months. An ultrasound scan reveals multiple lesions
in the liver suggestive o f liver metast asis. A tumour marker profile reveals a raised level of
CA 15-3.
What is the most likely primary tumour?
Small cell lung carcinoma
Breast carcinoma
Ovarian carcinoma
m
se
As
endometrial carcinoma
Dr
Colorectal carcinoma .
CD
Small cell lung carcinoma m
I Breast carcinoma GD
Ovarian ca rcinoma GD
endometrial carcino ma fD
CA 15-3 is a t umour marker in breast cancers

Important for me l ess im:>c rtc.nt
CA 15-3 is a tumou r marker in brea st cancers.
Bombesin is a tumou r marker in small cell lung cancers.
Carci noembryonic antigen (CEA) is a t umour marker in colorect al cancers.
m
se
As
CA 125 is a tumou r marker in ovarian cancers and also endometrial cancers.
Dr
Which of the following is most associated with thymomas?
Myelodysplasia
Thrombocytopenia
m
se
As
Red cell aplasia
Dr
Myelodysplasia
Thrombocytopenia
m
se
As
Red cell aplasia
Dr
A 72-yea r-o ld man with metastatic colon cancer is reviewed . He cu rrently takes co -
codamol 30/ 500 2 tablets qd s fo r pain re lief. Unfortunate ly this is not contro ll ing his pai n.
What is the most appropriate change to his med icatio n?
Switch to MST lSmg bd + paracetamol l g q ds
Switch to MST 35mg bd + paracetamol l g q ds
Add tramad oi SO-lOOmg 1-2 q ds
Switch to MST 2Sm g bd
m
se
As
Switch to MST lSmg bd
Dr
Switch to MST 15mg bd + paracetamol l g q ds
Switch to MST 3Smg bd + paracetamo l l g q ds
Add tramad oi SO-lOOmg 1-2 q ds
Switch to MST 2Smg bd
Switch to MST l Smg bd
His tota l cod e ine dose is 30 • 2 • 4 = 240 mg/day. Converting this to o ra l morphine = 24
mg/day.lt is the refore rea sona ble to start MST l Smg bd as his pain is not currently
m
se
contro ll ed. Pa racetamol should be continued as it has been shown to give benefits even
As
to patients on la rge d oses of morph ine
Dr
A 54-year-old woman is reviewed in oncology clinic follow ing d eb ulking su rgery fo r
primary perito neal cancer. She is known t o have two liver metastases. She underwent
surgery one month ago and has co me in for review prior t o adjuvant chemotherapy.
During her chemotherapy treatment, which t umour marker wou ld be most appropriate to
monitor disease prog ression?
CA 15-3
CA 19-9
CA 125
Human chorionic g onadotropin (hCG)
m
se
As
S-100
Dr
CA 15-3
CA 19-9
CA 125
Human chorionic g onadotropin (hCG)

-
~
S-100
Ovarian cancer - CA 125

CA 125 is the tumou r marker most associat ed w ith pri mary peritonea l cancer as well as
o varian ca ncer and can b e used to monit or response to chemotherapy, alongside regular
CT scans. It can also b e raised in various ot her ca ncers.
The ot her t umou r markers are more approp riate for o ther cancers.
Source:
m
se
St urg eon, C. M., L. C. Lai, and M. J. Duffy. 'Serum Tumour Markers: How to Order and
As
Interpret Them.' BMJ (2009): 852-58.
Dr
A 35-year-old woman presents with menorrhagia and a persistent sore throat. A full
blood count shows the following:
Hb 6.8 g/dl
Platelets
W BC
Neutrophils 0.8 * 109/ 1
Which one of the following medications is most like ly to account for this finding?
Trimethoprim
Rifampicin
Olanzapine
Montelukast
m
se
As
Clomifene
Dr
Trimethoprim CD
Rifampicin CD
Olanzapine fD.
Montelukast CD
Clomifene C!D
m
se
Trimet hoprim may cause pantcytopaenia
As
Dr
A 32-year-old man p resents to the emergency department with abdomina l pa in,
numbness and ting ling in bilate ral lower limbs and feeling generally tearful. There is a
history of recurrent abdomina l pa in and neu ro logical symptoms in the past, however a
diagnosis was never foun d. He is otherwise fit and well. On exam ination, there is reduced
sensation up to the knees in a stocking distribution in the lower limbs. The re is no other
neu ro logy of note. There is no rash found . You suspect a type of porphyria .
What is the most likely find ing to support the diagnosis o f this type of porphyria?
Ra ised urine lead level
Ra ised urinary porphob ilinogen
Ra ised urinary uroporphyrinogen
Ra ised urinary uroporphyrinogen decarboxylase
m
se
As
Ra ised urinary protoporp hyrin
Dr
Ra ised urine lead level
Raised urinary porphobilinogen
Raised urinary uroporphyrinogen
Raised urinary uroporphyrinogen decarboxylase

-
"""'
Raised urinary protoporphyrin
-
"""'
In acute intermittent porphyria, urinary porphobilinogen is typica lly raised
The presentation of abdominal pain, neurological and psychiatric symptoms raises the
suspicion o f acute intermittent porphyria. In acute interm ittent porphyria (AlP), urinary
porphobilinogen is typical ly ra ised.
Lead level is not usually raised in porphyria.
Uroporphyrinogen is usually raised in porphyria cutanea ta rda. The lack of skin lesions
makes acute intermittent porphyria more likely.
Uroporphyrinogen decarboxylase is not usually measured.
m
se
As
Urinary protoporphyrin may be slightly raised in AlP but raised porphobilinogen is more
Dr
likely.
A patient is invest igated for leukocytosis. Cyt ogenet ic analysis shows t he presence of t he
following t ranslocat ion: t(9;22)(q34;qll). Which haematolog ica l malignancy is most
st rong ly associated with this t ranslocation?
Burkitt's lymphoma
m
se
As
Mant le cell lymphoma
Dr
Acut e promyelocytic leukaemia
Burkitt's lymphoma
CML - Philadelphia chromosome - t(9:22)

The Philadelphia tra nslocation is seen in around 95% of patient s with chronic myeloid
m
se
leukaemia. Arou nd 25% of adult acute lymphoblastic leukaemia cases also have this
As
translocation.
Dr
A 25-year-o ld woman wit h primary anti phospholipid syndrome is reviewed. She has j ust
had a booking ultrasound at 11 weeks gest ation which confirms a viable pregnancy. This
is her first pregnancy and she is otherwise fit and wel l. Which one of the following is the
recommend treatment?
Low-molecular weight heparin
Prednisolone + low-molecular weight heparin
Aspirin + low-molecular weight heparin
Aspirin
m
se
Submit answer
As
Dr
~
Low-molecular weight heparin ~
Prednisolone + low-molecular weight heparin
I Aspirin + low-molecular weight hT arin
Aspirin
Anti phospholipid synd rome in pregnancy: aspiri n + LMWH

Impo rtant fo r me l ess important
The ultrasound at 11 weeks gestation wou ld show a fetal heart if the pregnancy was
viable. This patient should therefore be taking both aspirin and low-molecu lar weight
heparin.
[ .. I a' tt Discuss (2) Improve ]
Antiphospholipid syndrome: pregnancy
Antiphospholipid syndrome is an acquired d isorder characterised by a predisposition to

both venous and arterial th romboses, recurrent fetal loss and thrombocytopenia. It may
occur as a primary disorder or secondary to other conditions, most commonly systemic
lupus erythematosus (SLE)
In pregnancy the following complications may occur:

• recurren t miscarriage
• IUGR
• pre-eclampsia
• placental abruption
• pre-term delivery
• venous thromboembolism
Management
• low-dose aspirin should be commenced once the pregnancy is confirmed on urine
testing
• low molecular weight heparin once a fetal heart is seen on ultrasound. This is usua lly
em
discontinued at 34 weeks gestation

s
As
• these interventions increase the live birth rate seven-fold

Dr
A 58-year-old man presents w ith polyuria and polydipsia. His body mass index is 32
kg/m 2 A random blood glucose is 11.5 mmol/1confi rming the diagnosis of diabetes
mellitus. You decide t o st art him on metformin.
What is the mechanism of action of metformin?
Closure ATP-sensitive K-channels
PPARy (gamma) agonist
Dipeptidyl peptidase -4 (DPP-4)
SGLT2 Inhibit ors
m
se
As
Activation o f the AM P-activated protein kinase (AMPK)
Dr
Closure ATP-sensit ive K-channels
PPARy (gamma) agonist

-
~
Dipeptidyl peptidase-4 (DPP-4)
SGLT2 Inhibitors
Activation of the AM P-activated protein kinase (AMPK)
Metformin acts by activation o f the AM P-activated protein kinase (AM PK)

Important for me Less 'mpcrtont
Metf ormin acts by activation of the AMP-activated protein kinase (AM PK). AMPK is a
major cellular regulator o f lipid and glucose metabolism. Pharmacological activation of
AMPK p romotes glucose uptake, fatty acid oxidation, an d insulin sensitivity. It also inhibits
gluconeogenesis.
Sulphonylureas (e.g. gliclazide) act by closing ATP-sensit ive K-channels in pancreatic beta
cells. This causes increased insulin secretion.
Thiazolidinediones (e.g. pioglitazone) are PPARy (gamma) agonists which cause increased
insulin sensit ivity.
Sitaglipt in is a dipeptidyl peptidase -4 (DPP-4) inhibitor. This enzyme breaks down the
incretins GLP-1 and GJP. By preventing GLP-1 and GJP inactivat ion, increased insulin is
secret ed by t he pancreas.
em
Glif lozin drugs (e.g. dapagliflozin) are a class of medications that inhibit SGLT2 in the
s
As
kidneys, resu lt ing in decreased reabsorption o f glucose.

Dr
You are an F2 workin g in general practi ce. You are seeing a 64-yea r-old fema le who has
type ll diabetes. Her HbAlc rema ins high despite a trial of diet and lifestyle changes. You
plan to sta rt her on the most commonly prescribed first-line medication for type II
diabetes. Wh ich side effect should you warn her is the most likely?
Headache
Diarrhoea
Hypoglycaem ia
Constipation
m
se
As
Urinary tract infections
Dr
Headache CD
Diarrhoea (D
Hypoglycaemia m
Constipation CD
Urinary tract infections
•
Gastro intestinal side-effects such as dia rrhoea and b loating are a com mon sid e
effect with metfo rmin
The correct a nswer is nu mber 2. NICE that standard re lease metfo rmin should be the
initial drug of choice for patients with type II d iabetes. Gastro intestinal side effects such as
diarrhoea, flatulence and b loating are a very commo n side effect of metformin. It shou ld
be started at a low dose a nd g radually increased to reduce the risk. Gl side effects a re
usually less with modified release metformin tha n sta ndard re lease.
A headache can be a side effect of metformin but is less common than Gl side effects.
Hypoglycaem ia can occur with use o f other diabetic medica tions, including
m
su lphonylureas and insulin, but does not occur with metformin. Urinary tract in fections
se
and thrush are more common with SGLT2 inhibitors which increase the excretion of As
glucose in urine . Swelling of the feet and ankles can occu r with th iazolidinediones.
Dr
A 30-year-old female has been admitted to the medical take with an acute infection. She
had a case of anaphylaxis w hich was thought to be due to amoxicillin at age 20. She has
since been seen by the allergy specialist and is now known to have an IgE mediated
penicillin allergy. Wh ich of the following antibiotics would you be most wary of using in
this patient?
Gentamicin
Ciprofloxacin
Trimethoprim
Cefa lexin
m
se
As
Metronidazole
Dr
A small proportion (0.5 - 6.5%) of patients with an lg E medicated penicillin allergy
will also be allergic to cep halosporins
This patient is known t o have a severe penici llin allergy. None of the above antibiotics are
penicillin based. However, the BNF stat es that 0.5- 6.5% of patients who are proven to
have an lgE mediat ed penicillin allergy will also be allergic t o cepha losporins, including
cefa lexin. You wou ld, therefore, be most wary of giving cehriaxone t o this patient.
Penicillins, cephalosporins, and carbapenems are all members of the bet a-lactam group of
antibiotics and share a common beta- lact am ring. There is, therefore, a small risk of
allergy cross-over between all these antibiotics. The rat es of allergy cross-over are lower
with second and third generation cephalosporins than first generati on cephalosporins
such as cefa lexin.
Reported penicillin allergy is very common, with up to 10% of patients claiming t o be

allergic t o penicillin. However, less than 10% of these people have a true lgE mediated
allergy to penici llin. It is important to question the patient carefully to ascertain what
sympto ms they had on exposure t o penicillin. Symptoms such as an urticarial rash or
it ch ing make it more likely that they have an lgE mediated allergy.
em
BNF:
s
As
https://bnf.nice.org.uk/drug-class/penicillins-2.htm l#allergyAndCrossSensitivity
Dr
A 43-yea r-old woman is a bout to start trea tment with trastuzu mab fo r metastati c brea st
ca ncer. What is the most important investigation to perform prior to initiating treatment?
Pu lmonary function tests
Echo
Liver function tests
Chest x-ray
m
se
As
Glucose tolerance test
Dr
Pu lmonary function tests «D
I Echo
Liver function tests

CD
GD
~estx-rr «D
Glucose tolerance test CD
m
se
Trastuzuma b (Hercepti n) - ca rdiac toxicity is common
As
Dr
A 35-yea r-o ld man presents to the emergency d epartment aher a night out, having taken
an unknown substance. He is known to have a history of depression.
On exam ination his Glasgow coma scale (GCS) is 13/15, pup ils are d ilated and d ive rgent.
He is tachyca rdic with a heart rate of 110/min, his b lood p ressu re is 124/70mmHg. His
ECG shows sinus rhythm, with a lengthened QTc du ration of 480msec. He is dry to the
touch.
Which substance is he most li kely to have in gested?
Cocaine
Sertraline
Diazepa m
Amitriptyline
m
se
As
MDMA
Dr
I Cocaine
J fD
Sertra line GD
Diazepa m m
Amitriptyline GD
MDMA .
GD
The correct answer here is Amitriptyline - a tricyclic a nti de pressant (TCA) ove rdose.
Whilst the main effect of TCAs is to increase seroto nin an d noradre na line in th e brain by
slowing re-u pta ke, they a lso blo ck hista mine, choli ne rgic and alpha 1 recepto rs . Therefo re
in overdose the a nti-choline rgic effects give dilated pupils, dry skin, confusio n, urinary
retention and tachycardia. Dive rge nt p upils are a com mon find ing in tricyclic ove rd ose.
TCAs a re a lso cardioto xic by ina ctivating sodium chan nels in the hea rt lea di ng to, a s seen
here, a potential p rolongatio n of the QTc interval and a widened QRS complex. This can
potentia lly lead to ventricular arrhythmias.
Other effects o f TCAs not included here in clude seizu res a nd a meta bolic acid osis.
In overdose sertrali ne may present with serotonin syndrome. The Glasgow coma scale
may be re duced and pu pils dilated, b ut skin would not be dry. A classic fea ture of
seroto nin syndrome is hyperreflexia, often with muscle rig idity a nd tremor, which is not
d escribed he re. Ad ditionally QTc prolong ation is un likely with selective seroto nin
reuptake inh ibitors (citalop ram is an exception).
Cocaine produces sym pathetic effects - ag itation, restlessness, increased hea rt rate and
blood pressu re . In seve re toxicity hyperthermia a nd rhabd omyo lys is may o ccur. It would
not cause a reduced GCS o r a lte red QRS duration on ECG.
MDMA (ecstasy) excess presents similarly to cocaine, with increa sed psychomotor
a g itation, palpitations a nd hyperthe rmia . Add itiona lly teeth grinding (bruxism) is noted
frequently.
Diazepa m ingestion cou ld cause a re d uced GCS d ue to its sed ative effect s. However it
wou ld not g enerally affect pupil size, hea rt rate or ECG. It is associated with respiratory
em
d e pression.
s
As
Dr
Which one o f the followi ng is least associated wit h cocaine t oxicity?
Metabolic alkalosis
Hyperthermia
Psychosis
Rhabdomyolysis
m
se
As
Seizures
Dr
Metabolic alka losis
Hyperthermia
~chosis
Rhabdomyolysis
-
m
se
As
Seizures
Dr
Which of t he follow ing conditions may not be treated by d opamine receptor agonist s?
Parki nson's disease
Prola ctinoma
Nausea
Cyclical breast disease
m
se
As
Acromegaly
Dr
Parkinson's disease
Prolactinoma
Nausea
Cyclical breast a isease

-
~
m
se
As
Acromegaly
Dr
The INR of a patient who has recently started treatment fo r tubercu losis drops from 2.6 t o
1.3. Which one of the followi ng medications is most likely t o be responsible?
Rifampici n
Streptomycin
Ethambut ol
Isoniazid
m
se
As
Pyrazinamide
Dr
Rifa mpicin CD
Streptomycin CD
Ethambutol fD
Isoniazid flD
Pyrazinamide fD
Rifa mpicin is a P450 enzyme induct or

m
se
Rifampicin is a P450 enzyme inducer and w ill t herefore increase the metabolism of
As
wa rfarin, t herefore decreasing the INR.
Dr
A 31-year-old man is diagnosed with pulmonary tuberculosis. He is commenced on
rifa mpicin, isoniazid, pyrazinamide and ethambutol. Two months after commencing
treatment routine liver fu nction tests show the following:
Bilirubin 29 IJmol/1
ALP 179 u/1
ALT 163 u/1
yGT 219 u/l
Albumin 39 g/1
Which one of the following factors is most likely to increase his risk of isoniazid toxicity?
Concurrent use of lanzoprazole
Male gender
Acetylator status
Amount of aldehyde dehydrogenase
m
se
As
Chronic kidney disease stage 3
Dr
I Concu rrent use o f la nzoprazole tiD
Ma le gender
Acetylator status
•
GD
Amount of aldehyde d ehydrogenase tiD
Chronic kidney disease sta ge 3 GD
It was previo usly thou ght that 'fast acetylators' were mo re at risk of isoniazid than othe r
patients. Recent research now suggests howeve r that slow acetylators a re actually more
li kely to su ffe r hepatotoxicity.
Men, unusua lly, are actua lly less likely to d eve lo p isoniazid hepatotoxicity.
m
se
His concu rre nt use of rifampicin and pyrazinam ide is a lso a risk facto r ison iazid
As
he patotoxicity.
Dr
Which one of the following drugs is most likely to cause impaired glucose tolerance?
Sulfasalazine
Azathioprine
Leflunomide
Methotrexate
m
se
As
Tacroli mus
Dr
Which one o f t he followin g drugs is most likely to cause impaired glucose t olerance?
Sulfasa lazine G'D
Azathioprine CD
Lef lunomide CD
Methotrexate GD
I Tacrolimus ED
m
se
As
Tacrolimus is a cause of impaired glucose tolerance
Dr
Which one of t he following drugs may be cleared by haemodialysis?
Beta-blockers
Tricyclics
Aspirin
Benzodiazepines
m
se
As
Digoxin
Dr
Beta-blockers .
CD
Tricyclics .
GD
~irin crD
Benzodiazepines GD
m
se
As
Digoxin (f.D
Dr
Which of the following drugs is most likely t o cause impaired g lucose to lerance?
Bromocriptine
Interferon-alpha
Strontium
Imipramine
m
se
As
M o ntelukast
Dr
Bromocriptine ED
Interferon-a lpha CD
Strontium .
(D
j
Imipramine GD
Montelukast GD
m
se
Glycaemic control in diabet es may be worsened by interferon-a lpha
As
Dr
A 23-yea r-old man is taken to the Emergency Department by his friends after a night out.
He was found acting erratically outside a nightclu b as they were wa itin g for a taxi. His
friend reports that they snorted a white powder two hou rs earl ier. This is described as 'M-
CAT', a 'legal hig h' they obtained from the internet.
When managing this patient, which drug group is it most s imilar to?
Ketamine
Amphetamine
Opio id
Benzodiazepine
m
se
As
LSD
Dr
Ketam ine (D
I Amphetamine €D
Opioid CD
Benzodiazepine CD
m
se
As
LSD CD
Dr
A 69-year-old male patient presents to the GP surgery with a 6-month history of
persistent dry cough and shortness o f breath on exertion. His past medical history include
Parkinson 's disease, epilepsy, hypertension, type 2 diabetes mellitus. His current
medicatio ns include amlod ipine, sodium valproate, bromocriptine, bisoprolol and
metformin.
Which is most likely cause of his presenting symptoms?
Sodium valproat e
Bromocriptine
Am lodipine
Bisoprolol
m
se
As
Metf ormin
Dr
Sodium valproate f!D
Bromocriptine CD
AmlodipiL CD
Bisoprolol f.D
Metformin CD
Ergot-derived dopamine receptor agonists may cause pulmonary fibrosis

This patient has symptoms of pulmonary fibrosis. Ergot-derived dopamine receptor

agonists such as bromocriptine may cause pulmonary fi bros is.
m
se
Sodium valproate, amlodipine, bisoprolol and metformin do not usually cause pulmonary
As
fibrosis.
Dr
A 58-yea r-old female presents with flush ing, dia rrhoea and hypotension. A s mall bowe l
MRI demonstrates a mass in the ileu m. A diagnosis of carcino id syndrome is mad e. You r
consu ltant initiates treatment with octreotide.
What is the mechanism of action of octreotid e?
Somatostatin antagonist
Glucagon -l ike peptide-1 receptor ag on ists
Somatostatin an alogue
Glucagon -l ike peptide-1 receptor antagonist
m
se
As
Anti-serotonergic
Dr
Somatostatin antagonist
Glucagon -l ike peptid e -1 recepto r agonists

-~
Somatostatin analogue
Glucagon -l ike peptid e -1 recepto r antagonist
Anti-serotonergic
Octreotide is a so matostatin ana logue

Octreotide is a somatostatin ana logue. It is a potent inhibitor of gastrointestinal

secretions hence why its a first li ne treatment for ca rcinoid syndrome. It is also a potent
inhibitor o f g rowth hormone, glucagon, a nd insulin.
Cyproheptad in e is an antihistam ine drug which has anti-serotone rgic p roperties. It can
also be used in ca rcinoid syndrome.
m
se
Glucagon- like peptide-1 recepto r agon ists a re used to treat diabetes mell itus. They are
As
insu li n secretagogues.
Dr
A 24-yea r-old lady presents with abdomi nal pa in. She states that she is at 24 weeks
g esta tion of p regnancy. She has no other past medica l histo ry. On examination she has
rhythm ic contractions o f he r a bdomen which are occu rri ng four times per min ute . A
speculum exam ination shows a dilated cervix.
Which drug could have precipitated this p resentation?
Nimodipine
Coca ine
Terb utaline
Mag nesium sulphate
m
se
As
Indo metha cin
Dr
Nimodipine CD
I Coca in e CD
Terbutaline CD.
r :agnesium sulphate .
(D
Indomethacin fD
Coca ine can induce p reterm labour

Cocaine is a sympathomimeti c drug. Its use during pregnancy can result in pre-term
labour ( < 37 weeks gestation), congenital anomalies, and intrauteri ne growth ret ardation
(IUGR). Cocaine can initiate uterine contractions, and is therefore t he most likely agent to
predispose to pre -te rm labour.
m
se
All t he other options are tocolytics wh ich may be used during p re-term labour to slow
As
down and reduce the amplitude of contractions.
Dr
Which one of the following statements regarding metformin is true?
Should be stopped in a patient adm itted with a myoca rdial infarction
Hypoglycaem ia is a recogn ised adve rse effect
May cause a metabolic alka losis
May agg ravate necrobiosis lipo idica d iabeticorum
m
se
As
Increases vitam in B12 absorption
Dr
Should be stopped in a patient admitted with a myocardial infarctio n
Hypoglycaemia is a recogn ised adve rse effect
May cause a metabolic alkalos is
May agg ravate necrob ios is lipoidica d ia beticorum
Increases vitamin 812 absorption
Metformin shou ld be stopped following a myoca rd ia l infarction d ue to th e risk of la ctic
m
se
acidosis . It may be intro duced at a late r date . Dia betic contro l may be achieved through
As
the use o f a insu lin/dextrose in fusion (e.g. the DIGAMI reg ime)
Dr
A 27 -yea r-old man had p resented to accident and emergency 4 days ago fo llowing an
intentional pa raceta mol overdose. He ha d taken fifteen SOO mg ta blets, a ll at once. He
d en ies any alcoho l inta ke. Bloods 4 hou rs after ingestion showed
Paracetamol 14 mg/ 1
INR 1
Liver enzymes No abnormality detected
Bilirubin Mild elevation
He was seen by the menta l health team a nd discharged. You g ave him the advice to
attend his GP to have his bloods repeated to see if the hyperb ilirubinaemia had settled.
Tod ay he has presented to the hosp ital fro m his GP with 'abnorma l blood results.'
Bilirubin No abnormality detected
Urea 21 mmol/ 1
What is the likely cause of these results?
Pre-re na l AKI secon da ry to dehydration
Spurious blood result
Delayed paraceta mol nephrotoxicity
Minimal cha nge ne phropathy

em
s
As
Berger's disease
Dr
I Pre -rena l AKI secon dary to dehydration GD
Spurio us blood result
•
I Delayed paraceta mol nephrotoxicity GD
Minimal cha nge nephropathy m.
Berger's d isease
•
This gentlema n's blood results d emonstrate an acute kid ney inj ury. The re is nothing in the
history to sugg est that the patie nt is d ehyd rated and this would b e very unusual in an
o therwise we ll 27-yea r-old man. Minima l cha ng e nephro pathy typica lly presents with a
nep hrotic pictu re of kidney inju ry, whilst Be rge r's more co mmonly presents with isolated
hae matu ria.
Whilst paracetamol ove rdose is well known to cause hepatotoxicity, d elayed

nep hrotoxicity is an important e ntity to be aware of, especia lly in significant overd ose.
Ap propriate mo nitoring of a patie nt's b lood tests is important, as p er the gu id ance o f
TOXBASE.
The following refere nce provides mo re d eta ils and a ca se study
m
se
https://www.ncbi.nlm.nih.gov/pu bmed/18338302
As
Dr
A 56-year-old man with a history of epilepsy, atrial fibrillation and ischaemic heart disease
is noted to have a rash on his fo rearms and face in the ca rdiology clin ic. Which one of the
following drugs is most likely to be responsible?
Verapamil
Carbamazepine
Am iodarone
Digoxin
m
se
As
Clopidogrel
Dr
Verapa mil CD
Carbamazepine fD
I Amiodarone GD
Digoxin m
m
se
CD
As
Clopidogrel
Dr
A 55-yea r-old d iabetic man p resents to clin ic concerned about erectile dysfunction. What
is the mechanism of action of s ildenafil?
Phospho diesterase type V inhibitor
Nitric oxide syntheta se in hibitor
Nitric oxide donor
Non -selective p hospho diesterase inhibitor
m
se
As
Phospho diesterase type IV inhibitor
Dr
Phosphodiesterase type V inhibitor
Nitric oxide synthetase inhibito r
I'!Jitric oxide donor
Non -selective phosphodiesterase inhibitor
Phosphodiesterase type IV inhibitor
Sildenafil - phosphodiest erase type V inhibito r
m
se
As
Sildenafil is a phosphodiesterase type V inhibitor
Dr
A 43-year-old man from South Africa is reviewed in cl inic. He has recently started
treatment for tuberculos is but is com plaining of a deterioration in his vision. Which one of
the following drugs is most likely to cause decreased visual acuity?
Rifa mpicin
Streptomycin
Isoniazid
Ethambut ol
m
se
As
Pyrazinamide
Dr
A 43-yea r-old man from South Africa is reviewed in cl inic. He has recently started
treatment for tuberculos is but is complaining o f a d ete rioration in his vision. Which one o f
the following drugs is most likely to cause d ecreased visua l a cuity?
Rifampicin m
R reptomycin CD
Ison iazid CD
I Et ham butol fD
Pyrazinam ide CD
Optic neu ritis is common in patients taking etha mbuto l

m
se
As
Isoniazid may also cause optic neuritis but it is not as co mmon a cause as e thambutol.
Dr
A 21-yea r-old stu dent is b rou ght to the Emergency Department by his friends d ue to him
being confused. They repo rt he has been com plaining of headaches fo r the past few
weeks. He has a low-grade pyrexia and on exam ination is noted to have abnormally pink
mucosa. What is the most likely diagnos is?
Carbon monoxid e poisoni ng
Men ingitis
Pa racetamol overd ose
Subarachno id haemo rrhage
m
se
As
Methaemoglob in ae mia
Dr
I Carbon monoxide po isoning
Mening itis
P racetamol ove rd ose
Subarachno id hae mo rrhag e
Methaemoglobin aemia
m
se
Confusion and pink muco sae are typical featu res of carbon mon oxide poisoning. A low-
As
g ra de pyrexia is seen in a minority o f cases.
Dr
In the Vaughan Wil liams classification of antiarrhythmics disopyram ide is an example of a:
Class Ia agent
Class Ib agent
Class Ic agent
Class II agent
m
se
As
Class IV agent
Dr
I Class !a agent CD
Class Ib agent fD
~ass Ic agent .
fiD
Class II a gent (D
m
se
As
Class IV ag ent CD
Dr
A 45 -year-old man is started on ciclosporin following a renal transplant. Which one of the
following adverse effects is most likely t o occur?
Depression
Increased risk of ischaemic heart disease
Pulmonary fibrosis
Optic neuritis
m
se
As
Nephrotoxicity
Dr
Depression
Increased risk of ischaem ic heart disease
Pulmonary f ibrosis
Optic neuritis
Nephrotoxicity
-"""'
m
se
Ciclosporin may cause nephrotoxicity
As
Dr
A 27 -yea r-o ld wo man with a histo ry o f depre ss io n p resents to th e Emerg ency
Department. She re ports taking 50 para cetamo l tablets yesterday. Bloods a re taken on
a d mission. Which one o f the following wou ld most strong ly indi cate the need fo r a live r
transplant?
Blood g lucose 2.2 mmol/1
Al T 2364 iu/ 1
I NR 4.1
Creatinine 230 !Jmol/1
m
se
As
Arte rial pH 7.27
Dr
Blood glu cose 2.2 mmol/1
ALT 2364 iu/1

-
INR 4.1
Cre tinine 230 !Jmol/1

-
~
"""
Arterial pH 7.27
m
se
The arterial pH is t he single most important factor according to the King's College
As
Hosp ital criteria fo r liver t ransp lantation.
Dr
Which one o f the followin g is not an i ndicat ion for haemodialysis in salicylate overdose?
Acute renal failure
Seizures
Serum concentration = 400 mg/1
Pulmonary oede ma
m
se
As
Metabolic acidos is resist ant to treatment
Dr
Acute renal failure tiD
Seizures GD
I Serum concentration = 400 mg/1 6D
Pu lmonary oedema CD
Met abolic acidosis resist ant to t reatment fD
m
se
As
A serum concentrat ion of greater t han 700mg/ l is an indicat ion for haemodialysis
Dr
Which of the following drugs is least likely to be affected by a patients acetylator status?
Hydralazine
Isoniazid
Rifa mpicin
Procainamide
m
se
As
Sulphonamides
Dr
Hydralazine CD
Isoniazid CfD
Rifa mpicin .,
Procainamide f!D
m
se
As
Sulphonamides f!D
Dr
A 65-yea r-old ma n with a history o f isch aemic heart disease is admitted with ch est pain.
The 12-hour troponin T is neg ative. During admissi on his medications were altered to
reduce the risk of card iovascular disease and to treat previo us ly u nd iagno sed type 2
diabetes mellitus. Shortly after discha rge he p resents to his GP complaini ng of diarrho ea.
Which one o f the followin g medicati ons is most likely to be responsible?
Glicla zide
Clopido grel
Rosiglitazone
Metformin
m
se
As
Atorvastatin
Dr
Gliclazide CD
Clopidog rel ED
Rosiglitazone m
Metformin GD.
Atorvastatin ED
Gastrointestinal side-effects such as dia rrhoea and b loating are a common side
effect with metformin
Important for me l ess : m ::~c rtont
Gastrointestinal p roblems a re a common side-effect of many medications but are

frequently seen in patients taking metform in
m
se
If this patient had a raised troponin T then metformin may not be su itable as it is
As
contra indicated following recent e pisodes of tissue hypoxia.
Dr
A 75-year-old woman present s to the emergency department w ith a fall. She ca nnot reca ll
the exact events of the fall but does report a 2-month history of recurrent nausea and
headache. Her past medical history includes type 2 diabetes mellitus, hypertensio n and
ischaemic heart disease. Physical examination is unremarkable except an unsteady gait
although no ataxia evident. Her blood t ests are as follows:
Hb 124 g/ dl
Na• 125 mmoi/ L
K• 4.8 mmoi/L
Creatinine 59 IJmoi/L
Urea 5. 2 mmoi/L
Serum osmolality 265 mOsm/kg (reference range 275-295 mOsm/kg)
Which medication may be the cause for this clinica l picture?
Metf ormin
Aspirin
Chlorpropamide
Bisoprolol
m
se
As
Am lodipine
Dr
Metformin CfD
Aspirin m
Chlorpropamide GD
Bisoprolol CD
Amlodipine CD
Sulphonylureas may cause syndrom e of inappropriate ADH

Hyponatraemia in the cont ext o f euvolaemia and low serum osmolality suggests
syndrome of inap propriat e ADH (SIADH). Sulphonylu reas (particularly long-acting ones
such as chlorpropamide) are well -established causes of the syndrome of inappropriate
ADHl
Metformin, as pirin, b isoprolol and am lodipine d o not usually cause SIADH.
m
se
1. Sola D, Rossi L, Schianca GPC, et al. Sulfonylureas and their use in clinical practice.
As
Archives of Medica l Science: AMS. 2015;11(4):840-848. d oi:10.5114/ aoms.2015.53304. Dr
Which one o f the following side-effects is least recognised in patient s taking ciclos porin?
Hypokalaemia
Hyperplasia o f the gum
Hypertension
Tremor
m
se
As
Excessive hair growth
Dr
I Hypokalaemia f.D
Hyperplasia o f t he gum m
Hypertension m
I Trem or fD
Excessive hair growth CD
Ciclosporin side-effects: everything is increased - fluid, BP, K+, hair, gums, glucose
m
se
As
Hyperkalaemia rather t han hypokalaemia is seen wit h ciclospo rin use
Dr
A 57 -year-old man with a history of ischaemic heart disease is keen t o try sildenafil for
erectile dysfunction. Which one o f the followi ng medications may contraindicat e its use?
Nebivolol
Losartan
Nicorandil
Nifedipine
m
se
As
Ram ipril
Dr
Nebivolol m.
Losartan
Nicorandil CD
•
Nif edipine GD
Ram ipril CD
PDE 5 inhibitors (e.g. sildenafil) - contraindicated by nitrates and nicorandil

Important for me l ess ' m ::~crtc.nt
m
se
As
Nicorandil has a nitrate component as well as being a potassium channe l activator
Dr
A 25-yea r-old fema le who works in a photograph d evelopment laboratory is taken to the
Em ergency Department due to confusion. On admission she is hypoxic and hypotensive.
Cyan ide poison ing is suspected following discussion with the loca l poisons unit. What is
the definitive treatment?
Haemod ia lysis f!D

~droxocobalamin (iD
Pen ici lla mine CD

Ferrous su lphate CD
m
.
se
Desferioxam ine (D
As
Dr
Haemodialysis GD
I Hydroxocobalamin CD
Penici llamine CD
Ferrous su lphate CD
m
se
As
Desferioxamine .
(D
Dr
A 44-year-old fema le with a hist ory of alcohol excess and cirrhosis presents t o the
emergen cy department with pa lpitat ions. You receive a call fro m the laboratory who
t elephone throug h her electrolyte results:
Sodium 133 mmol/ 1
Potassium 3 .8 mmol/1
Phosphate 0 .82 mmol/ 1
Magnesium 0 .22 mmol/ 1
Aside from her alco hol excess, w hich of her medications is most likely to contribute to her
hypomagnasaemia?
Carvedilol
Furosemid e
Omeprazole
Thiamine
m
se
As
Spironolactone Dr
Carvedilol
Furosemide
•
CD
Omeprazole .
GD
Thiamine
Spironolactone
•
f!D
Both loop and thiazide diuretics inhi bit the reso rptio n o f magnesium in the kidney.
Potass ium-sparing diuretics such as spironolactone are not associated with

hypomagnesaemia.
Prote in pump inhibitors such as o meprazole a re associated with low magnesium levels
when taken in conjunction with loop or thiazi de d iuretics b ut are not independ ently
associated with hypoma gnesaemia.
m
se
As
Thiamine and carvedilol have no effect on ma gnesium haemostas is.
Dr
A patient is started on the monoclona l antibody trastuzumab. What is the most likely
indication?
Crohn's d isease
Chronic lymphocytic leukaem ia
Renal cancer
Colorecta l cancer
m
se
As
Breast cancer
Dr
Crohn's disease
IChro~ic lym phocytic leukaemia
Renal cancer
-
........
Colorectal cancer
Brea st cancer
m
se
Trastuzuma b (Hercepti n) - monoclona l antibo dy that a cts o n the HER2/neu recepto r
As
Dr
An 85-year-old gentleman with a background of osteoporosis and chronic kidney disease
was admitted following a fall at home. He was experiencing significant lower back pa in. A
lumbar spine x-ray was showing s igns of a fractured lumbar vertebra . A subsequent MRI
lumbar/sacral scan showed a new L3 bu rst fractu re with no evidence of cord co mp ression.
A neurosu rgical opinion was obtained who advised conservative management in the fo rm
of pain control, physiotherapy a nd mob ilisatio n as pa in allows. Given his background of
chronic renal impa irment with a creatinine clearance of 21ml/min, he was started on a
Buprenorphine patch. Which of the following opioids wou ld be safest to use for his
b reakthrou gh pain?
Peth id ine
Diamorphine
Mo rp hine
Oxycodone
m
se
As
Ibuprofen
Dr
Pethidine GD
Diamorphine flD.
Mo rp hine «D
I Oxycodo ne C!D
Ibu profen
•
Oxycodone is a safe r opioid to use in patients with moderate to end -sta ge renal
failure
Active metabol ites of morphine accumulate in rena l failure which means that long-te rm
use is contra indicated in patients with moderate/severe rena l failure. These toxic
metabolites can accumulate causing toxicity and risk overdose. Oxycodone is mainly
m
se
metabolised in the liver a nd thus safer to use in patients with moderate to end-stage
As
renal failure with dose reductions.
Dr
A 67 -year-o ld woman is noted to have cornea l opacities durin g a routine opticia ns
appointment. These a re not affecting her vision. Which one o f the following drugs is most
li kely to be th e cause?
Am iodarone
Sodium valproate
Methotrexate
Frusemide
m
se
As
Digoxin
Dr
Amiodarone GD
Sodium valproate CD
Methotrexate CD
[ :use mide fD
Digoxin CD
m
se
As
Am iodarone therapy can result in both corneal opacities and optic neuritis
Dr
Which one o f the following drugs is most likely to result in a photosensitive rash?
Gentamicin
Erythromycin
Penici llin
Tetracycline
m
se
As
Amoxicillin
Dr
Gentamicin m
Eryth romycin CD
Penici llin GD
Tetracycline GD
m
se
As
Amoxicillin CD
Dr
A 56-year-old man from Pakistan presents to his GP with numbness and tin gling in his
feet for 1 week. He tells you he has recently started some new medications. Looki ng at his
medical history you discover he has recently been diagnosed with tuberculosis and
hypertension.
Which of the follow ing medications are most likely to be causing the pro blem?
Rifa mpicin
Am lodipine
Ramipril
Isoniazid
m
se
As
Pyrazinamide
Dr
Rifa mpicin fD
Amlod ipi ne CD
Ram ipril CD
I Isoniazid GD
Pyrazinamide CD
Peripheral neu ropathy is a commonly recognised side effect of isoniazid. Although

pa raesthesia is listed under the side effects for amlodipine in the BNF, it is uncommon. In
this case isoniazid is the most likely answer.
Drug Most common side effects
Rifa mpicin Orange bodily flu ids, rash, hepatotoxicity, drug interactions
Isoniazid Peripheral neu ropathy, psychosis, hepatotoxicity
Pyrazinam ide Arthralgia, gout, hepatotoxicity, nausea
m
se
Ethambutol Optic neuritis, rash As
Dr
A 73-yea r-old man is prescribed cetuximab after being diagnosed with metastatic
colorectal cancer. What target is this monoclonal antibody d irected a ga inst?
Vascular endothelial growth facto r receptor
Ang iopoietin-2 recepto rs
CD20 protein complex
Epiderma l growth factor receptor
m
se
As
Fibroblast growth fa ctor receptor
Dr
Vascular endothelial growth facto r recepto r
Ang iopoietin -2 recepto rs
CD20 protein complex
Ep idermal growth factor receptor
Fibro b last growth factor receptor

-
~
m
se
Cetuximab - monoclonal antibody aga inst the epide rmal growth facto r recepto r
As
Dr
A 26-yea r-o ld woman with a histo ry o f schizo phre nia is reviewed in the Eme rgency
Department. Her ca re r rep orts that s he has been 'sta ring' fo r the past few hou rs but has
now deve lo ped a b normal head movements a nd has g one 'cross -eyed '. On exam ination
the patients neck is exte nd ed and positioned to the rig ht. He r eyes a re deviate d upwards
a nd a re slightly co nve rged. Given the li kely diag nosis, what is the most ap pro priate
treatment?
Procyclid ine
Do pamine
Selegiline
Haloperido l
m
se
As
Diazepa m
Dr
Procyclidine
.,
DopaT ine CD
Selegiline fD
....___
Haloperidol CfD
Diazepa m CfD
m
se
As
Benztropine and diphenhydramine are alternative options.
Dr
Which one of the following types of reaction takes place in phase n metabolism of a
drug?
Conjugation
Hydrolysis
Reduction
Deamination
m
se
As
Dealkylation
Dr
Conjugation GD
Hydrolysis fiD
Reduction f!D
Deamination CD
Dealkylation m
Drug metabolism
• phase 1: oxidation, reduction, hydrolysis
m
• phase II: conjugation
se
As
Dr
A 48-year-old female is adm itted with cellulitis of her right lower lim bs. A swab culture
grows MRSA sensitive to vancomycin, teicoplanin and linezolid. You decide to treat her
with teicoplanin.
What is the mechanism of action of teicoplanin?
Inhibits bacterial protein synthesis
Inhibits bacterial DNA synthesis
Inhibits bacterial cell wall formation
Inhibits bacterial folic aci d formation
m
se
As
Inhibits bacterial RNA synthesis
Dr
Teicoplan in is similar to vancomycin (e.g. a glycopeptide antibiotic), but has a
significantly longer duration of action, allowing once daily administration after the
loading dose
Teicoplanin is similar to vancomycin (e.g. a glycopeptide antibiotic), but has a significantly

longer duration of action, allowing once daily administration after the loading dose. It
inhibits bacterial cell wa ll formation.
Antibiotics that inhibits bacterial protein synthesis include macrolides, aminoglycosides,

and tetracyclines.
Antibiotics that inhibits bacterial DNA synthesis include the quinolones (e.g.
ciprofloxacin).
Antibiotics that inhibits bacterial RNA synthesis include rifampicin.

s em
Antibiotics that inhibits bacterial folic acid formation include trimethoprim and co-
As
trimoxazole.
Dr
A 62-year-old woman with a history o f recurrent deep vein thrombosis secondary to
antiphospholipid syndrome presents for review. She has taken wa rfa rin for the past 7
years, with a target I NR of 2.0 - 3.0. Her control is normally very good but her last read ing
was 1.2. Which one of the fo llowing wou ld explain her current INR?
Starting fluoxetine for depression
The fo rmatio n of lupus anticoagulant autoantibod ies
Giving up smoking
Recent rifam picin as she was a contact of a patient w ith meningococcal meningitis
m
se
As
A course of ciprofloxacin for a urinary tract in fection
Dr
Starting fluoxetine for depression
The fo rmatio n of lupus anticoagulant autoantibodies
Giving up smoking
Recent rifam picin as she was a cont act of a patient with meningococcal
meningitis
A course of ciprofloxacin for a urinary tract in fection
m
se
Rifa mpicin is a P450 enzyme induct or
As
Dr
Which one o f the fo llowing adre noceptors causes inhib ition of p re -synaptic
neu ro trans mitter re lease in response to sympathetic stimulation?
Alpha -1
Alpha -2
Beta-1
Beta -2
m
se
As
Beta -3
Dr
Alpha-1 fD
Alpha-2 CD
Beta-1 ('fD
Beta-2 ('fD
m
se
As
Beta-3 tiD
Dr
Which of the following drugs is considered most likely to precipitate an att ack of acute
intermittent porphyria?
Morphine
Aspirin
Atenolol
Metfo rmin
m
se
As
Dr
Morphine .
(D
Asp irin 6D
Atenolol GD
Metformin CD
m
se
As
Oral contraceptive pill eD
Dr
Which of the followi ng drugs is considered least likely to precipitate an attack of acute
intermittent porphyria?
Diazepa m
Penicillin
Thio pentone
Sulphonamides
m
se
As
Alcohol
Dr
Diazepa m f.D
p .nici llin tiD.
Th iopentone fD
Sulphona mides tiD
m
se
Alcohol CD
As
Dr
A 54-year-old woman is admitted to the Medical Admiss ions Unit following a collapse.
Bloods taken on admission show the following:
Magnesium 0 .40 mmol/ 1
Which one o f the following factors is most likely to be responsible for this resu lt ?
Excessive resuscit ation with intravenous saline
Frusemide therapy
Digoxin the rapy
Rhabdomyolysis
m
se
As
Hypothermia
Dr
I
Excessive resuscitation with intravenous saline
Frusemide therapy
Digoxin therapy
Rhabdomyolysis
m
se
As
Hypothermia
Dr
A 13-year-old boy has attended the acut e medica l unit with severe lethargy and j aundice.
He has recently taken a medication that his mother feels may have been the cause. She
noted her brother once had a similar reaction to a tattoo. You suspect he may have
glucose -6-phosphat e dehydrogenase (G6PD) deficiency.
Which o f the follow ing drugs wou ld most likely provoke a haemolytic crisis in G6PD
deficiency?
Trimethoprim
Ibupro fen
Ciprofloxacin
Chloroquine
m
se
As
Sodium valproate
Dr
Ibupro fen CD
Ciprofloxacin ED
Chloroquine CD
Sodium valproate CD
Ciprofloxacin is contra indicated in G6PD deficiency

The answer is ciprofloxacin. G6PD deficiency is a (usually) X-l inked recessive condition
that predisposes patients t o haemolytic crises following oxidative stress. This most
com monly manifest s in the form of certain medications, but some foods (broa d beans)
and even henna t attoos ca n prompt a crisis.
Variation occurs in known triggers amongst subjects. However, some triggers have a
higher likelihood than others - and as such are contraindicat ed absolutely. Quinolones
(ciprofloxaci n, norfloxacin & moxifloxacin) have a very high theoretical risk o f haemolysis.
Other drugs with a high risk include primaquine, sulfonam ides, methylene blue, dapsone
& doxorubicin. Chloroquine has a small risk of haemolysis. Trimethoprim, ibuprofen and
sodium valproat e have no th eoretical risk.
m
se
This table pro vides a good summary: As
http://www.cych.org .tw/pharm/ MI MS%20Summary%20Table-G6PD.pdf
Dr
A 46-year-old woman who has recently been diagnosed as having non- Hodgkin's
lymphoma is about to start CHOP chemotherapy (cyclophosphamide,
hydroxydaunorubicin, vincristine and prednisolone). Her blood s are as follows:
Hb 11.8 gfdl
WBC 11.2 ~ 109/1
Na• 143 mmol/ 1
K• 3.9 mmol/1
Urea 6 .2 mmol/1
Uric acid 0.45 mmol/ 1
Ciprofloxacin is also prescribed to reduce the risk of neutropenic sepsis. Which other drug
should be added to lower the risk of complications?
Tranexamic acid
Allopurinol
Ferrous sulphate
Aspirin
em
s
As
Furosemide
Dr
Tranexamic acid CD
I Allopurinol GD
Ferrous sulphate fD
I Aspi rin fD
Furosemide m
Patients receiving CHOP for non-Hodgkin's lymphoma are at particular risk of tumour
m
se
lysis syndrome and associated gout secondary t o hyperuricaemia. Allopurinol is therefo re
As
normally co-prescribed to redu ce this risk.
Dr
A 62-year-old male was admitted with a 9 day history o f a cough, productive of green
sputum associated with shortness of breath. He describes no weig ht loss, but fever and
sweats. He is orientated in time a nd place and states he develops anaphylaxis to
pen icil li ns. On exam ination he had coarse inspiratory crackles in the right base, percuss ion
was resonant and no added wheeze.
Observatio ns: Respiratory rate 25 breaths per minute, satu ration 86% on room a ir, b lood
p ressure 110/ 90mmHg, heart rate 94 beats per minute.
Hb 12.2 g/dl
wee 19 .2 gfdl
Platelets 344 g/ dl
Na + 139 mmol/ 1
K+ 4 .3 mmol/1
urea 9 .9 mmolfl
Creatinine 144 mmol/ 1
CRP 27 mg/1
Chest X- ray showed right lower zone radio -opacity with a ir bronchograms.
He was started on an antibiotic as per British thoracic society (BTS) gu idelines.
What is the mechanism o f action of that antibiotic?
Reversible inhib ition of 50s ribosome subunit
Inhibits DNA gyrase
Irreversible inhibition of 30s ribosome sub unit
Dihydrofo late reductase inhibitor

sem
Dihydropteroate reductase inhibitor

As
Dr
Reversible inhibition of 50s ribosome su unit
Inhibits DNA gyrase
Irreversible inhibition of 30s ribosome sub unit
Dihydrofolate reductase inhibitor
Dihydropteroate reductase inhibitor
This patient is likely suffering from a pneumonia with a CURB65 score of 1. As per BTS
guidance the patient should be started on either Amoxicill in or Clarithromycin. The latter
should be considered in light of his allergies.
m
se
Clarithromycin is a macrolide antibiotic with good gram positive cover and that of atypica l
As
organisms. It's mechanism of action is via reversible inhibition of 50s ribosome subunit.
Dr
A woman who is 24-weeks p regnant presents with a p rod uctive cough. On exam ination
crackles can be hea rd in the left base and a decision is mad e to give an antibiotic. Which
one of the following is least su itable to p rescribe?
Ciprofloxacin
Erythromycin
Co-amoxiclav
Cefalexin
m
se
As
Cefaclor
Dr
Ciprofloxacin CD
Erythromycin f!D.
Co -amoxiclav CD
~falexin CD
Cefaclor CD
The BNF advises avoiding quinolones in pregn ancy due to arthropathy in animal studies.
There have been some reports of an increased risk of necrotizing enterocolitis following
the use of co -amoxiclav in pregnancy. The evidence is however inconclusive and the BNF
m
se
states that co-amoxiclav is 'not known to be harmful'. A link is provided both to the BNF
As
and the UK t eratology information service.
Dr
A 34 yea r-old man presents to the Eme rgency Department a fte r being rescued fro m a
house fire. On examination he is s ho rt of breath, drowsy and confused, and com pla ins of
feeling dizzy with a wo rsen ing headache. He has no evidence of facia l bu rns and no
strid o r. His o bservations show: b lood pressure 110/ 82 mm Hg, heart rate 102b pm, o xygen
saturations o f 100% on air with a res pirato ry rate o f 35/ min. He appears markedly flushed
but is afebrile. His ve nous blood gas results a re shown below.
pH 7.28
pC02 3.5 k Pa
p02 15.9 kPa
Na + 139 mmoi/ L
K+ 4 .5 mmoi/L
Bicarbonat e 11 mmoi/L
Chloride 113 mmoi/ L
Lactat e 13.6 mmoi/L
In view of the likely diag nosis, what is the most app ropriate inte rve ntion?
Intubate and ve ntilate
Intrave nous hydroxo cobalamin
15 litres o f high-flow oxygen via face mask
Intrave nous dexa methasone

sem
Intrave nous so diu m nitro p russide

As
Dr
Intubate and ve ntilate
Intravenous hydroxocobala1 in
15 litres o f high-flow oxygen via face mask
Intrave nous dexa methasone
Intravenous sod iu m nitrop russide
This ma n ha s deve lop ed a cute cya nid e toxicity second ary to b urning plastics in th e house
fire. Cya nide ions inhibit mitochondrial cytochrome oxidase, preve nting aero bic
respiration. This ma nifests in norma l o xygen saturati ons, a high p02 a nd flus hing (o r
'brick re d' skin) brou ght o n by the excess oxyge nation of ve nous b lood . In the q uestion
above it is impo rta nt to note that the blood g as sa mple g iven is ve nous rath er than
arteria l. His blood g as a lso demonstrates a increased anio n g a p, co ns istent with his high
la ctate (generated by a naerobic resp iration due to the inab ility to use ava ila ble oxygen).
The recommend ed treatment fo r mod erate cya nid e toxi city in the UK is one of three
o ptio ns: sod ium thiosulfate, hydroxocobalam in or d icobalt edetate. Although a ny one o f
these may be used, the on ly optio n given is that of hydroxocoba lam in and this is
therefore the co rrect answe r. Hydroxocoba la min a dd itio na lly has the b est s ide -effect
p rofile and s peed of onset co mpa red with other treatme nts fo r cyanide poisoning .
Intu bation wou ld be a ppro priate treatme nt in the co ntext of a irway burns but this patie nt
has no evidence o f these, a lthough close monito ring wou ld be advised . High-flow oxygen
is the treatment fo r carb o n monoxid e po iso ning - a sensib le d ifferential. but this man's
ve ry hig h lactate and hig h ve nous p02 fit b etter with cya nid e toxi city. Intrave nous
d exameth asone wou ld be another treatment fo r a irway oed e ma once a e ndotracheal tube
had been p la ced . Intrave nous sodium nitro prussid e is a treatment fo r hig h blood p ressure
that can cause cyan id e po ison ing, and would the refo re be inap prop riate.
sem
As
I •• I •• tt Discuss (7) Improve J

Dr
Each of the fo llowing are true regarding tricycl ic overdose, except
Anticho linergic features are prominent early on
Metabolic acidosis is a common complication
ECG changes include prolongation of the QT interval
Dialys is is indicated in severe t oxicity
m
se
As
QRS duration > 160ms is associated w ith ventricu lar arrhythmias
Dr
Each o f the fo llowing are true regarding tricycl ic overdose, except:
Anticho linergic features are prominent early on
Metabolic acidosis is a common complication

-
~
ECG changes include prolongation of the QT interval
I Dialysis is indicated in severe toxicity
m
se
QRS duration > 160ms is associated with ventricular arrhythmias
As
Dr
What is the mechanism of action of ciclosporin?
Monoclonal antibody against IL-2 recepto r
Interferes with purine synthesis
IL-1 receptor decoy
Decreases IL-2 release by inhibiting calcineurin
m
se
As
Mercaptopurine antagonist
Dr
Monoclonal antibody against IL-2 receptor
IL-1 receptor decoy
I Decreases IL-2 release by inhibiting calcineu rin
Mercaptopurine antag onist
m
se
Ciclospori n + tacrolimus: inhibit calcineurin thus decreasing IL-2
As
Dr
A 24-yea r-old woman is admitted to hospita l after presenting with a paracetamol
ove rdose. She reported taking 30 pa raceta mol tab lets around 10 hou rs ago. Treatment
with acetylcysteine was commenced stra ig ht away following adm ission. She has g rade II
encephalopathy on exa mination. Around 24 hou rs after adm ission her bloods are
repeated. Which one of the following findin gs is associated with the worst p rognosis?
Arterial pH of 7.37
Bilirubin of 152 IJmo l/1
Creatinine o f 323 1Jmol/l
Prothrom bin time of 35 seconds
m
se
As
ALT of 2,687 u/ 1
Dr
Arterial pH of 7.37
Bilirubin of 152 1Jmol/l

-
""'
Creatinine of 323 j.Jmol/1
Prothrom b in t ime of 35 seconds
ALT of 2,687 u/1
m
se
A creatinine as high as 323 j.Jmol/1 is marker of poor p rognosis and one o f the criteria for
As
a liver transp lant.
Dr
A 65-yea r-old man with a history of type 2 diab etes me llitus an d ischaem ic heart d isease
p resents with e rectile dysfunction. It is decided to try si ld enafil therapy. Which one of the
fo llowing existing medications may b e continued without making any a djustments?
GTN s pray
Nico randil
Nateglinide
Doxazos in
m
se
As
Dr
GTN spray
Nicora dil
Nateglinide
Doxazosin
m
se
As
The BNF recommends avoiding alpha-blockers fo r 4 hours after sildenafil
Dr
A 14-year-old boy is brou ght to the Emergency Department. Whilst in school he inject ed
his friends EpiPen into the palm of his left hand. Shortly afterwards the left middle finger
became cold and pale. The capillary refill time was around 5-6 seconds. What is the most
appropriat e management?
Inhalation of Nitrox (mixture of nitrogen + oxygen)
Intravenous nitrate infusion
Local infiltration of hist amine
Intravenous prostacyclin infusion
m
se
As
Local infiltration of phentolamine
Dr
Inhalation of Nitrox (m ixt u re o f nitrogen + oxygen)
Intravenou s nitrate infusion
I local inf iltration of hist amine
Intravenou s prostacyclin infusion
~al infiltration of phentolamine
Adrena line induced ischaem ia - phent o lam ine

m
se
Phentolamine, a short acting alpha blocker, may be used in this situation. It is normally
As
used mainly to contro l blood p ressure duri ng surgical resection of p haeochromocytoma
Dr
A 42-yea r-old ma le patient p resents to the urgent ca re centre with a 4 -hour history of
rapidly evolving rash. He re ports the rash started on the abdomen a nd has not s prea d to
his back and the chest. Th e rash is itchy and angry-loo king . He d enies any facial a nd o ra l
swe lling . He re po rts that he was o nly sta rted on a course o f antibiotics by his GP fo r a
chest infection and took the first d ose an hour b efo re the onset of the rash. On
examination, th ere is an extensive erythematous rash with wheals on th e abdomen, back
a nd chest.
Which antibiotic has he most li ke ly been sta rted on?
Vancomycin
Cla rith romycin
Penicillin
Trimetho prim
m
se
As
Doxycycline
Dr
Vancomycin GD
Clarithromycin f!D
Penicillin GD
Trimethoprim CD
Doxycycline CD
Penicillin is a common cause of urtica ria

Penicillin is the most common antibiotic that ca n cause urtica ria. The other antibiotics can
all cause an allergic rea ction manifesting in urticaria but not as common as penicillin.
Given the history of chest infection, penicillin is most likely the antibiotic that was given.
Vancomycin is not usually given for community-acquired pneu monia
Trimethoprim is usually used for urina ry tract infections.
m
se
Doxycycline can cause urticaria but it does so not as co mmonly as penicillin. The questio n
As
is asking which antibiotic is most likely. Dr
What is the mechanism of action of rifampicin?
Inhibits DNA synthesis
Interferes with cell wall fo rmatio n
Causes misrea ding of mRNA
m
se
As
Inhibits protein synthesis
Dr
Interferes w ith cell wall formation
Inhibits RNA synt hesis
Causes misrea ding of mRNA
Inhibits p rotein synthesis
m
Rifa mpicin - inhib its RNA synthesis
se
As
Dr
A 55-year-old female is admitted following an overdose of amitriptyline. On examination
she has dilated pupils and is tachyca rdic at 145 bp m, w it h a blood pressure of 102/ 56
mmHg. ECG revea ls a b road comp lex tachyca rdia. Her GCS is 9/15 (M 5, V2, E2). What is
the most appropriat e management?
IV amiodarone
IV bicarbonate
IV magnesium
DC cardi oversion
m
se
As
Glucagon
Dr
IV am iodarone f!D
IV bica rbonate eD
IV magnesiu m GD
DC cardiovers ion fD
Gl ucagon CD
Tricyclic overdose -g ive IV b icarb onate

Arrhythmias following tricyclic overdose are d ifficult to treat as many commonly used
m
se
anti -a rrhythmics are contraindicated. The use of sodium bicarbonate has been shown to
As
be effective, even in patients who are not aci dotic
Dr
A 48-year-old woman with longstanding rheumatoid arthrit is is started on
hydroxychloroquine. She has been on met hotrexate monotherapy fo r 1 year and
continues to have frequent flares. She undergoes 12 weekly FBC, U&E & LFTs.
In the long-term, which additional monitoring is required?
Blood pressure
Urinalysis
Eye assessment
Thera peutic levels
m
se
As
Anti-histone antibodies
Dr
Urinalysis
I Eye assessment
Therapeutic levels
Anti-histone antibodies
Hydroxychloroquine can cause retinopathy

Patients on longt erm hydroxychloroquine require annual eye assessments as there is a

risk of retinopathy. Other important drug causes of retinopathy include ethambut ol,
vigabatrin and amiodarone.
Blood pressure measurement is important in ciclosp orin therapy. Urinalysis is required for
gold and penicillamine (for protein due to the risk of membranous glomerulonephritis)
and cyclophosphamide (for blood due t o the risk of haemorrhagic cystitis and bla dder
cancer).
No drug requires routine monitoring of anti -histone antibodies (althou gh penicillamine

can cause drug-in duced lupus) and therapeuti c levels are required for the ca lcineurin
m
inhibitors ci closporin and t acrolimus.
se
As
NICE provide an excellent summary here: https://cks.nice.org.uk/dmards#!management
Dr
Which one o f the fo llowi ng statements regard ing drug metab olism is incorrect?
Reduction is an exa mple of a p hase I reaction
The maj ority of both phase I and phase II reactions take place in the liver
Asp irin undergoes extens ive first -pass metabolism
Products of phase I rea ct io ns a re typica lly more lipid soluble
m
se
As
Products of phase II rea ctions are typica lly ina ctive and excreted in urine o r b ile
Dr
Reduction is an exa mple of a phase I reaction fi!D
The majority of both phase I and phase II reactions take place in the live r f!D
Asp irin undergoes extensive first-pass metabolism fiD
r Products of phase I reactions are typica lly mo re lipid soluble GD
Products of phase II reactions are typically inactive a nd excreted in urine o r b ile GD
m
se
As
Usually both phase I and II reactions decrease lipid solubility
Dr
A 19-year-old stu dent is admitt ed after being found friends confused and sweating in her
room. She is unab le to give a history. On examination temperature is 38.1 °C, pulse
108/min, BP 130/ 70 mmHg and resp iratory rate 30/ min. Heart sounds are normal but she
has b ibasal fine inspiratory crackles on her chest.
ABGs on air:
pH 7.28
pC02 2.8 k Pa
p02 14.2 kPa
Paracetamol overdose
Acute pancreatitis
Mycoplasma septicaem ia
Legionella p neumonia
m
se
As
Asp irin overdose Dr
Paracetamol overd ose
Acute pa ncreatitis
Mycoplasma septicaemia
I
Legionellj p neu monia
Asp irin overdose
The mixed resp irato ry al kalosis and meta bolic a cidosis in a sweaty, confused patient point
m
se
towa rds sa licylate overd ose. The deve lopment of pulmona ry oed ema su ggests severe
As
poison ing and is an ind ication fo r haemod ialysis
Dr
A 19-yea r-old ma n presents to the Emergency Depa rtment 5 hours ingestin g 20g o f
pa raceta mo l. N-a cetyl cystein e is starte d stra ight away. What is the mechanism of action
o f N-acetyl cyste ine?
Replen ishes glutathione
Inhibits P450 mixed function oxidases
Replen ishes glucu ro nic acid
Promotes formation o f N-acetyi- B-benzoquinone im ine
m
se
As
Neutra lises me rcaptu ric acid
Dr
Replenishes glutathione (D
Inhibits P450 mixed functio n oxidases fD

Replenishes glucuronic acid GD
Promotes formation o f N-acetyi-B-benzoquinone imine «D
m
Neutralises mercapturic acid fD
se
As
Dr
Dobutamine is an example of:
Alpha-1 agonist
Alpha-2 agonist
Beta-1 antagonist
Beta-2 antagonist
m
se
As
Beta-1 agon ist
Dr
Alpha-1 agonist fiD
Alpha-2 agonist .
GD
Beta-1 antagonist GD
Beta-2l antagonist CD
m
se
Beta-1 agon ist CJD
As
Dr
A 29-year-old man comes t o the gastroente rology clinic for review for his Crohn's disease.
He has a 2-year hist ory of an anal fistula which has been treat ed with a metronidazole,
azathioprine and set on placements, but none of which has been effect ive. Following
discussion with the consultant, you plan to start the patient on infliximab.
What is the mechanism of action of this medication?
Anti-CD 20 antibody
Anti-CD 52 antibody
Anti -TNF monoclonal antibody
EGFR inhibitor
m
se
As
Anti-CD 4 antibody
Dr
Anti-CD 20 antibody GD
Anti-CD 52 antibody m
I Anti -TNF monoclonal antibody GD
EGFR inhibitor
•
nti-CD 4 antibody
•
Infliximab is an anti-TNF monoclonal antibody used in the treatment of Crohn 's
disease
Infliximab is an anti-TNF monoclonal antibody used in the treatment of Crohn's disease.
An example of anti-CD 20 antibody is rituximab.
An example of anti-CD 52 antibody is alemtuzumab.
An example of EGFR inhibitor is cetuximab.
m
se
An example of anti-CD4 antibody is cedelizuma b.
As
Dr
A 65 -year-old female is admitted to the Emergency Department following an overdose of
a long -acting propranolol preparation. On admission she is bradycardic with a pulse of
36/min and BP 90/50. The bradycardia fails to respond to atropine. What is the most
Temporary cardiac pacing
Haemodialysis
Glucagon
Noradrenaline infusion
m
se
As
Salbut amol in fusion
Dr
Tem porary cardiac pacin g
Haemodialysis
Glucagon
Noradrenaline infusion
Salbut amol in fusion

-
~
Beta- blocker overdose management: atropine + glucagon

Glu cagon has a positive inotropic action on the heart and d ecreases renal vascular
m
se
resista nce. It is t herefore useful in patients with bet a-blocker card iot oxicity
As
Cardiac pacing should be reserved for patients unresponsive t o pharmacol ogical therapy
Dr
A confused 45 -year-old man is admitted to the Emergency Department. He tells staff he
has drunk two bottles of antifreeze. On exam ination his pu lse is 120 bpm and blood
pressure is 140/ 90 mmHg. Arterial blood g ases show an uncompensated metabol ic
acidosis . He is transferred to the high dependency unit and ethanol is given via a
nasogastric tube. What is the mechan ism of action of ethanol in this patient?
Binds to glyco lic acid
Inhibits aldehyde dehydrogenase
Inhibits alcohol dehyd rogenase
Competes with ethylene glycol for alcohol dehyd rogenase
m
se
As
Binds to glycoa ldehyde
Dr
11nds to glyco lic acid
Inhibits aldehyde d ehydrogenase

-
I
Inhibits alcohol de hyd rogenase
Competes with ethylene g lyco l for alcohol dehyd rogenase

-
"""
~
m
se
As
Binds to glycoa ld ehyde
Dr
A 45-year-old female is admitted to the burns unit fo llowing being invo lved in a house
fire. She is hypoxic, hypotensive and has flus hed red skin. You suspect cyanide toxicity
and treat her with intravenous hydroxocobalam in.
What is the mecha nism of cyanide toxicity?
Inhibits the mitochondria l enzyme cytochrome c oxidase
Carboxyhemoglobinemia
Methemoglobin emia
Depletion of glutathione stores
m
se
As
Competitive inh ibitio n of the enzyme alcohol dehydrogenase
Dr
Inhibits the mitochondrial enzyme cytochrome c oxidase
Carb oxyhemoglobine mia
Methemog o bin emia
Depletio n of glutathione stores
Competitive inhibition o f the enzyme alcohol d ehydrogenase
Cyanide inh ibits the enzyme cytochrome c oxidase, resulting in cessation of the
mitochondrial e lectron transfer chain
Important for me Less ' m::~c rtont
Fires invo lving the b urning o f plastics can resu lt in cya nid e toxicity. Cyanide inhib its the
enzyme cytochrome c oxidase, resulting in cessation of the the mitochondrial electron
transfer chain . This causes histotoxic hypoxia because the cells of an o rganism are unable
to create ATP.
Carb oxyhemoglobine mia is a featu re of carbo n monoxide p oisoning . Exposure to smal l

concentrations o f CO hind e r the ability of Hb to d elive r oxyg en to the bo dy, because
ca rboxyhemoglobi n fo rms more read ily than oxyhaemoglob in.
Methe moglo bin emia is a fo rm o f haemoglobin that conta ins the ferric [Fe3 +] fo rm o f
iron. The a ffinity for oxygen of the ferric iro n is impaired resulting in tissue hypoxia. It can
occur to genetic o r a cquired fo rms (e .g. the use of drugs such as amyl nitrite) .
Dep letion of glutathio ne stores occurs in paracetamo l toxicity.
Fomep izole is a competitive in hibito r o f th e enzyme a lcoho l d ehydroge nase and can b e
s em
used to treat methano l and ethyle ne glyco l toxicity.

As
Dr
A 45 -year-old man presents t o the Emergency Department stating he has drunk a bottle
o f antifreeze. Which one o f the following features are least associated w ith this kind of
poisoning?
Metabolic acidos is with high anion gap
Acute ren al failure
Hypertension
Confusion
m
se
As
Loss of vision
Dr
A 45-year-old man presents to the Emergency Department stating he has drunk a bottle
o f antifreeze. Which one o f the following features are least associated w ith this kind of
poisoning?
Metabolic acidosis with high anion gap
Acute renal failure
Hypertension
Confusion
I
Loss of vision
m
I
se
As
Loss of vision is seen in methanol rather than ethylene glycol poisoning
Dr
Which one of the following stat ement s regarding amiodarone-induced thyrotoxicosis
(AIT) is correct?
AIT type 2 should be treated with corticosteroi ds
Am iodarone should be conti nued in the majority of patient s
Carbimazole is contraindicated in AIT type 1
Goitre is usually present in AIT type 2
m
se
As
AIT type 1 is due t o a amiodarone-related destructive thyroiditis
Dr
AIT type 2 should be treated with co rticosteroi ds C!D
Am iodarone should be conti nued in the majority o f patients GD
~rbimazole is contra indicated in AIT type 1 CD
Goitre is usually present in AIT type 2 CD
m
se
As
AIT type 1 is due to a a mio da ro ne-related d estructive thyro iditis fD
Dr
A 66-year-old woman with a history of chronic kidney disease stage disease 4 metastatic
b reast cancer is admitted with a swollen rig ht calf. Investigations confirm a deep vein
thrombosis and she is started on treatment dose d a ltepa rin. As she has a significant
d egree of rena l impairment it is decided to monitor her response to daltepa rin. What is
the most appropriate blood test to p erform?
Anti-Factor Xa levels
Antithrombin III levels
Anti-Factor Villa levels
Protrombin time (PT)
m
se
As
Activated Pa rtial Throm boplastin Time (APTT)
Dr
Anti-Factor Xa levels
Antithrombin III level s
r:~ti-Factor Villa levels

Protrombin time (PT)
m
se
As
Activated Partial Thromboplastin Ti me (APTT)
Dr
Thrombocytopenia is associated w ith each of the following drugs except:
Abciximab
Quinine
Warfa rin
Penici llin
m
se
As
Sodium valproat e
Dr
Abciximab CD
Quinine CD
I Warfarin GD
Penicillin CD
m
se
As
Sodium valproate f.D
Dr
A 55-yea r-old female p resents to the Emergency Department with a de liberate overdose
of amitriptyli ne. Para med ics re port that a box of thirty 50mg ta blets was found e mpty by
her bed. On exa mination, she appears a little letha rgic however there is no focal
neu ro logical a bno rmality. Observations show heart rate 110/ min, b lood p ressure
105/75mmHg. An ECG shows a sinus tachycardia with a QRS duration of 135ms and a
corrected QT interval of 390ms. What is the most app ropriate initial management of this
patient?
Intravenous isotonic sa line
Intravenous glucagon
Intravenous lipid emu lsion
Intravenous sod ium bica rbonate
m
se
As
Intravenous magnesium su lphate
Dr
Intravenous isotonic sa line
Intravenous g lucagon
Intravenous lipid emulsion
Intravenous sodium bica rbonate
Intravenous sodium bica rbonate is the sta nda rd initial therapy for patients who develop
ca rdiotoxicity (usually a QRS > lOOms o r a ventricular arrhythm ia) as a resu lt of tricycl ic
antidep ressant (TCA) overdose.
Intravenous magnesium su lphate can be used as a second-line agent in refractory

arrhythmias.
Intravenous lipid emu lsion is an emerg ing thera py for overdose o f li pophil ic com pounds.
It may have a role in overdoses of verapam il, beta b lockers, and some TCAs. However it is
not an app ropriate first line age nt.
Intravenous glucagon is used in beta b locker overd ose.
m
se
Intravenous isotonic sa line is ind icated in a hypotens ive patient. As
Dr
Which one of the fo llowin g is an a bsolute contra indication to combined o ra l
contraceptive pill use?
Contro lled hypertension
Histo ry of cholestasis
Wome n more tha n 35 years o ld and smoking more than 15 cigarettes/day
BMI of 38 kg/ m " 2
m
se
As
Mig raine without aura
Dr
Contro lled hyperte ns ion
-
Histo ry of cholestas is (D
Women more than 35 years o ld and smoking more than 15 ciga rettes/day GJ
BMI of 38 kg/ m " 2 f!D
m
se
Migraine without aura CD
As
Dr
Which one of the following drugs cannot be cleared by haemodialysis?
Asp irin
Tricydics
Lithium
Barbitu rates
m
se
As
Am inophylline
Dr
Asp irin CD
I Tricyclics
Lithi um
CD
.
(D
I Barb:tu rates .
(D
m
se
GD
As
Am inophylline
Dr
A 45-year-old man presents with pain and swelli ng of his leh big toe. He has recently
started treatment for active tuberculosis. Which one of the following medications is likely
to be responsi ble?
Streptomycin
Rifa mpicin
Ethambutol
Isoniazid
m
se
As
Pyrazinam ide
Dr
Streptomycin CD
Rifa mpicin CD
Etham butol fi!D
Isoniazid fiD
Pyrazinamide
I GD
m
se
There are case reports of ethambutol-induced gout but it is not listed as a side-effect in
As
the BNF
Dr
Which one o f the following drugs causes shortening of the QT interval?
Digoxin
Sotalol
Am iodarone
Tricyclic antidepressants
m
se
As
Chloroquine
Dr
Digoxin
Sot alol
Amiodarone
Chloroquine
m
se
Digoxin causes shortening o f the QT int erval whilst the other fou r drugs cause QT
As
prolongation
Dr
A 79-year-old ma le patient p resents to the GP surgery with a 1-month history of
constipation. He reports that a month ago, he used to open his bowels once a day every
morning, but fo r the last month, he was only able to open bowels once every 3 days at
best and each time the bowel was opened, the stool is very d ry and lumpy and he has to
strain a lot on the toi let. He is very distressed by this. You notice that he was started on a
med ication one month ago and you suspect that this might have contributed to his
constipation.
Which is the most like ly medication he was started on?
Bisoprolol
Vera pa mil
Metfo rmi n
Warfarin
m
se
As
Aspirin
Dr
Bisoprolol «D
I Verapamil ED
Metformin tED
Warfarin m
Aspirin m
Verapamil commonly causes constipation
Verapamil, a calcium channel blocker, is a common cause of constipation. Even though

many medications can cause constipation, verapamil is the most like ly medication
amongst the options given.
Bisoprolol can cause constipation but not as commonly as verapamil.
m
se
As
Metformin, warfarin and aspirin do not usually cause constipation.
Dr
A 54-yea r-old ma n with a history of hypertension comes for review. He currently takes
lis inopril 10mg od, simvastatin 40mg on a nd aspirin 75mg od. His blood p ressure is well
contro ll ed at 124/76 mmHg but he also mentions that he is due to have a tooth
extraction next week. What advice shou ld be g iven with regards to his aspi rin use?
Take aspirin as norma l but take tranexam ic 1g tds acid 24 hours before and a fter
p rocedure
Stop 72 hours before, restart 24 hours after p rocedure
Stop 24 hours before, restart 12 hou rs after p rocedure
Ta ke aspirin as norma l
m
se
As
Stop 48 hours before, restart 24 hou rs after p rocedure
Dr
Take aspirin as norma l but take tra nexam ic l g td s acid 24 hou rs before a nd a fte r m
p roced u re
Stop 72 hours before, restart 24 hou rs after p rocedu re
Take aspirin as norma l
m
se
In the BNF section 'Prescribing in dental p ractice ' it advises that patients in this s ituation
As
s hould co ntinue taking anti-p late lets a s normal
Dr
In the Vaugha n Williams class ification of antiarrhythmics lidocaine is an example of a:
Class Ia agent
Class Ib agent
Class Ic agent
Class II agent
m
se
As
Class IV agent
Dr
Class Ia agent (D
~ss Ibagent CD
Class Ic agent f!D.
Class II agent CD
m
se
Class IV agent .
(D
As
Dr
A 52-year-old homeless man is admitted with suspected ethylene glycol toxicity.
Following admission to the High Dependency Unit it is decided to give fomepizole. What
is the mechanism of action of fomepizole?
Competitive inhibitor of aldehyde dehydrogenase
Binds to glycoaldehyde
Binds to glycolic acid
Promotes renal excretion of ethylene glycol
m
se
As
Competitive inhibitor of alcohol dehyd rogena se
Dr
Competitive inhibitor of aldehyde dehydrogenase
Binds to glycoaldehyde
Binds to glycolic acid
Promotes renal excretion of ethylene glycol
m
se
As
Competitive inhibitor of alcohol dehydrogenase
Dr
A 40-year-old woman who is known t o be HIV positive is reviewed in the respiratory
clinic. She has recently started treatment for tuberculosis and is complaining of a loss of
sensation in her hands Which one of the follow ing drugs is most likely to be responsible?
Indinavir
Pyrazinamide
Zidovudine
Streptomycin
m
se
As
Isoniazid
Dr
Indinavir CD
Pyrazinam ide CD
I Zidovudine CD
Streptomycin CD
Isoniazid GD
m
se
Isoniazid causes peripheral neu ropathy
As
Dr
A 34-year-old man wit h a history of d epression is admitted to the Emerg ency
Department. He stat es he has taken an o verdose of both diazepam and dosulepin. On
examination blood pressu re is 116/78 an d t he pulse is 140 bpm. His respiratory rate is 8
per minute and the o xygen saturations are 97% on room air. What is the most
appropriat e next course o f action?
Give flumazen il
Inse rt a haemodialysis line
Obtain an ECG
Give naloxone
m
se
As
Start N-a cetylcysteine infusion
Dr
Give flumazen il
Inse rt a haemodia lysis line
Obtain an ECG
Give naloxone
Start N-acetylcyste ine infusion
As this patient has a marked tachyca rdia the first step wou ld be to obtain an ECG. If
changes such as QRS widening are seen then intravenous bicarbonate should be g iven
m
Some users have argued that a n 'ABC app roach shou ld be taken, with flumazeni l g iven to
se
reverse the respiratory dep ression. The potential risk of doing this would be inducing a
As
seizure given the coexistent tricycl ic overdose
Dr
A 37-yea r-o ld wo man with a history of type 2 dia betes mellitus a nd obes ity p resents after
a late pe riod. The urina ry hCG test is positive . Her cu rrent med ication is as follows:
Orlistat l 20mg tds

Simvastatin 40mg on
Aspirin 7Smg od
Metformin l g bd
Paracetamol l g qds
Aqueous cream prn
Which one o f her med icatio ns must b e stopp ed stra ig ht away?
Pa raceta mol
Asp irin
Simvastatin
Orl istat
m
se
As
Metformin
Dr
Paracetamol m
Aspirin CD
I Simvastatin ED
Orlistat fD
Metformin f!D
Simvastatin is contraindicated in pregnancy and must be stopped immediately. Metformin

is sometimes used in pregnancy although many diabetic women are converted t o insulin
for the duration of the pregnancy to try and maximise control and minimise
compl ications.
m
se
Whilst orlistat is not a known teratogen it shou ld be used with 'caution' in pregnancy
As
according t o the BNF and the benefits are very likely outweighed by risks.
Dr
A 65-year-old man is rushed to the emergency depa rtment by his daughter. He complains
of crush ing, central chest pa in.
An immediate ECG trace o f his heart shows widespread ST e levation in the anterolatera l
chest leads.
He is started on aspirin, p rasug rel, morphine, metoclop ramide and nitrates and is taken to
the percutaneous coronary intervention (PCI) lab. The ca rdiologist attending suggests
starting him on a bciximab for the p revention of further ische mic events.
What is the mechanism of action of the drug suggested by the card iolog ist?
Direct factor X inhibitor
Direct th rombin inhibitor
P2Y12 inhibitor
Activates anti -thrombin III
m
se
As
Glycoprotein lib/lila inhib itor
Dr
Direct factor X inhibitor fD
Direct t hrom bin inhib itor CD
I P2Yl+ nhibitor CD
Activates anti -thrombin III m
I Glycoprotein lib/lila inhib itor GD
Abciximab is a glycoprotein lib/lila receptor antagon ist

Drug name MOA
Heparin activates anti-thrombin III
Prasugrel P2Y12 ADP in hibito r
Abciximab glycoprotein lib/lila inhi bito r
m
Dabigatran direct th rombin inhibitor
se
As
Rivaroxaban direct factor X inhibitor
Dr
A 45-year-old man with a history of epilepsy and psychiatric problems is admitted to the
Emergency Department w ith confusion following a se izu re earlier in the day. On
examination he is not ed to have a coarse tremo r, blood pressure is 134/86 mmHg, pulse
is 84/min and the temp erature is 36.7°C. What is the most likely diagnosis?
Carbamazepine overdose
Lith ium t oxicity
Benzod iazepine toxicity
Tricyclic overdose
m
se
As
Neuroleptic malignant syndrome
Dr
Carbamazepine overdose CfD
I Lithi um toxicity CiD

Benzodiazep ine toxicity CfD
Tricyclic overdose GD
Neuroleptic malignant syndrome GD
Lithium: fine t remor in chronic treatment, coarse t remor in acute t oxicity

m
se
As
A t ricyclic overd ose may present w ith seizu res but it d oes not typica l cause a t remor
Dr
A 74-year-old male presents to the surgical assessment unit. He has come in w ith lower
abdominal pain and has been unable to pass urine for the past 12 hours. On examination
he ha s a palpable bladder and is tender in the suprapubic region. On PR examination his
prostate is smooth and not enlarged. He has a background of high blood pressure,
depression, neuropathic pain and diabet es.
What is the most likely cause for this presentation?
Gabapentin
Am lodipine
Metformin
Am itriptyline
m
se
As
BPH
Dr
Gabapentin CID
Amlod ipine CD
etformin CD
Am it riptyline flD
BPH fD
Amitriptyline can cause urinary retention

This gentleman is in urinary retention. Amitriptyline can cause urinary retention through
its anticholinergic activity.
m
The other medications do not cause urinary retention.
se
As
The patient has a small prostate on PR examination so is unlikely to be suffering from BPH
Dr
A 56-yea r-old fema le with a history of dep ression is broug ht in to the Eme rgency
Depa rtment by a concerned neig hbou r. Besid e the patient a re em pty blister packets of
co-coda mo l 30/ 500, indicating that she may have taken up to 50 tab lets. She is confused
with a GCS of 14/15 and is una ble to say when she took the tab lets. What is the most
a ppropriate initial manage ment?
Sta rt N-acetyl cysteine imm ed iately
Immed iate referral for hae mod ialysis
Give na loxone
Sta rt N-acetyl cysteine 4 hours a fter prese ntation if leve ls a re elevated
m
se
As
Observe
Dr
Start N-acetyl cysteine imm ediately
Immed iate referral for hae mod ialys is
Give na loxo ne
Sta rt N-acetyl cysteine 4 hours a fter presentation if levels a re elevated
Observe
She may have consumed 25g o f paracetamol whi ch is a life-threatening overdose. N-

acetyl cysteine needs to b e commenced immediate ly.
m
se
There is no mention in the question of respiratory dep ression o r hypoxia to justify the use
As
of naloxone
Dr
A 45-year-old female with a history of bipolar disorder presents with an acute co nfusional
state. Which one of the following drugs is most likely to precipitate lithium toxicity?
Sodium valproate
Atenolol
Am inophylline
Sodium bicarbonate
m
se
As
Bendroflumethiazide
Dr
Sodium valproate CD
Atenolol CD
IAminop~ylline f!D
Sodium bicarbonate CD
I Bend rofl umethiazide CD
m
se
Both sodium bicarbonate and aminophylline may reduce plasma concentrations of
As
lithium. Sodium valproate is not listed in the BNF as interacting with lithium
Dr
A 20-year-old man is admitted to the Emergency Department with chest pain. He
confid es that he has snorted 'a large amount' of coca ine in the previous hours. Which one
of t he fo llowing features is his cocaine use most likely to cause?
Hypokalaemia
Hyperthermia
Decreased d eep t end on ref lexes
Hypot ension
m
se
As
Metab olic alkalosis
Dr
Hypokalaemia m
I Hyperthermia CD
Decreased d eep t end on ref lexes fD
I Hypot ension .
(D
m
se
CD
As
Metabolic alkalosis
Dr
Which of the following antibiotics act by inhibiting prot ein synthesis?
Cephalosporins
Gentamicin
Rifampicin
Trimethoprim
m
se
As
Flucloxacill in
Dr
Cephalosporins GD
I Gentamicin eD
Rifa mpicin «D
I Trimethoprim f!D
Flucloxacillin CD
m
se
As
Am inoglycosi des inhibit protein synthesis by acting on the 30S ribosomal unit
Dr
You are working in oncolo gy. A 50-year-old patient with an ad enocarcinoma of t he lung
(T3 N3 M 1a) comes to clinic. He is an ex-smoker of 20 pack years. He has previously been
treated w ith docet axel and cisplatin which have unfortu nately failed. He was subsequently
t ested for an EGFR g ene mutation wh ich was found to be negative. His p erformance
status is 0. He as ks you about a 'new ag ent' he has read about called nivolumab. How
d oes this drug work?
EGFR inhibit or
VEGF inhib itor
ALK-1 inhibitor
PD-1 inhibito r
m
se
As
CTLA -4 inhibitor
Dr
EGFR inhibit or GD
VEG F inhib itor 6D
ALK-1 inhib itor CD
PD-1 inhibitor ED
CTLA-4 inhibitor CD
Immunotherapy is an area which is rapidly advancing in oncology and haemat ology and it
is important cli nicians are awa re o f t hese advancements. One area o f immunot herapy t hat
has developed in recent years is the emergence of checkpoint inhibito rs.
Nivolumab is a PD -1 (programmed cell d eat h) inhibitor. PD - 1 receptors are fou nd on t he

su rface o f T cells. When a T cell is alerted t o a cancer cell t he cance r cell ca n express t he
PD-L1 p ro t ein. This is a ligand w hich bin ds to t he T ce ll recepto r and d eact ivates it. It is
therefore a mechanism cancer cells use to evad e t he immune syst em and disa ble T cells.
The PD -1 inhibit ors are antibod ies wh ich b lock t his receptor, leavi ng t he T cell s t o remain
active and alert other immune cell s for example macro phages t o the cancer ce lls.
EGFR is the epid ermal growth factor receptor. An examp le o f an inhibitor used in lung
cancer would be erlotinib (Tarceva).
VEGF inhib itors are vascular end ot helial growth fact or i nhibitors. An example is
bevacizumab which is used in colorect al cancer.
ALK-1 i nhibitors are drugs t hat act on anaplast ic lymphoma kin ase (a tyrosin e kinase).
Crizotinib is an ALK- 1 inhibitor wh ich is und ergoing fu rther t rials in NSCLC.
CTLA-4 (cytotoxic T -lymphocyte associat ed prot ein 4) is anot her immune checkpoint
which dow n-regulat es T cell responses. Blocking this with inhibit ors such as ipilimumab
again activat es t he immune syst em against cancer.
Nivolumab i n combinat ion wit h ipilimumab has show n encou raging results in pat ients
em
wit h st age 4 met astatic melanoma and lymphoma. It is currently und ergoing t rials into
s
As
many o t her so lid malignancies such as lung, oesop hagea l and head and neck cancer.
Dr
A 60-year-old lady with atrial fibrillation and type 2 diabetes att ends for DC
Cardioversion. She has continued her usual medications and 2mg of intravenous
diazepam are given for sedation. Her usual medications are aspiri n, ramipril, bisoprolol
and metformin. Following DC ca rdioversion she is found t o be in sinus bradycardia with a
heart rate of 29. Which reversal agent is most likely t o correct her bradycardia?
Intramuscular flumazenil
Intramuscular glucagon
Intravenou s flumazenil
Intravenou s gluca gon
m
se
As
Intravenou s amiodarone
Dr
Intramuscula r flumazenil
Intra muscula r g lucagon
Intrave nous flumazenil
~ravenous g lucagon
Intrave nous amioda rone
Beta-blocker - atrop ine, glucagon in resistant cases

This lady's b radycardia is most likely to be caused by beta bl ockad e from he r b isopro lol.
The recommend ed re ve rsal agent fo r b iso pro lol is intravenous gluca gon.
Atro pi ne is li ke ly to be ap prop riate based o n Advanced Life Support treatment pathways

to treat the bradyca rdia. The most likely reversa l a gent, however, wou ld be intravenous
gluca gon.
Intra muscula r glucagon may be used to treat hypoglycaem ia, however is not appropriate
fo r reversa l o f beta -blockad e.
Flumazenil is not the co rrect a nswer, fo r althou gh this wo uld reverse any remaining
sedatio n, it would not reverse the beta-blockade and b radyca rdia.
Amioda rone is not a re versal agent a nd thus not the correct answe r.
s em
Sou rce: BN F
As
Dr
A patient presents to the Emergency Department follow ing the development of an
urticarial ski n rash following the introduction of a new drug. Which one of the following is
most likely t o be respo nsible?
Omeprazole
Sodium valproate
Aspirin
Paracetamol
m
se
As
Simvastatin
Dr
Omeprazole m
Sodium valproate CD
Asp irin ED
Paracetamol CD
Simvastatin fD
Asp irin is a co mmon cause of urticaria

m
se
Although all medications ca n potentially cause urtica ria it is commonly seen secondary to
As
asp1n n
Dr
A 62-year-old man is attends the emergency department in fast atrial fibrillation. He is
successfully card ioverted aher the fa ilure of beta-blocker therapy. Upon discharge he is
placed on flecainide by the card iologist.
Which of the following best describes flecainide's mechanism of action?
Blocking cat echolamine stim ulation of beta one adrenergic receptors in the heart
Blocking the Navl.S sodium channels in the heart
Blocking the batrachotoxin activated sodium channels of the heart
Blocking the potassium, sodium and calcium channels o f the heart
m
se
As
Blocking the rectifier potassium current
Dr
Blocking catecho la mine stimulatio n of beta one adrenergic receptors in the heart 0
I Blocking the Navl.S sodium channels in the hea rt
Blocking the batrachotoxin activated sodium channels of the heart
Blocki ng the potassiu m, sodium and calcium channels of the heart
Blocking the rectifier potassium current
Flecainide works by blocking the Navl.S sodium channel in the heart wh ich slowing the
upstroke of the ca rdiac action potential.
Bisoprolol works blocki ng the stimulation of beta one adrenergic receptors fou nd ma inly
in the heart muscle which ultimately leads to decreased adrenergic tone and stimulation
of the heart muscle.
Procainamide works in a similar way to flecainide but instead indu ces a rapid blocking of
the batrachotoxin activated sodium channels rapidly.
Dronedarone's mechanism of action is unclear but it is believed to be involved in both the

inhibition of outward potassium channels as well as the reduction of sodium into the cells.
It is also thoug ht to have an effect on the calcium channels.
Ibutilide works primarily by pro longing the repolarization in atrial an d ventricular m

se
myoca rdium. This effect is caused by blocking !Kr, the rapid component of the cardiac
As
delayed rectifier potassium current.

Dr
A 35-year-old man with a known hist ory of peanut allergy is admitted to the Emergency
Department with a swollen face. On examination blood pressure is 85/ 60 mmHg, pulse
120 bpm and there is a bilatera l expirat ory wheeze. What is the most appropriate form of
adrenaline to give?
10m I 1:10,000 N
O.S mll:l,OOO IM
O.S mll:lO,OOO IM
Smll:l,OOOIM
m
se
As
Nebulised adrenaline
Dr
10m I 1:10,000 IV .
(D
0.5ml 1:1.000 IM GD
0.5ml~:10,000 IM CiD
5ml1:1,000 IM CD
Neb ulised ad renaline m
Recom mend Adult Life Support (ALS) adrenaline d oses
• anaphylaxis: O.Sml 1:1,000 IM
m
• ca rdiac arrest: 10m I 1:10,000 IV or 1m I of 1:1000 IV
se
As
Dr
A 45-yea r-old patient presented with significa nt malnutrition a nd wa s initiated on
naso ga stric feeding . Refeed ing blo od tests noted a s ignifica nt hypoma gnesem ia.
What ECG cha nges a re most li kely to b e present?
QT shortening
QT prolong atio n
T-wave inversion
Bra dyca rd ia
m
se
As
Peaked t-waves
Dr
QT shorte ning C!D
QT prolongation CD
T-wave inversion CD
Bra dyca rd ia .
CD
Pea ked t-waves fD
The ECG change most typically associated with hypomagnesaem ia is QT pro long atio n.
QT shorte ning is mo re typica lly seen with hyperca lcaem ia, cong e nita l QT syndrome and
digoxin.
T-wave inve rsion is more typica lly seen with coro na ry ischaem ia o r leh ve ntricu la r
hypertro phy.
Peaked t-waves a re more typically seen with hype rcalcaem ia.
m
se
hypomag nesemia d oes not typically cause a bradyca rdia.
As
Dr
Which one of the following drugs demonstrates saturat ion p harmacokinet ics?
Enalapril
Bendrofluazide
Atenolol
Phenytoin
m
se
As
Paracetamol
Dr
Enalapril CD
Bendrofluazide
•
Ateno lol
~enytoin
•
ED.
Paracetamol flD
m
se
Exhibits zero-order kinetics - phenytoin
As
Dr
Which one o f t he followin g drugs does not characterist ically und ergo ext ensive first- pass
metabolism?
Propranolol
Glyceryl tri nitrate
Diazepam
Aspirin
m
se
As
Verapamil
Dr
Proprano lol CD
Glyceryl tri nitrate GD
Diazepa m
.,
Aspirin tD
m
se
As
Verapamil f!D
Dr
A 45 -year-old man is referred to the acut e medica l unit. He had presented earlier in the
day to the GP complaining o f ongoing fatigue and polydipsia. A BM (finger-prick glucose)
taken in the surgery was 22.3 mmol/1. On examination he is an obese man (BMI 36kg/m 2)
with a pulse of 84 bpm and blood pressure of 144/84 mmHg. Blood t ests reveal the
following:
Na• 14 0 mmol/1
K• 3.9 mmol/1
Bicarbonate 23 mmol/ 1
Urea 5.2 mmolfl
Creatinine 101 molfl
Glucose 2 1.2 mmol/ 1
You encourage him to lose weight and discuss basic dietary advice. What is the most
appropriate initial management?
Gliclazide
Pioglitazone
Exenatide
Metformin
m
se
As
Commence insulin therapy

Dr
Gliclazide
Pioglitazo ne
Exenatide
Metformin
Commence insulin therapy

-
~
m
se
As
Whilst there is a role for exenatide in o bese patient s it is not used first -line.
Dr
Ta msu losin is a:
Alpha-lb agonist
Alpha-la agonist
Non-selective a lpha antagonist
Alpha-la antagonist
m
se
As
Alpha-lb antagonist
Dr
Alpha-lb agon ist
Alpha-la agonist
Non-selective alpha antagonist
I Alpha-la antagonist
m
se
As
Alpha-lb antagonist
Dr
Low molecular weight heparin has the greatest inhibitory effect on which one of the
following proteins involved in the coagu lation cascade?
Factor !Xa
Factor XIa
Factor Xa
Thrombin
m
se
As
Factor XI!a
Dr
Factor !Xa m
Factor Xla m
Factor Xa GD
Thrombin GD
m
m
se
Factor Xlla
As
Dr
A 70-yea r-old patient attends the GP with a 10-day history of increasing shortness of
breath and ankle swell ing . He has a past medica l history of hypertension, type II diabetes,
ischaemic heart disease and systolic heart failu re. He was started on a new medication 10
d ays ago. Which of the below drugs is most likely to have caused his new symptoms?
Bendroflumethiazide
Piogl itazone
Paracetamol
Dapagliflozin
m
se
As
Rivaroxaban
Dr
Bendroflumethiazide GD
I Pioglitazone GD
Paracetamol m
Dapagliflozin f!D
Rivaroxaban m
Glitazones can cause fluid retention and decompensation of heart failure
The correct answer is piog litazone. Glitazones are a class of ant i-hypoglycaemics wh ich
can cause ret ention o f f luid resu lting in d ecompensat ion of pre-existing heart failure.
Other medications which can cause worsen ing of heart fa ilure includ e NSA!Ds, non -
dihydropyridine ca lcium chan nel b lockers, non -cardia -selective beta blockers, some
arrhythmic agents and alpha blockers used for urolog ical p ro blems.
BNF:
https:/ / bnf.nice.org.u k/ drug/ piog Iitazone.htm I
m
American College of Cardiology:
http:/ /www.acc.org/latest -in-cardiology/ articles/2017/02/03/09/44/co mmon ly-used - se
As
drugs-can -cause -or-worsen-hf
Dr
What is the most a pp ropriate dose of a drena li ne to give during a cardiac a rrest?
1ml1:100,000 IV
10m I 1:1,000 IV
0.5ml1:1,000 IM
1ml1:10,000 IV
m
se
As
10m I 1:10,000 IV
Dr
1ml1:100,000 IV CD
10m I 1:1,000 IV CD
0.5ml1:1,000 IM m.
1ml1:10,000 IV ED
10m I 1:10,000 IV CD
Recom mend Adult Life Support (ALS) adrenaline doses

• anaphylaxis: O.Sml 1:1,000 IM
• cardiac arrest: 10m I 1:10,000 IV or 1m I of 1:1000 IV
10m I of the 1:10,000 p reparation contains 1mg of ad renaline.
From the BNF:
m
se
Adrenaline (epinephrine) 1 i n 10 000 (100 micrograms/mL) is recommended in a dose of 1
As
mg (1 0 mL) by intravenous injection repeated every 3 -5 minutes if necessary Dr
A 43-year-old male patient comes to t he GP surgery for a review of his recent glucose
t olerance t est. His past medical h istory inclu des ep ilepsy, renal transp lant, hypertension
and ischaemic heart disease. The results are as follows.
Fasting blood glucose 6 .8 mmoljl
2 hour post-oral load blood glucose 10.9 mmoljl
Which medicati on is most likely causing t hese results?
Am lodipine
Tacrolimus
Levetiracetam
Lamot rigine
m
se
As
Verapamil
Dr
Am lod ipine CD
I Tacroli mus fD
Levetiracetam m.
Lamotrigine m.
Verapamil CD
Tacrolimus is a cause of impaired glucose tolerance

This patient 's glucose tolera nce test shows impaired glucose tolerance. Tacro limus is a
cause of impaired glucose tolerance.
m
se
Am lodipine, levetiracetam, lamotrigine and verapam il do not commonly cause impaired
As
glucose tolera nce.
Dr
A 62-yea r-old female patient p resents to the GP surgery complaining of a rash on her
face and her chest. She reports that she first noticed the rash whilst she went on holiday
to Spain in July and she only got back 2 days ago. She has a past med ical history of
hypertension, ischaemic stroke, type 2 dia betes and epilepsy. On exam ination, there is a
ma culopapu lar erythematous rash on her forehead, both cheeks and anterior chest. You
notice that she was recently started on a medication.
What is the most likely med icatio n that may have caused this rash?
Clopidog re l
Am lodipi ne
Fu rosem ide
Bendroflumethiazid e
m
se
As
Metform in
Dr
Clopidog rel GD
j .mlodipine GD
Fu rosem ide CD
I Bend roflu methiazid e
Metfo rmin
ED
.
(D
Th iazides may cause photosensitivity

Given the d istribution o f the rash a nd the histo ry, it is like ly that this is a photosensitive
rash. Thiazides may cause photosensitivity.
m
se
Sodium valp roate, am lod ipine, furose mide and metfo rmin d o not usually cause
As
photosens itivity.
Dr
What is the most a p pro priate time to take b lood samples fo r thera peutic mon ito ring of
lithium leve ls?
At any time
Immed iate ly befo re next dose
4 hou rs after la st d ose
6 hou rs after last d ose
m
se
As
12 hou rs a fte r last dose
Dr
At any time m
Immed iate ly before next dose QD
4 hours after last dose CD

6 hours after last dose GD
m
se
6D
As
12 hours after last dose
Dr
A 59-yea r-old ma n with a history o f type 2 dia betes mellitus an d benig n p rostatic
hypertrophy develops urinary retention associated with acute renal fai lure. Which one of
the following drugs shou ld be disco nti nued?
Gliclazide
Paroxetine
Atenolol
Metformin
m
se
As
Finasteride
Dr
Gliclazide CD
Paroxetine CD
Atenolol m
Metformin ED.
Finasteride tiD
As the patient ha s develop ed acute rena l failure metformin should be stopped due to the
m
se
risk of lactic acidosis. In the long term paroxetine may also need to be stop ped as SSRi s
As
can co ntribut e to urinary retention.
Dr
A 58-year-old man who is taking lithium for bipolar disorder presents fo r review. During
routine examination he found t o be hypertensive with a blood pressure of 166/82 mmHg.
This is confirmed with two separate readings. Urine dipstick is negative and renal function
is normal. What is the most appropriate medication to start?
Amlodipine
Ramipril
Losartan
Bendroflumethiazide
m
se
As
Doxazos in
Dr
Amlodipine GD
Ram ipril CD
Losartan CD
Doxazos in CD
Diuretics, ACE-inhibitors and ang iotensin II recepto r antagonists may cause lithium
toxicity. The BNF advises that neu rotoxicity may be increased when lithium is given with
diltiazem or verapam il but there is no significant interaction with amlodipine. Alpha-
blockers are not listed as interacting with lith ium but they would not be first-line
treatment for hypertension.
m
se
The NICE hypertension gu idelines suggest amlodipine wouldn't be a bad first choice, even
As
if we ignore his lithium treatment.
Dr
Which one of the following immunosuppressant drugs inhibits ca lcineurin in T cel ls?
Mycophenolate mofetil
Basiliximab
Azathioprine
Ciclosporin
m
se
As
Methotrexate
Dr
Mycophenolate mofetil
Basiliximab
Azathioprine
Ciclosporin
Methotrexate
Ciclosporin + tacrolimus: inhibit calcineurin thus decreasing IL-2

Mycophenolate mofetil inhibits inosine mono phosphate dehydrogenase. Azathioprine is
m
se
metabolised to the active compound mercapto purine, a purine analogue that inhibits
As
DNA synthesis. Methotrexate is an antimetabolite which inhibits dihydrofo late reductase
Dr
A 36-yea r-old male wei ghing 70 kg presents to the Emergency De partment fo llowing an
o verdose of pa racetamol in an attempt to en d his life. The patient reports to have taken a
total of 15 grams of pa raceta mol over the course of the last 5 hou rs . He currently feels
nauseous, but d enies vom iting o r abdominal pain.
What is the most app ropriate next step in manag ing this patient?
Check se rum pa raceta mo l levels a nd act as per result
Give IV N-acetylcyste ine imm ediately
Give IV fom ep izole im med iately
Give IV sodium b icarbonate immediately
m
se
As
O bserve patient and d ischarge if remains asymptomatic
Dr
Check serum pa raceta mo l levels and act as per result
I Give N N-acetylcysteine immediately
Give N fom epizole im mediately
~Give N sod ium bicarbo nate immediately

Observe patient and d ischarge if remains asymptomatic
Patients who take a staggered pa raceta mol overdose shou ld receive treatment with
acetylcysteine
Patients who present following staggered ingestion of a potentially toxic dose of

pa racetamo l (> 75mg/kg) should be commenced on N acetylcysteine irrespective of
serum pa racetamo l co ncentrations.
A staggered overdose is defined as 'ingestion of a potentially toxic dose of pa racetamo l

over more than one hour'. This patient has ta ken > lSOmg/kg over a period of 5 hours
and therefore should be commenced on treatment.
Fomepizole is used to the treatment of ethylene g lycol (a ntifreeze) poisoning. N sod ium
bicarbonate can be g iven in the treatment of sa licylate and tricyclic antidepressant
overdose. em
Given that the patient has ingested a toxic dose, treatment shou ld not be delayed until
s
As
the development of symptoms.

Dr
A 62-year-old female with chronic renal failure (GFR = 35 mljmin) is diagn osed as having
pulmonary tuberculosis. What cha nges need to be made to her anti-tuberculosis reg ime
given her renal impairment?
Reduction in isoniazid dose
Reduction in rifampicin dose
Reduction in pyrazinamide dose
Reduction in ethambutol dose
m
se
As
No changes
Dr
Reduction in isoniazid dose
Reduction in rifampicin dose
Reduction in pyrazinamide dose
I Reduction in ethambutol dose
m
se
As
No changes
Dr
A 57 -year-old male patient presents to the GP surgery complaining of having very vivid
dreams. He repo rts a 6-week histo ry of having frequent nightmares w ith extremely
disturbing and vivid ima gery. He is quite distressed by this. You review his medication and
found t hat he was started on a new medication 6 weeks ago.
Which medication was he likely to have been started on?
Nitrat e
Bisoprolol
Am lod ipine
Vera pamil
m
se
As
Nicorandil
Dr
Nitrate GD
Bisoprolol fD
Amlodipine .
(D
Verapamil GD
Nicorandil ED
Beta- blockers can cause sleep disturbance

Beta-blockers can cause sleep disturbance.
Side effects of nitrates: hypotension, tachycardia and headache
Side effects of calcium channel b lockers: headache, flushing, ankle oedema
Verapamil can also cause constipation
m
se
As
Side effects of nico randil: headache, flushing and anal ulceration
Dr
Immunoglobulin therapy may be indicated in each of the following except:
Dermatomyositis
Guillain-Barre syndrome
Kawasaki disease
m
se
As
Thrombotic thrombocytopenic purpura
Dr
Dermatomyositis
Guillain-Ba rre syndrome

-
~
Kawasaki disease
Id io pathic thro t bocytopenic pu rpu ra
Thro mbotic thro mbocytopenic p urpurJ
m
se
The management o f management thrombotic throm bocyto pen ic pu rpu ra involves
As
stero ids and immunosu ppressants. Plasma exchange is a lso commonly used
Dr
Which of the follow ing drugs is most likely t o be affected by a patients acetylator status?
Ethanol
Hydralazine
Aspirin
Phenytoin
m
se
As
Verapamil
Dr
Ethanol CfD
~dralazine CD
Asp irin (!D
Phenytoin ED
Verapa mil CD
m
se
Is affected by acetylator status - hydralazine
As
Dr
A 43-year-old man presents with known acute intermittent porphyria is brought to the
Emergency Department by the police due to an acute psychosis. What is the most
suitable drug for sedation?
Chloral hydrate
Diazepam
Phenobarbitone
Chlorpromazine
m
se
As
Primidone
Dr
m
se
Chlorpromazine is considered safe to use in patients with acute interm ittent po rphyria.
As
The other d rugs are classified as unsafe
Dr
A 25-year-old stu dent p resents to t he GP surgery w it h a 3 -day history o f blocked and
runny nose, head ache and sore throat. He has no other sympt oms and has been g enerally
f it an d well. He asks you for a medication t o help relieve t he blocked nose. You p rescribe
him a phenylephrine hydroch loride nasal spray.
What is the mechanism o f action of this medication?
Beta-1 adrenoreceptor antagonist
Alpha-1 adrenoreceptor agonist
Alpha-2 adrenoreceptor antagonist
Beta-2 ad reno receptor agonist
m
se
As
Alpha-1 adrenoreceptor antagonist
Dr
Beta-1 ad renoreceptor antagonist
Alpha-1 adrenoreceptor agonist
Alpha-2 ar renorecepto r antagonist
Beta-2 ad renoreceptor agonist
Alpha-1 adrenorecepto r antagonist
Phe nyle phrine is an alpha-1 agonist

Phe nylephrine is an alpha-1 adrenorece pto r ago nist. It ca uses constrict ion of the blood
vessels to ach ieve the decongesta nt effect . It is also used as a vasopressor.
An exa mple of beta-1 antagonists is bisoprolol.
An exa mple of beta-2 antagonists is phentolamine.
An exa mple of beta-2 agonists is salbutamol.
m
se
As
An exa mple of alpha-1 anta gonists is doxazosin.
Dr
Which o f the fo llowing is true regarding the pathophysiology of pa raceta mo l overdose?
Paracetamol is norma lly exclusive ly meta bo lised by the P450 syste m
Paracetamol ove rdose leads to a n excess ive build up o f me rca ptu ric a cid
Conjugation o f paracetamo l becomes saturated in ove rd ose
Glutathio ne levels increase fo llowing pa racetamol o ve rdose leading to

hepatocellular death
m
se
As
N-acetyl cyste ine acts by antag onising glutathio ne
Dr
Paracetamol is normally exclusively metabolised by the P450 system
Paracetamol overdose leads to an excessive build up o f me rcaptu ric acid
I Conjugation of paracetamol becomes saturated in overdose
Glutathione levels increase following paracetamol overdose lea ding to

hepatocellular death
m
se
As
N-acetyl cysteine acts by antagonising glutathione
Dr
A 19-yea r-old female is broug ht to the Emergency De partment by her friend s fo llowing a
ni ght out. Her friends state she has taken an un known drug whilst out clubbing. Which
one of the following features would most point towa rds the use of ecstasy?
Tem perature of 39.5°C
Respirato ry dep ression
Hypernatraemia
Mios is
m
se
As
Urina ry incontinence
Dr
I Tem perature o f 39.5°(
Respiratory dep ression

CD
CD
Hypernat ra emia GD
I M iosis GD
m
m
se
Urinary incontinence
As
Dr
A 34-year-old female with a hist ory of anti-phospholipid syndrome is reviewed in clinic.
She is on long-term warfarin and her INR has been stable at 3.0 for over 2 years.
Mea surement from one week ago and t oday shows values of 1.5 and 1.3 resp ectively.
Which one o f the following medicati ons is most likely to b e res ponsible?
Ciprofloxacin
Fluconazole
Sodium valproate
Carbamazepine
m
se
As
Cimetidine
Dr
Ciprofloxacin GD
Fluconazole CD
f!D
.,
Sodium valproate
I Carbamazepine
Cimetidine CD
m
se
Carbamazepine is a P450 enzyme inductor
As
Dr
What is the most appropriate tim e to ta ke b lood samples for the rapeutic mon itoring of
p henytoin leve ls?
At any time
12 hours a fter last dose
6 hours after la st dose
m
se
As
Immed iately befo re next dose
Dr
At any time

-
~
6 hou rs after last dose
4 hou rs after last dose
m
se
As
Immediate ly before next dose
Dr
A 67 -year-old man with a history of atrial fibrillation and ischaemic heart disease presents
with symptoms consistent with a chest infection. His current medication incl udes
amiodarone, warfarin and simvastatin. Which one of the following antibiotics is it most
important to avoid if possible?
Trimethoprim
Co-amoxiclav
Cefaclor
Levofloxaci n
m
se
As
Erythromycin
Dr
Trimethoprim .
(D
Co-amoxiclav m
~faclor m
Levofloxaci n flD
Erythromycin GD
m
se
As
Eryth romycin may pot entially interact with amioda rone, warfarin and simvastatin.
Levofloxacin reacts to a lesser extent with both amiodarone and warfarin.
Dr
A 27 -year-old female patient presents to the Emergency Department with 3 episodes of
t on ic-clonic seizure in quick succession. Her past medical history includes epilepsy and
recent episode of pyelonep hritis. She is not t aking any medication for her epil epsy
because she has been seizu re-f ree for many years unt il t his episode.
Which medication she started may have caused the recurrence of seizu res?
Erythromyci n
Amoxicillin
Metronidazole
Flucloxacillin
m
se
As
Ciprofloxacin
Dr
Erythromyci n (D.
I AJ oxicillin CD
Metronidazole f.D
Flucloxacill in m
Cipro floxacin CD
Ciprofloxacin lowers the seizure threshold

Ciprofloxacin lowers the seizure th reshold. It is likely that it was st arted to treat
pyelonephritis.
Erythromycin can prolong QT interval.
Amoxicillin does not lower seizu re threshold.
Metronidazole can interact with alcohol.
m
se
Flucloxacillin can cause cholestasis.
As
Dr
Which of the following is least likely to be a precipitating factor in digoxin toxicity?
Hypernatraemia
Hypocalcaem ia
Hypokalaemia
Hypothermia
m
se
As
Hypomagnesaemia
Dr
Hypernatraemia 6D
I Hypocalcaemia
Hypokalaemia
CD
QD
~pothermi a GD
Hypomagnesaemia CD
m
se
As
Hyper-, not hypocalcaemia may be a precipitating fact or in digoxin toxicity
Dr
A 49-yea r-old male patient presents to the GP surgery for a routine review. You notice
that he has a ras h on his face. He said he first noticed the rash during a bicycle trip in the
south of France. Since he came back from the bicycle trip, the rash has faded slightly. He
has a past med ical history of ca rdiac arrhythmia. On examination, there is a
ma culopapular erythematous ras h on his forehead and both cheeks. The rest of the
exami nation is unremarkable.
What is the most likely med ication that may have caused the rash?
Am iodarone
Am lodipi ne
Bisoprolol
Nicorandil
m
se
As
Flecainide
Dr
Amiodarone GD
Amlodipine fD
Bisoprolol .
(D
Nicorandil fl':D
Flecainide CfD
Amiodarone is a cause of phot osensitivity

This patient is having a photosensitive rash. Given all the medications, amiodarone is the
most likely medication to have caused this rash.
m
se
As
Am lodipine, bisoprolol, nico randil, flecainide do not usually cause photosensitivity.
Dr
A 45 -year-old female is admitted with a seizure w hich does not respond to Sm g
lorazep am. She is then given an IV loading dose of phenytoin. This is followed by a
maintenance dose of once daily oral phenytoin. She lat er develops ataxia and nysta gmus
and you are concerned over phenytoin toxicity.
What is the most likely cause of phenytoin toxicity in this patient?
First -order elimination
Zero -order elimination
Renal dysfunction
Decreased volume of distribution
m
se
As
Long half life
Dr
First -order elimination
~o-order elimination
Renal dysfunction
Decreased volume of distribution

-
~
Long half life
Drugs which exhibit zero-order ki netics include phenytoin, alcohol and salicylates
In cl inical pharmacology, first order kinetics are co nsidered as a linear process, because
the rat e of elimination is proportional to the drug concentration. Th is means that the
higher the drug concentration, the higher it s elimination rate. In other words, the
elimination processes are not saturat ed an d can adapt to the needs of the b ody, to
reduce accumulation of the drug. 95% of the drugs in use at therapeutic concentrations
are eliminated by first order elimination kinetics.
Zero order elimination describes drugs in which the clearance rate depends on an easily
saturat ed enzyme syst em. As soon as the system is saturated, the rate of clearance
plateaus, and does not vary no matter how much drug is present. This result s in a
constant rate of elimination predisposing to high levels of the drug and toxicity. Drugs
which exhibit zero-order kinetics include phenytoi n, alcohol and salicylates.
The half life of phenytoin has an average of 14 hours. Drugs with long half lives are more
likely t o accumulat e and often need therapeutic drug monito ring. The half life is essential
t o decide on the appropriate dosing interval.
Phenytoin is metabolised by the liver and excret ed in bile as an inactive met abolite.
Phenytoin is minimally renal excreted, and dose modification is not required for renal
dysfunction, even if severe.
This patient is on a once daily dose of phenytoin, therefore the long half life of this agent
em
is unlikely to be be playing a dominant role in the mechanism of toxicity. It is therefore

s
As
most likely t o be the zero order pharmacokinetics resulting in t oxicity.

Dr
A 35-year-old female diabetic is started on erythromycin for gastroparesis. What is the
mecha nism of action?
Promotes gastric emptying
Inhibits bacterial overgrowth
Acts on central chemoreceptor trigger zone
Relaxation of pylo ric sphincter
m
se
As
Stimulates cholecystokinin release
Dr
I Pro motes gastric emptying
Inhibits bacterial overgrowth
Acts on central chemoreceptor trigger zone
Relaxation of pyloric sphincter
Stimulates cholecystokinin release
m
se
As
Erythromycin is used in gastroparesis as it has prokinetic properties
Dr
Each o f the following drugs are known to inhibit cytoch rome P450, except:
Ketoconazole
Cipro floxacin
Erythromyci n
Clopidogrel
m
se
As
Am iodarone
Dr
Ketoconazole «ED
Ciprofloxacin tiD
Eryth romycin «ED
~pidogrel eD
m
se
As
Am iodarone G'D
Dr
A 70-year-old man who takes warfarin for atrial fibrillation is found to have an INR o f 6.2.
Which of the follow ing drugs is he most likely t o have recently taken?
Ciprofloxacin
Flucloxacillin
StJohn's Wort
Carbamazepine
m
se
As
Aspirin
Dr
Ciprofloxacin ED
Flucloxacillin CD
StJohn's Wort .
f!D
Carbamazepine GD
Aspirin fD
Ciprofloxacin is a P450 enzyme inhibitor

m
se
Ciprofloxacin is a known inhibitor of the P450 syst em and hence may cause an increase in
As
INR.
Dr
A 54-year-old man with hypertension is reviewed in cl inic. He complains that over the
past two months he has developed ankle swelling. Which one o f the following drugs is
most likely to be responsible?
Perindopril
Am lodipine
Doxazosin
Moxonidine
m
se
As
Losartan
Dr
Perindopril fD
Amlodipine CD
Doxazosin
•
Moxonidine
Losarta n
•m
m
se
Calcium channe l blockers - side-effects: headache, flushing, ankle oedema
As
Dr
What is the main mechanism o f action of ond ansetro n?
Do pamine recepto r ago nist
5-HT2 recepto r antagonist
Do pamine receptor a nta gonist
5-HT2 rece pto r ag o nist
m
se
As
5-HT3 recepto r antagonist
Dr
Dopamine recepto r agonist
5-HT2 rece pto r antagonist
Dopamine receptor antagonist
5-HT2 recepto r agon ist
m
se
As
5-HT3 rece ptor antagonist
Dr
Which one o f t he followin g is an estab lished indicatio n for th e use of Bot ulinum toxin?
Strabismus
Hirschsprung's disease
Blepharospasm
Bell's pa lsy
m
se
As
Upper limb rigidity in Parkin son's disease
Dr
Strabismus
Hirschsprun g's disease
Blepharospasm
Bell's galsy
m
se
Upper limb rigidity in Parkinson's disease
As
Dr
A 22-year-old man co nsults you as he and his housemate have been feeling generally
unwell for the past few weeks. Which one of the following is the most common feature of
carbon monoxide poisoning?
Hyperpyrexia
Nausea
Cherry red skin
Confusion
m
se
As
Headache
Dr
Carbon monoxide poison ing - most common feature = headache
m
se
As
Cherry red skin is a sign of severe toxicity and is usually seen post -mortem
Dr
A 49-yea r-old homeless man is adm itted to the ITU ahe r drinking a large quantity of
metha nol. Treatment with fomepizole is started. What is the mechanism of action of
fomepizole?
Chelates methanol
Competitive inh ibition o f alcohol dehydrogenase
Converts methano l to ethanol
Competitive inh ibition o f al dehyde d ehydrogenase
m
se
As
Formaldehyde dehydrogenase in hibitor
Dr
Chelates methanol
! competitive inhibi tion of alcohol dehydrogenase
Converts methanol to ethanol
Competitive inhibitio n of aldehyde dehydrogenase
Formaldehyde dehydrogenase inhibito r
Fomepizole - used in ethylene glycol and methanol poisoning - competitive
m
se
inhibitor of alcohol dehydrogenase
As
Dr
Which one o f the following drugs is not known t o induce the cytochrome p450 enzyme
system?
Rifa mpicin
Isoniazid
Phenobarbitone
Griseofulvin
m
se
As
Carbamazepine
Dr
Rifampicin GD
I Isoniazid ED
Phenobarbitone m.
Griseofulvirn f.D
Carbamazepine CD
Isoniazid in hibits the P450 syst em

m
se
As
Isoniazid is an inhibitor of the P450 system
Dr
You are asked to review a 79-year-old man who reports new onset yellow tinting of his
vision. He reports he is on numerous medications but cannot remember their names. His
past medical history is significant for heart failure, benign prostatic hyperplasia and COPD.
Which of the following medications is most likely responsible for this side effect?
Furosemide
Ram ipril
Digoxin
Sildenafil
m
se
Salbut amol
As
Dr
Furosemide m
Ra ipril m
Digoxin GD
Sildenafil f!D
Salbutamol CD
Digoxin may cause yellow-green vision

Due to its narrow therapeutic range, digoxin has a high risk of causing toxicity in patients.
A characteristic feature of toxicity is xanthopsia or yellow-tinted vision.
m
se
As
Sildenafil can cause blue -tinted vision or cyanopsia.
Dr
Which one o f the following ECG changes is most consist ent w ith a tricyclic o verdose?
QRS widening
Bradycardia
Shortening o f QT inte rval
First d egree heart block
m
se
ST elevation
As
Dr
QRS widening
Bradycardia
-
Shortening o f QT interval
-
~
First degree heart block

-
~
m
se
As
Dr
A 41-year-old woman is admitted following a deliberate overdose of ethylene glycol. She
is confused and unable to give any fu rther history. On exami nation the pulse is 96 I min,
blood pressure is 142/ 84 mmHg and temperature 37.1°C. Blood t ests show:
Na• 139 mmol/ 1
K• 4.0 mmolfl
Chloride 104 mmol/ 1
Bicarbonat e 26 mmol/ 1
Urea 4.0 mmol/1
Creatinine 88 iJffiOI/1
What is the most appropriate management of this patient?
Ethanol
Fomepizole
Haemodialysis
Haemofiltration
m
se
Dantrolene
As
Dr
Ethanol
p omepizole
Haemodialysis
Haemofiltration
Ethylene glycol toxicity management - fome pizole. Also ethanol I haemodialysis

Fomepizole is now used first -line rather than ethanol in ethylene glycol toxicity. There is
m
se
no indication for haemodialysis at this st age, as a met abolic acidosis has not yet
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developed
Dr
A 44-year-old man asks fo r advice. He is due to go on a long bus j ourney but suffers from
debilitating moti on sickness. Which one of the followi ng medications is most likely t o
prevent motion sickness?
Cycl izine
Chlorpromazine
Metoclopramide
Prochlorperazine
m
se
As
Domperidone
Dr
Cyclizine CJD
Chlorpromazine CfD
I Metoc& ramide fl!D

Prochlorperazine mt
Domperidone fD
m
se
Motion sickness - hyoscine > cycl izine > promethazine
As
Dr
A woma n who is a bout to commence trastuzumab treatment for breast ca ncer has an
echoca rdiogram. Which class of chemotherapeutic age nt would predispose her to
d eve loping card iac dysfunction?
Vinca alkaloids
Platinum-based co mpound s
Anthracyclines
Taxa nes
m
se
As
Topoisomerase I inhibitors
Dr
Dr
As
se
m
A 54-year-old woman is treated with rituximab for non- Hodgkin's lym phoma. What is the
t arget of rituximab?
CD20
CD 52
Epidermal growth factor receptor
CD22
m
se
As
Vascular endothelial growth factor receptor
Dr
I CD20 CD
CD 52 CD
Epidermal growth factor receptor GD
I CD22

m
m
m
se
Rituximab - monoclonal antibody against CD20
As
ltrpor::a.r: "or me _ess rr:>e1.ar:t
Dr
A 26-year-old fema le is commenced on carbamazepine for complex partial seizures. She
has no previous medical history of note and consumes a moderate amount of alcohol.
Three months lat er she is admitted due t o series of seizures and carbamazepine levels are
noted to be subtherapeutic. A pill-count reveals the patient is fu lly compliant. What is the
most likely explanation?
Auto-inhibition of liver enzymes
Prescription of omeprazole
Prescription of fluoxetine
Auto-induction of liver enzymes
m
se
As
Alcoho l binge
Dr
Auto-inhibition of liver enzymes
Prescription of omeprazole
Prescription of fluoxetine
-
~
Auto -induction of liver enzymes
Alcohol binge
Carbamazepi ne is a P450 enzyme induct or

m
se
Carbamazepine is an inducer of the P450 system. This in turn increases the metabolism of
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carbamazepine itself- auto-induction
Dr
A 24-year-old woman presents following a sudden, acut e onset of pain at the back of the
ankle whilst jogging, during which she heard a cracking sound. Which one ofthe
following medications may have contributed t o th is injury?
Metronidazole
Nitrofurantoin
Fluconazole
Ciprofloxacin
m
se
As
Terbinafine
Dr
Metronidazole f.D
Nitrofura ntoin GD
Fluconazole CD
Ciprofloxacin GD
Terb inafine GD
Cipro floxacin may lea d to tendino pathy

This patient has classical signs o f Achilles tendon ruptu re. Tend o n d a mage is a we ll
d ocum ented co mplication of qu inolone thera py. It appea rs to be an idio syncratic
m
se
reaction, with the actual media n duration of treatment bei ng 8 days before problems
As
o ccur
Dr
A 14-year-old girl is t aken t o the Emergency Department, aher being found lyi ng on her
bed next to an empty bott le of pills prescribed for her mothe r. On examination she is
agitat ed, has a clenched j aw and her eyes are deviated upward s. Which drug is she most
likely t o have consu med?
Phenytoin
Metoclopramide
Amitriptyline
Carbamazepine
m
se
As
Nifedipine
Dr
A 14-yea r-old gi rl is taken to the Eme rgency Department, aher being found lyi ng on her
bed next to an empty bottle of p ills p rescribed fo r her mother. On exam ination she is
ag itated, has a clenched jaw and her eyes a re d eviated upwa rds. Which drug is she most
li kely to have consumed ?
Phenytoin fD
r :toclopram ide ED.
Amitriptyline fD
I Carbamazepi ne fD
Nifed ip ine CD
m
se
As
This is a classic d escription o f an ocu lo gyric crisis, a fo rm of extra pyra mida l disorder
Dr
A 46-year-old fema le with a backgrou nd of alcoho l excess has rout in e bloods checked by
her GP. The magnesium result comes back as follows:
Magnesium 0.43 mmol/ 1
(Normal ra nge 0.7-1.0 mmol/1)
What side effect of ora l magnesium replacement is likely to be the limiting factor w hen
increasing the oral dosage?
Tachya rrhyt hm ias
Vom iting
Pruritus
Diarrhoea
m
se
As
Flushing
Dr
Tachya rrhythm ias CD
Vom iting f!D
Pruritus
Diarrhoea (D
-
Flus hing CD
Diarrhoea is the correct answer. Magnesium salts ca n be given as laxatives. Other uses for
m
se
ma gnesium include polymorphic ventricular tachycardia (torsade de pointes), acute
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asthma an d prevention/treatment of seizures in pre-eclampsia.
Dr
A 62-yea r-o ld man presents fou r weeks a fte r initiating metfo rmin fo r typ e 2 diabetes
me ll itus. His bo dy mass index is 27.5 kg/ m " 2. Despite slowly titrating the d ose up to
SOOmg td s he has exp erienced sig nificant diarrhoea. He has tried red uci ng the d ose back
d own to SOOmg bd but his symptoms pers isted. What is the most a ppro priate action?
Switch to p io glitazone 15mg o d
Switch to g liclazide 40 mg od
Sta rt modi fied relea se metformin SOOm g od with even ing mea l
Add loperamide a s requ ired
m
se
As
Arra nge colon oscopy
Dr
Swit ch to p ioglitazone lSmg od
Swit ch to gliclazide 40mg od
I Start modified release metformin SOOmg od w ith evening meal
Add loperamide as required
Arrange colonoscopy
Metformin shou ld be titrated slowly, leave at least 1 week before increasing dose
If a patient is intolerant to standard metformin then modif ied -release preparations should
m
se
be t ried. There is some evidence that t hese produce fewer gastroint estinal side-effect s in
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patients intolera nt of st andard-release met formin.
Dr
A 43-year-old male presents to the Emergency Department after being foun d at home
drowsy and unresponsive. His only regular medication is citalopram. The following arterial
blood gas is obtained on arrival.
pH 7.20 kPa
pC02 3.4 kPa
p02 13.0 kPa
Anion gap 24 mmol/ 1
Lactate 2.1 mmol/1
Glucose 5.6 mmolfl
(normal range anion gap: 12-16 mmol/1)
Both ethanol and paracet amol levels are normal.
Which of the following is the most appro priate treatment?
Flumazenil
Naloxone
Ethanol
Insulin infusion m
se
As
N -acetylcystei ne
Dr
Flumazenil eD
Naloxone G'D
Ethanol ED
Insulin infusion fD
N -acetylcystei ne (fD
The causative agent here is ethylene glycol (antifreeze) . A background of depression and
a raised anion gap that cannot be explained by lactic or ketoacid osis are clues towards
intentional overdose of a toxin causing acidosis. By eliminating the other options, the only
viable answer is ethanol.
The blood gas shows metabolic acidosis with respirato ry compensation. Flumazenil would
be used in benzodiazepine overdose, naloxone in opiat e overdose and n-acetylcysteine in
pa racet amol overdose. Opiates and benzodiazepines are more likely to cause resp iratory
acidosis through respiratory depression. In view o f t he normal glucose level this exclud es
diabetic ketoacid os is and thus insulin infusion is not appropriate. Given the normal serum
pa racet amollevels, n-acetylcyst eine is not indicated. N-acetylcysteine act s by p rotectin g
hepatocytes from a toxic metabolite produced when the liver b reaks d own paracetamol.
Paracetamol overdose wou ld also cause a high anion gap metabolic acidosis usually due
t o an associated elevation in lact ate.
The anion gap can be used to identify the cause of a metabolic acidosis.
The ca lculation is as follows: (Na+ + K+) - (CI- + HC03-)
Ra ised anion gap causes include:

• lact ic aci dos is
• ketoacidosis
• renal fa ilure (high urate)
• t oxins such as methanol, ethylene glycol. salicylates
The treatment for ethylene glycol poisoning includes oral or parenteral ethanol which
competes w it h ethylene glycol p reventing toxic metabolit e formation. Methan ol
poisoning would p resent in a similar fashion alth ough this is often associat ed with visual
disturbance and occasionally b lindness. Fomepizole can also be used to treat ethylene
glycol poisoning.
em
In most centres t here is a delay in obtaining ethylene glycol levels and t hus treatment is
s
often given based on cl inical suspicion.

As
Dr
A 44-yea r-old wo man with oestrogen receptor positive b reast cancer co mes fo r review,
three months after starting ta moxifen. Which o ne o f the fo llowing a dve rse effects is most
like ly to occu r in this patient?
Myalg ia
Cata racts
Alop ecia
Hot flushes
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se
As
Cervica I cancer
Dr
Myalg ia
Cata racts
•
fD
.
Alopecia flD
Hot flushes CD
Cervical cancer f!D
Tamoxifen may cause hot flushes

m
se
Alopecia and catara cts a re listed in the BNF as possible s id e -effects. They a re however no t
As
a s p revalent as hot flu shes, which are very com mon in pre-menopa usal women
Dr
An elderly man is admitted t o the acut e medical unit w ith dyspnoea. He is know n to have
ischaemic heart disease and chro nic heart failure (NYHA class III). He develops atrial
fibrillation with a fast ventricular resp onse during his admiss ion. Which one of the
following drugs is contra indicated?
Am iodarone
Digoxin
Bisoprolol
Flecainide
m
se
As
Warfarin
Dr
Am iodarone CD
Digoxin CD
(fD
.,
Bisoprolol
Flecainide
Warfa rin m
m
se
Flecainide is contraindicated in patient s w ith structural heart disease.
As
Dr
A 52-year-old lady is admitted f rom the emergency department to t he int ensive care unit
with sept ic shock second ary t o pyelonep hrit is. Despit e 4000ml o f IV 0.9% saline in the
emergen cy d epartment she remained hypot ensive and was co mm enced on noradrenaline
and a fixed d ose vasop ressin infusion. Unfortun ately, despite escalating doses of
noradrenaline, her mean arterial pressure (MAP) remains SOmmHg (ta rget > =65 mmH g).
She has a rising serum lact ate and she has produ ced only 25m I urine since admission 2h
ago. Follow ing consult ation with your consu ltant you elect to start an adrenaline infusion
in ad dition to t he vasopressin and noradrenaline. Which of the fo llowing biochemica l
abnormalit ies can be expect ed on commencing an IV adrenaline infusion?
Hyperkalaemia
Hypoglycaemia
Hypernatraemia
Increase in lactate productio n
m
se
As
Hypercalcaemia
Dr
Hyperka lae t : _
Hypoglycaem ia
Hypernatraemia
~rease in lactate production

Hypercalcaem ia
Adrena li ne induces hyperglycem ia, hyperlactatemia and hypokalaemia. Because insu lin
-
"""'
secretion is suppressed by a lpha adrene rgic stimulation, p lasma concentration of insulin
rema ins low. Hyperglycem ia is induced by an increase in g lucose production caused by an
increase in hepatic g lycogenolysis and an increase in g luconeogenes is. There is also a
ma rked increase in oxygen consumption. In skeleta l muscle, epinephrine increases
m
glycolysis and g lycogenolysis, inducing an upsurge in lactate. Muscular lactate serves as a
se
substrate for hepatic neog lucogenesis (Cori cycle). Epinephrine a lso increases li polysis and
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decreases muscu lar proteolysis.
Dr
A 17 year-old male presents to the Emergency department after being fou nd collapsed at
home. He has no past medica l history. He is afebrile. On exam ination he appears unwell.
His Glasgow Coma Score (GCS) is 9 (eyes 2, voice 2, motor 5), and he has poor pupillary
responses bilaterally. Fundoscopy revea ls macular oedema. His arteria l b lood gas on a ir is
s hown:
pH 7.21
pC02 4 .7 k Pa
p0 2 15.6 kPa
Na+ 143 mmoi/ L
K+ 4 .7 mmoi/L
HC03- 12 mmoi/L
Cl- 108 mmoi/ L
Glucose 12.4 mmoi/L
What is the likely diagnosis?
Diabetic ketoacidosis
Ethylene glycol overdose
Addisonian crisis
Methanol toxicity
sem
As
Vira l meningitis
Dr
Diabetic ketoacid osis 6D
~hylene g lycol overaose
I fD
Addisonian crisis CD
I Methanol toxicity CD
Viral menin gitis CD
This patient has features o f a raised anion-gap metabolic acid osis. The most important
differentia ls g iven a re methanol toxicity o r ethylene glycol po ison ing, which cause a very
s imilar b iochemical and clinica l p icture. Howeve r, the find ing of eye signs (macular
oed e ma and poor pupilla ry responses) in the context of a drowsy patient with ra ised
anion gap meta bo lic acidosis is strongly suggestive that methanol is the cu lp rit. In exams,
cases invo lving methanol toxicity often invo lve patients not meeting your gaze or asking
for the lights to be switched on, as well as the more traditiona l visua l acuity resu lts .
The patient"s blood gl ucose is not high enough to consid e r diabetic ketoacidosis. An
m
se
Addisonian crisis would not typically generate a high a nion gap. Vira l mening itis is
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unli kely to cause collapse and impaired GCS, and wou ld not explain his aci dosis.
Dr
A 49-year-old man with a history of bipolar disorder, COPD and hypertension is started
on a new anti-hypertensive medication. Two weeks later he is admitted to hospita l with
lithium toxicity. Which med ication is most likely to have precipitated this?
Ramipril
Am inophylline
Atenolol
Am lodipine
m
se
As
Doxazosin
Dr
Ramipril 6D
Aminophylline flD.
Atenolol CD
Am lodipine f!D
m
se
Doxazosin .
(D
As
Dr
A 67 -yea r-old man has a fu ll blood count 8 days after being adm itted with a severe
community-acquired pneumonia. He had been treated with intravenous antibiotics and
subcutaneous low-mo lecular weight heparin as he had a history of deep vein
thromobosis. The resu lts are as follows:
Hb 13.0 g/1
Platelets 21 ~ 109/1
WBC 12.1 ~ 109/1
What is the most likely cause of the abnormalities in the blood test?
Antibodies against complexes of p latelet factor 4 (PF4) and heparin
Antibodies against platelet -activating factor
Antibodies fo rm against complexes of GPlb-IX-V and von Willebrand factor
Antibodies against hepa rin act as agonists of the GP!lb/llla receptor
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se
As
Antibodies fo rm against factor VII
Dr
Antibodies against comp lexes of p latelet factor 4 \(F4) and heparin
Antibod ies against p latelet-activating factor

-
~
Antibod ies form against complexes of GPlb-IX-V and von Willebrand factor
-
Antibodies against heparin act as agonists of the GPIIb/llla receptor
Antibod ies form against factor VII

-
~
"""'
m
Heparin-induced thrombocytopaenia - ant ibod ies form against co mplexes o f
se
p latelet factor 4 (PF4) and heparin
As
Dr
A 20-year-old stu dent drinks around 500 ml o f vodka at a party. The next morning he
feels thirsty and finds he is passing more urine than normal. Which one of the follow ing
best explains why people who drink excessive amounts alcohol develop polyuria?
Etha nol inhibits ADH secretion
Etha nol induces vasoconstriction of the renal arteries
Etha nol increases aquaporin proteins in the proximal convoluted tubule
Osmotic diuresis induced by ethanol
m
se
As
Supratentorial reflex to cleanse the body of toxins
Dr
Ethanol inhibits ADH secretion
Etha nol induces vasoconstriction of th e renal arteries
Ethanol incrj ases aquaporin proteins in the p roximal convoluted tubule
Osmotic diuresis induced by ethanol
Supratentorial reflex to cleanse the body of toxins

-
~
Ethanol reduces t he calcium-dependent secretion of anti-diuretic hormone (ADH) by

blocking channels in the neurohypophyseal nerve terminal.
Nausea associated with hangovers is mainly due to vagal stimulation to the vomiting
m
centre. Following a particular severe episode of alcohol excess people may experience
se
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tremors. These are due to increased glutamat e p roduction by neurones to compensate
for the previous inhibition by ethanol.
Dr
Which one o f the following s ide -effects is most associated with ciclosporin use?
Hepatotoxicity
Bone marrow toxicity
Red cell aplasia
Haemorrhag ic cystitis
m
se
As
Tinnitus
Dr
I Hepatotoxicity
Bone marrow toxicity

ED
(D
Red cell aplasia GD

Haemorrhag ic cystitis CD
Tinnitus GD
m
se
As
Dr
The hos pital you wo rk at is o n red a le rt after a susp ected che mical attack in the city.
Twenty five patients have been ad mitted to the hospita l. The patients are extremely
unwe ll. Their sym ptoms inclu de salivation, lacrimatio n, diarrhoea, and emesis.
Yo u are instructed by p ublic health that the most likely ag ent used was sarin g as.
What is the mechanism o f actio n of sa rin g as?
Inhibition o f acetylcholineste rase
Anti-cho li nerg ic
Sym pathomimetic
Sed ative -hypnotic
m
se
As
Seroto nerg ic
Dr
I Inhibition of acetylcholinesterase GD
Anti-cholinergic GD
GD
Sedative-hypnotic m
Serotonergic f.D
Sarin gas is a highly toxic synthetic organophosphorus compound which causes

inhibition of the enzyme acetylcholinesterase
Important for me Less important
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition
of the enzyme acetylcho linesterase. This results in high levels of acetylcholi ne (ACh).
The effects of excessive ACh can be remembered by the mnemonic DUM BELLS:
• Diarrhoea
• Urination
• Miosis/muscle weakness
• Bronchorrhea/ Bradycardia
• Emesis
• Lacri mation
• Salivation/ sweating
s em
As
Organophosphate poisoning is treated with the anti-muscarinic atropine.

Dr
Which one o f the following is least recognised as a side-effect of sildenafil?
Blue disco lou ration o f vision
Abnormal liver function test s
Flushing
Nasal congestion
m
se
As
Non-arteritic ant erior ischaemic optic neuropathy
Dr
Blue disco lou ration o f vision GD
I Abnormal liver function tests
Flushing
CD
CD
Nasal congestion GD
m
se
As
Non-arteritic anterior ischaemic optic neuropathy
Dr
Which one of the following is not a recognised indication for the use of octreotide?
Acute variceal haemorrhage
Acromegaly
V! Poma
Carcinoid syndrome
m
se
As
Hepatic encephalopathy
Dr
Acute variceal haemorrhage GD
Acromegaly .
(D
I~PomJ flD
Carci noid syndrome f.D
m
se
I I
As
Hepatic encephalopathy ED.
Dr
A 23-yea r o ld g entle man presents to the emergency d epartment having ingested
a pproximate ly 120 ml o f household b leach two hou rs a go. He has a background o f
d e pression and p revious su icid a l id eatio n. Cu rrently he is re porting pa in on swa llowing
sa liva s ince the in gestio n. Card iovascular, respirato ry and a bd om inal exam inatio n we re
unre ma rka ble. The re is no e vide nce o f su rg ica l emphysema o r strido r. A chest x-ray is
reported as no rmal.
What is the most ap pro priate cou rse o f action?
Tria l of oral fluid, observe fo r 6 hou rs and discha rge if his sym ptoms d o not worse n
Ni l by mouth, intravenous proton p ump inhibitor, o esophago -ga stroduodenoscopy

in 5 days
Inse rt a wid e-bore naso gastric tube and apply s uctio n
Ni l by mouth, intravenous proton p ump inhibitor, urgent oesophago -

g astroduodenoscopy
m
se
As
Ni l by mouth, oesophago -g astrodu odenoscopy in 5 d ays
Dr
worsen
Nil by mouth, intravenous proton pump inhibito r, oesophago-

gastroduodenoscopy in 5 days
Insert a wid e-bore nasogastric tube and apply suction

-
......,
I Nil by mouth, intravenous proton p ump inhibito r, urgent oesophago-

g astrod uodenoscopy
Ni l by mouth, oesophago-gastroduodenoscopy in 5 d ays
Early e ndosco py and risk stratification is im porta nt in patie nts with symptomatic
caustic ingestion
Caustic in gestion is a re latively common p resentation, with a re lative paucity of evidence

to support its management. The co rrect answer here is early endoscopy, ideally within 12
hours (sometimes 24 hou rs dependent on local guida nce). It would seem te mpting to
wa it until after the initial insult has passed until performing an endoscopy: however, most
guidelines advocate avo iding endoscopy between days 5 a nd 15 post ingestion when
oesophag ea l stre ngth is at its lowest (based on experime ntal data fro m animal models).
Both o ptio ns advocating delayed end oscopy a re therefore incorrect. Nasogastric tube
m
insertion invo lves potentia l re-exposu re o f the upper GI tract to th e substance and is
therefo re not advisable. A tria l of o ral fluid and observation may be app ropriate in se
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asymptomatic patie nts however this patient has odynophagia and shou ld be investigated.
Dr
A 43-year-old gentleman present s to t he emergency department wit h central crushing
chest pain. ECG shows anterior T wave inversion. He admits t o insu fflating t hree lines of
cocaine around one hou r p rior to presentation. He is a heavy smoker but has no past
medical hist ory. In ad dit ion to t he standard acut e coronary syndrome management, which
f urthe r t reat ment should this pat ient be o ffered?
IV b eta-b locker
IV alp ha-blocker
IV b enzodiazepine
IV haloperidol
m
se
As
IV dext rose
Dr
IV beta-b locker tiD
IV alpha-blocker CD
I IV benzodiazepine ED
IV ha loperidol CD
IV dextrose CD
Patients with MI secondary to coca ine use s hould be g ive n IV be nzodiazepi nes as
pa rt of acute (ACS) treatment
Consensus agreement from bodies such as the America n Heart Association recommend
early IV benzodiazepine therapy in addition to ACS treatment in patients with cocaine-
related MI. The benzodiazepi nes a re thought to temper the system ic effects of cocaine.
m
se
Beta - blocker therapy is suggested to be avoided as unopposed alpha-activation in
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cocaine intoxication can worsen coronary spasm.
Dr
Which one o f the following adverse effects is most likely t o be seen in patients taking
ciclosporin?
Hypertension
Hypokalaemia
Alop ecia
Dehydration
m
se
As
Atrophy of the gums
Dr
I Hypertension CD
Hypokalaemia tiD
Alopecia «!D
~ehydrati on
Atro phy of the gums
•
GD
m
se
Ciclosporin side-effects: everything is increased - fluid, BP, K•, hair, gums, glucose
As
Dr
Which one of the following stat ement s is true regarding monoclonal antibodies?
They are produced by the polymerase cha in reaction
Infliximab is useful in chronic lymphocytic leukaemia
A hybridoma is a combination of human spleen ce lls and mouse B-cells
The constant region of the antibody is human in origin
m
se
Alemtuzumab is used in the prevention of ischaemic events in patients undergoing
As
percutaneous coronary interventions
Dr
They are produced by the polymerase cha in reaction
Infliximab is useful in chronic lymphocytic leukaemia
A hybridoma is a combination of human spleen cells and mouse B-cells
The constant region of the antib dy is human in origin
m
se
Alemtuzumab is used in the prevention of ischaemic events in patients
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undergoing percutaneous coronary interventions
Dr
A 46-year-old man with a history o f hyperlipi daemia is reviewed in clinic. He is currently
t aking simvastatin l Omg on but his cho lesterol level remains high. Previou s attempts to
increase the dose of simvastatin have resulted in myalgia. Given the histo ry of myalgia,
which lipid-regulating drug shou ld b e avoided?
Nicotinic acid
Beza fibrate
Colestyramine
Omega-3 fatty acid
m
se
As
Ezetimibe
Dr
Nicotinic acid fD
r :afibrate CD
Colestyramine GD
Omega-3 fatty acid CD
Ezetimibe fD
Tough question as both fibrates and nicotinic acid have been associated with myos itis,
especially when combined with a statin. However, the Com mittee on Safety of Medicines
m
se
has p roduced guidance which specifically warns about the concomitant prescription of
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fibrates with statins in relation to muscle toxicity
Dr
A patient known to have bipolar disorder presents to the Emergency Department with
confusion. Wh ich one of the following drugs is most likely to precipitat e lithium toxicity?
Frusemide
Sodium valproate
Digoxin
Sodium bicarbonate
m
se
As
Bendroflumethiazide
Dr
Frusemide fD
Sodium valproate CD
Digoxin .
(D
Sodium bicarbonate
Bend roflumethiazide
•
ED
m
se
As
The BNF states that 'loo p diuretics are safer than thiazides' in the interactions sect ion.
Dr
A 62-year-old is started on allopu rinol prophylaxis following h is second episode of gout
in the past 12 months. What is the mechan ism of action o f a llopurino l?
Promotes excretion of uric acid
Causes the d epolymerisation of intracell ula r microtub ules
Uric acid chelator
m
se
As
Xanthine oxidase activator
Dr
Pro motes excretio n of uric acid CD
Causes th e depolymerisation of intracell ula r microtubu les CD

Uric acid chelator m
Inhibits xanthine oxidase GD
Xa nthine oxidase activato r CD
Allopurinol inhibits xanthine oxidase

m
se
As
Xa nthine oxida se is responsible for the oxidation of 6-mercaptopurin e to 6 -thiouric a cid
Dr
You are counsell ing a 20-year-old female who is planning to start taking the combined
oral contraceptive pill. Which of the following statements is correct?
She will still be protected against pregnancy if she takes amoxicillin for a lower
respirato ry tract infection while on the combined pill
She should not take the com bined pill if she has heavy periods
She is like ly to put on 2-3 kilograms of weight per yea r while using the combined
pill
She will not require any monitoring once she has started taking the co mbined pill
m
se
As
There is only one type and brand of co mbined pill
Dr
I She will stil l be protected against pregnancy if she takes amoxici ll in for a lower
respiratory tract infection while on the combined pill
She shou ld not take the combined p ill if she has heavy periods
-
..wr
She is like ly to put on 2-3 kilograms o f weight per yea r while using the
combined pill
She will not require any monitoring once she has started taking the combined
p ill
There is on ly one type and brand o f combined pill
There is no evidence that antibiotics other than enzyme inducing antibiotics such as
rifa mpicin reduce the effica cy of the comb ined o ra l contraceptive pill
It was previously a dvised that barrier methods of contraception should be used if taking
an antibiotic while using the contraceptive p ill, due to concerns that antib iotics might
reduce the absorption of the p ill. This is now known to be untrue. Howeve r, if the
absorptive ab ility of the gut is comprom ised for another reason, such as severe diarrhoea
or vomiting, or bowel disease, this may a ffect the efficacy of the p ill.
The exception to the antibiotic rule is that hepatic enzyme- indu cing anti biotics such as
rifa mpicin and rifaximin do reduce the efficacy of the p ill. Other enzyme-inducing drug s,
such as p henytoin, phenobarb ital, carbamazep ine o r StJohn's Wort can also reduce the
effectiveness of the pill.
The other statements are not true. The comb ined p ill is often p rescri bed for women with
heavy p eriods as it can make them lighter and less pa infu l. There is no evidence that
women on the comb ined pil l put on any significant weight, a lthoug h they may experience
b loating at certain times in the course. Women on the p ill require monito ring of their
b lood pressure. The re are multiple d ifferent types of comb ined p ill.
BNF:
https:// b nf.nice.org. u k/treatm ent-summa ryI contra ce pt ives- interactions. htm I
NICE - the gui de to the comb ined contraceptive p ill:

s em
https:/jwww.nhs.u k/co nd iti ons/contraception-guide/pages/ combined -co ntraceptive-

As
pill.as px
Dr
What is the mechanism of actio n of flecai nide?
Calcium channel blockers
Potass ium channe l blocker
Sodium channel blocker
Potassium channe l activator
m
se
As
ADP receptor antagonist
Dr
Calcium channel blockers CD
Potassiu m channe l blocker GD
p odium channel blocker GD
Potassium channe l act ivator f.D
m
se
~p recepto r antagonist m
As
Dr
A 29-yea r-old male with testicular cancer is receiving cisplatin-based che mothe rapy. He
has b een give n d examethasone, metoclopramide an d apre pitant prior to receiving
chemotherapy. He is now ag itated, very anxious and co mpla ining of ab norma l eye
movements. What is the best immediate treatment?
Aspirin
IV b enztrop ine
Hydrocortisone and p ro methazine
Cease cisplatin
m
se
As
Lorazepam
Dr
Aspirin
IV b enztropine
Hydrocortisone and promethazine
Cease cisplatin
-
~
Lorazepam
An oculogyric crises, which is w hat the patient is experiencing, is a dystonic reaction to

drugs, in particular neuro leptics and dopaminergic medications (classically
m
metoclopram ide and haloperidol) cha racterized by a prolonged involuntary upward
se
As
deviation (bilat eral elevation o f the visual gaze) of the eyes. The standard remedy for this
is benztropine.
Dr
A 78-year-old woman with a history of recurrent ventricular tachycardia has routine blood
tests 3 months after starting amioda rone therapy:
TSH 14.5 mu/ 1
Free T4 8 . 2 pmol/1
How should her thyroid dysfunction be managed?
Continue amiodarone and add folic acid
Stop amiodarone and start thyroxine
Stop amiodarone and add carbimazole and thyroxine
Stop amiodarone and repeat bloods in 4 weeks
m
se
As
Continue amiodarone and add thyroxin e
Dr
Continue a miodarone and add fo lic acid
Stop am ioda ro ne and sta rt thyroxine

-
~
Stop am ioda ro ne and ad d carbimazo le a nd thyroxin e
Stop am ioda rone and repeat bloods in 4 weeks
I Continue a miodarone and add thyroxine
Patients who d evelop hypothyroidism whilst ta kin g amioda rone can continue to take the
m
se
drug if this is desirable. Give n that this patient has a histo ry o f ve ntricular tachycardia it
As
would be unwise to withdraw am iodarone abruptly
Dr
A 39-year-old woman who has recently been diagnosed with hypertension comes for
review. She is sexually active but does not cu rrently use any form of contraception other
than barrier methods. Which one o f the following medications should be avoided?
Hydralazine
Nifedipine
Methyldopa
Labetalol
m
se
As
Lisinopril
Dr
I Hydralazine fl'D
Nifedi pine GD
Methyldopa GD
Labeta lol .
(D
I Lisinop ril ED
When prescribing this woman shou ld be treated as if she were p regnant g iven the
absence o f effective contraception. AC E inhibito rs such as lisinopril a re known te ratogens
and most be avoided.
NICE a re ve ry clear on this point:'Offer antihypertensive drug treatment to women of child-
m
se
bearing potential in line with the recommendations on Management of pregnancy with
As
chronic hypertension·
Dr
A 37 -year-old man with a history o f alcohol excess is admitted with alcohol-withdrawal
seizures to the acute medical unit. Admission bloods show the following:
Na• 137 mmol/ 1
K• 3.0 mmol/1
urea 2.0 mmolfl
What other blood abnormality is he also most likely to have?
Hypomagnesaemia
Elevated ammonia levels
Hypophos phataemia
Partially compensated met abolic alkal osis
m
se
As
Raised bilirubin
Dr
Hypomagnesaemia
Elevated ammonia levels
Hypophos phataemia
Partially com pensated met abolic alka losis

-
"""'
m
se
As
Ra ised bilirubin
Dr
Which of the following relat ing to St John's Wo rt is false?
Adverse effect s in trials is similar to pla cebo
May cause serotonin syndrome
Mechanism of action is similar t o selective serotonin reuptake inhibito rs
Causes inhibition o f t he P450 system
m
se
As
Has been shown to be effective in treating mild -moderate d epression
Dr
Adverse effects in trials is s imilar to p la cebo
May cause seroton in syndrome
Mechanism of actio n is similar to selective seroton in reuptake inhibitors

-
~
Causes inh ibition of the P450 system
Has bi en shown to be effective in treating mild-moderate d e pression
m
se
As
StJohn's Wort is a known inducer o f the P450 system
Dr
A 71-year-old man who has atrial fibrillation and heart failure is started on digoxin. What
is the mechanism of action of digoxin?
Blocks Ca2+ release fro m the sarcoplasmic reticu lum
Blocks Na• entry into myocytes
Agonist of the myocyte sodium-calcium exchanger
K• channel blocker
m
se
As
Inhibits the Na./K• ATPase pump
Dr
Blocks Ca2+ release from the sarcoplasmic reticu lum
Blocks Na +
entry into myocytes
Agonist of the myocyte sodium -calcium exchanger

-~
+
K channel blocker
I Inhibits the Na
+
/K +
ATPase pump
m
se
Digoxin - inhibits the Na+/K+ ATPase pump
As
Dr
Which of the following may reduce the action of aminophylline in patients?
Ciprofloxacin
Acute ethanol consumption
Omeprazole
Smoking
m
se
As
Erythromycin
Dr
Ciprofloxacin
Acute ethanol consumption
Omeprazole
Smoking
Erythromycin
Smoking is a P450 enzyme inductor

m
se
Smoking is known to in duce CYP1A2 isoenzyme, reducing the effectiveness of
As
aminophylline
Dr
A 49-year-old homeless gentlemen is brou ght to the emergency department with a
reduced glasgow coma scale o f 14/15.
His pupils are equal but poorly rea ctive t o light and he is complaining of poor eyesight.
An ABG is performed.
pH 7.21
p0 2 12.3 kPa
pC02 4 .7 k Pa
HC0 3- 14 mmol/1
Na+ 140 mmol/ 1
K+ 3 .6 mmol/1
Cl- 102 mmol/ 1
Lactate 2.3 mmol/1
Which subst ance is he most likely to have ingested?
Aspirin
Alcohol
Methanol
Am itriptyline
sem
Ethylene glycol
As
Dr
Jrer
Asp irin f!D
Alcohol CD
I Methanol ED
Am itriptyline
Ethylene g lycol
•
QD
This is a com mo n MRCP q uestio n.
The inclusion o f a n ABG with a meta bo lic a cidosis invites the read er to calculate the anion
g a p.
In this case {[Na +) + [K +)} - {[HC03-) + [CI -)} = 27.6 mmol/1

A ra ised anio n ga p metabo lic acidosis - a ll of the possible answe rs he re may p rod uce this
p ictu re .
As this man is homeless and we a re given no fu rthe r info rmation the most li ke ly causes
fo r his p resentatio n a re a lcohol, metha no l a nd ethylene g lycol (a ntifreeze).
The answe r he re is indicated by the reduced vision and poorly reactive pupils - a com mon
comp lication of methanol poisoning . A meta bo lite o f methanol, fo rmic a cid, accu mulates
in the o ptic nerve causing visua l d isturbance a nd eventua lly bli ndness.
Alcoho l a nd ethylene g lycol wo uld not p rod uce these visual changes.
Aspirin ove rdose mig ht a lso be associated with a respiratory alkalosis - not seen he re .
Desp ite the li mited info rmation this p resentatio n d oes not su gg est tricyclic ove rdose -
sem
you would expect dilated pupils a nd a history of d epression.

As
~ I •• I • I nrow::~o
Dr
orer D ic:r • •sc: f?:) Tm J

What is the most commo n adverse effect experienced by women taking the progestogen
only pill?
Irregular vag ina l bleeding
Acne
Mood swings
Reduced libido
m
se
As
Weight gain
Dr
Irregular vaginal bleeding
Acne
Mood swings
Reduced libido
m
se
As
Weight gain
Dr
A 16-yea r-o ld gi rl is a dmitted to the Emergency Department late on a Friday night. She is
comp laining of palpitations and feeling 'unwell'. Her friend s state that she has had a bad
reaction to the alcohol they've been drinking and deny the use o f any illicit substances.
On exam ination she is agitated and cl utching her chest. Her pu pils are myd riatic and the
pulse rate is 108/ mi n, blood p ressure 130/ 90 mmHg. She says that she is going to be sick.
Which of the following substances may account fo r this presentation?
Cannabis
Coca ine
LSD
Hero in
m
se
As
Ketam in e
Dr
Cannabis CD
I Cocaine CD
LSD GD
~oin (D
m
se
m.
As
Ketamine
Dr
Which one of the following drugs is most likely to cause impaired glucose tolerance?
Beza fibrat e
Simvastatin
Nicotinic acid
Cholestyramine
m
se
As
Gem fibrozil
Dr
Bezafibrate f1D
Simvastatin fl!D
I Nicotinic acid CD
Cholestyramine GD
Gemfibrozil f!D
m
se
Glycaemic control in diabetes may be worsened by nicotinic acid
As
Dr
What is the most a p pro priate time to take b lood samples fo r the rapeutic mon itoring o f
ciclosporin leve ls?
Immed iately before next dose
At any time
12 hou rs a fte r last dose
m
se
As
Dr
6 hours after last dose GD
I Immediately befo re next dose e:D

At any time fD
12 hours a fter last dose 6D
m
se
As
4 hours after last dose fD
Dr
Which one of the followin g adrenocepto rs cause vasoconstriction and relaxation of GI
muscle in response to sympathetic stimulation?
Alpha-1
Alpha-2
Beta-1
Beta-2
m
se
As
Beta-3
Dr
I Alpha-1 CD
Alpha-2 fD
I Beta-t CD
Beta-2 «ED
m
se
f.D
As
Beta-3
Dr
A 65-year-old man presents to the Emergency Department with lethargy and leg swell ing.
Initia l bloods show the followi ng:
Na+ 138 mmol/ 1
K+ 5.6 mmolfl
Urea 19.3 mmol/ 1
His renal fu nction six months ago was normal. Which one of his regular medications is it
most important to stop straight away?
Ibuprofen
Warfa rin
Paracetamol
Diazepa m
m
se
As
Atenolol
Dr
Ibuprofen .
GD
Warfarin m
Paracetamol CD
Diazepa m CD
Atenolol m
m
se
NSA!Ds such as ibuprofen can significantly wo rse n rena l impairment and must be avo ided
As
in patients w ith acute kidney injury or chronic kidney disease.
Dr
Doxazos in is a:
Alpha-1 antagon ist
Alpha-1 agonist
Non-selective a lpha antagonist
Alpha-2 agonist
m
se
As
Alpha-2 antagon ist
Dr
I Alpha-1 antagon ist
Alpha-1 agonist
-
~
I
Non -selective a lpha antagonist
Alphl -2 agonist
-
'"""'
Alpha-2 antagon ist

-
'"""'
m
se
Doxazosin is an alpha-1 adrenoceptor antagonist used in the treatment of hypertension
As
and ben ign prostatic hypertrophy
Dr
A 58-year-old male patient present s to the ophthalmology w ith deteriorating vision. He
reports a 6-months hist ory of gradually worsening blurred vision. His past medica l hist ory
includes a history of ventricu lar t achycardia, angina, hypertension, hypercholesterolaemia,
type 2 diabetes mellitus and recent malaria. Slit-lamp examination reveals bilat eral diffuse
corneal opacity.
What is the most likely medication to have caused this clinical pictu re?
Ethambut ol
Aspirin
Bisoprolol
Am iodarone
m
se
As
chloroquine
Dr
Ethambutol GD
spirin
Bisoprolol
-
CD
I Amiodarone
.,
chlo roqu ine ED
Amiodarone can cause cornea l opacities

Am iodarone is t he only medication from t he opt ions to be known to cause corneal

opacification.
Aspirin and b isoprolol are not known to cause cornea l opacification.
m
Ethambut ol can cause optic neuritis but cornea l opacificat ion is unusual.
se
As
Chloroqu ine can cause retinopathy but corneal opacif ication is unusual.
Dr
Which one o f t he followin g features is least associated wit h ecst asy poisoning?
Rhabdomyolysis
Hyperthermia
Ataxia
Hypertension
m
se
As
Hypernatraemia
Dr
Rhabdomyolysis GD
Hyperthermia .
CD
Ataxia CD.
Hypef e nsion CD
Hypernatraemia CD
m
Ecstasy is thought to stimu late the prod uction of anti-diuretic hormone. Users of ecstasy
se
a lso commonly drink to much water in the (mistaken) belief that this will protect them
As
from the adve rse effects.
Dr
Of the following, which one is the most usefu l prognostic ma rker in pa raceta mol
ove rdose?
ALT
Prothrom bin time
Paracetamolleve ls at presentation
Paracetamolleve ls at 12 hou rs
m
se
As
Paracetamolleve ls at 24 hours
Dr
ALT
Prothrom b in time
Paraceta molleve ls at presentation
m
An e leva ted prothro mbin time s ig nifies live r fa ilure in pa racetamol ove rd ose and is a
se
ma rke r o f p oo r p ro g nosis. Howeve r, arte rial pH, creatinin e a nd encephalo pathy a re also
As
ma rke rs of a need fo r live r transp la ntatio n
Dr
What is the mechanism of action of hepa rin?
Activates antith rombin ni
Vitamin Kantagon ist
Activates tissue plasminogen activator
m
se
As
Inhibits protein C
Dr
Activates antithrombin ni GD
Vita min Kantagon ist CD
Activates tissue plasminogen activato r m
Inhibits antithrombin III 6D
m
se
As
Inhibits protein C CD
Dr
A 44-yea r-old Bangladeshi man with a history of mitral stenosis and atrial fibrillation is
diagnosed with tuberculosis. He is commenced on anti-tuberculosis therapy. Th ree weeks
after starting treatment his INR has increased to 5.6. Which one of the following
medications is most likely to be responsible for this increase?
Pyrazi namide
Iso niazid
Rifa mpicin
Ethambutol
m
se
As
Streptomycin
Dr
Pyrazinamide CiD
I Isoniazid C!D
Rifa mpicin ED
Etha mbutol m
Streptomycin fD
Isoniazid inhibits the P450 syste m

It is impo rtant when answering questions relating to liver enzymes to be su re whether the
question is asking about inductio n or inhibition. Drugs causing indu ction are ohen well
m
se
known and candidates may rush to give these as the answer. A raised INR is a result of
As
inhibited liver enzymes
Dr
What is the mechanism of action of tacrolimus?
Mercaptopurine ant agonist
Inhibits inosine monophosphate dehydrogenase
Monoclonal antibody against IL-2 receptor
m
se
As
Decreases IL-2 release by inhibiting calcineu rin
Dr
Mercaptopurine antagonist
Interferes with pu rine synthesis
Inhibits inosine monophosphate dehydrogenase
Monoclonal antibody aga inst IL-2 receptor
m
I
se
As
Decreases IL-2 release by inhibiting calcineurin
Dr
A 54-yea r-old obese man presents with lethargy and polyu ria . A fasting blood suga r is
requested:
Fasting glucose 8.4 mmoljl
He is g iven dietary advice and a decision is made to start metformin. What is the most
appropriate p rescription?
Metformin SOOmg od with food for 5 d ays then metfo rmin SOOmg bd for 5 days
then metformin SOOmg tds for 20 days then review
Metformin SOOmg td s with food
Metformin SOOmg od with food for 14 days then metformin SOOmg bd for 14 days
then review
Metformin lg tds with food
m
se
As
Metformin SOOmg td s taken at least 1 hour before meals
Dr
Metformin SOOmg od with food for 5 d ays then metformin SOOmg bd for 5 days fiD
then metformin SOOmg td s for 20 days t hen review
Metformin SOOmg td s with food (D
etformin SOOmg od with food for 14 days then metf.ormin SOOmg bd for 14
ys then review
GD
Metformin 1g td s with food D

Metformin SOOmg td s taken at least 1 hour befo re meals 8
Metformin shou ld be titrated slowly, leave at least 1 week before increasing dose
m
se
Gastrointest inal side-effects are more likely t o occur if metformin is not slowly tit rat ed up.
As
The BNF advises leaving at least 1 week before increasing the d ose.
Dr
A 43-year-old man with a history of bipolar disorder is admitt ed with acute conf usion.
Whilst b eing t ransferred to hospita l he ha d generalised seizu re wh ich terminated
spontaneously after aroun d 30 seconds. On arrival in the Emergency Department his GCS
is 14/ 15 and he is noted t o have a coarse t remor. A diagnosis of lithium toxicity is
suspected. Intravenous access is obt ained, bloods are ta ken and a saline infusion is
started. Blood results reveal the following:
Lithium level 4 .2 mmol/1
Na• 136 mmol/ 1
K• 4 .6 mmolfl
Urea 8 . 1 mmol/1
Creatinine 99 iJmoljl
What is the most app ropriate management?
Arra nge haemodialysis
Int ravenous magnesium
Int ravenous bicarb onate
Int ravenous hypertonic sal ine

m
se
As
Arra nge plasma exchang e

Dr
I Arra nge hae modialysis .,
Intravenous magnesium m
Intravenous bicarbonate flD
Intravenous hypertonic saline f.D
Arrange plasma exchange f.D
m
se
As
The high lithium level and reduced GCS are an indication for haemodialysis in this patient.
Dr
A 62-yea r-old man is com me nced o n finaste ride fo r symptoms of bladd e r outflow
o bstruction. Which one of the fo llowing adve rse effects is most associated with this
treatment?
Alo pecia
Gynaecomastia
Prosta te ca nce r
Increased levels of serum prostate s pecific antigen
m
se
As
Po stural hypotensio n
Dr
Alopecia m
Gynaecomastia
.,
Prostate cancer CD
Increased levels o f serum prostate specific antige n GD
m
se
Postural hypotensio 6D
As
Dr
You are working in oncology. You are reviewing a 55-year-old woman in cli nic with St age
!Vb metastatic melanoma. Her disease has sprea d to her liver, lungs and her bra in. Her
BRAF st atus is negative. She has been treated with a co mbination of nivo lumab and
ipilimumab for the last four month s with a good response. Her recent re-staging CT scan
showed no new sites of disease and a good reduction in tumour size. However in the last
four weeks she has felt particu larly low in mood and complains that she ohen feels
fatigued and lacking energy. She has also complained of a vague int ermittent abdominal
discomfort. What would be your first investigation?
Thyroid function test s
Screen the patient for depression
MRI of the brai n
Synacthen t est
m
se
As
CT of the abdomen and pelvis
Dr
Thyroid f unction test s
Screen the patient for depression
MRI of th e bra in
Synacthen test
-
. .wr
CT of the abdomen and pelvis
Nivoluma b (PD -1 inhibitor) and ipi limumab (CTLA-4 inhibito r) are checkpoint inhibitors
which are used in the treatment of metastatic melanoma. Effects on t he endocrine system
are being increasingly reported w ith prolonged therapy (hypophysitis and
hypot hyro idi sm) and therefore it is important to assess patients caref ully who present
with symptoms o f hypothyroidism whilst on these drugs. Answer 2 is not unreasonable
but an organic cause fo r her sympto ms must be ruled out first. The vague abdominal
discomfort may be constipation related to the hypot hyroidism although many other
causes in so meone with metastatic malignancy cou ld be associated. Even so, answer 5
should not be the first investigation. Even though the cancer is responding to treatment
the patient has new symptoms which should warrant investigation. Answer 3 is wrong; an
m
se
MRI is not indicated here. Answer 4 is to test for Addison 's disease which is incorrect in
As
this scenario.
Dr
A 25-year-old woman is diagnosed with a uri nary tract infection. She has a past history of
epilepsy and is cu rrently taking sodium valproate. Which one of the fo llowing antibiotics
should be avoided if possible
Co-amoxiclav
Nitrofurantoin
Cefixime
Trimethoprim
m
se
As
Ciprofloxacin
Dr
Co-amoxiclav m
Nitrofurantoin CD
ll fixime CD
Trimethoprim fiD
Ciprofloxacin GD
Ciprofloxacin lowers the seizure threshold

Whilst many antibiotics can lower the seizure thres hold, this effect is seen particularly with
m
se
quinolones. The BNF advises that quinolones 'shoul d be used with caution in patients with
As
a history of epilepsy, or conditions that predispose to seizures'
Dr
A 21-year-old woman presents to t he emergency department w ith confusion, agitation
and sweating. Her friends report she has taken an unknown quantity of ecstasy (3,4-
Methylenedioxymethamphetamine, MDMA) app roximately two hours ago. She is taking
sertra line for depression, but has no o t her past medical history. She has no known drug
allergies.
Neurologica l examinat ion reveals globally increased muscle tone, hyperreflexia and
clo nus. Her tym panic membrane temperatu re is 41.2° C.
Which management strategy wou ld be most app ropriate?
Cyproheptadine
Pi peraci llin/Tazo bactam
Lipid emulsion therapy
Alteplase
m
se
As
Dimercapro l
Dr
I Cyproheptadine CiD
Pi peraci llin/Tazo bactam CD
I Lipid emulsion therapy fD

Alteplase CD
Dimercap rol fiD
SSRls + MDM A = higher risk o f serotonin syndrome

This is serotonin syndrome. The com bination of two or more sero tonergic medications
greatly increases the risk: in th is case an selective serot on in uptake inhibitor (sertraline)
and MDMA. Cyproheptadine is an Hl and nonspeci fic SHT antagonist, recommend ed for
treatment of severe serotonin syndro me. Piperacillin/tazobact am is a b road sp ectrum
beta -lactam antibiotic, often used to t reat sepsis. Lipid emulsion the rapy is used in local
m
anaest hetic toxicity and may also be cons id ered in t ricycl ic overdose. Alteplase is the
se
thro mbolytic ag ent most commonly used in acut e st roke. Dimercaprol is used in heavy
As
metal poisoning.
Dr
A 23-year-old man is admitted to the emergency department aher being found by his
friends 'collapsed' in the bathroom at a house party. On admission he is initially
incoherent and combative but settles following diazepam. Thirty minut es aher admission
he remains tachycardic with a pulse of 108/ min, blood pressure 144/ 90 mmHg and
temperature 37.3°C. You are asked to review him again as he is com plaining of severe
abdominal pain. He also reports passing some blood in his stool (which was looser tha n
normal) when he went to the toilet 5 minutes ago.
What is the single most likely cause of his abdominal pain?
Bleeding duodenal ulcer
Haemorrhagic pancreatitis
Ischaemic colitis
Disseminat ed intravascular coagu lation
m
se
As
Ruptured aortic abdominal aorta
Dr
Bleeding duodena l ulcer
Hae f1orrhag ic pancreatitis
lschaemic colitis
Dissem inated intravascula r coagu lation
Ruptured aortic abdo mina l aorta
m
se
Ischaemic colitis is a recognised p henomenon fo llowing cocaine ingestion a nd should be
As
considered if patients develop abd om inal pa in or rectal bleeding.
Dr
A 59-year-old man with a known history of type 2 diabet es mellitus, atrial fibrillation and
epilepsy presents as he is feeling generally unwell. His main complaint is a blue tinge to
his vision. Which one of his medications is most likely to be responsible?
Phenytoin
Metformin
Sildenafil
Pioglitazone
m
se
As
Digoxin
Dr
Phenytoin f.D
Metf ormin
Sildenafil
•
fZD
Pioglitazone CD
Digoxin GD
Visual changes secondary t o drugs

• blue vision: Viagra ('the blue pill')
m
• yellow-green vision: digoxin
se
As
Dr
A 62-yea r-old male with a history of type 2 diabetes mellitus is investig ated for lethargy.
Blood tests are as follows:
Na• 139 mmol/ 1
K• 4 .2 mmolfl
urea 15.2 mmol/ 1
Glucose 9 .2 mmolfl
Which one o f the followin g is most likely to be contributing to the low bica rbonate value?
Vom iting due to gastropares is
Renal tubular acidosis
Addison's disease
Metfo rmin
m
se
Rosig litazone As
Dr
Vom iting due to g astro pa resis
Renal t ubular acid osis
Addison's disease
Metformin
Rosig litazone
Althou gh ra re, lactic acidosis is an important sid e-effect of metfo rmin

Whil st the d ecreased bica rbonate va lue may be wo rsened by de te rio rating renal functio n,
m
it is important to exclude lactic acidosis seconda ry to metfo rmin.
se
As
The rai sed a nio n ga p is aga inst a diagnosis o f renal tub ula r acidosis.
Dr
Which one of the following is a mixed alpha and beta adrenoceptor antagonist?
Doxazosin
Phenoxybenzamine
Yohimbine
Propranolol
m
se
As
Carvedilol
Dr
Doxazosin CD
Phenoxybenzamine CD
Yohimbine GD
Propranojl ol CD
m
se
CD
As
Carvedilol
Dr
A 18-yea r-old ma le is admitted aher deliberately ingesti ng 40 gra ms o f pa racetamo l.
Twenty-four hours ah e r adm ission he is reassessed with a view to live r transplantation. Of
the following, which one wou ld most strongly indicate the need for a live r tra nsp lant?
CRP 306
Arterial p H 7.25
Grade IV encephalopathy
m
se
As
INR 5.7
Dr
CRP 306
Arterial pH 7.25
•
ED
Creatinine 267 llmol/1 ' CD
Grade IV encephalopathy fD
INR 5.7 tiD
m
se
The arterial pH is the single most important factor. The creatinine, encephalopathy grade
As
and I NR must all be grossly abnormal otherwise
Dr
Which one of the following pairs of features wou ld be expected to occur fo llowing
administratio n of an anticholinesterase (acetylcholinesterase inhibitor)?
Bradycardia and miosis
Bradycardia and urinary retention
Tachycardia and diarrhoea
Bradycardia and mydriasis
m
se
As
Tachycardia and lacri mation
Dr
Bradyca rdia and miosis ED
Bra dyca rd ia and urina ry retention CfD
Tachycl dia and d ia rrhoea GD

Bra dyca rd ia and mydriasis QD
Tachycardia and lacri mation f!D
Organophosphate insecticide p oisoning - bradycardia

m
se
As
A clin ical exa mple of an anticholi nesterase is organophosphate compounds
Dr
A 71-year-old man is prescribed digoxin fo r new onset atrial fibrillation. His doctor
explains that the full effect will not be seen for one week. Which one of the following is
responsible fo r this delayed effect?
Clearance
Volume of distribution
Absorption
First pass metabolism
m
se
As
Half- life
Dr
Clearance m
Volume o f distribution ED
I Abrorption (D
First pass metabolism GD
I Half-life ED.
m
se
The half-l ife of digoxin is arou nd 36-48 hours. This results in a delay before steady plasma
As
levels are seen
Dr
In which one of the following conditions is intravenous immunoglobuli n therapy most
Iikely to be beneficia I?
Graves' ophthalmopathy
Kawasaki disease
Inclusion body myositis
Multiple sclerosis
m
se
As
Rheumatoid arthritis
Dr
In which one of the fo llowing conditions is intravenous immunoglobu lin therapy most
Ii kely to be beneficia I?
Graves' ophthalmopathy
Kawasaki disease
Inclusion body myositis
Multiple sclerosis
m
se
Rheumat oid arthritis
As
Dr
A 27 -yea r-old female patient p resents to the e mergency de partment with a 4-d ay history
of a rash. She reports having taken an overdose of a a medication 1 day p rior to the rash
d evelop ing but she refuses to say what she took. She has no past medical history of note
but has a history of recu rrent d epress ion and p revious overdose. No fam ily history of
note. On p resentation, her observations are: heart rate 56 beats per minute, blood
p ressure of 127/72 mmHg, respiratory rate 18 breaths per minute, oxygen saturation
100% on air. On examination, you note a g eneralised non- bla nching petechial rash. Blood
resu lts are as follows.
Na• 134 mmoi/L
K• 4 .8 mmolfl
Hb 130 g/ L
Platelet 75 x 109/L
Which is the most likely medication she took?
Ibu profen
Pa racetamol
Amlodipi ne
m
se
Sertra line As
Dr
Simvastatin
Ib uprofen GD
-
Paracf amol .
(D
Am lod ipine
Sertraline
•
ED
Simvastatin
•
NSA!Ds a re a cause o f th rom bocytopenia
This patient has evidence of thrombocytopaen ia, like ly secondary to NSA!Ds.
m
se
Paracetamol, am lod ipine, sertraline and simvastatin do not usually cause
As
thrombo cytopaen ia .
Dr
Which one o f the fo llowin g enzymes is invo lved in p hase I drug meta bolism?
UD P-glucuro nosyl transferases
Pyruvate ca rb oxylase
Succinic d e hyd rog enase
N-acetyl transferases
m
se
As
Alcoho l d ehydroge nase
Dr
UDP-glucuronosyl transferases «D
Pyruvate ca rboxylase GD
Succinic dehydrogenase CD
N-acetyl transferases GD
m
I
se
I Alcoho l dehydroge nase ED
As
Dr
A 29-year-old wo man is admitted to the Emergency Department with ca rb on monoxide
poisoning. High-flow oxygen is applied on arrival. Which one of the following is not an
indication for hyperbaric oxygen therapy?
A carboxyhaemoglobin concentration o f 16%
Arrhythmia
Extrapyramidal features
Loss of consciousness w hen initially fou nd by paramedics
m
se
As
Pregnancy
Dr
A carboxyhaemoglobin concentration of 16%
Arrhythm ia
Extra pf amidal features

-
"""'
Loss of consciousness when initially found by paramedics
Pregnancy
m
se
As
Heavy smokers may have a carboxyhaemoglobin concentration of 10-15%
Dr
Which one o f t he followin g is no t a recogn ised side-effects o f dopamine recept or
agonists?
Postural hypotension
Daytime somnolence
Galactorrhoea
Nausea
m
se
As
Hallucinations
Dr
Postural hypotension GD
..
Daytime somnolence «!D
Galactorrhoea
Nausea «!D
m
se
«!D
As
Hallucinations
Dr
A 54-year-old female is being investigated for a macrocytic anaemia. Bloods test reveal a
low vitamin B12 level. Which one o f the following medications may be co ntributing to
this?
Bendroflumethiazide
Digoxin
Am iodarone
Sodium valproat e
m
se
As
Metf ormin
Dr
Bendroflumethiazide fD
o r oxin CD
Amiodarone CD
Sodium valproate 6D
m
se
As
Metformin CiD
Dr
A 30-yea r-old ma le is admitted to the medica l take with fever, rigo rs, confusion and
vom iting. He is found to have a low neutrophil count and is started on treatment for
neutropen ic seps is. He had recently b een started on a new anti-epileptic med icatio n.
Which o f these medications is most likely to be the cause?
Topiramate
Lacosam ide
Carbamazepi ne
Phe nytoin
m
se
As
Levetira cetam
Dr
Topiramate .
(D
Lacosam ide m
Carbamazepine ED
Phenytoin .
fiB
Levetiracetam fD
Carbamazepine can cause ag ranulocytosis

The correct answer is carbamazepine. Valproate is a lso associated with agranulocytosis.

The othe r anti-epileptics a re not classically known to cause agranulocytos is.
m
se
BNF
As
https://bnf.nice.org.uk/drug/carba mazep ine.html
Dr
Which one of the followin g statements regarding metformin is false?
Does not cause hypoglycaem ia
Increases insu lin sensitivity
Decreases hepatic gluconeogenesis
Increases end ogenous insu lin secretion
m
se
As
Reduces GI abso rption o f carbohydrates
Dr
Does not cause hypo glycaemia
~reases insulin sensitivity

Decreases he patic gl uconeogenesis
I Increases endogenous insulin secretion
Reduces GI a bso rption of carbohyd rates

-
~
m
se
As
Su lphonylureas have the p roperty of increasing endogenous insu lin secretion
Dr
A 34-yea r-o ld ma n with a histo ry o f bipo la r disorde r is ad mitted with acute co nfus io n.
Lithi um levels confirm the clinica l diag nosis of lithium toxicity. A d ecision is mad e to give
sod iu m bica rbonate . What is the mechan ism of action o f sodium b icarbonate in th is
sit uation?
Reduce gastro intestinal tract absorption
Myoca rdia l stabil iser
Neutra lises lith ium ions
Centra l nervous system me mbrane sta ba liser
m
se
As
Increases urine alkalinity
Dr
Reduce gastrointestinal tract absorption
Myocardial stabiliser
Neutra lises lith ium ions
Central nervo us system membrane stabaliser
Increases urine alkalinity

-
........
m
se
Increasing the alka linity of the urine promotes lith ium excretion. The preferred treatment
As
in severe cases wou ld be haemodialysis
Dr
A 54-year-old man who had a renal transplant two years ago is reviewed in cl inic. He is
currently taking a combination of ciclosporin and mycophenolat e as immunosuppressive
therapy. Two weeks ago he was discharged on oral fluconazole after inpatient treatment
for a fungal pneumonia. His creatinine level has increased from 114 !Jmol/1before
hospital admission t o 187 IJmol/1t oday. What is the most likely factor contributing to this
rise?
Amphotericin -B induced membranous glomerulonephritis
Ciclosporin nephrotoxicity
5-fluorocytosine induced minimal cha nge glomerulonephritis
Mycophenolate nephrotoxicity
m
se
As
Fluconazole nephrotoxicity
Dr
Amphotericin-B induced membranous glomerulonephritis
Ciclosporin nephrotoxicity
5-fluorocytosine induced minimal change glomerulonephritis
Mycophenolate nephrotoxicity
Fluconazole nephrotoxicity
-
. ..wl'

m
se
Fluconazole inhibits the met abolism of ciclosporin which increases the risk of ciclosporin
As
nephrotoxicity.
Dr
Which one o f the following stat ement s regarding heparin -induced thrombocytopaenia
(HIT) is correct?
A fall in the plat elet count of greater than 15% is diagnostic
HIT is a pro thrombotic condition
Tranexamic acid is the treatment of choice
HIT usually develops with 2-3 days of starting treatment
m
se
HIT is more common with low -molecular w eight heparin than w ith unfractionated
As
heparin
Dr
A fa ll in the platelet count of greater than 15% is diagnostic
HIT is a prothrombotic condition
Tra11examic acid is the treatment of choice
HIT usually develops with 2-3 days of starting treatment
m
HIT is more common with low-molecular weight heparin than with
se
unfractionated heparin
As
Dr
What is t he mechanism of action of macrolides?
Causes misreading of mRNA
Interferes with cell wall fo rmation
m
se
As
Inhibits protein synthesis
Dr
What is the mechanism of action of ma crolides?
m
se
Macrolides - inhibits p rotein synthesis by acting on the 50S subun it of ribosomes
As
Dr
A 21-yea r-old patient with long-term pins and needles in both hands and a p rotruded
lowe r jaw d evelops rig ht upper q uad rant pa in after being started on a new medication for
his condition, which medications acting on his endocrine system is responsible for this
adverse effect?
Octreotide
Bromocriptine
Desmopressin
Metfo rmin
m
se
Levothyroxine
As
Dr
I Octreotide
Bromocriptine
Desmopressin
Metformin
-
~
Biliary stasis and subsequently ga llsto nes is a common adverse effect of octerotide
Octreotid e is a somatostatin ana logue, which is known to inhibit hepatic bile secretion
and gallbladde r emptying leading to biliary stasis and subseq uently an increased risk of
developing gallstones.
Bromocriptin e - a do pam ine ago nist with side effects arising from its stimu lation o f the
brain vomiting centre
Desmopress in - predom inantly used in patients with dia betes insipid us by increasing the
presence of aq uaporin channels in the dista l collecting duct to increase water
reabso rption from the kidneys. Ma in sid e e ffects incl ude headache and facia l flushing d ue
to hypertension.
Metformi n - ma in ly reduces hepatic gluconeogenesis in patients with type 2 diabetes,

commo n side effects include d iarrhoea, vomiting and lactic acidosis
Levothyroxine - synthetic thyroxine used in patients with hypothyro id ism, com mon side
s em
e ffects resu lt from incorrect dosing and mi mic the sym ptoms o f hyperthyro idism.
As
Dr
A 45-year-o ld woman presents to you with ongoing constipation. This started about 3
weeks ago after she was started on a new medication by her cardiologist. She is clearly
not happy and blames him for it. She has a past medical history of hypertension, atrial
fibrillation and psoriasis.
Which one of the following drug may be responsible for her presentation?
Warfarin
Bisoprolol
Omeprazole
Verapamil
Clindamycin
m
se
As
Submit answer
Dr
Warfarin CB
Bisoprolol CD
Omeprazole GD
I Verapam il CD
Clindamycin CB
Verapamil can cause const ipation

Impo rta nt fo r me Less important
Drug Adverse effect
Beta-blockers Cold peripheries, sleep disturbances, bronchospasm

(contraindicated in asthmatics)
Calcium channel Ankle oedema, constipation, dyspepsia (relax lower

blockers oesophageal sphincter)
Clindamycin C.diff, joint pain, heart burn
Warfarin severe bleeding, red or brown urine, black or bloody stools,

stomach pain
Omeprazole diarrhoea, fever, cold symptoms and headache
[ .. I a• tit Discuss Im prove J
Next question )
Calcium channel blockers
Calcium channel blockers are primarily used in the management of cardiovascu lar d isease.
Voltage-gated calcium channels are present in myocardial cells, cells of t he conduction
system and t hose of the vascular smooth muscle. The various types of calcium channel
blockers have varying effects on these three areas and it is therefore important to
differentiate their uses and actions.
Side-effects
Examples Indications & notes and cautions
Verapamil Angina, hypertension, arrhythmias Heart failure,

.,,,.,,,,,,,,,,,,,,,,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,.
constipation,
Hig hly negatively inotropic hypotension,
.~ra.9Y<:a.r9 ia.!
Should not be given with beta -blockers flushing
as may cause heart block
Diltiazem Angina, hypertension Hypotension,

.~r.a.9Y<:.a..r9ia.!
Less negatively inotropic t ha n verapam il heart failure,
but caution should still be exercised ill1~1~ S.v.Y.~IIif19.
when patients have heart failure or are
taking beta -blockers
Nifedipine, Hypertension, angina, Raynaud's Flushing/

amlodipine, headache/....ankle
.. ...
.,.,,,.,,,.,,,.,,,.,,,.,,,.,,,.,,,.,,,., , ,,.,,,.,,,.,,,.,
felodipine Affects the peripheral vascu lar smooth

(dihydropyridines) muscle more than t he myocardium and
t herefore do not result in worsening of
heart failure
ell,._
Step 1
Step 2 A+C
~-----------,r-----------~
KO)'
A • AC E -
C =- C.r.•u"" eMmet
•t~• o 4-$ """""'..,. ep!WI04K'Ie,.. bkX:Io:!r
Step 4
......_..._., ...................-.................. _________.
•K• •4.1....W ... .......,._........_..........,....
m
se
As
Flow chart showing the m anagement of hypertension as per

Dr
current NICE guideliness

Which of the following conditions may not be treated by dopamine recepto r agonists?
Parkinson's disease
Prolactinoma
Nausea
Cyclical breast disease
Acromegaly
m
se
As
Submit answer
Dr
Parkinson's disease CD.
Prolactinoma CD
Nausea C!D
Cyclical breast disease GB
Acromegaly G8
[.. I•• tt Discuss (2) Improve J
Next question )
Dopamine receptor agonists
Indications
• Parkinson's disease
• prolactinoma/galactorrhoea
• cycl ical breast disease
• acromegaly
Currently accepted practice in the management of patients with Parkinson's disease is to

delay treatment until the onset of d isabling symptoms and then to introduce a dopamine
receptor agonist. If the patient is elderly, L-dopa is sometimes used as an initial treatment
Overview
• e.g. bromocriptine, ropinirole, cabergoline, apomorphine
• ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide*)
have been associated with pu lmonary, retroperitoneal and cardiac fibrosis. The
Committee on Safety of Med icines advice that an ESR, creatinine and chest x-ray
should be obtained prior to t reatmen t and patients should be closely monitored
Adverse effects
• nausea/vomiting
• postural hypotension
• hallucinations
• daytime somnolence
sem
As
*pergolide was withdrawn from the US market in March 2007 due to concern regarding
increased incidence of valvu lar dysfunction
Dr
The INR of a patient who has recently started t reat ment for tuberculosis drops from 2.6 to
1.3. Which one of t he following medications is most likely to be responsible?
Rifampicin
Streptomycin
Ethambuto l
Isoniazid
Pyrazinamide
m
se
As
Subm it answer
Dr
The INR of a patient who has recently started treatmen t for tuberculosis drops from 2.6 to
1.3. Which one of the following medications is most likely to be responsible?
I Rifampicin G8
Streptomycin
•
Ethambutol
Isoniazid
•
GB
Pyrazi namide
•
Rifampicin is a P450 enzyme inductor
Impo rtant fo r me l ess important
Rifampicin is a P450 enzyme ind ucer and will therefore increase the metabolism of
warfarin, therefore decreasing the INR.
[ .. I 8' tt Discuss (1) Improve
Next question )
P450 enzyme system
Induction usually requires prolonged exposure to the inducing drug, as opposed to P450
inhibitors, where effects are often seen rapid ly
Inducers of the P450 system include

• antiepileptics: p~~r)yt()ir), carbamazepine
• barbitura tes: p~~rl()~<lr~it()r)~
• rifampicin
• StJohn's Wort
• chronic alcohol intake
• griseofulvin
• smoking (affects CYP1A2, reason why smokers require more aminophylline)
Inhibitors of the P450 system include

• antibiotics: ciprofloxacin, erythromycin
• isoniazid
• ci metidi ne,.()rr'l~Er<lz:()l~
• amiodarone
• allopurinol
• im idazoles: ketoconazole, fluconazole
• SSRis: fluoxet ine, sertraline
• ritonavir
em
• sod ium valproate

s
As
• acute alcohol inta ke

• qu inupristin
Dr
A 20-year-o ld woman comes in requ iring contraception and wants to find out more about
the combined oral contraceptive pill. She has heard it can cause cancer and wants to find
out more about its risks. W hich of the following is the correct advice you can tell her?
There is no evidence that the combined oral contraceptive pill causes increased risk
of cancer
The combined oral contraceptive pill increases the risk of breast and cervica l cancer
but is prot ective against ovarian and endometrial cancer
The combined oral contraceptive pill increases the risk of breast and ovarian cancer
The combined oral contracept ive pill decreases the risk of breast cancer but
increases the risk of endometrial and ovarian cancer
Only after 10 years of use does the combined oral contraceptive pill increase the
risk of breast cancer
m
se
As
Submit answer
Dr
There is no evidence that the combined oral contraceptive pill causes increased
risk of cancer
I The combined oral contraceptive pill increases the risk of breast and cervical
cancer but is protective against ovarian and endometrial cancer
The combined oral contraceptive pi ll increases t he risk of breast and ovarian

cancer
The combined oral contraceptive pi ll decreases t he risk of breast cancer but

increases the risk of endometrial and ovarian cancer
Only after 10 years of use does the combined oral contraceptive pill increase the GB
risk of breast cancer
Combined oral contraceptive pill

• increased risk of breast and cervica l cancer
• protective against ovarian and endometria l cancer
There is a small increase in breast cancer in women taking the combined ora l
contraceptive pill. Therefore, in women with known breast cancer mutat ions such as
BRCA 1, the risk may exceed the benefit, and women w ith current breast cancer should not
take the combined oral contraceptive pill. There is a small increase in cervical cancer risk
after 5 years of use of the combined oral contraceptive pill and this increase to a 2-fold
risk after 10 years. However cervical cancer is not a contraindication to use.
[ .. Ia• tit Discuss Improve ]
Next question )
Combined oral contraceptive pill:

advantages/disadvantages
Advantages of combined oral contraceptive pill

• highly effective (failure rate< 1 per 100 woman years)
• doesn't interfere with sex
• contraceptive effects reversible upon stopping
• usually makes periods regu lar, lig hter and less painful
• reduced risk of <?\/a.r.ia.n.! ~f'l<:ic:lr:n.~tri a.l - this effect may last for several decades after
cessation
• reduced risk of colorectal cancer
• may protect against pelvic inflammatory disease
• may reduce ovarian cysts, benign breast disease, acne vu lgaris
Disadvantages of combined oral contraceptive pill

• people may forget to take it
• offers no protection against sexually transmitted infections
• increased risk of venous thromboembolic disease
• increased risk of breast and cervical cancer
• increased risk of stroke and ischaemic heart disease (especially in smokers)
• temporary side-effects such as headache, nausea, breast tenderness may be seen
m
se
As
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a
Cochrane review did not support a causal relat ionship.
Dr
A 20-year-o ld female is found at home by her mum w ith empty packets of paracetamol.
She is taken to hospita l and states she wanted to end her life and took unto 60
paracetamol ta blets over a period of 3 hours.
The reg istrar immed iately start s an infusion of N-acetylcysteine (NAC).
Why is NAC commenced as treatment?
Acts as a precursor to g lutathione to replenish stores to conjugate the active

metabolite
N-acetyi-B-benzoquinone imine stores are replenished
Homocysteine stores decrease
Methionine can act as a by product of NAC to conjugate the active metabolite
Cysteine stores are increased t o inhibit cyt ochrome P450
m
se
As
Submit answer
Dr
Acts as a precursor to glutathione to replenish stores to conjugate the active
metabolite
N-acetyi-B-benzoqu inone imine stores are replenished
Homocysteine stores decrease
1-!!a
Methionine can act as a by product of NAC to conjugate the active metabolite ~
Cysteine stores are increased to inhibit cytochrome P450
N-acetylcysteine is a precursor of g lutathione

Met hionine can be convert ed to homocysteine to cysteine and subsequently convert ed to

glutathione under enzyme action. When excess paracetamol is ingested it is metabolised
to N-acetyi-B-benzoqu inone imine which can deplete g lutathione. Thus N-acetylcysteine
is given as it is a precursor of glutathione to replenish t he stores. Thus option 1 is correct.
Option 2 is the toxic metabolite produced when g lutathione becomes saturated.
Ho mocysteine, met hionine and cysteine are precu rsors in glutathione production. Thus
option 3 is incorrect as production is increased.
Option 4 is incorrect as it is not a by product.
Option 5 is incorrect as cysteine is not involved in activation o r inhibition of cyt ochrome

P450.
[ .. Ia• tt Discuss (1) Improve ]
Paracetamol overdose: metabolic pathways
The liver normally conjugates paracetamol w ith glucu ronic acid/sulphate. During an
overdose the conjugation system becomes saturated leading to oxidation by P450 mixed
function oxidases*. This produces a toxic metabolite (N-acetyi-B-benzoquinone im ine)
Norma lly glutathione acts as a defence mechanism by conjugating with the toxin forming
the non-toxic mercapt uric acid. If glutathione stores run -out, t he toxin forms covalent
bonds w ith cell proteins, denaturing them and leading to cell death. This occurs not only
in hepatocytes but also in the renal tubu les
N-acetyl cysteine is used in the management of paraceta mol overdose as it is a precursor

of glutathione and hence can increase hepatic glutathione production
em
*this explains why there is a lower threshold for treating patients who take P450 inducing
s
As
medications e.g. phenytoin or rifampicin

Dr
A 86-yea r-old gentleman on a care o f the e ld e rly wa rd he is awa iting socia l ca re an d is
feeling well. The nurses have as ked you to review him as he is becom ing increasingly
confused . His cl inical exa mination is normal. Yo u ord er some bloods:
Na• 123 mmol/ 1
K• 4. 5 mmol/1
Urea 3.6 mmolfl
Creatinine 91 IJmolfl
In light of the low sodiu m, serum a nd urine os mo la lities are o rde red. They are as follows:
Plasma osmolality 182 mOsmolfkg 285-295 mOsmol/ kg
Urine osmolality 995 mOsmolfkg sao - 800 mOsmolfkg

Urinary sodium concentration 5 1 mmol/ 1
What is the most ap propriate initial treatment?
Oral sod ium tab lets
Flu id restrict
IV saline
Increased dieta ry sa lt
s em
As
Encourag e o ral flui ds

Dr
Oral sodium tablets m
I Fluid restrict
IV saline
GD
QD
I creased dietary salt CD

Encourage oral fluids CD
SIADH is treated with fluid restriction

This patient has SIADH, the initial treatment is flu id restriction.
Giving oral or IV salt wou ld not treat his hyponatraemia as it is caused by the dilutionary
affect of increased ADH.
m
se
Increasing his fluid intake would worsen his hyponatraemia as you would dilute the
As
sodium in his serum even further.
Dr
A 60-year-old gentleman presents to the Emergency Department with drowsiness,
confusion, and some nausea and vomiting. His daughter attends with him and tells you
that he has been feeli ng tired and run -down with a p ersistent coug h, and that he has
smoked 20 cigarettes per day for 40 years. The patient himself is unable to g ive a full
history due to the confusion but is able to tell you that sometimes he brings up blood
when cough ing and his urine has been darker than usual, but he did not want to worry his
d aughter. On examination, he appears euvolaem ic but short of breath . After ta king some
b lood you find a low serum sodium, a high urina ry sodium, a low p lasma osmolality, and
a high urina ry osmolality. Renal and thyroid function tests are no rmal. A chest x-ray
indicates a lung ca rcinoma, and so you suspect th is presentation may be ca used by a
syndrome of inappropriate anti-diuretic hormone secretion.
What is the underlying mecha nism causing the hyponatra em ia?
Inhibition of the sodium-chloride cotransporters
Insertio n of sodium-pota ssium-chloride cotra nsporters
Insertio n of aqua porin-1 channels
Insertio n of aqua porin-2 channels
m
se
As
Inhibition of sodium-glucose symporters
Dr
Inhibition of the sodium-ch lorid e cotransporte rs
Insertion of sodium-potass ium-chloride cotranspo rte rs
Insertion of aquaporin-1 channels

-
~
Insertion of aquaporin-2 channe ls
In~ibition of sod ium-g lucose sym porters
Antidiu retic hormone p romotes water reabso rption by the inse rtio n of aquaporin-2
channels
This is a history of a synd ro me o f inapp ropriate anti-d iuretic ho rmone (ADH) secretion
(SiAD H), caused as a pa raneoplastic synd ro me to small cell lung cancer. SiAD H causes
inappro priate re lease o f ADH due to the fa ilure o f the no rma l negative feedback loo p. As
a result. ADH production is not stopped once serum os mo la lity returns to normal.
ADH p romotes wate r reabsorption via in sertion of aquaporin -2 channels into the
collecting d ucts. In SiADH, th is causes a euvolaemic hyponatraemia as the body does not
lose as much wate r but continues to lose sodi um, making the urine mo re co ncentrated.
m
se
So, the underlying mechanism of the hyponatraemia is actually due to a pe rsistently As
increased number o f aquaporin-2 cha nn els caus ing water reabsorption rather tha n any
Dr
effect on any o f the sodiu m tra nsport mechan isms.

Which one o f t he followin g foods is the best sou rce of folic acid?
Cheese
Red meat
Liver
Fish
m
se
As
Milk
Dr
Cheese fD
Red meat tiD
Liver 6D
Fish GD
Milk fD
m
se
As
Folic acid is also p resent in green vegetables and nuts
Dr
A stu dy is designed to assess a new proton pu mp inhibitor (PPI) in e lde rly patients who
are takin g aspirin. The new PPI is g iven to 120 patients whilst a control group of 240 is
given the standard PPI. Over a five yea r period 24 of the g roup receiving the new PPI ha d
an upper GI b leed compared to 60 who received the standa rd PPI. What is the absolute
risk reduction?
15%
10%
12
5%
m
se
As
20
Dr
15% .
(D
10% f!D
12 f!D
5% ED
20 f!D
Absolute risk reduction = (Control event rate) - (Experimental event rate)
Control event rat e = 60 / 240 = 0.25

Experimental event rate = 24/120 = 0.2
m
se
As
Absolute risk reduction = 0.25 - 0.2 = 0.05 = 5% reduction
Dr
A new drug is being developed by a pharmaceutical company to help treat ovarian
cancer. Wh ich phase of clinical trials specifically looks at the efficacy of the drug?
Phase I
Phase Ila
Phase lib
Phase III
m
se
As
Phase IV
Dr
I Phase I flD
Phase Ila 6D
I Phase lib ED
Phase III fD
m
se
Phase IV GD
As
Dr
An 18-year-old ma le is adm itted to hospita l for haemoptysis. He mentioned that his urine
has recently become brown in colour. On examination, his blood pressu re is noted to be
170/110. A kidney biopsy is sta ined pos itive for autoantibodi es confirming a diagnosis of
Goodpasture's synd rome. Wh ich type of collagen does this patient produce
autoantibod ies aga inst?
Collagen type 1
Collagen type 2
Collagen type 3
Collagen type 4
m
se
As
Collagen type 5
Dr
Collage n type 1 CD
Collagen type 2 GD
Collagen type 3 GD
I Collagen type 4 eD
Collagen type 5 m
Goodpasture's synd rome is caused by autoa ntibodies ag ainst co llagen type IV

Collagen IV is d efective in Goodpastu re's syndrome.
Ehlers -Danlos syndro me is p rimarily caused by a genetic d efect in colla ge n typ e III.
m
se
Collagen Type V is a lso affected in a less commo n va ria nt of Ehle rs- Da nlos syndrome.
As
Collagen type I is de fective in osteogenesis imperfecta.
Dr
A 54-year-old man is brought to the Emergency Department aher being found collapsed
in the street. He is known to have a history of alcoholic liver disease. Blood tests reveal
the following:
Calcium 1.62 mmol/1
Albumin 33 g/1
Which one of the following is the most appro priate management of the calcium result?
10m I of 10% calcium chloride over 10 minutes
20% albumin infusion
10m I of 10% calcium gluconat e over 10 minutes
No action
m
se
As
10m I of 10% calcium chloride over 4 hours
Dr
10ml of 10 calcium chloride over 10 minutes
20% albumin infusion
110m I of 10% calcium gluconat e over 10 minutes

No action
10m I of 10% calcium chloride over 4 hours
Intravenous calcium gluconate is used for the acute mana gement of hypocalcaemia
m
se
Even after correction for the low albumin level this patient has significant hypocalcaemia
As
which should b e correct ed.
Dr
Where is the majority of iron fou nd in the body?
Bone
Haemoglobin
Ferritin and haemosiderin
Myoglobin
m
se
As
Plasma iron
Dr
Bone
Haemoglobin
Ferritin and haemosiderin
Myoglobin
m
se
Plasma iron
As
Dr
Which of the following is responsible for the rapid depolarisation phase of the myocardial
action potential?
Ra pi d sodium influx
Slow sodium efflux
Slow efflux of calcium
Efflux o f potassium
m
se
As
Ra pi d calcium influx
Dr
I Rapi d sodium influx
Slow sodium efflux m

.
CD
~w efflux of calcium CD
Efflux of potassium CD
m
se
Rapid calcium influx CD
As
Dr
A 63-year-old man presents with a 6-month history of diarrhoea. He is accom panied by
his daughter who is concerned about his increasing confusion over the last 3 months. She
thinks he might be developing dementia due to his excessive alcoho l intake. On
examination, you note a dark red ras h around his neck with a well-defined border.
Of which vitami n is this man most likely deficient?
Riboflavin
Nia cin
Thiamine
Cobalam in
m
se
As
Pyridoxine
Dr
Riboflavin .
(D
Niac in eD
Thiamine fD
Cobalam in fD
Pyridoxine fD
Pellagra is caused by vitam in B3 (niacin) deficiency

m
se
This man is presenting with the classic 3 D's of pellagra: diarrhoea, de rmatitis and
As
dementia. Pellagra is caused by a vitam in B3 (n iacin) deficiency.
Dr
A 68-year-old man p resents with headaches at the s ides of his head, worse on chewing
and yawning . Which of the fo llowing find ings wou ld exclude giant cell arteritis?
Presence of non-pulsatile tempo ral a rtery
Normal plasma viscosity
No past medical history of polymyalgia rheumatica
Normal tempo ral a rtery biopsy
m
se
As
Normal temperatu re
Dr
Presence of non -pulsatile temporal artery
Normal plasma viscosity
No past medical histo ry of polymyalgia rheumatica
Norma l tempo ral artery biopsy
Norma l temperature
-
~
A norma l temporal artery biopsy in a patient with suspected giant cell arteritis does
not exclude the disease because of the potential for skip lesions
The correct answer is normal plasma viscosity. Viscosity, ESR and CRP are almost
invariably raised in patients with active giant cell arteritis. A norma l temporal artery biopsy
would make it less likely that he has GCA but is less reassu ring than a normal viscosity
because GCA can present in the tempo ral artery with skip lesions.
GCA is more common in patients with polymyalgia rheu matica but can present alone. The
tem poral artery is likely to be thickened and non-pulsatile in GCA.
m
se
NICE CKS: giant cell arteritis
https:/ /cks.nice.org.u k/giant -cell-arteritis As
Dr
A 50-year-old man is reviewed in the neurology cl inic. For the past four months he has
been experiencing problems with his right shoulder. On examination he has weakness of
shoulder abduction and to a lesser ext ent wea k elbow flexion. A small pat ch of numbness
is noted over the deltoid muscle but otherwise sensation is normal. Where is the
neurological lesion?
C4
cs
C6
C7
m
se
As
C8
Dr
C4 CD
I cs ED
C6 CfD
C7 CD
C8 CD
~
m
se
As
This man has weakness of both t he delt o id (CS, C6) and the b iceps muscle (CS, C6, C7).
The location of t he senso ry loss po int s to a CS lesion however
Dr
A randomised co ntrolled trial is performed to look at a new drug to prevent hip fractu res
in postmenopausal women. Group A consists of 1,000 women who take th e new drug
whilst group B contains 1,400 women taking a placebo. The hip fractu re rate in grou p A is
2% and in group B is 4%. What is the number needed to t reat to prevent one hip fracture?
10
50
12
m
se
As
2
Dr
10 f.D
50 CD
6 CD
12 CD
2 GD
NNT = 1 I Abso lute Risk Reduction

They key to answering this question is t o ignore irrelevant data su ch as the number o f
patients in each group.
Control event rat e = 4% = 0.04

Exp erimental event rat e = 2% = 0.02
m
se
Absolut e risk reduction = 0.04 - 0.02 = 0.02
As
Number needed t o treat = 1 I 0.02 = 50
Dr
A 49-year-old male patient is referred by his GP t o the dermatology clinic with a lesion on
the middle finger o f t he left hand. He reports that he first noticed the lesion 3 years ago.
Initially it was very small but has been slowly growing over the past 3 years. He d enies
pain over the lesion or any other lesion present. He was started on steroid creams by the
GP but did not have any effect on the lesion. On examination, t here is a hardened
eryt hematous plaque on the dorsum of the middle finger of the left hand. He reports t hat
he is working in an office but had worked in an aquarium befo re. There"s no recent
foreign travel history of not e. A biopsy is taken and an organ ism is grown.
What is the most likely organism to have been grown from the lesion?
Mycobacterium marinum
Mycobacterium lepromatosis
Borrelia burgdorferi
m
se
As
Streptococcus pyogenes
Dr
I Mycobacterium marinum GD
Staphylococcus aureus m
Mycobacterium lepromatosis GD
Borrelia burgdorferi GD
Streptococcus pyogenes m
Fish tank granuloma is caused by Mycobacterium marinum
The lesion is likely fish ta nk granuloma, especially given t he history o f aquarium work. Fish
tank granuloma is caused by Mycobacterium marinum.
Staphylococcus aureus does not usually cause such lesions.
Mycobacterium lepromatosis is unlikely given t he singl e lesion and lack o f travel history.
Borrelia burgdorferi is t he causat ive organism for Lyme disease.
m
se
As
Streptococcus pyogenes is the causat ive organism for rheumatic fever. Dr
A 45-year-old lady was discha rged from hospita l fo llowing treatment with pam idronate
for hypercalcaem ia. She now presents with symptoms consistent o f hypocalcaemia
includ ing muscle s pasms and tetany. Which ECG changes are most likely to be present?
T wave inversion
Pea ked T waves
Corrected QT interva l prolongation
U waves
m
se
As
Corrected QT interva l shortening
Dr
T wave inversion
Pea ked T waves
Corrected QT interval prolongation
U waves
Corrected QT interva l shortening
The clinical picture p resented is not atypical when a patient who initially has
hyperca lcaemia is treated with bisphosphonates and rapidly develops hypocalcaemia.
The following ECG changes a re associated with hypocalcaemia:
• Com mon: Co rrected QT inte rva l prolongation

• Ra re: Atria l fibrillation o r to rsade d e pointes
(Note: In hypercalcaemia shorten ing of the QT interva l may be observed, in seve re cases
Osbo rn (o r J-waves) may be present)/
m
se
Sou rce: http://jou rna I.publications.chestnet.org/ a rticle.aspx? a rticleid = 1079481)
As
Dr
A 57-yea r-old lady is referred by he r GP to the rheu matology clinic compla ining of
arthralgia. On further q uestioning, she reports dry, gritty eyes a nd a dry mouth. Blood
tests show that she is rheu matoid factor positive and anti-Ro positive.
Which HLA is most associated with the likely diagnosis?
H LA-827
H LA-DR2
H LA-DR3
H LA-DQ2
m
se
As
H LA-BS
Dr
HLA-B27 f.I!D
HLA-DR2 fiD.
HLA -DR3 ED.
HLA-DQ2 GD
HLA-BS CfD
Sj ogren's syndrome is associ ated with HLA -DR3

m
se
As
Sj ogren's syndrome is associated with HLA-DR3. Therefore 3 is the correct answer.
Dr
A contin gency ta ble is co nstructed for a new blood protein marker to screen for prostate
cancer in men aged between 50 and 70 years:
Prostate cancer present Prostate cancer absent
New test positive 19 20
New test negative 14 723
What is the positive predict ive va lue of the new test?
19/20
723/743
19/39
19/33
m
se
As
723/737
Dr
19120 D.
723[743 CD
19139 ED
19133 GD
723/737 m
Positive predictive value = TP I (TP + FP)

Positive predictive va lue = true positives I (true positives + fa lse pos itives)
m
se
As
= 19 I (19 + 20)
Dr
A 73-yea r-old lady was re-adm itted after fai ling to recover from an ep isode of
community-acqu ired pneumonia. She was d ischarged 5 days ago on o ral a ntibiotics
howeve r is still reporting on-go ing fevers, headache and a pro ductive cough with
brownish phlegm. She began respond ing to a cou rse of intravenous a ntibiotics and
re ported that she had felt a lump in the breast for the past month coincidi ng with her
pe rsisting headaches not responding to analgesics. She was reviewed by the general
su rgical reg istra r on-ca ll. A su bsequent ultrasound scan of the b reast showed the
presence of a suspicious lump ind icating a possible cancerous les ion.
Given the histo ry and clinical find ings, what is the best investigation for her headaches
provided there are no co ntra indications?
Magnetic resonance angiography
Magnetic resonance imaging with contrast enhancement
Magnetic resonance imaging without contrast enhancement
Com puterised to mogra phy scan with contrast enhancement
m
se
As
Magnetic resonance venog ra phy
Dr
I
Magnetic resonance angiography
Magnetic resonance imaging with contrast enhancement

-
~
Magnetic resonance imaging without contrast enhancement
Computerised tomography scan w ith contrast enhancement
Magnetic resonance venography

-
~
Contrast M RI sca n is the g old st andard investigation for cerebral metast ases -
p rovided no contraindications
MRI cont rast is the investigatio n o f cho ice as it s t he most sens it ive. Single or even
multiple well -d emarcat ed lesions are seen with adjacent oedematous changes. Non-
enhancing lesions following the int roduction of contrast enhancement are far less likely to
be metastatic in origin. Contrast -enhanced MRI also has t he advantage of detectin g
leptomeningeal involvement. Bigg er metastatic foci appear as ring enhanced lesions w ith
a cent ral non -enhancing area due to und erlying necrotic tissue.
Whilst aCT scan w ith cont rast enhancement increases diagnostic accuracy, it is not as
sensitive as an MRI scan wit h contrast.
Magnetic resonance angiography (MRA) is used to visualise blood vessels and wou ld not
be of much benefit in t his situat ion.
em
Magnetic resonance venography is used to det ermine the absence o f blood f low wit hin
s
As
the sinuses, which would occu r in t he presence of venous sinus thrombosis.

Dr
Which one of the following reduces the secretion of reni n?
Erect posture
Adrena line
Hyponatraemia
Hypot ension
m
se
As
Beta- blockers
Dr
Erect posture m
Adrenaline 6D
Hyponatraemia m
Hypote+ ion GD
m
se
As
Beta -b lockers GD
Dr
A 22-yea r-o ld fe ma le stud ent presents to the med ica l team with a 7 -day histo ry o f fro ntal
headache, feve r, a bdomi na l pa in and seve re mya lgia. She thoug ht it was flu so just staye d
at home witho ut seeking medical he lp. 24 hou rs a go, she noticed a rash sta rting in both
he r a rms a nd now becomi ng more g e nera lised. On furthe r questio ning, she a d mitted to
having just retu rned from an extend ed excurs ion in Centra l America and had tick bites.
On exam ination, the re is a g ene ra lised petechia l rash cove ring th e a rms and sma ll areas o f
the trunk. Rocky Mounta in spotted fever was suspected.
What is the orga nis m implicated in this case?
Coxiella burnetti
Rickettsia typhi
Rickettsia prowazekii
Ehrlichia
m
se
As
Rickettsia rickettsii
Dr
Coxiella burnetti
Rickettsia typhi
Ehrlichia
I Rickettsia rickettsii
Rickettsia ricketsii is the causative organism for rocky mountain spotted fever
Rickettsia rickettsii is the causative organ ism fo r rocky mountain spotted fever.
Coxiella burnetti is the o rganism causing Q fever.
Rickettsia typhi is the organ ism causing endem ic typhus.
Rickettsia prowazekii is the organism causing epidemic typhus.
m
se
As
Ehrlichia is the organ ism causin g ehrlichiosis.
Dr
A sma ll study looks at the weight of patients diagnosed with type 2 diabetes mell itus.
Overall 64 patients were reviewed. The average weight was 81 kg, with a standa rd
deviation of 12 kg. What is the standa rd erro r of the mea n?
Square root (64 I 12)
Square root (81 I 12)
1219
9 I 12
m
se
As
1.5
Dr
Square root (64 I 12) tiD
Square root (81 I 12) fD
12 I 9 tiD.
9 I 12 .
(D
1.5 fJ!D
Standard error of the mean = standard deviation I square root (number of patients)
The st andard error of the mean is ca lcu lat ed by the standard deviation I square root
m
(number of patients)
se
As
= 12 I square root (64) = 12 I 8 = 1.5
Dr
A 29-year-old woman present s with dysuria and frequency four weeks after giving birth.
The antenatal period and delivery were unremarkable. She is exclusively breastfeeding her
child at the current tim e. Abdominal examinati on is unremarkable and she is apyrexial. A
urine dipstick shows blood +, protein+, leu cocytes +++and nitrates positive. What is the
most appro priate management?
Ciprofloxacin
Co -amoxiclav
Trimethoprim
Amoxicillin
m
se
As
Co -amoxiclav + metronidazole
Dr
Ciprofloxacin
Co -amoxiclav
~methoprim
Amoxicillin
Trimethoprim in breastfeedin g is co nsidered safe to use
m
se
As
Trimethoprim is co nsidered safe to use in breastfeeding women.
Dr
An 88-yea r-old woman with metastatic b reast cancer presented with a 4-week history of
fatig ue, nausea and loss of appetite. More recently, she reported itchy skin and so me
yellowing of her eyes du ring the past week. On exam ination, she had jaundiced sclera
with so me tenderness of the right upper q uad rant on deeper palpation. He r b lood tests
showed a persistent rise o f her liver enzymes particular alanine transam inase (ALT) and
alkali ne phosphatase (ALP) over the last month.
Given the cl inical deta ils, what investigation is most sensitive in detecting the underlying
cause?
Tl-weighted MRI scan
Liver ultrasound
Liver b iopsy
Contrast-enhanced CT
m
se
As
Non -contrast CT
Dr
Tl-weighted MRI scan CD
Live r ultrasou nd fD
Liver biopsy f!D
Contrast-enhanced CT GD
Non -contrast CT tED
Contrast-enhanced CT is ve ry sensitive in d etecting hepatic metastases

This patient is suffe ring from symptomatic hepatic metastases seconda ry to u nd erlying
b reast ca rcinoma. The most sens itive investigatio n to d etect this wo uld be a co ntrast-
enha nced CT scan.
Ultrasound is a g ood initia l sca n and is ve ry sensitive althoug h the pattern o f metastases
ca n be qu ite va ria b le and not specific to the prima ry site. The lesions can appea r e ither a s
hypoecho ic o r hyperecho ic. In co lorectal ca ncer, la rger/mode rate ly sized les io ns ca n be
visualised.
Contrast-enha nced CT is ve ry sensitive in d etecting hepatic metastases (80- 90%). Such

lesions a ppear would appea r a s a reas o f reduced attenuatio n with associated ring
enha nceme nt. Calcificatio n may be d etected with a n a rea o f ce ntra l necrosis.
MRI is more used for difficu lt prob lem -solving cases. When using an MRI the meta stases
em
appea r with red uced attenuatio n o n Tl-we ighted a nd with increa sed signa lling on T2-
s
As
weighted imag es.

Dr
A 24-yea r-old man presents with a three day history of painful ulcers on the shaft of his
penis and dysu ria. He has ha d no sim ilar previous episodes. A clinical diagnosis of primary
genital herpes is made. What is the most appropriate management?
Topical fa mciclovir
No treatment is indicated
Topical podophyllotoxin
Topical valaci clovir
m
se
As
Ora l aciclovir
Dr
A 24-yea r-old ma n p resents with a three d ay history o f painful ulce rs on the s ha ft o f h is
pen is and dys uria. He has ha d no sim ilar previo us episodes. A cl inica l d iag nosis of p rima ry
g en ital herpes is made . What is the most appropriate management?
Topical famciclovir f.D

No trea tment is indicated .
(D
-
Topica l pod ophyllotoxin GD
Topica l va laciclovir GD
I Ora l aciclovir CD
m
se
Ora l antivira l the ra py is indicated fo r prima ry genital herpes infect ions, eve n if the
As
presentation is delayed for up to 5 days
Dr
Which one of the following best describes the characteristics of a negatively skewed
distribution?
Median < mode < mean
Mean < median < mode
Mode < mean < median
Median < mean < mode
m
se
As
Mean < mode < median
Dr
Median < mode < mean
I Mean < median < mo de
Mode < mean < median
Median < mean < mode

-
. .:.;wl'
Mean < mode < median
Skewed distributions
• alp habetical order: mean - median - mode
m
• '>'for pos itive, ' <' for neg ative
se
As
Dr
Which one of the following is t he most important stimulator of the central
chemoreceptors?
Decrease in p02
Decrease in pH
Decrease in pC02
Increase in nitric oxide
m
se
As
Increase in K+
Dr
Decrease in p02 GD
I Decrease in pH CiD
Decrease in pC02 ED
Increase in nitric oxid e CD
m
se
CD
As
Dr
Which one o f the followin g statements reg ard ing growth hormone is incorrect?
Doesn't act d irectly on chondrocytes or osteoblasts
Is an anabolic ho rmone
Is responsible for changes in protein, li pid, and ca rbohydrate meta bolism
Is secreted by the somatotroph cell s
m
se
As
Acts o n a tra nsmembra ne receptor
Dr
I Doesn't act d irectly on chondrocytes or osteoblasts
Is an anabolic hormone
Is responsible for changes in protein, lipid, and ca rbohydrate metabolism
Is secreted by the so matotroph cell s
Acts on a transmembrane receptor
m
Growth hormone acts both directly on tissues (e.g. stimulates d ivision a nd multiplication
se
o f cartilage chondrocytes) a nd a lso ind irectly following the secretion of insulin-like
As
growth factor 1
Dr
The pa re nts of a 3 -yea r-o ld boy with cystic fib rosis ask fo r a dvice. They a re co nsideri ng
having mo re children. Ne ither of the pare nts have cystic fib rosis. What is the cha nce that
the ir next ch ild will be a ca rrie r of the cystic fibrosis g ene?
50%
100%
1 in 25
25%
m
se
As
66.6%
Dr
50% CiD
100%
1 in 25
•
CD
25% ED
66.6% CD
As cystic fibrosis is a n autosomal recessive condition there is a 50% chance that their next
m
se
child will be a carrier of cystic fibrosis (i.e. be heterozygous for the genetic defect) a nd a
As
25% chance that the ch ild will actually have the disease (be homozygous).
Dr
Haematuria is suspected by the p resence o f red o r brown urin e. It may be visi ble
ma croscopica lly (g ross haem atu ria) or d etectable in the urine sed iment by microscopy. It
is ohen a symptom of an underlying disease, most of them treatable, so that is extremely
impo rta nt to d o a cl inica l ap proach in o rder to identify its cause. Which o f the fo llowing
d ata e nhances the possibility that haematuria is o f g lomerula r o rigin?
Initia l haematu ria
Dysmorphic red b lo od cells found o n urine microscopy
Haematuria p lus pyuria
Mono -sympto matic haematu ria
m
se
As
Fresh blood in urine with prese nce of clots
Dr
Initial haematuria
I Dysmorphic red blood cel ls found on urine microscopy
Haematuria plus pyuria
Mono-symptomatic haematuria
Fresh blood in urine with presence of clots
Dysmorphic red blood cel ls if found in urine sediment indicates a glomerular o rigin
of hematuria
Abnormalities in the shape of red cells in the urine (dysmorphism) i ndicates a glomerular
o rigin of hematu ria.
Initial haematuria and presence of fresh blood usually indicat es lower urinary bleeding,
such as urethral bleeding.
Pyuria indicates infection or inflammatory disease but not necessary of a glomerular

o rigin.
m
If a mono-symptomatic haematuria is not ed in a middle age patient, in the absence of se
As
inf ection, a bladder tumour should be ruled out.
Dr
Which one o f the fo llowing ho rmo nes is most respo nsible fo r the secretio n of b icarbonate
is the uppe r gastro intestinal tract?
Somatostatin
Gastrin
Secretin
CCK
m
se
As
Vasoactive intestinal peptide
Dr
Somatostatin
I
Gastrin
Secretin
-~
CCK
Vasoactive intestina l peptide

-
~
Secretin increases secretion of b icarbonate- rich fluid from pancreas and hepatic
m
se
duct cells
As
Dr
Where is somatostatin secreted from?
D cells in the pancreas
I cells in upper s mall intestine
K cells in upper sma ll intestine
S cells in upper sma ll intestine
m
se
As
G cell s in stomach
Dr
I cells in upper small intestine

-
~
Kcells in upper small intestine
S cells in upper small intestine
G cells in stomach
Somatostatin is produced by D cells in the pancreas & sto mach

m
se
As
D cells are also found in the stomach and intestine
Dr
Which one o f the fo llowin g statements rega rd ing leu ko trienes is not true?
Secreted by leuko cytes
Fo rmed from arachi don ic acid
Attract leukocytes
Ca use broncho dilation
m
se
As
Increase vascular p ermeability
Dr
Secreted by leukocytes
Formed from arachi donic acid
Attract leu._
t _oc_y_t_e_s - - - - - - - - -·
Cause bronchodilation
m
se
As
Increase vascular permeability ~
Dr
You are a STl d octo r in medicine doi ng a nig htshift. An elderly patient with co lorectal
ca ncer has been adm itted to the Emergency Department with suspected bowel
obstructio n. The Emergency Department F2 d octor ha s tried to refer the patient to the
su rg eons but was to ld th at as no surg ical intervention is li kely the patient should be
a d mitted to th e medics. The F2 doctor therefore phones yourself and asks you to accept
the patient. What is the most app ropriate response?
Accept the patient and ask the staff to transfer her to the medica l assessment unit
Simply refuse in order to avoid the patient being admitted under an inapp ropriate
specialty
Tell the su rgical registrar that you will contact the on-call surgica l consultant if he
refuses to accept the patient
Go down to the eme rgency department an d review the patient
m
se
As
Phone the surgica l team yourself to discuss the matter
Dr
Accept the patient and ask the staff to tra nsfer her to the medi cal assessme nt unitG)
11rply refuse in order to avoid the patient being admitted under an

I it propnate s pec1alty
Tell the s urgical registrar that you will contact the on-call surgical consultant if he G)
refuses to accept the patient
I Go d own to the eme rgency department an d review the patie nt
Pho ne the surgical team yourself to discu ss the matte r

-
~
Scena rios simila r to this occu r o n a n a lmost d aily basis for admitti ng medica l teams. The
p riority in a ll of this has to be the patient. It may be the case if the patie nt is e nd -stage
the n medical ad missio n is more app ro priate. If they a re Duke 's A a nd awaiting an
o peratio n the n clearly they a re su rg ical. Until you review the patient yo urself yo u will not
have a ll the facts a nd th is is the refore the best o ption.
Discussing the matter with the surgica l team will help to clarify the ir opinio n a bout the
patient and is the next best optio n. Accepti ng the patie nt without review risks p laci ng a
patient with a n acute su rgical pro blem o n a medica l wa rd. Th is may d e lay o r compromise
ca re.
m
se
Getting into an a rgument with the su rgica l registrar is not constructive and is a poo r As
cho ice, as is sim p ly refusing to see the patient as this ind icates a disrega rd for the patient.
Dr
A female with severe renal failu re undergoes a kidney transplant. After a few hours, the
patient develops a fever and stops passing u rine. It is suspected she has hyperacute organ
rejection. Which cells are primarily responsible for this?
Helper T Cells
Neutrophils
Eosinophils
Macro phages
m
se
As
B Cells
Dr
Helper T Cells mt
Neutro phils f!D
Eosino phils CD
Macro phages 6D
I B Cells mt
B cells med iate hyperacute o rgan rejection

B Cells mediate hyperacute organ rejection. Helper T cells med iate both acute and chronic
rejection. Macrop hages and neutrophils may be seen due to local inflammation but a re
m
se
not chiefly res ponsible for mediating hyperacute organ rejection. Eosinophils do not p lay
As
a role in transplant rejection
Dr
Which one of the following is a recognised cause of hypokalaemia associat ed with
hypertension
Liddle's syndrome
Bartter's syndrome
Gitelman syndrome
Ciclosporin
m
se
As
Dr
I Liddle's syndrome fD
Bartter's syndrome GD
Gitelman synd rome (!D
Ciclosporin CD
Renal tubular acidosis (!D
Liddle's syndro me: hypokalaemia + hype rtens ion

Liddle's syndrom e is a n autosoma l dominant disorder that mim ics hypera ld osteronism,
resu lti ng in hypokalaemia associated with hypertens ion.
Bartte r's synd rome is an inhe rited cause (usually autosomal recessive) of severe
hypokalaemia d ue to defective chloride absorption at the Na• K• 2CI- cotransporter in
the ascend ing loo p of Henle. It should be noted that it is associated with normotension.
m
se
Gitelman's syndrome is due to a defect in the thiazide-sensitive Na • Cl- transporte r in the
As
distal co nvoluted tu bule. It is associated with hypokalaemia and normotension.
Dr
A man w ith glucose-6-phosphate dehydrogenase deficiency asks for advice regarding his
son. What is the chance his son will also develop t he disease?
2 in 3
No increased risk
Will definitely be affected
1 in 2
m
se
As
1 in 4
Dr
2 in 3
No increased risk
Will ! efinitely be affect ed

j
1 in 2
-
~
1 in 4
m
se
X- linked recessive cond itions - no male-to-male transmission
As
Dr
A 72-year-old woman who is d iagnosed with osteoporosis after suffering a Col les'
fracture is prescribed vitamin D supplementation. Which one of the following benefits will
vita min D result in?
Increased calcium absorption in the gut
Promoting renal phosphate excretio n
Decreased osteoclastic activity
Inhibition of th e prol iferation and differentiatio n of osteoblasts
m
se
As
Decreases osteocalcin release
Dr
Increased calcium absorption in the gut
ProL ing renal phosphate excretion
Inhibition of the proliferation and differentiation of osteoblasts
Decreases osteocalcin release
m
The effects of vitam in Don osteoblasts a re complex and not fully understood. Inhibition
se
o f osteoblastic activity would not however be in keeping with a beneficial effect on
As
osteoporosis.
Dr
Which one of the following conditions may cause hypokalaemia in association with
hypertension?
Gitelman syndrome
21-hydroxylase deficiency
Bartter's syndrome
Phaeochrom ocytoma
m
se
As
11-beta hydroxylase deficiency
Dr
11-beta hyd roxylase deficiency associated with hypertension
m
se
21-hydroxylase deficiency, which accounts for 90% of co ngenita l adrena l hyperp las ia
As
cases, is not associated with hypertension
Dr
Which one o f the followin g types o f blood vessel is first to vasoconstrict in t he presence
o f hypoxia?
Muscle arteries
Skin arteries
Hepatic arteries
Renal arteries
m
se
As
Pulmonary arte ries
Dr
Muscle arteries CD
Skin arteries ED
I Hj patic arteries m
Renal arteries «!D
I Pulmonary arteries ED
m
se
Pulmonary arteries vasoconstrict in the presence of hypoxia
As
Dr
Patients with deficiencies o f which one of the following complement proteins a re
predisposed to Leiner disease?
C2
C3
C4
m
se
cs
As
Dr
NC2
flD
flD
C3 fD
C4 CD
m
se
1cs CD
As
Dr
A 52-yea r-old ma n p resents to the emerge ncy d epartm e nt with a 5-day history o f
abd ominal pai n. He repo rts a histo ry of recu rre nt a bd om inal pain in the right upper
abd om en but they have always been se lf- reso lving. On e xa mination, he is jaundiced.
Tend e rness is elicited o n palpating the rig ht upper q uadrant. Murphy's s ign is neg ative.
His ba sic observati ons includ e te mperature 38PC, hea rt rate 100 beats per minute,
respirato ry rate 24 brea ths per minute, blood pre ssure 110/62 mmHg.
What is the first-line investi gation for this patient?
Mag netic resonance cho langiopancreato graphy (MRCP)
CT abdo men and pelvis
Endoscopic retrogra de chola ngio pancreatography (ERCP)
Ultra sound scan (USS)
m
se
As
CT abdo men
Dr
Magnetic resonance cho langiopancreatogra phy (MRCP)
R domen and pelvis
Endoscopic retrograde cholangiopancreatography (ERCP)
~rasound scan (USS)

CT abdomen
USS is the first line investigation fo r suspected cho langitis

This patient has the Charcot's triad of right upper qua drant pa in, fever and jaundice . USS
is the first line investi gation for suspected cholangitis.
MRCP is hel pful to visua lise the b ilia ry tree b ut not the first line investigation.
ERCP is helpfu l for the investigation of biliary pathology and therapeutic removal of
g a llstones but it is not the first li ne investigation for susp ected chola ngitis.
m
se
CT abdomen (and p elvis) is helpful to rule out other abdominal pathologi es but
ultrasound is usually the first line.
As
Dr
A study looks at the use o f a moxicillin in the treatm ent o f acute s inusitis compa red to
placebo. The following results are o bta in ed:
Total number of Number who achieved resolution of

patients symptoms at 7 days
Amoxicillin 100 60
Placebo 75 30
What is the od ds ratio a patient achieving resolution of sympto ms at 7 days if they take
amoxicill in compa red to placebo?
1.5
0 .5
2.25
0.6
m
se
1.66 As
Dr
1.5 fD
0.5 flD
2.25 CID
0.6 (D
1.66 CD
The od ds of sympt oms resolution with amoxicillin = 60 I 40 = 1.5
The od ds of sympt oms resolution with p lacebo = 30 I 45 = (213)
m
se
As
Therefore the o dds ratio = 1.5 I (213) = 2.25
Dr
Which one o f t he followin g statements regarding hypocalcaemia is incorrect?
Most features are a result o f neuromuscular excitability
Chronic hypocalcae mia may cause cata ract s
PerioraI paraesthesia is seen
Chvost ek's sign is more sensitive and specif ic t han Trousseau's sign
m
se
As
Prolonged QT int erval is seen
Dr
Most features are a result o f neurom uscular excitability
Chronic hypocalcaemia may cause cataracts
Periof aI pa raesthesia is seen
Chvostek's sign is more sens itive and specific t han Trousseau's sign
-
~
Prolonged QT int erval is seen
m
se
Hypoca lcaemia: Tro usseau's sign is more sensitive and specif ic t han Chvostek's sign
As
Dr
A 64-year-old female patient is referred to th e upper GI cli nic under the two -week rule.
Her son first noticed that her skin a nd eyes are becoming yellow. Her past medical history
includes neu rofibromatosis type 1. She was recently dia gnosed with Type 2 diabetes
mell itus however the blood glucose has been very poorly controlle d despite maximu m
thera py of metfo rmin a nd gliclazide. On exam inatio n, she is jaundiced. The re is mild
discomfort in the epigastric region and the rig ht upper quadra nt. An urgent a bdom inal CT
scan shows a mass arising from the head of the pa ncreas and d ilated common bile duct.
A subsequent endoscopic retrograde cholangiopancreatogra phy (ERCP) and biopsy
confirms a pancreatic somatostatinoma.
Which cells in the pa ncreas is this t umour originating from?
H cells
S cells
G cells
I cells
m
se
As
D cells
Dr
H cells m
S cells GD
G cel ls fD
I ce lls GD
I D cells GD
Somatostatin is pro duced by D cells in the pa ncreas & sto mach

The questio n is essentia lly asking fo r the cells that produce somatosta tin.
Somatostatinoma is a somatostatin-p roducing tumou r aris ing from the D cells in the
pa ncrea s a nd stomach. Somatostatin is pro duced by D cell s in the pancreas & stomach .
The newly-d iagnosed diabetes is like ly due to the excessive secretion of soma tostatin, as
somatosta tin in hibits the relea se of insulin a nd g lucagon.
There's no H cel ls in the gastroi ntestinal system.
S ce lls produce secretin.
m
se
G cells p roduce g astrin. As
Dr
I cells p rod uce CCK.

Which one o f t he followin g diseases is most strongly associat ed w ith HLA ant ig en DR4?
Ankylosing spondylit is
Behcet's disease
Reiter's syndrome
Rheumat oid arth ritis
m
se
As
Coeliac disease
Dr
Ankylosing spondylit is
Behcet's disease
-
'"""'
Reiter's syndrome
Rheumat oid art h ritis
Coeliac disea se
Rheumat oid arth rit is - HLA DR4

Around 70% of patient s with rheumatoid arthritis are HLA- DR4. Patients w ith Felty's
m
se
syndrome (a t riad o f rheumatoid arthrit is, splenomegaly and neutropaen ia) are even more
As
strongly associated with 90% being HLA-DR4
Dr
A 43-year-old man has a routine medical for insurance purposes. The following result is
o btained:
Uric acid 622 ~mol/1 (210- 480)
He is well with no significant past medical history. What is the most appropriat e test t o
perform next ?
Lipid profile
Thyroid function test
Calcium
Parathyroid hormone
m
se
As
Pyro phosphate levels
Dr
Lipid profile ED
Thyroid fu nction test CD
Calcium CD
Parathyroid hormone fiD
Pyrophosphate levels f.D
m
se
Hyperuricaemia may be associated w ith both hyperlipidaemia and hypertension. It may
As
also be seen in conjunction w ith the met abolic syndrome
Dr
Each one of the following causes o f hyponat raemia is associated w ith a urinary sodium of
less tha n 20 mmoi/L, except
Diarrhoea
Psychogenic po lydipsia
Burns
Secondary hyperaldosteronism
m
se
As
Syndrome of inappropriate ADH
Dr
Diarrhoea tiD
Psychogenic polydipsia (fD
I Burns ....._ CD
(fD
..
Secondary hyperaldosteronism
I Syndrome of inappropriate ADH

I
m
se
As
Syndrome of inappropriate ADH is associated w ith urinary sodium > 20 mmol/1
Dr
The commonest chromosomal defect in Down's syndrome is:
Trinucleotide repeat disorder
Autosomal dominant
Translocation
Mosaicism
m
se
As
Non-dysjunction
Dr
Trinucleotide repeat disorder f!D
Autosomal dominant m
Translocation QD
Mosaici sm CD
m
se
As
Non-dysjunction CD
Dr
A 34-week-old ba by was born by emergency caesa rean section due to placental
a bruption. Po lyhydramnios wa s detected antenata l but no cause fo und . Wh ilst o n the
neonata l un it, the baby showed fa ilure to thrive, o cca sional vo miting . Blood gas showed
hypoka laem ia, hyponatraem ia, hypoch loraem ia and metabo lic alkalosis. Subsequently
excessive sodium, pota ss ium and chlo rid e were fou nd in the urine.
Diabetes in sip idus
Syndrome of ina pp ropriate AD H
Addison's disease
Bartter's syndrome
m
se
As
Diabetes mell itus
Dr
Diabetes in sipidus GD
I Syndro me of inap pro priate AD H
Addison's disease
(D
(ID
I Bartter's syndrome CD
Diabetes mellitus m
Bartter's syndrome is a cause of metabolic a lka los is
This baby p resents with sympto ms a nd sig ns of Bartter's syndrome. Bartter's syndrome is
a ca use of metabo lic a lkalos is along with excessive loss of sod ium, pota ssium and
chlo ride. Polyhydra mnios is typ ical in the neo natal form o f Ba rtter's syndrome.
Diabetes insip idus typically p resents with hypernatraemia rather tha n hypo natrae mia a s in
this case.
Addison's disease typically presents with hyperka laemia and in some cases metabo lic
a cido sis.
m
se
Diabetes mellitus do es no t typica lly cause meta bolic a lka losis.
As
Dr
A cohort study is being designed to look at the relatio nship between smoking a nd breast
cancer. What is the usual outcome measu re in a cohort study?
Odd s ratio
Experimental event rate
Relative risk
Absolute risk increase
m
se
As
Numbers need ed to harm
Dr
Odds rat io CD
Experiment al event rate m
I Relative risk ED.
Absolute risk increase m.
Numbers need ed to harm m
m
Cohort studies - relative risk
se
As
Dr
Which one o f the following statements regarding nitric oxide is incorrect?
Promotes platelet aggregation
Ra ises intracellu la r cGMP levels
An inducible fo rm of NOS is p resent in ma crophages
In sepsis increased levels of NO contribute to septic shock
m
se
Causes venodilation
As
Dr
I Promotes p latelet aggregation CiD
Raises intra ce llula r cGM P levels GD
~ induct le form of NOS is p resent in ma cro phag es «D
In sepsis increased levels of NO contribute to septic shock «D
Causes venodilatio n GD
Nitric oxide - vasodilation + inhibits plate let agg regation
m
se
As
Nitric oxide inhibits, rather than p romotes, platelet aggregation
Dr
Which one of the following types of immunoglobulins are responsible for haemolytic
blood transfusion reactions?
IgD
IgE
IgM
IgA
m
se
As
IgG
Dr
IgD m
IgE f!D
IgM ED
IgA f!D
m
se
As
IgG ED
Dr
A 17 -year-old girl with Tu rner's syndrome is reviewed in the cardi ology clinic. Other than
coarct ation of the aorta, what is t he most common cardiac ab normality found in patients
with Turner's syndrome?
Aortic st enosis
Pu lmonary steno sis
m
se
As
Parti al anoma lous venous drainage
Dr
Ventricular septal d efect
Aortic st enosis
Pulmonary steno sis
Partial anomalous venous drainage
Tu rner's syndrome - most co mmon ca rdiac defect is bicuspid aortic valve
m
se
As
Up to 15% o f adult s with Turner's syndrome have bicusp id aortic valves
Dr
A 15-year-old b oy is reviewed. He has been referred by his GP w ith ptosis, diplopia and
night blindness. On examination he is noted t o have a degree of ophthalmoplegia,
bilateral partial ptosis and evidence of retinitis pigment osa during fundoscopy. His
mother developed a similar pro blem when she was 18-years-old. What is the most likely
diagnosis?
Kea rns-Sayre syndrome
Alpert's syndrome
Usher syndrome
Refsum disease
m
se
As
Lawrence-Moon -Biedl syndrome
Dr
Kearns-Sayre syndrome
Alpert's syndrome
Usher syndrome
Refsum disease
Lawrence-Moon-Bied l syndrome
Kearns-Sayre syn drome

• mitochondrial inheritance
• onset < 20-years-old
• external ophthalmop legia
m
• retinit is pigmentosa
se
As
Dr
A 67 -yea r-old man is discha rged a fte r having a pe rcutaneous coronary intervention
following an acute coronary syndrome (ACS). He had no past med ical of note p rior to the
ACS. Which type of lipid modification therapy should he have been sta rted on during the
admission?
Simvastatin 40m g on
Atorvastatin lOmg on
Atorvastatin 20mg on
m
se
As
Dr
Simvastatin 40mg on CD
I Atr vastatin lOmg on CD

Atorvastatin 20mg on CD
Atorvastatin 40mg on CD
Atorvastatin 80mg on GD
m
se
Patients with esta blished CVD should ta ke atorvastatin 80mg on
As
Dr
A 61-year-old woman is admitted to the Acute Medical Unit as she is generally unwell
with muscle twitching. Blood pressu re is recorded at 114/ 78 mmHg, pulse 84/min and she
is apyrexial. Blood t ests reveal the following:
Calcium 1.94 mmolfl
Albumin 38 g/1
Which one of the following tests is most useful in elucidating the cause of her symptoms?
Urea
Vita min D
Phosphate
Parathyroid hormone
m
se
As
Magnesium
Dr
Urea m
I Vitamin D flD
Phosphate GD
~athyroid hormone 6D
Mag nesium GD
m
se
Pa rathyroid ho rmone is the si ngle most usefu l test in determin ing the cause of
As
hypoca lcaemia
Dr
Which of the following conditions is inherited in aX-linked recessive fashion?
Androgen insensitivity syndrome
Myotonic dystrophy
von Willebrand's disease
Ehlers-Danlos syndrome
m
se
As
Huntington's disease
Dr
Androgen in sensitivity syndrome
Myotonic dystrophy
I von Willebrand 's disease
Ehlers-Danlos syndrome
m
se
As
X-linked conditions: Duchenne/ Becker, haemophilia, G6PD
trrportar t "or me _ess ·rroc-tam
Dr
A case-control study is be ing d esigned to loo k at the relatio nsh ip between epi lepsy and a
new vaccin e fo r va ricel la . What is the usua l outcome measure in a case-control study?
Odds ratio
Exp erimental event rate
Absolute risk increase
m
se
As
Relative risk
Dr
Odds ratio
Experimental event rate
Absolute risk increa se
Relative risk
m
se
Case-control studies -odd s ratio
As
Dr
A 24-year-old man is investigated for visual loss and is diagnosed as having Leber's optic
atrophy. Given the mitochondrial inheritance of this condition, w hich one o f the follow ing
relatives is most likely to be also affected?
Daught er
Sister
Son
Paternal uncle
m
se
As
Father
Dr
Daughter «D
I Sister ED
Son tiD
Paternal uncle t:D
Father f.D
Mitochondrial diseases follow a maternal inheritance pattern

m
se
All t he children of an affected mother will inherit a mitochondrial condition. His sister will
As
therefore also be affect ed.
Dr
Which cell organelle is involved in the breakdown of oligopeptides?
Golgi apparatus
Rough endoplasmic reticu lum
Peroxisome
Lysosome
m
se
As
Smooth endoplasmic reticulum
Dr
Golg i appa ratus
Rough endoplasmic reticulum

-
""""
Peroxisome
~osome
-
~
Smooth endoplasm ic reticu lum
m
se
Protein degradation in eukaryotes is also carried out by prote in complexes called
As
proteasomes.
Dr
Which one o f the following is equivalent to the pre-test probability?
Post test odds I (1 + post-test odds)
Pre-test odds x li keli hood ratio
The prevalence o f a condition
The incidence of a condition
m
se
As
Post-test odds I likelihood ratio
Dr
Post test odds I (1 + post -test odds)
Pre-test odds x li kelihood ratio
The p revalence of a condition

-
~
The incidence of a condition
Post-test odds I likelihood ratio
The prevalence is the p roportion of a population that have the condition at a point in
m
se
tim e whilst the incidence is the rate at which new cases occur in a popu lation du ring a
As
specified tim e pe riod.
Dr
A 24-year-old male is admitted with a head inju ry. App roximately one hour ago he was hit
o n t he lateral aspect o f his head by a hi gh velo city cricket ball. A collateral history reveals
that he lost consciousness immediately after the impact . Paramedics on the scene noted
his Glasg ow co ma score o f 15. On examination he has Glasg ow com a score of 13 (M S, V4,
E4) on arrival in the department. He has anterograd e and retrog rade amnesia t o events.
You arrange an urgent CT scan.
Which cl inical sign wou ld be most co ncern ing in this patient?
Pyrexia
Hypot ension
Bradycardia
Tachycardia
m
se
As
Decreased pulse pressure
Dr
Pyrexia
Hypotension
Bradycardia
Tachycardia
Decreased pulse pressure

-
~
The Cushing ref lex is a physiologica l nervous system response to increased

intracranial pressure OCP) that result s in hypertension and b radycardia
The mechanism o f injury, loss of consciousness and 'lucid int erval' should ring alarm bells
for an extradural haematoma. The Cushing reflex is a physio logica l nervous system
response to increased int racranial p ressure t hat resu lts in hypertension and bradycardia.
Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - int racranial pressure.
Therefore if int racranial pressure is high, t he only way the body can co mpensate to
increase CPP is by increasing MAP. A sympat hetic reflex therefore results in hypertension.
m
se
This results in a counter parasympathetic reflex by stimulation of t he baroreceptors
As
resulting in bradycardia.
Dr
Which one o f the followin g ka ryotypes is associated with s hort statu re?
45,XO
46,YO
46,XO
47,XYY
m
se
As
47,XYY
Dr
45,XO (D
46,YO D
46,XO GD
47,XYY D
m
se
As
47,XXY CD
Dr
You are trying to assess the risk of hepatic dysfunction associated with a new drug for the
treatment of cardiac failure. In total there have been 5 phase 3 studies and a ca rdiac
outcome study has been published.
Which of the following is the optima l way to assess the ris k of hepati c dysfunction?
Case control study
Coho rt study
Mechanistic study in patients with hepatic dysfunction
Meta -analysis of published ra ndomised controlled trials
m
se
As
New p rospective randomised controlled trial
Dr
Case contro l study
Coho rt study
Mechanistic study in patie nts with hepatic dysfunction
I Meta-analysis of pu blished randomised contro ll ed trials
New p ros pective ra ndom ised contro lled trial
in this s ituatio n, time is of the essence in eva luating the possible signa l o f hepatic
dysfunctio n b ecause of ris k to patie nts. By a ma lga mating data from published
ra nd o mised contro lled trials, o ne s ing le study which wou ld not have the power to d etect
a signa l fo r he patic dysfunction cou ld be co mbi ned with o thers to confirm o r refute a ny
risk of incid ent live r disease. This is, therefo re, the pre fe rred optio n.
A case-contro l st udy is unlikely to have the g ranula rity to confirm o r refute risk of incident
live r disease, and a co ho rt study wo uld be a massive and lengthy und e rtaking. A new
m
p rospective ra nd o mised contro lled trial would have to be la rge and lo ng to confirm a live r
se
s ignal, and a mechanistic study in patients with he patic dysfu nction may we ll not b e
As
re flective of the po pulatio n of cli nica l use.
Dr
A 28-year-old fema le with a hist ory of p rimary amenorrhoea and short stat ure is reviewed
in cl inic. On examination blood pressure in her right arm is 175/ 84 mmHg and 170/82
mmHg in her left. What is the most likely cause fo r her elevated blood pressure?
Coa rctation o f t he aorta
Conn's syndrome
Essential hypertension
Renal ap lasia
m
se
As
Renal artery stenosis
Dr
Conn's syndrome
I Essential hypertens ion
Renal a plasia
Turne r's syndrome is associated with aortic coarctation

This patient has Turner's synd rome which is associated with coa rctation of the aorta. The
s ite o f the coa rctation, for example if it invo lves the o rigin of the left subclavian artery,
determ in es whether there is a difference between the right a nd left a rm blood p ressure
readings. There is no sign ificant difference in this case.
Another cause worth consid ering in a young hypertensive patient with primary
ameno rrhoea would be congen ita l adre nal hyperplas ia
m
se
As
Essential hypertension would be unusual in a 28 -year-o ld
Dr
A 23 -yea r-o ld fe ma le with Down's syndrome is reviewe d in cl inic. Which o ne of the
fo llowing featu res is least associate d with he r condition?
Infertility
Hypothyroidism
Alzhe imer's d isease
Short statu re
m
se
As
Ventricu lar septa l d efect
Dr
Infertility
Hypothyroidism
Alzheimer's disease
Short st ature
Ventricula septa l defect
m
se
As this patient is female she is likely t o be subfertile rather than infertile - please see the
As
notes below
Dr
A 12-yea r-old gi rl d evelops facia l swel li ng and an erythematous itchy rash shortly aher
being ad ministered the first dose o f the HPV vaccin e. On a rriva l the pa ramed ics note a
bilatera l expiratory wheeze and blood pressure of 80/50 mm Hg. In the GelI and Coom bs
classification of hypersensitivity reactions this is an example o f a:
Type I rea ction
Type n rea cti on
Type mreaction
Type N reaction
m
se
As
Type V reaction
Dr
Type I reaction GD
Type II reaction fD
Type III reaction (D
Type IV reaction C!D
Type V reaction CD
m
se
Type I hypersensitivity reaction - anap hylaxis
As
Dr
In terms of the ce ll cycle, mitosis takes place in:
MO
Gl
m
se
As
G2
Dr
M ED
MO f!D
Gl CD
s CD
m
se
CD
As
G2
Dr
What is the correct formula to calculat e the posit ive p redict ive value?
TP = true posit ive; FP = false positive; TN = t rue negative; FN = false negat ive
Sen sitivity I (1 - specificity)
TP I (TP + FP)
TN I (TN + FP)
TN I (TN+ FN)
m
se
As
TP I (TP + FN )
Dr
Sensitivity I (1 - specificity)
- ~
TP I (TP + FP)
-
~
TN I (TN+ FP)
TN I (TN+ FN)
- ~
TP I (TP + FN )
m
se
Posit ive pred ictive value = TP I (TP + FP)
As
Dr
A 68-yea r-o ld ma n is a d mitted with haematemesis. A g astroscopy perfo rmed a s a n
inpatient shows a carcinoma which is confirmed o n biopsy. Who is the most ap prop riate
perso n to inform the patie nt of the dia gnos is?
The F2 docto r on the wa rd who has most conta ct with th e patient
The doctor who performed the g astroscopy
His GP following discharge
The consu ltant in-charge o f his care
m
se
As
His next- of-kin a fter you have told him/her
Dr
The F2 doctor on the ward who has most conta ct with the patient
The doctor who performed the g astroscopy

-
~
His GP following discharge
The consultant in-charge of h is care
His next-of-ki n a fter you have told him/her
One of the key a ims of the entrance exam is to assess a d octors ability to act in a
compassionate and empathetic way. Many of you may recall incidences of patients being
told a bout a cancer diagnosis in ina ppropriate circumstances.
The most appropriate person to inform the patient is the consultant in this scenario.
He/she is currently in charge of their care and will b e best placed to answer questions
about management an d prognosis. The F2 doctor will be less able to do this but wi ll at
least be known to the patient.
The doctor who p erformed the gastroscopy is unlikely to know the patient apa rt from
their brief meeting prior to the procedure. Asking the GP to tell the patient is a 'cop-out'
on a number of levels. Firstly the patient may feel that the hospital team 'could not be
bothe red' to tell him themselves. Second ly it resu lts in an unnecessary delay and thirdly
m
se
the GP may not be best p laced to give information on management and prognosis. As
Tell ing the next-of-kin is the worst option as it b reaks confid ential ity.
Dr
A 19-yea r-o ld fe ma le with a history o f anorexia nervosa is a dmitted to hosp ita l. He r BMI
has dro pped to 16. She has agreed to be fed by nasogastric tube. Which one o f the
fo llowing e lectro lyte distu rba nces is most likely to occu r?
Hyperka laem ia
Hypocalcaem ia
Metab olic acidos is
Hypophos phataem ia
m
se
As
Hypermag nesem ia
Dr
Hyperkalaem ia CD
Hypoca lcaem ia CD
Metabo lic acidos is m
Hypophosphataemia fD
Hypermagnesem ia fD
Refeeding syndrome causes hypophosphataem ia

m
se
Th is patie nt is at risk o f refeedin g syndrome, which can lead to p rofo und
As
hypop hosphataem ia
Dr
Which layer of the epidermis are melanocytes found in?
Stratum lucidum
Stratum germinativum
Stratum spinosum
Stratum corneum
m
se
As
Stratum granulosum
Dr
Stratum lucidum f.D
Stratum germinativum CD
Stratum spinosum GD
Stratum corneum (D
Stratum granulosu m fiD
Epidermis - 5 layers - bottom layer = stratum germinativum which gives rise to
m
se
keratinocytes and contains melanocytes
As
Dr
A 2-day-old baby gi rl is noted to become cyanotic whilst feeding and crying. A diagnosis
o f congenital heart disease is suspected. What is the most like ly cause?
Transposition of the g reat a rteries
m
se
As
Dr
I Transpos ition of the great arteries CD
Coa rctatio n o f the a o rta m
Patent d uctus a rte riosus (D
Tetra logy of Fa llot fD

Ventricu la r septal d efect CD
Congenita l heart d isease

• cyanotic: TGA most common at b irth, Fallot's most common overa ll
• acyanotic: VSD most common cause
The key point to this q uestio n is that whilst tetra logy of Fallot is more com mon tha n
tra nsposition of the g reat a rteries (TGA), Fa llot's d oesn't usually p resent u ntil l -2 months
fo llowing the id e ntificatio n of a mu rmu r o r cya nosis. In the neonate, TGA is the most
m
com mo n presenting cause o f cya notic congenita l hea rt disease
se
As
The other 3 o ptio ns a re causes of acyanotic congenita l hea rt disease
Dr
Each one of the following is associated with hyperka laem ia, except:
Rhabdomyolysis
Carbenoxolone
Acute renal fa ilure
Ciclosporin
m
se
As
Addison's
Dr
Rhabdomyolysis .
(D
Carbenoxo lone ED
Acute renal fa ilure m
l
Ciclosporin f!D
m
se
As
Addison's @D
Dr
Which o f t he following conditions is inherited in an aut osomal recessive fashion?
Hypoka laemic periodic paralysis
Adult polycyst ic disease
Hunting ton's disease
Friedreich's ataxia
m
se
As
Ehlers- Danlos syndrome
Dr
Hypokalaem ic periodic paralysis
Adu lt polycystic disease
Friedreich's ataxia
Ehle rs -Dan los syndrome
Autosomal recessive conditions are 'metabo lic' - exceptions: inherited ataxias
Autosomal dominant conditions are 'structura l' - exceptions: Gilbert's,

hyperlipidaemia type II
Important for me l ess im:>ortc.nt
m
se
As
Dr
Which one o f the following is least associated wit h homocyst inuria?
Recurrent rena l st ones
Downwards lens dislocation
Deep vein thrombosis
Arachno dactyly
m
se
As
Learn ing difficu lties
Dr
I Recu rrent renal stones fi!D
Downwards lens dislocat ion G'D
Deep vein thrombosis fD
Arachnodactyly fD
Learn ing difficulties CD
m
se
As
Cyst inuria not homocystinuria is associated with recurrent renal stones
Dr
A new drug which may reduce the chance of patients with chro nic kid ney d isease
d eve loping gout is introduced. In one study of 2,000 patients 1,200 received the new drug
o f which 120 patients develop g out. The remaining 800 patients re ce ived a placebo of
which 200 developed gout. What is the absolute risk reductio n of deve loping g out?
0.1
15%
120
25%
m
se
As
6.66
Dr
0.1 .
(D
15% GD
12~ (D
25% GD
6.66 GD
Ab solute risk reduction = (Control event rate) - (Experiment al event rate)

Absolut e risk reduction = (Experimental event rate) - (Control event rat e)
Cont rol event rat e = 200 I 800 = 0.25
m
Exp erimental event rat e = 120 I 1,200 = 0.1
se
As
Absolut e risk reduction = 0.25 - 0.1 = 0.15 = 15% reduction
Dr
A 28-year-old woman presents with a 3-day history of dysuria and increased urinary
frequency. She denies any vaginal discharge or menorrha gia. Urine dipstick is positive for
leukocytes and nitrites. Urine culture grows a urease-bacteria that is identified as Proteus
mirabilis. She is treated with antibiotics.
Chronic and recurrent infectio ns with th is bacteria predispose patients to which of the
following types of rena l stones?
Calcium oxalate
Calcium phosphate
Am monium magnesium phosphate (struvite)
Uric acid
m
se
As
Cystine
Dr
Calcium oxalate
Calcium p hosphate
Ammonium magnesium p hosphate (struvite)
Uric acid
Cyst ine
Recurrent urease-positive bacteria (eg. prot eus mirabilis) infections p redispose

individuals to struvit e renal stones
St ruvite accounts for 15% of st ones. It is caused by infections with urease- positive
bact eria (e.g. Proteus mirabilis) t hat hydrolyze urea to ammonia and alkalize t he urine.
They com monly form stag horn calculi.
Calcium - based renal st ones account for 80% o f all stones. They are most ly idiopathic but
may resu lt f rom antifreeze ingestion, vitamin C abuse, hypocit rat uria and malabsorpt ion
(e.g. Crohn disease).
Uric acid renal stones account for about 5% of all stones. Risk factors include reduced
uri ne volume, arid climat es, acidic pH. It is strongly associat ed w ith hyperu ricaemia (e.g.
g out) and is often seen in diseases w ith high cell turnover (e.g. leukaemia)
Cyst ine rena l stones result from a heredita ry condit ion in which cyst ine-reabso rbing PCT
em
transporter loses f unction, causing cyst inuria. Cystine is poorly soluble, t hus st ones form
s
As
in t he u rine. They ca n also form stag horn calculi.

Dr
A neonate female born at 37 weeks gestation d eve lo ps seve re cya nosis 1 hou r afte r birth.
She deve lo ps wo rsen ing respirato ry d istress a nd becomes hig hly tachypnoeic with
difficu lty feeding. She is soon transfe rred to the neonatal intensive ca re unit fo r
suppo rtive treatment. Her mother d id not seek a ny ante natal care a nd the baby was born
via a n uncomplicated spo nta neous vag inal delive ry.
On phys ica l exa mination, the neonate is cya nosed a nd letha rgic. Her vital signs we re as
fo llows: res pirato ry rate 62/ min, o xygen saturation 84% (o n 60% o xygen), heart rate
160/ min, blood p ressu re 96/ 66 mmHg. Cardiac auscultation revea ls a lou d 52 heart
sound .
Chest x-ray shows the cardiac s il houette with an 'eg gs o n a string' ap pea rance.
El ectro ca rd iogra m (ECG) shows a right ventricu la r d o minance. Further d iag nostic workup
with echocardi og ra phy co nfirms a cong enita l heart d efect.
Which o f the fo llowing is the most likely u nd erlying embryo lo gica l pathology in this
neonate 's cong enita l hea rt d efect?
Absent tricuspid va lve and hypop lastic rig ht ventricle
Antero superio r dis pla cement of the infundibula r septum
Defect in interatrial septum
Fai lure o f the a o rtico pu lmona ry septum to spira l

m
se
As
Aortic na rrowing near insertion of ductus arteriosu s

Dr
Absent t ricuspid valve and hypop lastic right ventricle
Anterosuperior disp lacement o f the infundibular septum
Defect in 'nteratrial sept um
Failure of t he aorticopulmonary septu m to spiral
Ao rtic narrowing near insertion o f ductus arteriosus
Transpos it ion of great vessels is due to the fa ilure o f the aorti copu lmonary septum
t o sp iral
Important for me Less :mpc rte;nt
The clinical st em here is significant for a cyanot ic heart disease. The clinical findings as
well as t he cla ssic X-ray d escript ion point towards a diagnosis of t ransp osit ion o f great
vessels wh ich is caused by t he failu re o f t he aorticopu lmonary sept u m to spiral during
early life.
Absent t ricuspid valve and hypoplast ic right ventricl e are seen in t ricusp id at resia
(cyanot ic heart d efect).
Anterosu perior di sp la cement o f t he inf undibular sept u m is seen in Tet ralogy of Fallot
(cyanot ic heart d efect). The x-ray in t his condition wou ld show a 'boot -shaped' heart.
A d efect in t he int eratrial sept um is present in the at rial septal def ect (non-cyanotic).
s em
As
Ao rtic narrowi ng near t he insertion o f ductus arteriosus occu rs in aortic coa rctation.
Dr
A patient presents with an ina bility to abduct his right shoulder. Which nerve su pplies the
delto id muscle?
Lateral cutaneous
Suprascapular
Muscu locuta neous
Axillary
m
se
As
Median
Dr
Late ral cutaneous m.
Suprascapu lar «D
Musculocutaneous CD
I Axillary ED.
Median m
m
se
Shoulder abduct ion - deltoid muscle - axillary nerve (CS,C6)
As
Dr
Which one of the following serum proteins is most likely t o increase in a patient with
severe pneumococcal pneumonia?
Transferrin
Transthyretin
Ferritin
Albumin
m
se
As
Cortisol binding protein
Dr
Transferrin «!D
Transt yretin flD
Ferritin CD
Albumin (iD
m
se
~
As
Cortisol binding protein '
Dr
What level of evidence does a randomised control trial offer?
Ia
Ib
IIa
lib
m
se
As
IV
Dr
Ia QD
Ib ED
IIa tiD
lib GD
m
se
IV C!D
As
Dr
Each one of the following promotes the release o f endothelin, except:
Prostacycl in
ADH
Ang iotensin II
Hypoxia
m
se
As
Mechanical shearing force
Dr
I Prostacyclin ED
ADH fD
r :g iotenst II GD
Hypoxia GD
m
se
As
Mechanica l shearin g force CD
Dr
A study is designed to assess the efficacy of a new anti-hypertensive med ication. Two
groups of patients are randomly assigned, one to take the established drug for 3 months
whilst the other takes the new drug for 3 months . Blood pressure is measured before and
a fter the intervention. There is then a period off medication for 1 month. After this period
has elapsed the medication th at the groups receive is swapped around and again b lood
p ressure is measured before and 3 months later. The difference in blood pressu re after
the respective medications is calculated for each patient. Which one of the fo llowing
s ignificance tests is it most appropriate to app ly?
Student's unpaired t-test
Student's pai red t-test
Pea rson's test
Mann-Whitney test
m
se
As
Chi-squared test
Dr
Student's unpaired t-test «D
I Student's pai red t-test Ci.D

Pea rson's test tiD
Mann-Whitney test tiD
Chi-squa red test GD
This describes a crossover stu dy. As we are comparing parametric data from the same
m
se
patients (they swapped med ication ha lfway th rough the stu dy) the Student's paired t-test
As
should be used.
Dr
A 1-yea r-old girl is not ed to have a continuous murmur, loudest at the left st ernal edge.
She is not cyanosed. A diagnosis of patent ductus arteriosus is suspected. What pulse
abnormality is most associated with this cond ition?
Collapsing pulse
Bisferiens pulse
Pulsus parodoxus
'Jerky' pulse
m
se
As
Pulsus alternans
Dr
Collapsing pulse CD
Bisferiens pulse GD.
Pulsus pa rodoxus f!D
'Jerky' pulse f!D
Pulsus alternans GD
m
se
Patent ductus arteriosus - large volume, bou nding, collapsing pulse
As
Dr
A 3 -year-old boy has been broug ht into the GP su rgery by his parents. He presents with
pallor, lethargy and enlargement o f the abdomen. The boy's parents said that they only
noticed these symptoms for the past 2 weeks but it has been gradually wo rsening over
the longer period. The boy was born in the UK by normal vaginal delivery following an
uncomplicated preg nancy. There is no significant past medical history or recent t ravel
hist ory. The mother reports a family hist ory of a form of metabolic disorder but couldn't
remember the name. On examination, there is generalised pallor. There is enlargement of
the abdomen w ith massive splenomegaly which is firm but not tender. Hepatomegaly is
also noted. There is no j aundice or lymphadenopathy.
Gaucher's disease
Heart failure
m
se
As
Kala azar
Dr
Gaucher's disea se
Heart failure
Ka la azar
Gaucher's disease is t he most common lipid storage disorder and a cause of

hepatosplenomegaly
Gaucher's disease is an autosomal recessive disease and it is the most common lipid
storage disord er. It's a cause of hepatosplenomegaly. The fa mily history in the history
indicat es Gaucher's disease as t he most likely.
Heart failure is unusual in ch ildren and does not usually cause massive splenomegaly.
Chronic myeloid leukaemia can cause massive sp lenomega ly but it is unusual in chi ldren.
Acute myeloid leukaemia can cause splenomegaly but massive splenomegaly is rare. It is
not usually inherited.
m
se
Ka la azar, also known as visceral leishmaniasis, is a cause o f massive splenomegaly but
As
given the lack of t ravel history, it is unlikely.

Dr
A stu dy is performed to find the normal reference range for Ig E levels in adults. Assuming
IgE levels follow a normal distribution, what percenta ge of adults will have an IgE level
higher than 2 standard deviations from the mean?
1.25%
2.3%
1.96%
5%
m
se
As
0.5%
Dr
1.25% GD
I 2.3% tD
1.96% fi.D
5% fiD.
0.5% GD
For normally distributed d ata 95.4% of va lues lie within 2 standa rd deviations of the
m
mean, leaving 4.6% outsid e this range. The refo re 2.3% of values wil l be higher and 2.3%
se
will be lower than 2 standa rd deviations fro m the mean. This figu re is so metimes
As
approximated to 2.5%
Dr
Which one o f the following is true regarding Escherichia coli infection?
It is a Gram negative coccus
E coli is an important cause of neonatal meningitis
The 0157:H7 strain is typically spread via shellfish
Severe infection should be treated w ith t eicoplanin
m
se
As
It is an aerobic bacteria
Dr
It is a Gram negative coccus GD
I E coli is an impo rtant cause of neonata l mening itis CD
The 0157:H7 stra in is typically spread via she llfish «D
Severe infection s hould be treated with teicoplan in fD
It is an aerobic bacteria «D
m
se
As
Escherichia coli is classified as a facultative ana erobe
Dr
You are working in oncology in the breast ca ncer division. A 30 -yea r-old lady has been
referred to you by her GP with a mass in her left b reast. She underwent treat ment for a
sa rcoma of t he left deltoid muscle one year previously. She has a family history of ca ncer.
Her mot her died o f a brain t umour in her mid 40's and her b rot her died of an
osteosarcoma in his early teens. A mutat ion in which gene is accountable for this
syndrome?
RET
CMYC
RAS
P53
m
se
As
VHL
Dr
RET CD
I CMYC flD
RAS flD
I P53 ED.
VH L flD
A mutation in the P53 gene can cause Li-Frau men i syndrome which can present with soh
m
se
tissue sa rcomas, breast carcinoma, g lioblastoma, lymphoma a nd leukaem ia. It is a rare
As
autosomal dom inant disorder.
Dr
A 23 -year-old man is admitted w ith sepsis. Blood cultures are rep orted as follows:
Neisseria gonorrhoeae
Which o f t he follow ing complement prot ein s is the pat ient most likely t o deficient in?
Clq, Clrs, C2, C4
C3a + CS a
CS-9
C4
m
se
As
C2
Dr
Clq, Clrs, C2, C4 fD
C3a + CSa GD
CS-9 GD
C4 fD
~
C2 m
Whilst C3 deficiency is associated with recu rrent bacterial infections, CS d eficiency is more
m
se
characteristically associated with dissem inated men ing ococcal infectio n and other Gram
As
negative d ip lococcal infections
Dr
A 33-year-old female is referred to the endocrine cli nic. She has missed her last two
periods and has been lactating. She has gained weight and com plains of vaginal dryness.
The endocrinologist chooses to measure her prolactin levels. Which hormone is
responsible for i nhibiting prolactin release from the pituitary glan d?
Thyrotropin releasing hormone
Oestrogen
Gonadotropin releasing hormone
Luteinising hormone
m
se
As
Dopamine
Dr
Thyrotropin releasing hormone
-
~
Oestrogen

-
~
Luteinising hormone
Dopamine
Prolactin release is persistently inhibited by dopamine

Dopamine persistently inhibits prolactin. Prolactin release is upregulated by thyrotropin-
m
se
releasing hormone and oestrogen. Prolactin has an inhibitory effect on gonadotropin-
As
releasing hormone and luteinising hormone.
Dr
Which one o f the following is not associated with hypocalca em ia combined with a raised
p hos phate level?
Chronic rena l failure
Pseudohypoparathyroidism
Hypopa rathyroid ism
Osteomalacia
m
se
As
Acute rha bdomyo lysis
Dr
Which one of the fo llowin g is not associated with hypoca lcaem ia combined with a ra ised
phosphate leve l?
Chronic re nal failure f!D

Pseudohypoparathyroidism E1D
Hypopa rathyroid ism f!D
I Osteomalacia ED.
Acute rhabdomyolysis GD
m
se
Osteomalacia causes hypocalcaemia associated with a low serum phosp hate, rather than
As
a ra ised phosphate level.
Dr
Which one o f the following occu rs duri ng reverse t ranscriptase polymerase chain
reaction?
Proteins are converted to DNA
DNA is converted to RNA
Used to amplify DNA
RNA is converted to DNA
m
se
As
Proteins are converted to RNA
Dr
Prot eins are converted to DNA
DNA is converted t o RNA
Used to amplify DNA

-
~
r
RNA is converted to DNA
m
se
As
Prot eins are converted to RNA
Dr
A 45 -yea r-o ld fema le is brought to the e me rgency d epa rtment by an am bulance after s he
was found colla psed on the street by a bystander. With in a few minutes of arrival she
d eve loped seve re abdominal pain and b ecame seve re ly ag itated.
Her res piratory rate is 35 breaths p er minute, heart rate 110 beats p er minute,
temp erature 39.3°C. Her prothrom bin time a nd activated partial thromboplastin time are
increased, and her fib rinogen leve ls a re lower than normal. Her D-d imer is positive.
Hb 96 gfl
8
Plat elet s 85 109/1
8
WBC 14 109/1
Blood s mea rs a re sent to the laborato ry.
What is most like ly to be seen in the blood smea rs?
Heinz bodies
Bite cells
Dacrocytes
m
Schistocytes
se
As
Ell iptocytes
Dr
Heinz bodies .
f!D
Bite cells C!D
Dacwcytes fD
Schistocytes ED.
Ell iptocytes fD
Schistocytes are seen o n blood smea rs in DIC

Also known as 'consumptive coagulopathy,' DIC is a syndrome in which the coagu lation
cascade is activated to the point in which norma l mechan isms of clotting a re exhausted,
which in turn p roduces unchecked haemorrhage.
Typical ly, haemostasis is mainta ined by mainta ining a ba lance between clot formation (i.e.
coagulation) and b reakdown (i.e. fibrinolys is). Thrombin is produced through the
activation o f the coagu lation cascade . Thrombin converts fibrinogen to fib rin (the fina l
p roduct o f clotting). Fibrinolys is is the b reakdown of fibrinogen and fibrin. In the presence
o f thrombin, a substance called plasmin is generated, b reaking down form ed clots. Fi brin
d egra dation p ro ducts (FDPs) or fibrin spl it products (FSPs) a re produced as a resu lt.
Thrombin plays a key role in hemostasis, in both coagu lation and fibrinolysis.
Patients with DIC can present with a wide range of abnormalities in their laboratory
va lues. Typically, p rolonged coagu lation times, throm bocytopen ia, high levels of fibrin
d egra dation p ro ducts (FDPs), e levated D-d ime r levels, and microangiopathic patho logy
(schistocytes) on peripheral smears are suggestive findings.
The activation of the cascade leads to thrombi formation which causes an accumulation
o f excess fibrin formation in the intravascular circulation. The excess fibrin strands cause
mechan ical damage to the red b lood cells resu lting in schistocyte formation and a lso
thrombo cytopen ia and consumption of clotting facto rs.
A bite cell is an abno rmally shaped red b lood cel l with one o r more semicircular portions
removed from the cell margin. These "bites" result from the removal of denatured
haemoglobin by macrophages in the spleen. Glucose-6-phosphate dehydrogenase
d eficiency (G6PD), in which uncontrolled oxidative stress causes haemog lobin to denatu re
and form Heinz bodies, is a common d iso rder that leads to the fo rmation of b ite cells.
The He inz Bodies a re seen as antigen ic and a re quickly phagocytosed. Because the Heinz
Bodies a re derivatives of haemoglobin, they a re located inside the cell, and thus
phagocytosis takes a s ign ificant "bite" out of the cell.
Dacrocytes (tea rdrop cells) a re usually characteristic of myelofibrosis and seen with
ma rrow d isorders or marrow infiltrations, rea lly because of im p roper production of blood
cells from the bone ma rrow. In post-splenecto my patients, the number of dacrocytes
drastically increases, s ince the spleen cannot remove the improperly formed cells.
Red cells varying in shape from e longated to oval, and rich in haemoglobin, a re ca lled
elliptocytes. They can be seen in hered itary disorders, such as hered itary elliptocytosis, o r
em
in acquired disorders, such as iron deficiency anaemia, infectious anaemias, tha lassaem ia,
s
As
and in newborn babies.

Dr
A 29-yea r-old ma n p resents with a productive coug h, fever a nd p leuritic chest pa in. A
chest x-ray shows loba r co nso lidation and a sp utum culture grows Haemophilus
infiuenzae. This is his fourth chest infectio n in the past seven mo nths. Streptococcus
pneumoniae has been grown from the sputum of the previous three e pisodes. Six-weeks
following the latest infection a full blood count, urea a nd elect rolytes, CRP and chest x-ray
are a ll reported as normal. What is the most app ropriate next investigatio n?
Serum imm unoglobul ins
Sp iro metry
HIV test
Colonoscopy
m
se
As
Urinalysis
Dr
A 29-yea r-old man presents with a productive cough, fever and p leuritic chest pain. A
chest x-ray shows lobar consolidation and a sputum culture grows Haemophilus
influenzae. This is his fourth chest infection in the past seven months. Streptococcus
pneumoniae has been grown from the sputum of the previous three episodes. Six-weeks
following the latest infection a fu ll blood count, urea and e lectrolytes, CRP and chest x-ray
are all reported as normal. What is the most appropriate next investigation?
Serum imm unoglobulins
Spirometry
HIV test
Colonoscopy
This patient has had repeated infectio ns with encapsulated bacte ria which should raise
m
se
the suspicion of immunoglobu lin deficiency. HIV would be suggested by infectio ns
As
associated with im pa ired cel lular immunity.
Dr
A 33-year-o ld woman who is known to have fam ilial hypercholesterolaemia comes for
review. She is planning to have children and asks for advice rega rd ing medication as she
currently takes atorvastatin 80mg on. What is the most appropriate advice?
Switch to atorvastatin l Omg
Continue current drug at same dose
Stop atorvastatin before trying to conceive
Switch to ezetimibe
m
se
As
Switch to simvastatin 40mg
Dr
Switch to atorvastatin l Omg CD
Continue current drug at same dose ED
I Stop atorvastatin before trying to conceive ED

Switch to ezetimibe CD
Switch to simvastatin 40mg m
m
se
Statins shou ld be discontinued in women 3 months befo re conception due to the risk of
As
congen ital defects
Dr
Which one o f the following is in direct anatomica l contact with the leh kidney?
Stomach
Distal part of small intestine
Spleen
Pancreas
m
se
As
Duodenu m
Dr
Stomach
Spleen
Pancreas
m
se
As
Duodenu m
Dr
Which one of t he followin g signif icance test s is used to analyse data which is measured
and follows a norma l distribution?
Chi-squared test
Spearman's ra nk co rrelation coefficient
Wilcoxon matched -pairs
Mann -Whitney test
m
se
As
Stu dent's t -test
Dr
Chi-squared test
Spearma n's rank co rrelation coefficient
Wilcoxon matched-pairs
Mann-'fhitney test
Student's t -test
m
se
Student's t -test is used to analyse pa rametric d ata. The other tests a re used on non-
As
pa rametric d ata
Dr
Which one o f the fo llowin g stimu lates the re lease of ga strin fro m G-cells?
Hista mine
Somatostatin
Ga stric acid
Cholecysto kinin
m
se
As
Luminal pe ptides
Dr
Histamine GD
Somatostatin tiD
Gastric aci d fiD
Cholecystokinin GD
m
se
As
Luminal peptides eD
Dr
Which o f the fo llowing statements is true regardi ng hyponatraemia?
In a dehydrated patie nt with urina ry sodi um < 20mmoi/L it may be due to the
diuretic stage o f re na l fa ilure
SIAD H typically leads to uri ne osmo la lity o f < 500 mmo l/kg
Hyperlipid ae mia may cause pseudohypo natrae mia
Ca rdiac fa il ure a nd live r cirrhos is may lea d to prima ry hype ra ld oste ro nism
m
se
As
It is known to cause a lo ng QT interval
Dr
In a dehydra ted patient with urinary sodium < 20mmoi/L it may be due to the
diuretic stage of renal failure
SIADH typically leads to urine osmolality of < 500 mmol/kg
I Hyperlipidaemia may cause pseudohyponatraemia
Cardiac failure and liver cirrhosis may lead to primary hyperaldosteronism
m
se
It is known to cause a long QT inteNal
As
Dr
A 35 -year-old male presents to the clinic with bilateral pitting oedema, low er limb pain
and tingling in both arms. On examination, ti ny, painless papules were noticed on his
abdomen and a w horl-like co rneal pattern of cream-colou red lines in the patient's cornea.
He has no si gnifica nt past medica l history.
Hb 131 g/ 1 Na• 137 mmol/ 1
Platelets 330 * 109/ 1 K• 4.7 mmol/1
WBC 7.2 * 109/ 1 Urea 12.9 mmol/1
Neuts 3.7 * 109/ 1 Creatinine 150 ~mol/1
Lymphs 1.9 * 109/ 1 CRP 12 mg/ 1
C3 1.49 g/1
C4 0 .3 g/ 1
Anti-nuclear antibodies negative
Anti-neutrophil cytoplasmic antibodies negative
His urine dip showed prot einuria and the 24 hou r pro t ein urine collection was quantified
at 1.8 gram/ day. What is th e most likely diagnos is?
Gaucher's disease
Hypercholesterolaemia
Fabry's disease
Amyloi dosis
sem
As
IgA nephropathy
Dr
Gaucher's disease .
GD
Hypercholestero laemia m
Fabry's disease GD
Amyloidosis f!D
IgA nephropathy f!D
The patient p resented with nephrotic synd ro me and sensory neuropathy bilatera lly in the
arms. Of the above options, Fabry's disease and amylo idosis can p resent as such. The
pa inless papu les on the abdomen are angiokeratomas and the corneal findi ngs are
cha racte risti c of cornea verticil lata, both of which are suggestive fabry's disease. No ne of
the othe r 4 o ptions p resents with such characteristic clinica l s ig ns.
Fabry's disease is an X-lin ked recessive di sord er characterised by abnormal d eposits of a

pa rticular fatty substance called glo botriaosylce ram id e in blood vessel walls throughout
the body. The prima ry defect wh ich a llows th is to occur is the inhe rited deficiency of the
enzyme, a lpha-galactosidase A, which is norma lly responsible for the b reakdown of
glo botriaosylce ra mide.
This abno rmal accumulation of fatty substance resu lts in the na rrowing of b lood vessels
and a whole ran ge of symptoms and signs which include:
• Li mb pa in
• Sensory neuropathy
• Raynaud's disease
• Cardiac arrhythmias, cardio myopathy
• Nephrotic syndrome
• De rmatolog ical manifestation; angiokeratomas, anhidrosis, cornea verticil lata
sem
As
Dr
A 26-yea r-old gent leman has been recently diagnosed with an int racran ial neoplasm. His
fam ily history includes that o f multiple ca rcinomas. These include breast, bone an d co lon
cancer. A d iagnosis o f Li-Fraumeni is suspect ed.
What is the likely gene d efect caus ing this co nd ition?
APC
NFl
p53
wn
m
se
As
BRCAl
Dr
APC CD
NFl CD
I p53
wn
CD
CD
BRCAl fD
The answer is the p53 tumour suppresso r gene.
Li -Frau men i is an autoso ma l d o minant disorder cha racterised by multiple cancers such as
leukaem ias, sarcomas, b rain, breast and adrena l ma lig nancies.
The othe r answers are all tumou r suppressor genes. APC is associated with colo rectal
m
cancer, NFl with neurofibromatosis, WTl with Wilms tumou r, and BRCAl with breast and
se
As
ovarian cancer.
Dr
Yo u have b een asked to investigate the potential benefit of setting up a service to help
patie nts with mu ltiple sclerosis in the loca l area. What is the most impo rta nt facto r when
d etermining how many resources will b e requ ired ?
Incidence
Bayesian facto r
Preva le nce
Denominator da ta
m
se
As
P value
Dr
Incidence f!D
Bayesian factor .
(D
Prevalence CD
Denom inator data .
(D
m
se
As
P value CD
Dr
A 40-year-old woman with rheumatoid arth ritis is diag nosed as having type 1 renal
tubular acidosis. Wh ich one of the fo llowing features is most li kely to be seen as a
consequence?
Hyperkalaemia
Osteomalacia
Decreased b icarbonate reabsorption in the proxim al tubu le
Ra ised an ion gap metabolic acidosis
m
se
As
Nephrocalcinos is
Dr
Hyperkalaemia
Osteomalacia
Decreased b icartionate reabsorption in the proximal tubu le
Ra ised anion gap met abolic acidosis
Nephrocalcinosis
-
""""
Hypokalaemia, nephrocalcinosis -type 1 renal tubular acidosis

m
se
As
Osteomala cia is more commonly seen in type 2 rena l tubu lar acidosis.
Dr
A 37-yea r-old femal e patient p resents to the GP surgery with a 6-months histo ry of joint
pa ins. She reports the jo int pa ins mainly involve the e lbows, knees, j oints in the fingers
a nd toes. She has an erythematous rash cove ring the cheeks, sparing the nasolabia l fold s.
She re po rts the rash was wo rse when she we nt to Spain on ho liday.
What is the most com mon complement deficiency associated with this con dition?
CS-9 d eficiency
CS d eficiency
Cl inhibitor (Cl-INH) p rotein d eficiency
C3 d eficiency
m
se
As
Clq, Clrs, C2 a nd C4 deficiency
Dr
CS -9 d eficiency
CS d eficiency
-
"""'
Cl in hibito r (Cl-INH ) p rote in d eficie ncy
C3 deficiency
Clq, Clrs, C2 and C4 deficiency

-
~
Deficiency in Clq, Clrs, C2 and C4 p red isposes to immune complex disease such as
SLE
This lady has sig ns o f systemic lupus (SLE). Deficiency in Clq, Clrs, C2 and C4 predisposes
to immu ne com p lex d isea se such as SLE.
CS -9 pre disp oses to Neisseria meningitidis infections.
C3 d eficie ncy causes recu rrent ba cteria l in fections.
CS d eficie ncy pre d isposes to Leine r d isease
m
se
As
Cl inh ibito r (Cl-IN H) p rotein d eficiency causes he reditary a ng ioed ema.
Dr
A 42-yea r-old male patient p resents to the GP surgery with a 6-months history o f
prog ressive weakness of both lower limbs. He complains of difficulty climb ing stairs,
lethargy and muscle loss in the lower limbs. He had a history of type 2 diab etes mellitus
a nd ad mits to heavy alco hol use fo r the last 4 years. On exa mination, the re is a ma rked
loss of fine touch and p roprioception in a stockin g d istribution bilatera lly. There is no
evidence of ataxia.
What is the likely diag nosis?
Wernicke's encep halopathy
Wet beriberi
Pellag ra
Dry beriberi
m
se
As
Ab etal ipoproteinaem ia
Dr
Wernicke's encephalopathy «!D
Wet beribel flD
Pellag ra (D.
I Dry beriberi CD
Abetalipoproteinaemia GD
Dry beriberi is caused by thiamine d eficiency and causes peripheral neuropathy

This patient has a rapid ly prog ressive p olyneuro pathy. Given the alcohol histo ry, the most
likely diagnosis from the options is dry b eriberi, caused by thiam ine d eficiency.
Wernicke's encephalopathy is a lso caused by th iam ine deficiency but it d oes not usually
involve p eripheral neuropathy.
Wet beriberi is another manifestation o f thiamine d eficiency but it causes heart fa ilure.
Pellagra is caused by vitam in B3 deficiency wh ich causes dermatitis, d ementia and

dia rrhoea.
Abeta lipoproteinaemia is caused by vitam in E d eficiency which can present with m

se
periphera l neuropathy and cereb ellar ataxia . The absence of ataxia here makes dry
As
beribe ri more likely.

Dr
A 70-year-old male presents for advice regarding hyperlipidaemia. In the recent past he
has trialled diet modification and exercise. He has a past history o f hypertension and Type
2 diab etes, and his medications incl ude aspirin, perindopri l and metformin. He has a
family history o f his brother and mother having a coronary artery bypass grafti ng.
Tot al cholest erol 5 {Normal < 5.2)
LDL cholest erol 2.5 {Normal <3.5 )
HDL 1.1 {Normal >1 )
Triglycerides 2.3 (Normal < 1.5)
Which wou ld be the most appro priate management choice to reduce his risk o f
cardiovascular events?
Cholestyramine
Atorvastatin
Ezetimibe
Gem fibrozil
m
se
As
Omega 3 fatty acids Dr
--
Cholestyram ine CD
Atorvastatin 6D
Ezetimibe flD
Gem fib rozil flD
Omega 3 fatty acids CD
The patient has an isolated hypertriglyceridaemia and significant cardiac risk facto rs. This
is what the question is trying to demonstrate. While fibrates a re well known to b e
effective aga inst hypertriglyceridaemias, his risk facto r burden is enough that a statin
(which is also functional on triglyceride levels, not just LD Ls) is the first cho ice in this
s ituation. In particular, fibrates have not been shown to reduce card iovascular events in
the p resence o f d iabetes, while statins have.
Thus, an isolated hypertriglyceridaemia in the p resence o f sign ificant cardiovascu lar risk
m
se
factors, in a patient not currently on a statin, s hould be managed with the introduction of
As
a statin.
Dr
A 25-year-old man p resents t o end ocrinolo gy clinic for review. He has b een ref erred with
a sodium of 130mmoi/L. He feels well in himself an d d enies any systemic symptoms and
specif ically has no head aches or neurolog ical symptoms. He has been pass ing normal
volumes of uri ne. He has a past medical hist ory of familial hypercholest erolemia and is
under review by a metab olic team as he still has a t ot al cho lesterol of 9.lmmoi/L. Paired
osmolalities are normal. Uri ne dipstick t est is normal. His examination is largely normal
apart from eviden ce of xanthomas. U&E, FBC, LFTs are normal. What is the most likely
diagnosis?
Pseudohyponatraemia
Nep hrog enic SIADH
Cranial SIAD H
Diabet es in sip idus
m
se
As
Type two diab etes mellit us
Dr
Pseudohyponatraemia
Nephrogen ic SIADH
-
~
Cranial SIADH
Diabetes insipidus
Type two diabetes mellitus
The correct answer is pseudo hyponatraemia. This is a patient with clinical and
bioche mical evidence of very high cholesterol levels in addition to his mild
m
se
hyponatraemia. The normally paired osmolalities exclude SIADH and diabetes insipidus,
As
whilst the absence of glucosuria makes diabetes an unlikely cause.
Dr
A 46-year-old female is referred to the dermatologist for a rash on b oth her elbows. The
rash is red, is papulovesicu lar in nature, and looks like it has many small blisters. The
dermatolog ist diagnoses her w ith dermatitis herp etiformis. Wh ich HLA haplotype is th is
associated w ith?
HLA-A3
HLA-85
HLA-DR3
HLA-DR4
m
se
As
HLA-827
Dr
HLA-A3 CD
HLA-85 fi!D
HLA -DR3 eiD
HLA-DR4 f1D
HLA-827 CD
Dermatit is herpeti form is is associated with H LA-DR3

Dermatitis herpetiformis is an autoimmune condition associated with HLA-DR3.
HLA-A3 is associat ed w ith haemochromatosis. HLA-85 is most commonly associated with

8ehcet's disease. HLA-DR4 is associated with both type 1 diabetes mellitus and
m
se
rheumat oid arthritis. HLA-827 is most commonly associat ed wit h several diseases, most
As
commo nly ankylosing spondylitis.
Dr
An 18-year-old man is seen in the infect ious diseases clinic some 6 weeks after admission
t o the Emergency department with meningococca l meningit is. Th is was co nfirmed on
lumbar puncture and represented his second ep isod e of meningitis over t he last 6
months. He has no other past medica l hist ory and takes no regu lar medicat ion.
Which of t he follow ing is most likely to be d eficient?
Cl
C3
C4
cs
m
se
As
CD59
Dr
Cl CD
C3 GD
C4 .
(D
cs e:D
CD 59 GD
CS is cleaved into CSa and CSb, CSa is involved in che motaxis, a nd CS b fo rms the first p art
o f the membrane attack complex. Deficiencies of the membrane attack co mplex, (CS -C9)
a re pa rticularly associated with meningococcal infection. CS activatio n may also have a
role in prog ression of fibrotic live r d isease.
Deficiencies o f the Cl com plex are recognised to b e closely associated with the
d eve lopment of system ic lupus e rythematosus. C3 d eficiency is associated with a
p red is position to infection with ca psulated bacte rial infections such as pneumococcus
a nd Haemop hilus which begi ns q u ite soon after birth. C4 deficie ncy is ra re a nd is
associated with ea rly o nset system ic lup us erythematosus. CD59 deficie ncy is invo lved in
m
the pathogenes is of pa roxysma l nocturnal haemoglo bi nuria.
se
As
Dr
A 90-year-old man is admitted to hospit al. He is taking no regular medication. On
admission his blood pressure is 170/68 mmHg. Wh ich one of the follow ing is the main
factor w hich account s for the large pulse pressure?
Calcified brachial arteries
Autonomic dysfunct ion
Reduced aortic compliance
m
Reduced left ventricular ejection fraction
se
As
Reduced circulating volume
Dr
Calcified brachial arteries
Autonomic dysfunction
Reduced aortic compliance
Reduced left ventricular ejection fraction

J
m
se
As
Reduced circulating volume
Dr
Yo u a re working in ge ne ral medicine. You a re on the wa rd rou nd a nd see a 40-year-old
patient who has been adm itted with a very swollen a nd painful right knee. He was unable
to walk on it so came into hosp ital. It is cu rre ntly b eing treated as g out with no n steroid al
anti-inflammatory drugs. You no tice he is of short sta tu re, has sho rte ned a rms and legs
and a flat nasal brid ge. A mutation in which gene is re spons ible for this condition?
Fibro blast growth fa ctor recepto r
Vascular e ndothelial growth factor receptor
Mesodermal growth factor receptor
Epiderma l growth facto r receptor
m
se
As
Tyrosin e kinase recepto r
Dr
I Fibroblast growth factor receptor
Mesodermal growth facto r receptor
Ep iderma l growth factor receptor
Tyrosine kinase receptor
The condition d escribed is achondroplasia. This is due to a ga in of function mutation in

the FGFR3 (fib roblast growth factor receptor) gene. It is an autosomal dom inant
condition.
The vascular endothelial g rowth factor receptor is inhibited by certain monoclonal

antibod ies in so me cancers and in wet macula r degeneration by bevacizumab injections.
m
se
The e pid e rmal g rowth factor receptor and tyrosine kinase receptor a re again inh ibited by
As
certain anti-cancer d rugs. The mesode rmal growth facto r receptor is made up.
Dr
A 36-yea r-old woma n presents with a 3 week history o f wea kness worse at the end of the
d ay. In pa rticular she noti ced difficulty getting out of her chai r in the even ing. Her
husba nd has noticed that whilst driving at nig ht s he complains of d ifficulty keeping he r
eyes open, d esp ite not bei ng tired .
On examination you note a b ilatera l facia l nerve weakness, complex ophthalmo pleg ia and
symm etrica l proximal powe r loss (M RC power 4/5). Upon repetitive stimulation of
movements fatigab ility is noted .
What Gell a nd Coo mbs hypersens itivity class is she li kely to be suffe ring from?
Type 1
Type 2
Type 3
Type 4
m
se
As
Type 5
Dr
Type 1 m
Type 2 (D
Type 3 GD
Type 4 (D
Type 5 ED
The patient is a young female presenting with a p roxima l myopathy with complex
ophtha lmopleg ia with evidence of fatigability. This p ictu re is classic fo r myasthenia g ravis.
m
se
An autoimmune disease caused by antibodies to acetylcholine nicotin ic postsynaptic
As
receptors.
Dr
A 34-year-old female is referred to the oncologist due to a susp icion of lymphoma. She
has suffered from a fever and night sweats. Moreover, she has previously suffered from
glandular fever. On examination, her cervical lymph nodes are swollen. She und ergoes a
lymph nod e biopsy wit h st aining for a cell surface marker. This reveals the presence of
Reed -Ste rnberg cells, confirming a diagnosis of Ho dgkin's lymphoma. Wh ich cell surface
marker is associated with Reed-Sternberg cells?
CD3
CD4
CDlS
CD16
m
se
As
CD21
Dr
CD3 CD
CD4 C!D
I CD15 ED.
CD16 CD
CD21 mt
CD15 is found on Reed-Sternberg cells

CDlS is found on Reed-Sternberg cells. Reed-Sternberg cells are found in those with
Hodgkin's lymphoma.
m
se
CD3 is found on all T cells . CD4 is found on T helper cells. CD16 binds to the Fe portion of
As
IgG. CD21 is the receptor for the Epstein-Barr virus.
Dr
A 54-yea r-old woman with a history of rheumatoid arthrit is p resents w ith a one week
history of b loody d iarrhoea. This has been associated with fever and abdominal pain. Her
rheumatoid is normally well controlled with methotrexate. A stool sample is sent which
shows Campylobacter jejuni. What is t he most appropriate management?
Fluids alone
Fluids + metroni dazole
Fluids + ciprofloxacin
Fluids + clarithromycin
m
se
As
Fluids + mebendazole
Dr
Fluids alone
Fluids + metronidazole
Fluids + ciprofloxacin
r Fluids + clarithromycin
Fluids + mebendazo le
This lady is immunocomprom ised on methotrexate and a severe infection (fever, bloody
m
se
diarrhoea and prolonged history). She should therefore b e given an antibiotic. The BNF
As
advise clarithromycin first-line.
Dr
A new b lood test is developed to screen for prostate cancer. Trials have shown it has a
sensitivity for detectin g clinically significant p rostate cancer of 80% but a specificity of
60%. What is the likelihood ratio for a positive test result?
Cannot be calculated
0.8
m
se
As
0.2
Dr
Cannot b e calculated GD
2 ED
4 flD
0.8 tiD
0.2 flD
Li kel ihood ratio fo r a positive test result = sensitivity I (1 - sp ecificity)

Li ke lihood ratio fo r a positive test resu lt = sensitivity I (1 - sp ecificity)
m
se
As
= 0.8 I (1 - 0.6) = 2
Dr
Yo u are performing a study of blood pressu re rea d ings in patients with chroni c kid ney
disease. Assuming that the results a re no rmally d istributed, what p ercenta ge of va lues lie
within two standa rd deviatio ns of the mean blood p ressure read ing?
95.4%
5.3%
98.3%
10%
m
se
As
97.5%
Dr
95.4% (D
5.3% m
98.3% fi!D
P I% CD
m
se
As
97.5% f!D
Dr
A 43-year-old man requests a 'medical' as he is concerned about his risk of heart disease.
His father died at the age of 45-years follow ing a myocardial infarction. His lipid profile is
as fo llows:
HDL 1.4 mmoljl
LDL 5.7 mmoljl
Triglycerides 2.3 mmoljl
Total cholesterol 8 .2 mmoljl
Clinical examination reveals tendon xanthomata around his ankles. What is the most likely
diagnosis?
Familial hypercho lesterolaem ia (heterozygous)
Nephrotic syndrome
Mixed hyperl ipidaemia
Familial hypercho lesterolaemia (homozygous)
m
se
As
Hypothyroidism
Dr
Familial hypercho lesterolaemia (heterozygous)
Nephrotic syndrome
Mixed hyperlipi daemia
Familial hypercholesterolaemia (homozygous)

-
"""'
Hypothyroidism
The presence of tendon xanthomata and cholesterol levels meet the diagnostic criteria for
m
se
fam ilial hypercholesterolaemia. Homozygous familial hypercholesterolaemia is
As
exceedingly rare - most patients die in their t eenage years from a myocardial infarction.
Dr
An inte rcalating medica l student co nducts a case-contro l study for her dissertation,
exam ining the life-long exposu re to marijuana in g roups of patients with and without
COPD.
What form of bias is this study type most at risk of?
Detection bias
Observer bias
Publication bias
Reca ll bias
m
se
As
Response bias
Dr
Detection bias GD
Observer b ias GD
Pub lication bias GD
Reca ll b ias ED
Response b ias ED
Reca ll bias is a particu la r proble m in case-contro l studies

All doctors must p ractice evidence- based medicin e, as outlin ed by the GMC. This means
that it is crucia l fo r all docto rs to have an understand ing of how to criti ca lly a ppraise a
pap er, which invo lves d etecting potential sources of bias in the pape rs that you read . This
is something that is com monly tested in med ical school finals.
Case-contro l studies are particula rly susceptible to recall bias, as those with COPD may
re late their cond ition to their previous marijuana use and a re there fore more likely to
remem be r whether or not they have used ma rijuana in the past (and the extent o f their
previous use) than the patients in th e control g rou p who do not have CO PD.
• Detection bias: Outcomes are sought afte r more in one g rou p than in another
• Observer bias: There is observer subjectivity about the outcome
• Publication bias: Studies that report negative findings are less likely to be pub lished
• Recall bias: Patients a re mo re like ly to recall exp osures that they believe a re re lated
to the outcome
• Response bias: Those who resp ond to a q uestionnaire I vo lunteer for a trial are not
em
re presentative of the pop ulation

s
As
Dr
You a re desig ning a resea rch project looking at the sensitivities an d specificities of va rious
markers in re lation to myoca rdia l necrosis. Specifica lly you want to assess the mo lecu le
which tropo nin C b ind s to.
Which molecu le will you study in your research project?
Calcium ions
Tropomyosin
Actin
Myosin
m
se
As
Sa rcoplasmic reticulum
Dr
I Calcium ions
Tropomyosin
r:tin
Myosin
Sarcoplasmic reticulum
Troponin C binds to calciu m ions

Important for me l ess im:>crtant
Troponin C is res ponsible for binding calcium to activate muscle contraction. Tro ponin C
is released due to both skeletal and cardiac muscle damage resulting in poor specificity as
a marker for myocardial necrosis.
Troponin T binds to tropomyosin, form ing a troponin-tropomyosin complex. It is a

specific marker fo r myocardial necrosis.
Troponin I binds t o actin to hold the troponin-tropomyosin complex in place. It is a

specific marker fo r myocardial necrosis.
Myosin is the thick component of muscle fibres. Actin slides along myosin t o generate
muscle contractio n. em
The sarcoplasmic reticu lum regulates the calcium ion concentration in the cytoplas m of
s
As
striated muscle cells.

Dr
A 25-year-old man who has been morbidly obese for the past five years is reviewed in the
endocrinology cl inic. In this patient, which one of the following hormones would increase
appetite as levels increase?
Leptin
Thyroxine
Ad iponecti n
Ghrelin
m
se
As
Serotonin
Dr
Leptin .
ED
Thyroxine .
(D
Ad iponectin fD
Ghrelin eD
Serotonin fD
Obesity hormones
• l eptin Lowers appetite
• Ghrelin Gains appetite
m
se
Whilst thyroxine can increase appetite it does not fit w ith the clinical picture being
As
described
Dr
The average weight loss of a patient following a new type o f bariatric surgery is 18 kg. The
standard deviation o f weight loss is 3kg. Assuming the weight loss is normally distributed,
what percentage of patient s w ill loss between 9 and 27 kg?
97.4%
95%
95.4%
68.3%
m
se
As
99.7%
Dr
97.4% f!D
95% .
(D
95.4% f!D
68.3% GD
99.7%
I
ED
m
se
99.7% of values of a normally distributed variable lie within 3 standard deviations of the
As
mean.
Dr
A 7-week o ld male baby is referred to the paediatric clinic by the GP. The mothe r is
concerned that he has poor movement in his arms and legs and still unable to hold his
head up. She is a lso concerned as she feels that he is not seeing as we ll as she thinks a
baby this ag e should. They both immigrated to this cou ntry from Bangladesh 2 weeks ago
a nd she has not seen any of the healthcare p rofess ionals yet. Her pa rtner, the baby's
father, is her first cous in. There is a family history of d eath in early childhood but she
d oesn't re member the detai ls. On exa mination, the re is min imal head contro l and poor
power in all limbs. Fund oscopy revea ls che rry red sp ots on the macu la. There is no
hepatomeg aly or sp lenomegaly.
McArd le's d isease
Gaucher's d isease
Niemann -pi ck d isea se
Tay-Sachs disease
m
se
As
Fabry disease
Dr
McArdle's d isease
Gaucher's disease
Niemann-pick d isease
Tay-Sachs disease
Fabry disease
-
~
Tay-Sachs disease typica lly prese nts with deve lo pmenta l d elay a nd che rry red sp ot
o n the ma cula, without hepatomegaly o r sp lenomega ly
Tay-Sachs disease is a type of lysosomal storage disease which typically presents with
developmental delay and cherry red spot on the macula, without hepatomega ly or
splenomegaly. This is in co ntrast to Niema nn-p ick disease which can also p resents with
cherry red spot on the macula but with hepatosplenomega ly.
McArd le's d isease is a glycogen storage disease which presents with mya lgia and
myoglobinuria with exercise.
Gaucher's disease is a type of lysosomal storage disease which p resents with massive
splenomegaly.
m
se
Fabry's disease is a type of lysosomal storage disease wh ich has features including
As
angiokerato mas, peripheral neu ro pathy and rena l failure.

Dr
Yo u are reviewing the blo od results for a patie nt who was sta rted o n a torvastatin 20mg
on for prima ry preve ntion 3 months a go:
R&ent 3 months ago prior to starting treatment
Total cholesterol 4.2 mmoljl 6 .3 mmol/1
HDL cholesterol 1.1 mmoljl 1.0 mmoljl
Non-HDL cholesterol 2.1 mmoljl 4.0 mmol/1
Triglyceride 1.2 mmol/1 1.3 mmol/1
Liver function tests are no rma l.
What is the most a p propriate co urse o f action?
Reduce atorvasta ti n to l Omg on
Make no cha nges to med ication
Increase atorvastatin to 40mg on
Check c reatine kinase
m
se
As
Check comp liance Dr
Reduce ato rvastatin to 10mg on
r :ke no changes to medication
Increase atorvastatin to 40mg on
Check creatine kinase
Check complia nce

-
~
NICE look for a 40% reduction in non- HDL cho lestero l after 3 months. A 10% reduction in
m
a non-HDL cho lestero l of 4.0 would be 0.4 so a 40% reduction would take it down to (4.0
se
- 1.6 = 2.4 mmol/1). This patients no n-HDL cholestero l of 2.1 mmol/1 is therefo re
As
acceptable.
Dr
A study measu res a patients serum cholestero l before and aher a new lipid-l owering
therapy has been given. What type of significance test shou ld be used to a nalyse the
data?
Student's pa ired t-test
Student's unpa ired t-test
Chi-squared test
Pea rson's test
m
se
As
Spea rman test
Dr
Chi-squared test
Pearson's test
-
~
m
se
As
Spea rman test
Dr
A 15-yea r-old g irl presents with an urticaria l rash, angioed e ma and wheezing . Her mother
states that she has just come fro m her you nger s ister's party where she had been help ing
to blow up ball oons. What is the most like ly d iagnosis?
Cl-esterase d eficiency (hered itary an gioed ema)
Alle rgic contact d ermatitis
Pea nut a llergy
Latex allergy
m
se
As
Irritant co nta ct dermatitis
Dr
Cl-esterase d eficiency (hered itary angioedema)
All rgic contact dermatitis
Peanut allergy
I Latex alle rgy
Irritant contact dermatitis
Type I hypersensitivity reaction - anap hylaxis

Important for me Less 'mocrtant
m
se
This is a typical history of latex al lergy. Adrenaline s hould be g iven im mediately and usua l
As
anaphylaxis ma nagement followed
Dr
A 28-yea r-old man is ad mitted to the Emergency Depa rtment with dyspnoea and fever.
Two d ays ago he deve lop ed an itchy, vesicu la r rash a fte r coming into contact with a child
who had ch icken pox. On exam ination his temp erature is 38.6°C, resp irato ry rate 24 I min,
pulse 120 I min and blood pressure 135168 mmHg. Oxygen satu rations a re 95% on room
a ir. Exam ination of chest reveals on ly occasional fine crackles bilatera lly. What is the most
im portant intervention?
Elective intubatio n within the next 2 hours
Prednisolone
Varicella zoster imm unog lob ulin
IV aci clovir
m
se
As
Pa racetamol
Dr
Elective intubation within the next 2 hours
I Prednisolone
Varicella zoster immunoglobulin

-
.......,
F ciclovir
Paracetamol
Varicella pneumonia is the most common and serious complication of chickenpox

infection in adults. Auscultation of the chest is often unremarkable. Varicella zoster
m
se
immunoglobulin is used for the prevention of va ricella in at- risk groups (e.g.
As
Immunocomprom ised, pregnant women), rather than for treatment
Dr
The nicotinic acetylcholine receptor is an example of a:
Ligand -g ated ion channel
Guanylat e cyclase receptor
G p rotein -cou pled receptor
m
se
As
Intracellular recept or
Dr
I Ligand-gated ion channel
Guanylate cyclase receptor
G p rotein-coupled receptor
m
se
Nicotinic acetylcholine - ligand -gated ion channel receptor
As
Dr
A 22-year-old man present s w ith difficu lties sleeping. He states that as he is falling to
sleep he d evelops an unpleasant sensation and j erk w hich often causes him to awaken
sud denly. They are occu rring a few times a week and he is concern ed t hey may be due to
a serious und erlying di sord er.
What stage of sleep does t his p henomenon occu r?
Awake
Non -REM st age 1 (N l )
Non -REM st age 2 (N2)
m
se
As
REM
Dr
Awake CD
I Non-REM stage 1 (Nl)
Non -REM stage 2 (N2)

CD
(fD
Non -RE M stage 3 (N3) GD

REM tiD
Non -RE M stage 1 (N l ) sleep is the lig htest sleep which is a ssociated with
hypnagog ic je rks
A hypnago gic jerk is a type of myoclonus. It causes an invo luntary twitch which occurs
when a person is beginning to fall asleep, ohen causing them to jump and awaken
suddenly for a moment. They occu r in non-REM stage 1 (Nl) sleep -the lightest sleep
stage. There is a wide range of potential causes, inclu ding anxiety, caffeine, stress and
strenuous activities in the evening. However, most hypnagogic je rks occur as a no rm al
variant.
REM sleep d isorders are associated with lucid drea ming and the absence of the normal
m
se
atonia during th is stage of sleep. This can resu lt in patients acting out the ir dreams and
As
causing themselves and o thers physical harm .
Dr
A 43-yea r-old gentleman has returned back to the UK 2 weeks ago fo llowing a trip to
Africa. He attends his GP complai ning of a feve r, chi lls and a bite on his left hand . On
close inspection, you can see a l xl.Scm dark b lack crust over th e s ite.
What is the most li kely underlying o rganism?
Rickettsial conorii
Borrelia burgdorferi
Bartonella henselae
m
se
As
Mycobacterium leprae
Dr
Rickettsial conorii ED.
Streptococcus pyogenes CD
Borrelia burgdorferi eD
Bartonella henselae GD
Mycobacterium leprae GD
Rickettsia l infections can occu r on s ix continents, a lthough the clinical presentation may
vary between each o f them. As a rule, they tend to present with a combination o f rash,
headaches, and eithe r single or multiple eschars. The clue here is the presence of an
eschar which s hould lead you to consider the diagnosis a lon g with a history of recent
foreign trave l.
Borrelia burgdorferi and Bartonella henselae are the causative organisms of Lyme d isease
m
se
and cat-scratch fever. Mycobacterium leprae presents more with insensate patches and
As
wasting as it progresses.
Dr
Which one of the following immunoglobulins is invo lved in the activation of B-cells?
IgD
IgM
IgE
IgG
m
se
As
IgA
Dr
IgD ED
IgM 6D
IgE fD
IgG fiD
IgA m.
m
se
IgD is involved in the activation of B-cells
As
Dr
A 23 -year-old gentleman is referred to the respiratory cl inic with a possible diagnosis of
bronchiectasis. He has been suffering from recurrent chest infections his entire life and
has also struggled to maintain a healthy weight. He has no smoking history and no
notable family history. He has tried inhalers but th ese have had no noticea ble effect. He is
suspect ed of having cystic fibrosis and genetic t ests are sent for analysis.
What is the normal function of the cystic fibrosis transmembrane regulator?
Signalling molecule
Water channel
Potass ium channel
Chloride channel
m
se
As
Sodium channel
Dr
Signalling molecule
Wat er channel
•m
Potassium channel
Chloride channel
•
GD
Sodium cha nnel GD
The correct answer is chlorid e channel, sp ecifically a cyclic-AMP regulated ch lorid e

channel. There are many different mutations w hich can cause cystic f ibrosis but they all
disru pt the same gene, the cyst ic f ibrosis transmembrane conductance regulator gene.
m
se
This is a chloride channe l which when not f unction ing lea ds to increased viscosity of
As
secretions, which leads to the p athology o f cyst ic fibros is.
Dr
A 67 -year-old man with type 2 diabetes mellitus is receiving his annual diabetic check. He
is feeling more fatigued than usual. He has not attended his previous three annual check-
ups. His blood glucose control has been poor and he has not been comp liant w ith his
medications. Blood pressu re is 170/90 mmHg. Urinalysis shows microalbuminuria. A
blood test reveals his glomeru lar filtration rate (GFR) is 27ml/min per 1.73m 2 •
If a renal biopsy was to be performed in this patient, what wou ld be the expected
findings?
Nodu lar glomerulosclerosis and hyaline arteriosclerosis
Apple-green birefringence under polarised light
Enlarged and hypercellular glomeruli
Crescent moon shaped glomeruli
m
se
As
Wirelooping of capillaries in the glomeruli
Dr
Nodular glomerulosclerosis and hyaline arteriosclerosis
Apple-green birefringence under polarised light
Enlarged and hypercellular glomeruli
Crescent moon shaped glomeruli
Wirelooping of capillaries in the glomeruli
Diabetic nephropathy histological findings- Kimmelstiei-Wilson lesions, nodular

g lomerulosclerosis
This patient has a poorly controlled T2DM w ith an underlying diabetic nephropathy. The
histological findings are Kimmelstiei -Wilson lesions (nodular glomeru losclerosis) and
hyaline arteriosclerosis. Th is is due to nonenzymatic glycosylation.
Apple-green birefringence under polarised light is seen in amyloidosis.
Enlarged and hypercellular glomeruli is seen in acute post-streptococcal

glomerulonephritis.
Crescent moon shaped glomeruli is seen in rapidly progressive (crescentic)

glomerulonephritis.
em
Wire looping of capillaries in the glomeruli is seen in diffuse proliferative

s
As
glomerulonephritis (often due to SLE).

Dr
A 25-yea r-old female patient presents to the e mergency de partment with a 2-d ay history
of bloody d ia rrhoea and abdo mina l pain. She was adm itted under the med ica l team fo r
intravenous rehydration the rapy. The next d ay, she d eve loped gene ral oedema with
sudden drop in her urine output. An urgent b lood sample was sent with the results below.
Hb 9.0 g/dl
urea 30 .3 mmoi/L
Creatinine 28S~moi/L
Peripheral blood film presence of schistocytes
What is the likely infectio n causing this clinical picture?
Salmo nella
Shigella
Campylobacter
E.coli 0157: H7
m
se
As
Cholera
Dr
Salmonella m
Shigella CD
Cam pylobacter CD
I E.coli 0157: H7 GD
Cholera m
E.coli 0157: H7 is the strain caus ing haemolytic uraemic syndrome

The clinical picture suggests the haemolytic u raemic syndrome. The patient has a
comb in ation of bloody diarrhoea, acute rena l failure w ith a high urea and haemolyti c
anaemia (as confirmed by t he p resence of sch istocytes). E.coli 0157: H7 is t he strain
causing haemolytic uraemic syndrome.
Salmonella, sh igella and campylobacter can cause b loody diarrhoea b ut d o not commonly
cause haemolytic anaemia.
m
se
As
Cholera is no t a cause o f b loody diarrhoea.
Dr
A 31-yea r-old wo man is diagnosed with fam ilia l hypercholestero laemia. Genetic testing
shows that she is heterozygous fo r the condition. You discuss the possib ility o f screening
he r relatives. What is the chance he r brother will a lso be affected?
50%
66%
25%
100%
m
se
As
0%
Dr
50% ED
66% fD
25% CD
100% GD
0% .
(D
Familia l hypercho lestero laem ia is an autosomal d om inant condition

As fam ilia l hypercho leste ro laemia is an autoso ma l d o minant condition 50% of the first-
m
se
d egree re latives of heterozygotes will be affected. Please see the Pl oS link for more
As
d etails.
Dr
A 45-yea r-old fema le with poorly contro lled rheumato id arthritis attends a rheumato logy
a ppointment. She is started on a new medication called anakinra, a n IL- l receptor
a ntagon ist. Which cell is responsible for the p roduction of IL-1?
Neutrophils
Basophi ls
Eosino phils
T cells
m
se
As
Macro phages
Dr
Neutrophils 6D
Basophils m
Eosinophils m
T cells CD
Macro phages ED
The main sou rce of iL-1 is macrophages

IL-l, an acute inflammatory cytokine, is mostly produced by innate immune cells. Within
the innate imm une system, macro phages are responsible for the production of cytokines,
m
se
includ ing IL-l. Basophils, Neutrophils and Eosinoph ils all produce proinflammatory
As
cytokines but in lower volumes than macro phages. T cells don't produce IL-l.
Dr
A 12-year-old child co mes into the GP clin ic with her mother due t o a sore throat and
f ever. On examination, the GP diagnoses the patient w ith viral tonsillitis and recommends
paracet amol t o alleviat e the fever. Her mother is cu rious as to how her daughter will fight
off the inf ection. Which cytokine is responsible for differentiating ThO cells to Thl cells?
Tumour necrosis factor-a
Interferon-y
I L-12
I L-4
m
se
As
IL-5
Dr
A 12-year-old child comes into the GP cl inic w ith her mother due to a sore th roat and
fever. On examination, the GP diagnoses the patient with viral t onsillitis and recommends
paracetamo l to alleviate the fever. Her mother is curious as t o how her daughter will fight
off the infecti on. Which cytokine is responsible for differentiating ThO cells to Th1 cel ls?
Tumour necrosis factor-a
Interferon-y
~12
-
~
IL-4
IL-5
I L-12- main functions include: stim ulat es differentiation of naive T cells into Th1
cells
IL-12 is res ponsible for the differentiation of ThO cells to Th1 cells. Interferon-y is
produced by Th1 cells and is not responsible for the differentiation. IL-4 stimulates
m
se
differentiation of ThO cells to Thl ce lls. I L-5 is secreted from Th2 cells. Tumour necrosis
factor-a is a proinflammatory cytokine not involved in the adaptive immune response. As
Dr
Which one o f the following statements regarding mitochondrial inheritance is true?
Fried reich's ataxia is caused by defects in mitochondrial DNA
There is a 50% chance that the female o ffspring of an affected ma le will inherit the
disease
Affected fe ma les cannot pass on the d isease
Most cases of spinocerebella r ataxia are caused by d efects in mitochond rial DNA
m
se
As
Poor genotype:phenotype corre lation
Dr
Fried re ich's ataxia is caused by d efects in mitochondria l DNA
There is a 50% chance that the female offspring o f an affected male will inherit
the disease
Affected fema les cannot pass on the disease

I
Most cases of sr inocere be llar ataxia are caused by d efects in mitochond rial DNACD
m
se
As
Poor genotype:phenotype correlation
Dr
During cell division, at what stage do sister chromatids move to opposite ends o f the cell?
Prometaphase
Metaphase
Anaphase
Telophase
m
se
As
Cytokinesis
Dr
Prometaphase m
Metaphase .
f!D
~a phase CD
Telop hase 6D
Cytokinesis CD
During mitosis, sister chromatids move to opposite ends o f the cell during
anaphase
Anaphase is spl it into 2 parts:

• anaphase A: cohes ins that bind sister chromatids together are cleaved, fol lowed by
shortening of the kinetochore microtubules which pulls the daughter chromosomes
to opposite ends of the cell
m
• anaphase B: polar microtubu les push aga inst each other, causing the cell to
se
As
elongate
Dr
In the Gell and Coombs class ification of hypersensitivity reactions id iopathic
thro mbo cytopen ic purpura is a n exa mple of a:
Type I reaction
Type n rea ction
Type mreactio n
Type N rea ct io n
m
se
As
Type V reaction
Dr
Type I reaction CD
I Type II reaction ED
Type Ill reaction 6D.
Type N reaction f.D
Type V reaction m
m
se
Type II hyperse nsitivity reaction - ITP
As
Dr
What is the main constituent o f pulmonary surfactant?
Apolipoprot ein SP-B
Phosphatidylglycerol
Pulmonary elast ase
Ap olipoprot ein SP-A
m
se
As
Dipalmitoyl phos phatidylcholine
Dr
Pulmonary su rfactant - main constituent is dipalmitoyl phosphatidylcholine
m
se
(DPPC)
As
Important for me l ess :mpc rtont
Dr
Cystic fibros is is due to a defect in the cystic fibrosis t ransmembra ne conductance
regulator (CFTR) gene. Which chromosome is this gene located on?
Chromosome 3
Chromosome 7
Chromosome 11
Chromosome 14
m
se
As
Chromosome 15
Dr
Chromosome 3 CD
Chromosome 7 6D
Chromosome 11 CD
Chromo some 14 GD
m
se
As
Chromosome 15 CD
Dr
Which one o f the following syndromes is associated w ith an increased risk o f Crohn's
disease?
Tu rner's syndrome
Down's syndrome
Fragile X syndrome
Patau syndrome
m
se
As
Edward's syndrome
Dr
Turner's syndrome ED
Down's syndrome f1D
Fragile X syndrome CD
Pat au syndrome flD
m
se
As
Edward's syndrome GD
Dr
The atrial natriuretic peptide receptor is an example of a:
Guanylat e cyclase receptor
G p rotein -cou pled receptor
m
se
As
Dr
Ligand -gated ion channel
Intracellular receptor
Guanylate cyclase receptor
G p rotein-cou pled receptor
m
se
Atrial natriuret ic factor - guanylate cyclase receptor
As
Dr
Which one o f the followin g is true regardin g bacteria l exotoxins?
They a re mainly p roduced by Gram positive bacteria
Cholera toxin inhibits cAMP re lease in intestinal cells
Diphthe ria toxin necrosis is limited to the pharynx, nasopharynx and tonsils
Staph. aureus exotoxins a re not known to cause gastroenteritis
m
se
'Lockjaw' seen in tetanus is secondary to blockade of the neu romuscu la r junctio n
As
by Botulinus toxin
Dr
They a re mainly p rodu ced by Gram pos itive bacteria
Cholera toxin inhib its cAMP re lease in intestina l cells
Diphtlie ria toxin necrosis is limited to the pharynx, nasopharynx and tonsils
Staph. aureus exotoxins a re not known to cause gastroenteritis
m
se
'Lockjaw' seen in tetanus is secondary to blockade of the neu romuscular junctio naD
As
by Botulinus toxin
Dr
A 22 year-old man is referred to clinic with refractory hypertension.
Potassium 2.7mmol/l
Other U&E, FBC, calcium and LFTs are normal. Which wou ld be t he most app ropriate next
investigation?
CT abdomen
MR angiography ren al t ract
24 hour urinary catecholamines
USS abdomen
m
se
As
Plasma renin and aldosterone levels
Dr
CT abdomen .
(D
MR a ngiog rap hy ren al tract .

(D
-
24 hour uri na ry catecho la mines GD
USS a bdomen fD
I Plasma renin and aldosterone levels

I CD
The d iffe rential fo r hypertens ion with low potassium includes Con n's, Cushi ng 's, re nal
artery stenosis a nd Liddle's. The first step in this case should b e fu rther s imple
investigations. Quantifying the re nin and angiotensin leve ls will he lp to distinguish the
cause he re, b efo re going on to mo re sp ecia lised tests.
Cush ing's a nd Conn's wo uld be associated with a high ald osterone and a low renin, re nal
m
se
artery stenosis would be associated with a high renin and ald ostero ne, Lid dle's is
As
associated with a low renin and aldosterone.
Dr
Which o f the following conditions is inherited in an aut osomal recessive fashion?
Familial adenomatous polyposis
Noonan syndrome
Malignant hyperthermia
m
se
As
Congenital adrenal hyperplasia
Dr
~
I Fam jlial a denomatous polyposis
Noonan syndrome .
GD
•
Malignant hyperthermia (D
Antithrombin III deficiency fiD

Congenita l ad renal hype rplasia CD
Autosomal recessive conditions are 'metabo lic' - exceptions: inherited ataxias
m
Autosomal dominant conditions are 'structura l' - exceptions: hyperl ipidaemia type
se
II, hypokalae mic periodic para lysis
As
Dr
The chance of a 45-year-old mother giving birth to a child with Down's syndrome is
approximately:
1 in 5
1 in 10
1 in 50
1 in 100
m
se
1 in 500
As
Dr
1 in 5 CD
1 in 10 CfD
I 1 in 50 CID
1 in 100 fD
1 in 500 flD
m
se
As
Down's syndrome risk- l/1,000 at 30 years then divide by 3 for every 5 years
Dr
What is t he main action of atrial natriuretic peptide?
Promot es renin excretion
Reduces excretion of sod ium and water
Vasodi lation
Promot es aldosterone excretion
m
se
As
Vasoconstriction
Dr
Promot es renin excretion
Reduces excretion of sod ium and water
Vasodilation
Promotes aldosterone excretion
Vasoconstriction
m
se
As
Atrial natriuretic pept ide - powerful vasodilator
Dr
Which o f t he following is most likely to cause hypokalaemia associated wit h acidosis?
Cush ing's syndrome
Vom iting
Conn's syndrome
Diuretics
m
se
As
Acetazolam ide
Dr
Cush ing's syndrome CD
Vomiting GD
Conn's syndrome GD
Diuretics GD
I Acetazolamide CD
m
se
Acet azolamide causes hypokalaemia
As
Dr
What is the site of action of antidiuretic hormone?
Dist al convo luted tubule
Proximal convolut ed tubu le
m
se
As
Collecting ducts
Dr
Descending loop of Henle CD
Dist al convoluted tubule flD.
Ascending loop of Henle CD
Proximal convolut ed tu bule CD
I Collecting ducts
.,
m
se
Antidiuretic hormone (ADH) - site of action = collecting ducts
As
Dr
Which one of the following best describes the Hering-Bruer reflex?
Lung distension causing slowing of the respiratory rate
Raised hydrogen ion concentration in the ECF stimulating respiration
Low p02 stimulating the carotid and aortic bodies
Lung distension causing increase of the respiratory rate
m
se
As
Decreased hydrogen ion concentration in the ECF stimulating respiration
Dr
I Lung distension causing slowing of the respiratory rate tiD
Raised hydrogen ion concentration in the ECF stim ulating respiration 6D
Low p02 stimulating th e carotid and aortic bodies GD
Lung distension causing increase of the res pirato ry rate GD
m
se
As
Decreased hydrogen ion concentration in the ECF stimulating res piration GD
Dr
Which of the following statements is true regarding the standard polymerase chain
reaction (PCR)?
Restriction endonuclease enzymes are ap plied to DNA fragments prior t o

electrop horesis
PCR use is limited by its relatively low sensitivity
A t hermost able DNA p olymerase is required
PCR is currently limited to p renat al diagnosis and forensi cs
m
se
As
A single DNA oligonucleotid e primer is necessary
Dr
Restriction endonuclease enzymes are applied to DNA fragments prior to
electrophoresis
PCR use is limited by its relatively low sensitivity

-
~
I
A thermostable DNA polymerase is required
PCR is currently limited to prenatal diagnosis and forensics
m
se
As
A single DNA oljgonucleotide primer is necessary
Dr
A 46-yea r-old lady presents to the Emergency Department with acute interm ittent sharp
pa in in her right flank and haematuria. She has slight nausea, but feels otherwise fine in
herself. She has a history of hyperparathyroidis m, but has not experienced these
symptoms befo re. She has a body mass index of 28kg/m2 and revea ls that her diet
involves regular takeaways. On examination she appears restless and has right flank
tenderness.
What substance is most likely to be causing the pa in in this patient?
Calcium oxalate
Struvite
Calcium phosphate
Uric acid
m
se
As
Cystine
Dr
Calcium oxalate ED
Struvite flD
Calcium phosphate fD
Uric acid .
(D
Cystine CD
Renal stones are most common ly composed of calcium oxalate

This is a history of renal colic, caused by re nal stones, with intermittent sha rp flank pa in
causing restlessness in the patient. 85% of renal stones are composed of ca lcium oxalate,
with hypercalciuria and hyperparathyro idis m be ing ris k factors, and so this is by far the
most li ke ly cause in th is patient.
Struvite stones account for 2-20% of cases, but are associated with urease- pro ducing
bacteria an d chronic infections, which makes it unlikely in this patient.
10% of rena l stones are composed o f calcium phosp hate, with increased risk in rena l
tubular acidosis.
Uric acid stones a re usually more commonly seen alongside malignancies and only
account fo r 5-10% of cases.
1% o f stones are made of cystine and these may cause mu ltiple stones.
With the biggest risk facto rs in this patient a ppearing to be d iet, obes ity, and
em
hyperpa rathyroid is m, the most likely cause is calcium oxalate, usua lly the most common
s
As
cause across a ll types of renal stones.

Dr
During a newborn physical examination, a paediatricia n notes cleh pa late, low-set ea rs
and a ha lo -systo lic murmur a long the leh lowe r sternal borde r. Blood tests s how
hypoca lcaemia and che st x-ray reveals an absent thymic sha dow an d a 'boot-s haped '
hea rt. Furthe r investigatio ns confirm a ve ntricular septa l d efect, right ve ntricular
hypertrophy and an overriding ao rta.
Which of the following congenita l heart diseases is most likely p rese nt in this newborn?
Total anomalous pulmonary venous return
Transposition of great vessels
Ao rtic coarctation
Tetralo gy of Fallot
m
se
As
Tricusp id atresia
Dr
Total anomalous pulmonary venous return m
Transposition of great vessels tiD
Aortic coarctation m
I Tetralo gy of Fa llot CD
Tricusp id atresia m
Cardiac abnormalities o f DiGeorge syndrome inclu de truncus arteriosus and
t etralogy o f Fallot
This patient has a primary immunod eficiency disorder, DiGeorge syndro me, which is also
known as 22q 11.2 d eletion syndrome. It is highly associated with Tetralogy of Fallot and
truncus arteriosus.
'CATCH22' is a mnemonic used to d escribe so me of t he key features of th is cond ition:

C - Cardiac abnormalities
A -Abnormal facies
T - Thymic ap lasia
m
se
C - Cleft palate
As
H - Hypocalcaemia/ hypoparathyroi dism
Dr
22 - Caused by chro mosome 22 d eletion

You are asked to review some arterial blood g ases (ABGs) done on a patient w ho has
recently been admitted to the Emergency Department. The ABGs shown below were
t aken on air:
pH 7.53
pC02 5. 1 kPa
p02 13.9 kPa
Which one o f the followin g is t he most likely cause?
Chronic obstructive pu lmonary disease
Mesenteric ischaemia
Anxiety
m
se
As
Vom iting
Dr
r :esenteric ischaemia
Anxiety
I Vom iting
-~
Vom iting I aspiration - metabolic alkalosis

m
se
As
The blood gases show a metabolic alkalosis
Dr
Which one o f t he following is most commonly secreted by T -helper ce lls subset 2 (Th2
cells) ?
Interleukin 2
Tumour necrosis facto r
Interferon gamma
Interleukin 4
m
se
As
Interleukin 3
Dr
Interleukin 2 ED
Tumour necrosis facto r GD
Interferon gamma CD
I Interleukin 4 ED
m
se
As
Interleukin 3 fD
Dr
Frag ile X is associated with each one of the fo llowing, except:
Sma ll, firm testes
Mental retardation
Hypoton ia
Short statu re
m
se
As
La rge low set ears
Dr
Frag ile X is associated with each one of the following, except:
Small, firm testes CD

Mental retardation .
(D
Hypotonia GD
Short stature .
C!D
m
se
As
La rge low set ears fiD
Dr
An 8 -year-o ld is admitted with suspected appendicitis and has a laparoscopic
append icecto my. He is g iven 0.45% sod ium chlo ride post-ope ratively. When reviewed by
the su rg ical team he has developed featu res of a headache, confusio n, and d isturbance to
his ga it.
Na• 128 mmol/ 1
K• 4.0 mmol/1
Urea 5 mmol/1
Creatinine 60~mol/1
Glucose 4.0mmol/l
Which of the following is the most likely diagnosis?
Adverse rea ction to patient control led analgesia
Hyperos mo lar hyperglycaem ic state
Hyponatraemic encepha lo pathy
Norma l pressure hyd rocep halus
m
se
As
Central pontine myelino lysis Dr
Adverse rea ction to patient controlled analgesia
Hyperos molar hyperglycaemic state
Hyponatraemic encephalopathy
Normal p ressure hydrocephalus
Central pont ine myelinolysis

-~
Avoidance of using hypot on ic (0.45%) in paediatric patients - risk of hyponatraemic

encephalopathy
In paediatric pat ients, there are at higher risk of hyponat raemic encephalopathy. This is
most noted in those who receive hypotonic int ravenous f luids such as 0.45% sodium
chlo ride. There is a second reason for t he hyponat raemia in th is patient, a well
documented cause of SIADH is trauma and stress. ADH secret ion lowers serum sodium
levels t hrough open ing aquaporin chan nels allowing water to move int o the intravascular
space.
Central pont ine myelino lysis is a consequence of rapidly co rrectly hyponat raem ia which is
not the case here
Excessive use of patient controlled analgesia cou ld resu lt in a reduced conscious level and
respirato ry depression especially if opiates such as morphine were prescribed
Hyperosmolar hyperglycaemic stat e is a complication of diabetes mellitus and can result

in reduced conscious level - however by analysing t he blood test results the random
glucose level is normal.
em
Gait disturbance is a feat ure of normal pressure hydrocephalus but in associat ion with
s
As
dementia and urinary incontinence

Dr
A stu dy looks at the use of bisphosp honates in co ntrolli ng the pain associated with bone
metasta ses. One hun dred and twe nty patients (120) are enrolled in the study, 40 o f whom
are g iven conve ntiona l treatment with NSA!Ds and rad iotherapy. Of the 80 patients who
were g ive n b isp hospho nates, 40 rece ived significant pain relief.
What is the od ds of a patie nt with b one metastases receiving significant pain relief from
b isp hosphonates?
0.33
m
se
As
0.5
Dr
0.33 CD
3 fD
2 GD
I 1 ED
0.5 ED
The question is limited to the 80 patients who've been given b isp hosphonates. Odds are a
ratio of the number of people w ho incur a particular outcome to the number of people
who do not incur the outcome.
40 of t he 80 pat ients received significant pain relief
It can therefore be inferred that 40 of the 80 patients did not receive significant pa in
relief.
m
se
As
Therefore t he odds are 40 I 40 = 1
Dr
Where are G protein-coupled receptors located?
Nucleus
Golgi apparatus
Riboso me
Cell membrane
m
se
As
Mitochon dria
Dr
Nucleus m
Golgi apparatus f!D
Riboso me CD
Cell membrane GD
Mitochon dria .
(D
m
se
As
G p rot ein-coupled receptors span the ce ll membrane
Dr
Which of the following stat ements is t rue regarding the p53 gene?
It is an oncogene
Mutatio n resu lts in a gain of function
50% of fam ilies with a strong history of breast cancer have a p53 mutation
Li -Fraumeni syndrome p redisposes to the development of sarcomas
m
se
As
It is located on ch romosome 13
Dr
It is an oncogene
Mutation results in a gain of function
50% of fam ilies with a strong history of breast cancer have a p53 mutation
-
"""
I Li-F raume ni syndrome p red isposes to the d~velopment of sa rcomas
m
se
As
It is located on chromosome 13
Dr
A 17-year-old male is diagnosed with alpha-thalassaemia. What chromosome is the
alpha -globulin genes located on?
Chromosome 4
Chromosome 8
Chromosome 12
Chromosome 16
m
se
As
Chromosome 20
Dr
Chromosome 4 f!D
Chromosome 8 GD
Chromosome 12 GD
r
Chromosome 16 ED
m
se
As
Chromosome 20 fD
Dr
Aldosterone is secreted by the:
Juxtaglomerular apparatus
Zona glomerulosa
Posterio r pituitary
Zona reticu la ris
m
se
As
Zona fascicu lata
Dr
Juxtaglomerular apparatus CD
I Zona g lomerulosa fD
Posterior pituitary CD
Zona reticularis ('fD
Zona fasciculata GD
m
se
Adrena l cortex mnemonic: GFR - ACD
As
Dr
You are discussing co nception with two pa rents who both have a chondroplasia. They ask
you what the chances a re that a ch ild of theirs would be of norma l height. What is the
correct response?
0%
25%
50% independent o f gender
50% if male
m
se
As
75%
Dr
0%
25%
50% independent of gender
50% if male
-
~
75%
Many questions re lating to autosoma l do minant cond itions a re based a round one of the
pa rents being affected. With achondroplasia both pa rents are often a ffected which can
make the interpretation slightly trickier.
As an autosomal dominant co nditio n, two affected parents can expect:

• 1 in 4 chance o f an unaffected child
• 1 in 2 chance o f an affected heterozygous child
• 1 in 4 chance o f an affected homozyg ous child. With achondroplasia childre n
unfortunately don't live past the first few months o f life
m
se
As
The answer o f having a child o f norma l height is therefore 1 in 4 or 25%.
Dr
Which one of the following is only secreted by the adrenal medulla?
Noradrenaline
Aldosterone
Metadrena line
Cortisol
m
se
As
Adrena line
Dr
Noradrenaline QD
Aldosterone CD
Metadrenaline flD
Cortisol CD
m
se
As
Adrenaline tD
Dr
A nurse who is known to have an allergy to latex develops a w idespread urticarial rash
and facial oedema shortly after eating lunch . Wh ich food is she most like ly to have
consumed?
Peanut
Apple
Grapes
Pear
m
se
As
Banana
Dr
Peanut ED.
Apple CD
I Grapes CD
Pear .
(D
m
se
I
As
Banana ED
Dr
Which one o f the following stat ement s regarding leptin is incorrect ?
Is produced mainly by the hypothalamus
Stimulates the release o f melanocyte-stimulating hormone
Obese patients have higher leptin levels
Plays a key role in the regulation of body weight
m
se
As
High levels decrease appetite
Dr
I Is produced mai nly by thj hypotha lamus
Stimulates the re lea se o f mela no cyte-stimulati ng ho rmone
Obese patients have highe r leptin leve ls
I Plays a key role in the regulatio n of bo dy we ight
High levels decrease ap petite

-........
m
se
Leptin is secreted by ad ipose tissue
As
Dr
A 14-year-old girl presents with a swollen left knee. Her parents stat e she suffers from
haemophilia and has been treat ed for a right -sided haemarthrosis previously. What o th er
condition is she most likely to have?
Tu rner's syndrome
Down' s syndrome
Ataxia telangiectasia
Hunt er's syndrome
m
se
As
Coeliac disease
Dr
Turner's syndrome ED
Down's syndrome (D
'
Ataxia te langiectasia 6D
Hunter's syndrome fiD
Coeliac disease CD
Haemophilia is aX-linked recessive disorder and would hence be expected on ly to occur
m
se
in males. As patient s with Turner's syndrome only have one X chromosome however, they
As
may d evelop X- linked recessive conditions
Dr
A 39-yea r-old male with a history of type 1 d iabetes mellitus presents to his general
practice with d ip lo pia. It exacerbates when lo oking right and improved upon covering the
right eye.
What nerve is likely to be res ponsib le?
Right o ptic ne rve m

Right trochlear CD
Right ocu o motor f!D
Right abducens (D
m
se
As
Left abd ucens GD
Dr
Right o ptic ne rve m
-
Right trochlear CD
Right ocu omotor OD
Right abducens CD
Left abduce ns CD
As the ho rizonta l g aze to the rig ht is whe re the d iplop ia is wo rst and is improved o n
cove ring the right eye then the right abducens is affected as this contro ls the rig ht lateral
rectus and thus rightwa rd g aze.
The trochlea r ne rve wou ld lead to nysta gmus on looking down a nd out.
m
se
As
The o ptic ne rve wo uld not lead to diplopia.
Dr
Which o f t he following feat u res is not associated with patent ductus arteriosus?
Cont inuous 'ma chinery' murmur
Bisferiens p ulse
Heaving apex beat
Wid e pulse pressure
m
se
As
Left su bclavicular th rill
Dr
Continuous 'machinery' murmur
Bisferiens p ulse
Heaving apex beat
Wide pu lse pressure

-
~
Left su bclavicular t hrill
m
se
As
PDA is associated with a collapsing pu lse
Dr
In the Gell and Coombs classification of hypersensitivity reactions scabies is an example of
a:
Type I reaction
Type n reaction
Type mreaction
Type N reaction
m
se
As
Type V reaction
Dr
Type I rea ction fD
Type ll rea ction (tiD
Type mreaction GD
Type N reaction CD
Type V reaction (D
Type N hype rse nsitivity reaction - scabies

m
se
Sca b ies produces a delayed type N hypersensitivity rea ction app roximately o ne month
As
a fter infestatio n. This pro duces the characteristic intense itching
Dr
A study is d esigned to co mpa re the calcium leve ls of males and females who have Cro h n's
disease. The investigato rs a im to discove r whethe r the re is a di ffere nce between the
ave ra ge ca lcium leve l in ma les co mpare d to fema les. Fro m p revious studies it is known
that the calcium leve ls a re no rmally distributed. Which o ne of the fo llowing statistical
tests is it most a ppro priate to use?
Pea rson's test
Ma nn -Whitney test
Chi-squared test
m
se
As
Student's pa ired t-test
Dr
Pea rson's test
Mann-Whitney test
Chi-squared test
-
"""'
Student's unpaired t-test
m
se
As the d ata is para metric and compa res two independ ent sam ple from the sa me
As
population an unpa ired t-test is the most ap p ro p riate test to use
Dr
When establish ing a screening prog ramme, which one of the following is not a key
criteria as defined by Wilson a nd Jung er?
There should be a recogn ised latent or early symptomatic stage
The condition shou ld be an important public health problem
The test or exam ination shou ld be acceptable to the popu lation
There should be ag reed po licy on whom to treat as patients
m
se
As
The cond ition shou ld be potentially curable
Dr
When esta blis hing a screening p ro gra mme, which one o f the following is not a key
criteria as defined by Wilson and Junger?
There shou ld be a recognised latent o r early symptomatic stage
The condition shou ld b e a n importa nt public health pro blem
The test o r exam ination shou ld be accepta ble to the pop ulation
There shou ld be ag reed po licy o n who m to treat as patients
m
se
As
The condition should be potentia lly cu rab le
Dr
A 59-yea r-old male patient p resents to the gastroentero lo gy cli nic with a 6-months
histo ry of weight loss, freq uent loose and greasy stool. He has a long -stand ing history o f
heavy alco hol use and recurre nt hosp ital admissions for acute pancreatitis. On
exam ination, the patient looks malnou rished. There is mild ten derness el icited on
palpation of the ep igastric region.
Whi ch hormone will likely b e relevant in the investig ation o f his symptoms?
Gastrin
Secretin
Increti n
Insu lin
m
se
As
Glu cagon
Dr
Gastrin flD
Secretin CD
Incretin CD
Insulin GD
Glucagon CD
Secretin increases secretion of b icarbonate-rich f luid from pancreas and hepatic

duct ce lls
This patient has symptoms suggestive o f pancreat ic insufficiency likely secondary to

chronic pancreatit is, given the weight loss and steatorrhoea as well as the history of
alcohol misuse. Secretin increases t he secretion of bicarbonate -rich fluid from pancreas
and hepatic duct ce lls and it can be used as a t est for pancreatic function (secret in
st imulation t est).
Gastrin increases HCL p roduction.
Incret in is released following food intake and stimulates insul in secretion.
Insulin and glucagon are pancreatic hormones but they are not t he main hormones that m
st imulat e the secret ion o f bicarbonate-rich fluid from pancreas and hepatic duct cel ls.
se
As
They are mainly involved in glucose regulation.

Dr
A 45-year-old man attend s the GP for a health check. His cholesterol is found to be
raised. He has a strong fam ily history o f high cho lesterol. Genet ic testing shows he is
heterozygous for the affected allele.
If this man has a child with a woman who is not a carrier of the affected allele, what is the
likelihood t hat the child w ill have the cond ition?
0%
25%
50%
75%
m
se
As
100%
Dr
0% (!D
25% GD
I 50% GD
75% CD
100% m
Fami lia l hypercho lestero laem ia is an autosoma l d om inant cond ition

This q uestion is testing your knowledge a bout inheritance. You shou ld recall that familia l
hypercholestero laemia is an autosomal domi na nt condition. A child born to this couple if
50% likely to have the condition. Drawing the genotypes of each pa rent is often helpful.
This is often done using a Pun nett squa re .
0% - this is not the co rrect answer. There will always be a chance of an a ffected child in an
autosomal dominant conditio n. Drawing a Punnett square will show this.
25% - this is not the correct answer. Drawing a Punnett square can be helpful in this
s ituation and will s how that the li keli hood of having an affected child is actually 50%.
50% - this is the correct a nswer. There is a 50% chance this child will be affected by the
condition.
75% - this is not the correct answer. Drawing a Punnett square can be helpful in this
s ituation and will s how that the li keli hood of having an affected child is actually 50%.
em
100% - this is not the correct answer. There will only be a 100% cha nce o f a ch ild having
s
As
an autosoma l co nditio n if both partners are homozygous for the affected a lle les.
Dr
A s mall study is desig ned to look at the li nk between drin king a lcoho l and live r cirrhosis.
One hundre d patients with live r cirrhosis were q uestioned a nd it was found that 80 of
them dra nk excess ive alco ho l. As a contro l, one hundred patients without live r cirrhos is
we re q uestioned and o nly 20 o f these patie nts drank excessively. What is the o dd s ratio of
d eve loping live r cirrhosis fo r people who drink excessive ly compa red to those who d o
not?
0.25
16
m
se
As
3
Dr
2 fD
4 tD
0.25 flD
16 CJD
3 CD
Odds - remember a ratio of the number of peop le w ho incur a particular outcome

to the number of people who do not incur the outcome
NOT a ratio of t he number of people who incur a particular outcome to the tot al
number of people
The od ds of a pat ient wit h liver cirrhosis having a history of excessive drinking is 80/ 20 =
4.
The od ds of a pat ient wit hout liver cirrhosis having a history of excessive drinking is 20/ 80
= 0.25.
m
se
As
Therefore t he odds ratio = 4 I 0.25 = 16
Dr
A new drug d esigned to prevent exacerbations o f g e nita l herpes und ergoes clinica l trials.
One hu ndred patie nts are g iven the new drug. During a three mo nth period 10 of the
patie nts have a n e pisode o f g e nita l herpes. In the co ntro l group there a re 300 patie nts
who a re give n a placebo. In this g roup 50 people have a n exacerbation du ring the same
tim e period. What is the relative risk of having an exa cerbation o f g enital herpe s whilst
ta king the new drug?
0.8
0.2
1.66
0.6
m
se
As
0.06
Dr
0.8 D.
0.2 f!D
1.66 GD
I 0.6 CD
.
0.06 GD
Exp erimental event rat e, EER = 10 I 100 = 0.10
Contro l event rate, CER = 50 I 300 = 0.166
m
se
As
Therefore the relative risk = EER I CER = 0.1 I 0.166 = 0.6
Dr
Which of the follow ing secondary causes of hyperlipidaemia result in predominantly
hypercholesterolaemia, as opposed to hypertriglyceridaemia?
Diabet es mellitus
Bendrofluazide
Nephrotic syndrome
Alcohol
m
se
As
Obesity
Dr
Diabetes mellitus GD
Bendrofluazide GD
~phrotic syndrome ED
Alcohol CD
Obesity GD
m
Hypercholesterolaemia rather than hypertriglyceridaemia: nephrotic syndrome,
se
cholestasis, hypothyroidism
As
Dr
A 25-year-old woman presents with a symmetrica l arthropathy affecting her hands. On
examination she has synovit is of the 2nd and 3rd metacarpophalangeal joints. What type
o f HLA allele is most associated w ith this co ndition?
HLA DR3
HLAA3
HLA DR4
HLA DR2
m
se
As
HLA 827
Dr
HLA DR3 GD
HLAA3 CD
HLA DR4 eD
HLA DR2 CD
HLA 827 GD
Rheumat oid arth ritis - HLA DR4
m
se
As
This patient has rheumat oid arthritis.
Dr
Which one of the following is the most co mmon genetic cause of Prader-Willi syndrome?
Microdeletion of the paterna l 15ql l-13
Matern al uniparental disomy of chromosome 15
Paternal uniparenta l disomy of chromosome 15
Microdeletion of the mat ernal 15qll-13
m
se
As
Trisomy 18
Dr
Which one of the following is the most common genetic cause of Prader-Willi syndrome?
I Microdeletion of the paternal15f l l-13
Maternal uniparental disomy of chromosome 15
Paternal unipa enta l disomy of ch romosome 15
Microdeletion of the maternal 15qll-13
Trisomy 18
• Prader-Willi - pat ernal
m
• Angelman syndrome - maternal
se
As
Dr
Which of the following statements is true rega rding autoso mal dominant inheritance?
Individua ls who are symptomatic of the disease always have parents who are
symptomatic of the disease
Only heterozygotes ma nifest disease
50% of children will be carriers
Responsible for the majority of enzyme deficiency disorders
m
se
As
The risk remains the same for each successive pregnancy
Dr
Individua ls who are symptomatic of the d isease always have parents who are
symptomatic of the disease
Only heterozygotes ma nifest disease
50% of children will be carriers
Responsible fo r the majority o f enzyme deficiency diso rders

-
~
The ris k remains the same for each successive pregnan cy
m
se
As
Due to no n-penetra nce affected individuals do not a lways have affected parents
Dr
A 32-yea r-old fema le patient presents to the GP with a 2-day histo ry of a bd ominal pain
and bloody dia rrhoea. She re ports that she has been co mpletely wel l until o ne week ag o
whe n she started having a hea dache and g enera l tiredness. On furthe r questioning, she
a d mitted to eating a t a d odgy takeaway 3 days before the start o f the sympto ms.
Dive rticulitis
E. co li
Cholera
Giardiasis
m
se
As
Campylobacter
Dr
Diverticu litis m
E. coli fiD
Cholera CD
Giardiasis (!D
I Campylobacter 6D
Campylobacter infection is characterised by a prodrome, a bdo mina l pa in an d

b loody diarrhoea
Campylobacter infection is characterised by a prodrome, abdomina l pa in and bloody

diarrhoea.
Diverticu litis can cause bloody stool but the history here suggests an in fectious cause.
Most strains of E. coli, in general, do not cause bloody diarrhoea .
Cholera does not cause b loody diarrhoea.
m
se
As
Gia rdiasis has a longer incu bation period and does not cause bloody dia rrhoea .
Dr
Which one o f t he followin g congenita l infections is most characteristical ly associated w ith
senso rineural deafness?
Toxoplasma gondii
Parvovirus B19
Rubella
Treponema pallidum
m
se
As
Group B streptococcus
Dr
Toxoplasma gondii CD
Parvovirus B19 .
(D
Rubella GD
Treponema pallidum m
Group B streptococcus CD
Congenital ru bella
• sensorineural deafness
m
se
• congenital cat aracts
As
Dr
Which one of the followin g statements rega rd ing the standa rd e rror of the mean is
correct?
Is the square root of standard deviation
It is independent of sample s ize
Is a measure of correlation between two variables
Confidence intervals cannot be applied to the standa rd error o f the mean
m
se
As
Gets smaller as the sample size increases
Dr
Is the square root of standard deviation
F t pendent of sample size
Is a measure of correlation between two variables
I
Confidence intervals cannot be applied to the standa rd error of the mean
-
"""'
m
se
As
Gets smaller as the sample size increases
Dr
What is the most commo n ca rdiac defect seen in patients with Down's syndrome?
Ventricu la r septa l defect
Endocardial cushion defect
Secundum a trial septal defect
Tetra logy of Fa llot
m
se
As
Dr
Endoca rdial cushion defect
Secund um atrial septa l defect

--
~
Tetralogy of Fallot
m
se
Endocardial cushion defects account for a bout 40% of congenital heart disease seen in
As
patients with Down's syndrome
Dr
A 75-year-old female presents with weakness of her left hand. On examination, wasting of
the hypothenar eminence is seen and there is weakness o f finger abduction. Thumb
adduction is also weak. Where is the lesi on most likely to be?
C7
Median nerve
Radial nerve
Anterior interosseous nerve
m
se
As
Ulnar nerve
Dr
A 75-year-old female p resents with weakness of her left hand. On examination, wasting of
the hypothenar eminence is seen and there is weakness o f f ing er abduction. Thumb
adduction is also weak. Where is t he lesi on most likely to be?
C7
Median nerve
r:dial nerve
Anterior interosseous nerve

-
~
m
se
As
Ulnar nerve
Dr
A stu dy is performed looking at the chance o f stroke in high -risk patients taking a new
oral antithrombotic drug compa red to warfarin. The following results are obtained:
Total number of Number who had a stroke within a 3 year

patients period
New 200 10
drug
Warfarin 600 12
What is the relative risk of having a stroke w ithin a 3 year period for patients taking the
new drug compared t o warfarin?
3.33
0.66
1.2
2.5
m
se
As
Cannot calculate from above data
Dr
3.33
0.66
1.2
2.5
Cannot calculate f rom above data

-
........
Relative risk = EER I CE R

Contro l event rate, CER = 12 I 600 = 0.02
m
se
As
Therefore the relat ive risk = EER I CER = 0.05 I 0.02 = 2.5
Dr
A 70-yea r-old p atient is brought to the emergency department. She has a GCS of 11. Her
relatives tell you that she has b een drinking la rge a mounts of water in o rde r to rema in
wel l hydrated du ring the hot weather. You find that she has a sodium level of 108 mmol/1.
Her most recent sod iu m was 131 mmol/1 when last checked 3 weeks a go . What is the
unde rlying pathology by which acute hyponatraem ia is causing her reduced GCS?
Central pontine mye linolysis
Concurrent hypoglycaem ia
Intracra nial hae morrha ge
Cere bral oedema
m
se
As
Cere bral vasospasm
Dr
Central pontine myelino lysis
Intracra nia l hae mo rrha ge
Cerebral oedema
Cere bral vasospa sm
Acute seve re hyponatraem ia can cause cere bra l oed e ma

The correct answe r is cere b ral oedema. The patient has acute hyponatraemia, most li kely
as a result of wate r intoxication in this sce na rio. Acute hyponatrae mia causes ce re b ral
oed ema by reducing plasma os mo la lity, which causes water to move o ut of the plasma
into the b rain cells down the osmotic gra dient. Cere bral oedema causes d rowsiness a nd
seizures.
Central pontine myelino lysis can occur if hyponatraemia is co rrected too ra pidly. The
other mecha nis ms a re not classica lly involved in hyponatraem ia.
m
se
Effects of hyponatraemia o n the bra in
https:/ /www.ncbi. nlm.nih.gov/ pmc/a rticles/PMC44 7017 6/ As
Dr
A 61-year-old man complains of a four month history of neck and a rm pain. The pa in is
d escribed as b eing li ke 'electric shocks' and is wo rse when he turns his head. There is no
history of trauma and no other obvious trigge r. He is otherwise fit and well and takes no
other med ication. On exam ination he has decreased sensation on the d orsa l aspect of the
thumb and index finger. What is the most like ly underlying dia gnos is?
C4 radi culopathy
CS radiculopathy
C6 radi culopathy
C7 radi culopathy
m
se
As
T1 radiculopathy
Dr
C4 radiculopathy m
CS radiculopathy (fD
C6 radiculopathy GD
C7 radiculopathy flD.
m
se
m
As
Tl radiculopathy
Dr
A 3-year-old boy is investi gated for lethargy. Examination is unremarkable w ith a blood
pressure of 90/46 mmHg (normal for his age). Blood test s reveal:
Na• 140 mmol/ 1
K• 2.6 mmolfl
Urea 4 .2 mmolfl
Which one of the following conditions is most likely to be res ponsible?
Cushing's syndrome
Conn's syndrome
Bartter's syndrome
m
se
As
Liddle's syndrome
Dr
Cush ing's syndrome
Conn's syndrome
-
'""""
~tter' s syndro me
Liddle's syndrome
Bartter's syndrome is associated with normotension

Bartter's syndrome is an inherited cause (usually autosomal recessive) of severe
m
se
hypoka laem ia due to defective chloride absorption at the Na• K• 2CI- cotransporter in
As
the ascend ing loop of Henle
Dr
A scientist is studying the role of regulatory proteins in intracell ular trafficking. He has
isolated and identified various intracellular proteins tagged with mannose-6-phosphate.
These proteins are desti ned to which of th e following organelles?
Lysoso me
Rough endoplasm ic reticu lum
Nu cleus
m
se
As
Mitochondria
Dr
Lysoso me

-
~
Nucleus
Mitochondria
Golgi adds mannose-6-phosphate to prot eins for t rafficki ng to lysosomes

m
se
As
Golgi adds mannose-6-phosphate to proteins for trafficking to lysosomes
Dr
CD4 fD
CD2b CD
CDl .
(D
~8 6D
CD2 fD
m
se
CD8 - co-receptor for MHC class I
As
Dr
Which one o f the following molecu les act s as t he co -recept or for cells expressing
antig ens comb ined with MHC class I molecules?
CD4
CD2b
CDl
CD8
m
se
As
CD2
Dr
A young boy is diagnosed as having DiGeorge syndrom e. Which one of the following
infections is he most at risk from, secondary to his immune system dysfunction?
Klebsiella pneumoniae
Haemophilus influenzae type b
Cryptococcus neoformans
Neisseria meningitidis
m
se
As
Salmonella typhi
Dr
Klebsiella pneumoniae f!D
Haemophilus influenzae type b tiD
I Cryptococcus neoformans tD
Neisseria meningitidis CD
Sal onel/a typhi CD
m
se
Patients who have T-cell dysf unction are mo st at risk from recurrent viral an d f ung al
As
infections.
Dr
A follow-up study is performed looking at the hei ght of 100 adu lts who were given
steroid s during childhood. The averag e height of the ad ults is 169cm, with a standard
deviation of 16cm. What is the standa rd error of the mean?
1.69
0.16
1.6
m
se
As
1.3
Dr
Cannot be calculated .
(D
1.69 tiD
0.16 GD
r:1.3
ED
CD
Standard e rror of the mean = standard deviatio n I squa re root (number of patients)
The standard error of the mean is calculated by the standard deviation I sq uare root
(number of patients)
m
se
As
= 16 I square root (100) = 16 I 10 = 1.6
Dr
Which foramen does the maxillary nerve go thro ugh?
Jugular foramen
Foramen ovale
Superior orbital fissure
Optic canal
m
se
As
Foramen rotundum
Dr
Jugular foramen CD
Fora men ovale fD
Superior orbital fissure .
C!D
Optic canal m
I
m
se
Foramen rotu ndum
I
GD
As
Dr
A 77 -year-old woman who lives alone is assessed. She has a history of Alzheimer's
disease. Her neighbours are increasingly concerned about her behaviour- t hey often see
her wandering around outside in an apparent ly confused state. You feel she may need a
care packa ge or residential care but she refuses to countenance such a proposa l. What is
the most appropriate legal f ramework to use to approach this issue?
Mental Health Act
Mental Capacity Act
Health and Social Care Act
Common law
m
se
As
Professional Performance Act
Dr
Mental Health Act
Mental Capacity Act
Hea lth and Social Care Act
Common law
Professional Performance Act
!l.s this is not a menta l health d iso rder the most app ropriate lega l framewo rk to use is the
lA e ntai Capacity Act.
rhe Menta l Capacity Act o f 2005 came into force in 2007. It ap plies to a dults ove r the age
)f 16 and sets out who can take d ecisions if a patient becomes inca pacitated (e.g.
'ollowing a stro ke). Menta l ca pacity in cludes the ab ility to make d ecisions affecting da ily
ife, hea lthca re and financial issues.
rhe Act contains 5 key principles:

• A pe rson must be assumed to have capacity un less it is esta blished that he lacks
capacity
• A pe rson is not to be treated as unable to make a decision unless a ll practicable
ste ps to he lp him to d o so have been taken witho ut su ccess
• A pe rson is not to be treated as unable to make a decision merely because he
makes an unwise d ecision
• An act d one, or decision ma de, und e r th is Act for o r on beha lf of a p erson who lacks
capacity must b e done, o r mad e, in his best interests
• Before the act is d o ne, o r the decision is ma de, regard must be had to whether the
pu rpose fo r which it is needed can be as e ffectively achieved in a way that is less
em
restrictive of the pe rson's rights a nd freed om of actio n

s
As
Dr
Yo u a re ca ring fo r a local cardiology consu lta nt's father who has been adm itted fo llowing
a myocard ia l infarction. He bleeps you from the switchboa rd a nd asks how his father is
d oing . Yo u recogn ise his vo ice on the p hone . What is the most a ppro priate respo nse?
Decli ne to give a ny d eta ils over the phone b ut offer to meet the consultant face -to-
face for a chat
As a matte r o f professiona l courtesy ask for his advice on post-myo ca rdia l

infarction ca re
Ask permissi on from his fathe r then g ive re levant deta ils
Give full d eta ils inclu de the tro po nin I value and o ffer to fax the ECG
m
se
As
Say he is 'do ing fine'
Dr
Decl ine to give any details over the phone but offer to meet the consultant face- CD
to-face for a chat
As a matter of professional cou rtesy ask for his advice on post-myocardial

infarction care
I Ask permission from his father then g ive relevant d eta ils
Give full details include the troponin I value and offer to fax the ECG
Say he is 'doing fine'
The main nub of this question relates to confidentiality. You cannot g ive deta ils over the
phone to anyone, even his son, without the patient's express permission. Whilst it may be
presumed that this is what the patient wou ld want it is impossible to be su re of the fa mily
dynam ics.
If the patient has g iven permiss ion and you a re sure you are speaking to the son the n
giving re leva nt d eta ils is the best option. Asking the consultant to co me in as an option
but may not be necessa ry if the previous conditions a re met. Saying he is 'doing fine' is
unli kely to satisfy a consu ltant cardiologist.
Giving deta ils without first getting permiss ion from the patient is breaking co nfidentiality,
m
se
however well intentio ned. Involving a relative in the ma nagement of a patient is As
inapp ropriate and the worst optio n.
Dr
Which of the following conditions is NOT inherited in aX-linked recessive fashion:
Myotonic dystrophy
G6PD deficiency
Haemophilia B
Colou r blindness
m
se
As
Fabry's disease
Dr
I Myotonic dystrophy ED
G6PD def iciency CD
Haemophilia B CD
Colou r blindness CD
Fabry's dise< ~e flD
m
se
X-linked cond itions: Duchen ne/ Becker, haemophilia, G6PD
As
Dr
A 22-yea r-o ld gentleman is ad mitted to the Emergency Department with wo rsening
shortness of b reath with s igns of left ve ntricula r failure. He has a known genetic co nd itio n.
On exam ination, you note an ejection systo lic murmur loudest over the aortic area
radiating to the carotids, bibasal crepitations and pitting oedema to the knees bilaterally.
On closer inspection of the patient, you note a wide vermillion border, small spaced teeth
and a flat nasal bridg e . The patient also has a dis inhibited friendly d emeanou r.
What is the likely p recipitating valvular issue?
Subvalvular aortic stenosis
Valvu lar aortic stenosis
Ao rtic sclerosis
m
se
As
Ao rtic regu rg ita tion
Dr
Subvalvular aortic stenosis
Valvu la r aortic stenosis
Aortic scle rosis
Aortic regu rgitation
The answer is suprava lvular aortic stenosis, which is associated with a condition called
Will iam's syndrome. This synd rome is a genetic condition associated with transient
neonatal hypercalca em ia, sho rt stature, and a friendly demea nour.
A subva lvular aortic stenosis is associated with hypertrophic obstructive cardiomyopathy.

Ao rtic sclerosis d oes not typically cause radiation to the carotid s and associated with a
more senio r demogra phic. Aortic regurgitation is associated with an early diastolic
m
se
mu rmur and va lvular aortic stenosis tends to be related to senile calcification or a
As
bicuspid aortic valve.
Dr
A 59-yea r-old male patient p resents to the gastroentero logy cli nic with a 6-month history
of abdomina l pa in, d ia rrhoea and weight loss. Gastroscopy revea ls a gastrinoma in the
antrum of the stomach.
What is the function of the hormone secreted by th is tumour?
It increases HCL production and reduces gastric motility
It increases the secretion o f pancreatic fluid
It inhibits HCL p roduction and reduces gastric motility
It increases HCL production and increases gastric motility
m
se
As
It inhibits HCL p roduction and increases gastric motility
Dr
It increases HCL production and reduces gastric motility
~It increases the secretion of pancreatic fluid

It inhibits HCL p roduction and reduces gastric motility
I It inc reases HCL production and increases gastric motility
It inhibits HCL p roduction and increases gastric motility
Gastrin increases HCL p roduction and gastro intestinal moti lity

Gastrinoma is a gastrin -secreting tumou r. Gastrin increase HCL productio n and

gastro intestina l motility.
Options 1 is incorrect because gastrin actually d ecreases gastric motility.
Option 2 is incorrect because gastrin doesn't increase the secretion o f pancreatic flu id .
VIP, CCK a nd secretin increases the secretio n of pancreatic fluid.
Option 3 is incorrect because gastrin increases HCL production and increases gastric
m
se
motility.
As
Option 5 is incorrect because gastrin increases HCL production.
Dr
Which one of the following stat ement s regarding the power of a study is co rrect?
Is the proba bility of rejecting the null hypothesis w hen it is fa lse
Decreases with increasing sample size
Lies within 2 st andard deviations of the mean
Is the chance a significant p value will be reached
m
se
As
Is equal to 1 - (the probability of a type I error)
Dr
I Is the probability of rejecting the null hypothesis when it is false
Decreases with increasing sample size
I Lies within 2 st andard deviations of the mean
Is the chance a significant p value will be reached
Is equal to 1 - (the probability of a type I error)
Pow er = 1 - the proba bility of a type II erro r

The power of a study may be defined in a number of ways:

• in general terms, the probability that a statistically significant difference will be
detect ed
• probability of (correctly) rejectin g the null hypothesis when it is fa lse
• which also means the probability of confirming the alt ernative hypothesis when the
alternative hypothesis is true
m
se
• power = 1 - the probability of a type II error or 1 - ~
As
Dr
A ra pid urine screening test is developed to detect Chlamydia. A trial involving 200 men
and women is performed comparing the new test to the existing NAAT techniques:
Chlamydia present Chlamydia absent
New test negative 5 172
What is the negative pred ictive value of the new test?
172/177
20/23
172/192
172/175
m
se
As
20/25
Dr
I 1721177 CD
20123 m
1 1721192 fD
1721175 fiD
20125 CD
Negat ive pred ictive value = TN I (TN + FN)

Negative p redictive value = TN I (TN + FN)
m
se
As
= 172 1(172 + 5)
Dr
Which foramen does t he ocu lomotor nerve go t hrough?
Superior orbital fissure
Foramen ovale
Foramen rotundum
Optic canal
m
se
As
Inferior orb ital f issu re
Dr
I Superior orbita l fissure
Foramen ovale
CD
.
CD
Foramen rot undum CD

Opt ic canal crD
m
se
As
Inferior orbita l fissure crD
Dr
Each one of the following is associated w ith Noonan's syndrome, except:
Webbed neck
Short stature
Fa ctor XI deficiency
Pulmonary va lve stenosis
m
se
As
Abnorma l karyotype
Dr
m
se
As
In contrast to Turner's syndrome, the ka ryotype is normal
Dr
A 64-year-old man collapses and dies shortly aher com plaining of chest pain. During the
post-mortem extensive coronary artery disease is found. Examination o f the
atherosclerotic plaques reveals multiple foam cells. What is the origin of foam cells?
Neutrophils
Cardi ac myocytes
Macrophages
Endothelial cells
m
se
As
Lymphocytes
Dr
Neutrophils CD
Cardiac myocytes CD
I Macrophages
Endothelial cells
GD.
.
(D
Lym p hocytes
•
m
se
Foam cells are fat-laden macrophages
As
Dr
A 25-yea r-o ld ma n is cou nsell ed rega rding the g enetics of Hu ntingto n's d isease. Which
one of the fo llowing best describes the co ncept of a nticipation?
The psycho log ica l effect of a patient knowing they will d eve lo p a n incurab le
co nditio n
Earlie r a ge of onset in successive gene ratio ns
Mo re severe d isea se in success ive g e nerations
Where there is a known history o f inh erited conditio ns, patie nts may attribute
symptoms to the onset of the d isease
m
se
As
Screening at risk families to a llow ea rly inte rventio n a nd improve outcomes
Dr
I
The psycholog ical effe ct of a patient knowi ng th ey will d evelop an incu rab le
condition
Earlier age of onset in successive generations

- ~
More severe disease in successive generations
Where there is a known history o f inherited conditions, patients may attribute

-
~
sympto ms to the o nset of the disease
Screening at risk fam ilies to allow ea rly intervention and improve outco mes
Anticipation in trinu cleotide repeat diso rde rs = earlier onset in successive

generations
Difficult question. In the exam both Band C were g iven as choices. The 'classic' definition
o f anticipation is earlier onset in success ive generations. However, in most cases, an
increase in the severity of symptoms is a lso noted. If both options a re presented then B
m
se
should be chosen, as this represents the more accepted definition of anticipation. What
As
do you think?
Dr
Patients with deficiencies o f which one of the following complement proteins a re most
pred isposed to disseminated meningococca l infection?
Cl
C2
C3
C4
m
se
cs
As
Dr
Cl
C2
•m
C3 flD
C4 CD
I cs fZiD
m
se
Whilst C3 deficiency is associated with recu rrent bacterial infections, CS deficiency is more
As
characte ristically associated with disseminated mening ococcal infectio n
Dr
A 45 -year-old woman was commenced on treatment for a tubercu losis infection, 3
months ago. She has since developed a burning sensation at the base of her feet.
Which of the following medications may have caused this new 'burning sensation'?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
m
se
As
Amoxicillin
Dr
Rifa mpicin m
I Isoniazid G'D
Pyrazinamide e'D.
Ethambutol .
(D
Amoxicillin CD
Isoniazid therapy can cause a vitamin B6 deficiency causing peripheral neuropathy

TB drugs have a variety of side effects, many of which are w idely test ed in medical school
examinations. Th is patient is reporting evidence of a p eripheral neuropathy which can be
caused by the vitamin b6 deficiency that can result with Isoniazid therapy. Usually,
m
se
prophylactic pyridoxine hydrochloride is prescribed at the sa me time as Isoniazid to
As
prevent the p eripheral neuropathy.
Dr
Vitamin D causes which one of the following:
Increased plasma p hosphate
Decreased plasma calcium
Decreased gut absorption of calcium
m
se
As
Decreased renal tubular absorption of calcium
Dr
I Increased plasma phosphate
Decreased p lasma calcium
~creased osteoclastic activity

Decreased gut absorptio n o f calcium
-
Decreased renal tubular a bsorptio n o f calcium
-
....,
Vita min D increases plasma calcium and plasma phosphate leve ls by promoting renal
m
se
tubular absorpti on and gu t absorption of calcium and increasing rena l phosphate
As
rea bsorption
Dr
Which one o f t he followin g conditions is NOT an autosomal recessive condition?
Haemochromatosis
PKU
Tay-Sach's
m
se
As
Fried reich' s ataxia
Dr
Haemochromato sis
PKU
Heredit ary sp herocytos is
Tay-Sach 's
-
~
Friedreich's ataxia
-
~
Autosomal recessive conditions are 'metabolic' - exceptions: inherited ataxias
Autosomal dominant conditions are 'structu ral' - exceptions: Gilbert's,

m
Important for me Less ·mocrtant
se
As
Heredit ary spherocytosis is inherited in an aut osoma l dominant fashion.
Dr
A male ch ild from a travelling community is diagnosed with measles. Which one of the
fo llowing co mplications is he at risk from in the immediate ah ermath of th e initial
infection?
Arthritis
Pancreatitis
Inferti lity
Subacute sclerosing panencephalitis
m
se
As
Pneumonia
Dr
Arthritis
Pancreatitis
Infertility
-
. ..wl'
Subacute sclerosing panencepha litis
Pneumon ia
m
se
Su bacute sclerosing panencep hal itis is seen but develo ps 5-10 years following the illness.
As
Pancreatitis and inferti lity may follow mumps infection
Dr
Which layer of the epidermis is immed iately next to the dermis?
Stratum gra nulosum
Stratum lucidum
Stratum corneum
Stratum germinativum
m
se
As
Stratum spinosum
Dr
Stratum gra nulosum CD
Stratum lucidum
Stratum corneum
•
tiD
Stratum germinativum GD
Stratum spinosum f!D
Epidermis - 5 layers - bottom layer = stratum germinativum which gives rise to
m
se
keratinocytes and contains melanocytes
As
Dr
A 54-year-old woman who is obese comes t o the Emergency department complaining of
pain at the back of her right knee and swelling of the right ca lf, which she tells you came
on all o f a sudden. She is awaiting a knee replacement for ost eoarthritis o f the right knee.
Routine blood t esting reveals that the D-dimer is in the normal range.
Deep vein thrombosis
Ruptured popliteal cyst
Pseudogout
Ruptured ca lf mu scle
m
se
As
Septic arthritis
Dr
Deep ve in thrombosis fD
I Ruptured pop liteal cyst 6D

Pseudogout m
Ruptured ca lf muscle CD
Septic a rthritis m
Sud den onset of pain, particula rly when this is associated first with symptoms behind the
knee, and calf swelling, is ve ry sus picious of an underlying ruptured popliteal cyst. The
fact she is awaiting a right total knee replacement also suggests s ignifica nt osteoarthritis
o f the knee, which predisp oses to the cond ition. Physiotherapy and ana lgesia are the
mainstay of therapy for the condition. Patients may compla in of posterior knee and calf
pa in fo r a num ber of weeks after the original incident.
The fact that pain began b ehind the knee, and that the D-d imer is norma l. cou nts a gainst
a dia gnos is of deep vein thrombos is. Pseudogout is prima rily a ssociated with anterior
m
se
knee pain and swelling, as is septic arthritis. A ru ptured ca lf muscle is more likely to
As
p resent with pain in the body of the calf itself. rather than pain behind the knee.
Dr
An 18-year-old un iversity student goes to see her GP due to a sore throat. She also has a
marked fever and says she has been feeling tired for the past three weeks. On
examination, she has swollen cervica l lymph nodes. An antibody test confirms infectious
mononucleosis. Which cell surface p rotein does the Ebstein -Barr virus bind to?
CD3
CD4
CD14
CDlS
m
se
As
CD21
Dr
CD3 tiD
CD4 GD.
CD14 GD
CD15 f1D
I CD21 ED
CD21 is t he receptor for the Ebstein -Barr virus

Infectious mononucleosis is caused by t he Epstein-Barr virus (EBV) - CD21 is t he receptor

for EBV.
CD3 is a cell su rface marker found on all T cells. CD4 is a cell su rface marker found on T
m
se
helper cells. CD14 is a cell surface marker found on macrophages. CD15 is a cell surface
As
marker found on Reed-Sternberg cells.
Dr
A 16-year-old female is brou ght to her primary ca re physician by her parents with a
complaint of sho rt stat ure and delayed puberty. Further quest ioning reveals primary
amenorrhoea. The patient's height is significant ly shorter t han her mid parental height.
On physica l examination, she is in Tanner Stage I fo r breast develo pment and in early
Ta nner Stage ll for pubic hair develop ment. She also has a webbed neck.
Laboratory invest igations show a signif icantly raised Luteinizing Hormone (LH ) and
Foll icle -Stimulating Hormone (FSH) with reduced oest rogen levels. Karyotyp ing confirms
the diagnosis.
Which of t he following card iac pathologies is most commonly associated wit h th is

condition?
Aortic dissection
Mitral stenosis
m
se
As
Patent ductus arteriosus Dr
Aortic d issectio n
Mitral stenosis
Hypertrophic ca rdiomyo pathy
Patent ductus a rte riosus
Tu rne r's syndrome is associated with a ortic coarctation

The stem in q uestion lists some o f the classic featu res of Turner Syndrome (45, XO).
m
se
Bicusp id aortic valve a nd aortic coa rctatio n a re both com mon card iac com plicatio ns o f
As
this syndro me.
Dr
A new blood test which can show sig ns o f myocardial da ma ge within one hou r o f the
o nset of chest pain is develo ped. In a tria l of 100 patients prese nting with chest pa in, 40
o f the patients are later p ro ve n to have had myoca rd ia l ischaem ia by conve ntional
tropo nin tests. Of these patients the new test was positive in 20 cases. The new test was
also positive in 20 o f the re ma ining 60 patie nts later shown to have a negative tropon in.
What is the negative pred ictive value of the new test for myo ca rd ia l ischae mia?
0.5
0.66
0.8
Cannot calculate
m
se
As
0.33
Dr
0.5 GD
~6 GD
0.8 mt
Cannot calculate tiD
0.33 «D
Negative predictive value = TN I (TN + FN)

The new test was negat ive in 20 of the patients later show n to have myocardial ischaem ia
(fa lse negative) and negative in 40 patient s confirmed not to have myocardial ischaem ia
(true negative)
Negative predict ive value = TN I (TN + FN)
m
se
As
= 40 I (40 + 20) = 0.66
Dr
What is the main advantag e of non-infe rio rity trials when testing a new drug?
Preve nts ethica l dilemmas
Robust resu lts a re produced
Useful fo r cond itions where the re is no pro ve n drug treatment
Useful fo r co nd itio ns where the re is a high placebo respo nse rate
m
se
As
Small sa mple size is require d
Dr
Prevents ethical dilemmas
Robust resu lts are produced
Useful for conditions where there is no proven drug t reatment

-
......,
Useful for conditions where there is a high placebo response rate
m
se
As
Small sa mple size is required ~
Dr
A 10-year-old boy is found to have haemophilia A following investigation fo r a
haemoarthrosis. Which one of his relatives is most likely to have the condition?
Father
Mother's brother
Father's sister
Mother
m
se
As
Father's brother
Dr
Father crD
I Mother's b rother ED
Father's sister m
Mother CD
Father's brother
•
m
X-li nked recessive cond it ions are only seen in males which therefore excludes two of the
se
options. As male to male transmission is not seen this means the answer is mother's
As
b rother.
Dr
Which o f t he following statements is t rue regarding X-linked recessive inheritance?
A female child of a heterozygous f emale carrier has a 50% chance of being a carrier
An example is Friedreich 's ataxia
50% of t he male offspring of affected males will manifest the disease
An affected ch ild's uncle on the paternal side w ill also manifest the disease
m
se
As
50% of t he female offspring of affected males w ill be ca rriers
Dr
carrie~ has a 50% chance of being a
I A female child of a heterozygous female
earner
An example is Friedreich's ataxia
1 50% of the male offspring of affected males will manifest the disease
An affected child's uncle on the paternal side will also manifest the disease
-
~
m
se
As
50% of the female offspring of affected males will be carriers
Dr
Which one o f the followin g tech niques wou ld be most suitable to detect and quantify a
viral protei n?
m
se
As
Dr
Polymerase chain reaction
Northern blotting
I West ern blotting
Southern blotting
Eastern blotting
-
"""'
Molecu lar biology techniques

• SNOW (Sout h - NO rth - W est)
• DROP (DNA - RNA - Prot ein)
m
se
As
Dr
Dr
As
sem
20 extra patients in the p lacebo group ha d a stroke
For 1000 patients treated with active therapy, there would be 50 fewer st rokes
For 1000 patients treated with active t herapy, there would be 20 fewer st rokes
For every 1000 patients treated wit h active t herapy t here would b e 100 f ewer
strokes
20 patient s in t he treatment group were p rotect ed f rom stroke
This prevention study for stroke reveals that 20 patients need to be treated t o p revent
o ne event.
Thus if you treat 1000 patient s then you w ill expect to have 50 f ewer stro kes.
NNT is a t ime-speci fic epidemiological measure of the number of patients w ho need t o

be treated in order to prevent one adverse out come. A perfect NNT w ould be 1, where
m
se
everyone improves w ith t reat ment, t hus the higher the NNT, t he less effect ive the
As
treatment.
Dr
A coho rt study is desig ned to look at the associatio n between wo rking lo ng hou rs a nd
blood pressu re.
The following resu lts a re o btained afte r 10 yea rs of fo llow-up:
Number of patients with Number of patients

normal blood pressure diagnosed with
after 10 years hypertension after 10 years Total
Working < 1000 50 1,050

40 hours/
week
Working > 600 60 660

40 hours/
week
What is the odds ratio of develo ping hype rtension if yo u wo rk more than 40 hou rs/week
com pared to people who work less than 40 hou rs/week?
60/ 600
0 .5
50/ 60
s em
As
60/ 50
Dr
60/600 .
(D
0.5 fD
2 GD
50/60 GD
60/50 CD
The odds of developing hypertension if you work < 40 hours/week is 50 I 1000 = 1 I 20

o r 0.05
The odds of developing hypertension if you work > 40 hours/week is 60 I 600 = 1 I 10 or

0.1
m
The odds ratio is therefo re = (odds of developing hypertension if you work > 40
se
hours/week) I (odds of developing hypertension if you work < 40 hours/week) = 0.1/0.05
As
=2
Dr
Which one of the following best describes the Haldane effect?
Increase in p02 means C02 binds less well to Hb
Increasing acidity (or pC02) means oxygen binds less well to Hb
Decreasing acidity (or pC02) means oxygen binds less well to Hb
Ra ised 2,3 -DPG enhances oxygen delivery to the tissues
m
se
As
Decrease in p02 means C02 binds less well t o Hb
Dr
I Increase in p02 means C02 b inds less wj ll to Hb C!D
Increasing acidity (or pC02) means oxygen binds less well to Hb fD

Decreasing acidity (or pC02) means oxygen binds less well to Hb CD
I Raised 2,3-DPG enhances oxygen delivery to the tissues GD
m
se
As
Decrease in p02 means C02 binds less well to Hb
Dr
Which o f the follow ing secondary causes of hyperlipidaemia result in predominantly
hypercholest erolaemia, as opposed to hypertriglyceridaemia?
Hypothyroidism
Obesity
Liver disea se
Bendrofluazide
m
se
As
Chronic renal failure
Dr
Hypothyroidism CD
Obesity f!D
Liver disease GD.
Bendrofluazide f!D
Chronic rena l failure CD
Hypercholesterolaemia rather t han hypertriglyceridaemia: nephrotic syndrome,
m
se
cholestasis, hypothyro idism
As
Dr
You review a 21-yea r-old woman who has recently been d iagnosed with type 1 diabetes
mell itus. She was adm itted three months ago with vomiting, abdom ina l pain and weight
loss and was found to hyperglycaemic. A d iagnosis of type 1 d ia betes mell itus was made.
She was started on insulin. Recent bloods show the following:
Na• 140 mmol/ 1
K• 3.8 mmolfl
Urea 3.4 mmolfl
Creatinine 72 mol/1
Total cholesterol 5.1 mmolfl
HDL cholesterol 1.0 mmolfl
LDL cholesterol 2. 9 mmol/1
Triglyceride 1. 7 mmolfl
Urine di p: No p rotein o r b lood
She has no fa mily history of note and her body mass index is 20.5 kg/ m. What is the most
appropriate management with regards to lipid modification?
Start atorvastatin l Omg on
Sta rt atorvastatin 20mg on
Start atorvastatin 40mg on
Perform a QRISK2 assessment

sem
As
Reassure her that lip id modification therapy is not required at this stage
Dr
I Start atorvastatin 40mg on
Perform a QRISK2 assessment

-~
I Reassure her that lipid modificat on the rapy is not required at this stage
-~
NICE specifically state that we s hould not use QRISK2 for type 1 diabetics. Instead, the
following crite ria a re used:
• older than 40 years, or
• have had d iabetes for more than 10 yea rs o r
• have estab lished nephropathy o r
• have othe r CVD risk factors
m
se
As
None of these apply in this case.
Dr
Which one o f the following cell organelles contains dou ble-stranded circu lar DNA?
Nucleus
Ribosome
Nucleolus
Golgi apparatus
m
se
As
Mitochon dria
Dr
Which one o f t he followin g ce ll organelles contains dou b le-stranded circu lar DNA?
Nucleus fD
Ribosome CD
Nucleolus CD
Golgi ap paratus CD
m
se
I I
As
Mitochondria CD
Dr
Which one o f the following best describes the main act ion of the polymerase chain
reaction?
DNA identi fication using RNA
DNA amplification
RNA translation to prot ein
RNA amplification
m
se
As
DNA to RNA conversion
Dr
DNA identification using RNA CD
I DNA amplification GD
RNA translation to prot ein fD
RNA amplification G.D
m
se
DNA t o RNA conversion .
(D
As
Dr
Which one of the following statements regard ing the normal d istribution is correct?
Is a discrete p roba bil ity distribution
99.7% of values lie within 2 standard deviations of the mean
Mea n = mode = med ian
Standard deviation = mean I square root (va riance)
m
se
As
Is also referred to as the b inomia l distribution
Dr
Is a discrete proba bil ity distribution (D
99.7% o f va lues lie within 2 sta nda rd d eviatio ns of the mea n f.D
I Mean = mode = median
I CD
Standa rd d eviatio n = mean I squa re root (variance) mt
Is a lso referred to as the b inom ia l distributio n GD
m
se
As
The No rma l distribution is a continuous proba b ility d istributio n
Dr
Which one o f the fo llowin g best d escribes th e functio n of the p53 gene?
Inhibits ang io genesis
Onco gene
Encodes proteins which regu late the cell cycle
Encodes proteins which activate of natu ral kille r cells
m
se
As
Encodes proteins which d irectly repai r d amaged DNA
Dr
Inhibits angiogenesis
Oncogene
-
~
I Encodes proteins w hich regu late the cell cycle
Encodes proteins which activate of natural killer cells
Encodes proteins w hich directly repair damaged DNA
m
se
Whilst p53 can trigger cell cycle arrest to allow DN A to be repaired the encoded proteins
As
do not directly repair DNA.
Dr
A new blood test to screen patients for heart fai lure is tria lled on 500 patients. The test
was positive in 40 o f the 50 patients shown to have heart fa ilure by echocardiography. It
was a lso positive in 20 patients who were shown not to have hea rt failure. What is the
pos itive pred ictive va lue of the test?
0.8
0.66
0.33
0.1
m
se
As
Dr
0.8 GD
I 0 .66 ED.
0.33 CD
0.1 .
CD
Cannot b e calculated f.D

A contingency table can be co nstruct ed f ro m the above data, as shown below:
Heart failure No heart failure
Test positive 40 20
Test negative 10 430
m
se
Positive predict ive value = TP I (TP + FP) = 40 I (40 + 20) = 0.66 As
Dr
A 24 -yea r-o ld fe ma le present with a ton ic-clo nic seizu re which self-resolved a fte r 3
min utes. The re was no warning befo re the seizu re and he r boyfriend says the re was no
inco ntinence o r to ngue biting. She complained she was having a mi ld head ache, o n and
o ff fo r the last 2 weeks. Her most recent trave l histo ry includ ed a trip to Turkey 3 years
ago where s he doesn't remem ber what s he exactly ate. The re we re no o ther sympto ms.
On exam ination, the re we re no s igns of neuro logical d eficit o r s ig ns of ra ised intracra nia l
hypertension. She had aCT hea d which d e monstrated n ume rous s ma ll foca l calcificatio n
throug hout both cereb ra l hem ispheres with no e nha ncement. What is the most like ly
diag nosis?
Cere bral a bscess
Neurocysticercosis
Cere bral metastasis
Amoe bic encepha litis
m
se
As
Tuberculomas
Dr
Cerebral a bscess CD
Neurocysticercosis GD
Cerebral metastasis
Amoebic encepha litis

•
GD
Tuberculomas GD
Neu rocysticercosis often presents initia lly as a seizu re. It also can present as headaches,
altered mental state, and neu rological deficits. It occu rs from eating food o r drinking
water conta minated by hu man faeces conta ining T. soliu m eggs. The time between in itial
p resentation and ingestion is extremely va ried. It has characteristic neu roimag ing find ings
which depend on the stage of the disease. The stage described in this patient is the
nodu la r calcified stage which is represented here by mu ltiple calcified les ions on the CT
head. It is im portant to note neu rocysticercosis is extre me ly ra re and on clinical
examination a lone, this diagnosis wou ld be very low on the list of differentia l diagnosis.
The other 4 o ptions can all p resent as a tonic-seizure and headache. However, the CT
findings a re only characteristic of neu rocysticercosis. The other 4 options do not have
such characteristic CT findings o f numerous small foca l calcification throughout both
he mispheres and therefore it is impossible for these options to be the answer. As well as
the characteristic imaging findings, the trip to Tu rkey is another clue. Cerebral abscess,
m
se
cerebra l metastasis and tuberculomas will all typically show en hancing lesions on CT.
As
Amoebic encepha litis often a ppears norma l on CT in the ea rly stages and then may show
some patchy low- level enhance ment after that.
Dr
An 18-year-old female is admitted with a headache, photophobia, fever and confusion.
She is managed with empi rical antibiotics. What is the mechanism of action of the most
commo nly used first li ne antibiotic class?
Inhibition of RNA polymerase
Inhibition of cell wa ll synthesis
Inhibition of DNA gyrase
Inhibition of the ribosome
m
se
As
Inhibition of folate synthesis
Dr
Inhibition of RNA polymerase
Inhibition of cell wall synthesis
Inhibition of DNA gyrase

-
~
Inhibition of the ribosome
Inhibition of folate synthesis
Cephalosporins act by inhibiting cell wall formation

The correct answer is inhibition of cell wall synthesis. The first line antibiotics for possible
bact erial meningitis are cephalosporins. Penicillins, cephalosporins, carbapenems and
monobactams all act via inhibition of ce ll wall synthesis.
m
se
BNF
As
https://bnf.nice.org.uk/ treatment-summary/ cepha losporins.html
Dr
A 35-year-o ld male has recently had a sp le nectomy following damag e to his s pleen in a
mo to rcycle accid ent. He is up to date with a ll vaccinations which were offe red as part o f
his child hood vaccinatio n scheme. It is July. Which of the following vaccinations does he
requ ire in the first instance?
Influenza, pneumococcus, Haemophilus type B, pertussis
Pneu mococcus, meningitis ACWY, pertussis
Meningococcus type B and C, Haemophilus type B, BCG
Pneu mococcus, meningococcus type B and C, Haemophi lus type B
m
se
As
Haemoph ilus type B, pneumococcus, BCG, mening itis ACWY
Dr
Influenza, pneumococcus, Haemophilus type B, pertussis
Pneumococcus, meningitis ACWY, pertussis
Meningococcus type B and C, Haemophilus type B, BCG
Pneumococcus, meningococcus type B and C, Haemop ilus type B
Haemophilus type B, pneumococcus, BCG, meningitis ACWY
Patients with hyposplenism should be vaccinated aga inst pneumococcal,

Haemop hilus type B and meningococcus type C
Adu lts who have had an unplanned splenectomy should be vaccinated against
Pneumococcus, meningococcus type B and C, and Haemophilus type B initially. These
vaccines should be given at least 14 days post-splenectomy fo r maxima l efficacy. They
should also receive the influenza vaccine if during the autumn or winter months. They
should also have meningitis ACWY and a further dose of meningitis Bafter 2 months.
m
se
As
NICE Evidence sea rch: post -splenectomy antibiotics
Dr
A new t est to screen fo r pulmonary embolism (PE) is used in 100 patient s who present to
the Emergency Department. The test is positive in 30 of t he 40 patient s w ho are proven to
have a PE. Of t he rema ining 60 patients, on ly 5 have a posit ive t est. W hat is t he sensit ivity
o f t he new test?
8.33%
30%
40%
66.66%
m
se
As
75%
Dr
8.33% CD
30% CD
40% tiD
66.66% CD
75% ea.
A cont ingency ta ble can be co nst ruct ed from t he above data, as shown below:
PE diagnosed No PE
Test positive 30 5
Test negative 10 55
m
se
As
The sensitivity is t herefore 30 1 (30 + 10) = 75%
Dr
A patient receives vincristine t o help treat non-Hodgkin's lymphoma. What stage in the
cell cycle does vincristine act?
Gl
MO
G2
m
se
As
s
Dr
Gl GD
MO CD
~ CD
G2 CD
s GD
m
se
As
Vincrist ine inhibits formation of microtubu les and arrests mitosis
Dr
A 19-year-old man with a history o f learning disabilities and ectopia lent is is diagnosed as
having homocystinuria. Supplementation of w hich one of the follow ing may help improve
his condition?
Folic acid
Niacin
Pyridoxine
Vitamin B7
m
se
As
Thiamine
Dr
Folic acid CD
Niacin CD
I Pyridoxine GD
Vita min B7 CD
Thiamine CD
m
se
Homocystinuria - g ive vitam in B6 (pyridoxine)
As
Dr
A 67 -yea r-old man presents to the emergency d epartment with letha rgy, abd ominal pain
and polyuria. He underwent a cadaveric renal trans plant for end-stage renal d isease two
months a go . He has a background of type 2 diab etes mell itus and diabetic neph ropathy.
Blood s ind icate the following:
Na• 135 mmol/ 1
K• 4.6 mmol/1
Urea 8 mmol/1
Corrected ca2• 3.16 mmol/ 1
Phosphate 0.6 mmolfl
HbA1C 48 mmol/1
Parathyroid hormone 100 ng/1 (reference range 10-65ng/ l)
Tertia ry hyperparathyroidism
Secondary hyperparathyroid ism
Graft rejectio n
Vita min D deficiency

em
s
As
Poo rly controlled diabetes

Dr
Tertia ry hyperparathyro idism
Secondary hyperpa rathyroidism
Graft rejectio n
-
~
Vitamin D deficiency
Poorly controlled dia betes
Tertia ry hyperparathyroidism is an important d ifferential in hype rca lcaemia post

renal rep lace ment therapy
This is tertiary hyperparathyroidism. Most patients with chronic kidney disease d evelop a
d egree o f secondary hype rpa rathyroidism prior to ren al transplantation. Seconda ry
hyperparathyroidis m is associated with hypo - or normocalcaemia . Fo llowing rena l
replacement therapy, up to half of these patients develop persistent hyperparathyroidism
with o r without hypercalcaemia, this is termed tertia ry hyperpa rathyro idi sm. A mino rity o f
these patients will become symptomatic.
Graft rejectio n would not be most likely here, the creatinine is only mildly elevated, o ther
m
se
electrolytes a re within normal li mits. Vitamin D deficiency would not be associated with
As
hypercalcaemia. Diabetic control is good.
Dr
A 42-year-old gent leman is admitted to the Emergency Department as a p ot ential stroke.
A later CT scan o f his head confirms an est ablished infarct and is unfortunately outsid e
the th romb olysis window. During his time in the Emergency Department, you notice a
rash in a bathing -suit distribution consistent with angiokerato mas.
Testing you r hypothesis, you use a slit-lamp to confirm t he p resence of corneal whirls.
CADASIL
Fabry disease
M ELAS
Primary CNS angiitis
m
se
As
Cholesterol embolism
Dr
CADASIL ED
~rydisease eD
MELAS CD
Primary CNS a ngiitis CD
Cholesterol em bolism CD
The answe r is Fabry d isease. This condition typica lly p resents with prote in uria and is
associated with ea rly o nset strokes o r myocardial infa rctio ns with a typical rash known as
a ng iokeratomas.
CADASIL o r cereb ral autosoma l do mi na nt arterio pathy with subcortica l infa rcts a nd
leukoence phalo pathy is an inhe rited cond ition wh ich p resents with a history of migra ines
a nd multiple stro kes. It is not associated with angiokeratomas o r cornea l whirls. MELAS o r
mitochondrial ence phalo pathy with la ct ic acidos is a nd stroke symptoms is weakened by
the absence of la ct ic acid osis in the stem. The re is no evide nce o f connect ive tissue
disease in the stem to suggest p rimary CNS angiitis and cho lestero l embo lis m is typica lly
m
se
associated with eosino p hilia, lived o reticu la ris a nd a p recipitant such as p recedi ng
As
a ng iography.
Dr
Each one of the following features is seen in phenylketonuria, except:
Learning difficulties
Seizures
Eczema
Recu rrent infections
m
se
As
'Musty' urine
Dr
Learning difficulties m
I Seizure m
Eczema CID
~urrent infections aD
m
se
As
'Musty' urine (D
'
Dr
Which of the following is most likely to cause hypokalaemia associated with alkalosis?
Acetazolamide
Partially treated diabetic ketoacidosis
Diarrhoea
Cushing's syndrome
m
se
As
Dr
Acetazolami de
Partially treated diabetic ketoacidosis

-
~
Diarrhoea
Cushing's syndrome

-
~
m
se
Cushing's syndrome causes hypokalaemia with alkalosis
As
Dr
A 34-year-old male comes into the GP complaining of haemoptysis. He notes that he
wakes up at night due to waking up in a pool o f sweat and mentions he recently returned
f rom a holiday in Pakistan. The GP suspects tuberculosis and refers him to a respirato ry
physician. Which of the following cytokines is p rimarily responsible for activating
macrophages?
Il -l
ll -3
ll -4
Tu mour necrosis facto r-a
m
se
As
Interferon-y
Dr
Il -l GD
I ll-3
ll -4 GD
-
Tu mour necrosis factor-a fD
I Interferon-y ED
Interferon-y is respons ible for activating macrophages

Interferon-y is a cyto kine re leased from Thl ce lls and is resp onsib le fo r activating
ma cro p hag es. Tubercu losis el icits the re lease of Interfe ro n-y fro m T-cell s and this is the
rea son macrophages a re tied to its patho logy.
Il -2 is secreted from macrophages. Il-3 stim ulates the p ro liferation a nd d ifferentiation of
m
se
myeloid progenito r ce lls. ll-4 is respo nsible for the pro liferation o f B cell s. Tumour
As
necrosis factor-a is respons ible for acute fevers and neutro phil chemotaxis.
Dr
In a no rmal distribution what percentage of va lues lie within 3 standard d eviations of the
mean?
68.3%
98.3%
95.4%
99.7%
m
se
97.2%
As
Dr
68.3% GD
98.3% (fD
95.4% GD
99.7% CiD
m
se
As
97.2% (fD
Dr
A 43 -yea r-o ld man visits his GP because he is coughing up g reen phlegm. He has chest
pain o n his le ft-h and s id e. On exa mination, crackles can be hea rd in the base o f his left
lung. He has bronchia l breathing p resent too. He has reduced chest exp ansion on his left
s id e too. He has no significant past medica l histo ry, except an a lle rgy to p enicillin. An x-
ray is performed a nd he is diagn osed with p neumon ia. He is sta rted on d oxycycline. What
is the mechanism o f actio n of d oxycycline?
Inhibit 50S subun it of ribosomes
Inhibit 30S subun it of ribosomes
Inhibit p rotein wa ll synthesis
Inhibit DNA synthesis
m
se
As
Inhibit RNA synthesis
Dr
Inhibit 50S subunit of ribosomes f.D
I Inhibit 30S subunit of ribosomes CD

Inhibit protein wall synthesis mt
Inhibit DNA synthesis tiD
Inhibit RNA synthesis CD
Tetracyclines inhibit the 30S subunit of ribosomes

Doxycycline is a tetracycli ne often prescribed for patients allergic to penicillin and with
mild pneumonia. Tetracycl ines inhibit the 30S subunit of ribosomes, which leads to an
m
se
inability of bacteria to produce proteins. Tetracyclines are commonly co nfused with
As
macrolides, which inhibit the 50S subunit o f ribosomes.
Dr
Interferon-alpha may b e used in the management of each one of the following, except:
Metast atic rena l cell cancer
Hepatit is B
Ka posi 's sa rcoma
Hepatitis C
m
se
As
Dr
Metastatic rena l cell cancer CD
Hepatit is B «D
I Kaposi's l arcoma flD
Hepatit is C GD
I
m
se
Chronic granulomat ous disease CD
As
Dr
You are a STl doctor in medicine. A 67-year-old man has been investigated for anaemia
and weight loss. En doscopy shows a gastric tumour which is confirmed as an
a denocarcinoma on b iopsy. On discussing the diagnosis the patient states that he has
had 'a good life' and doesn't want any treatment. Clinical exam ination is unremarka ble.
He is able to retain and understand the informatio n you g ive to him, including the li kely
curative nature of su rgery. What is the most a pp ropriate action?
Respect his wishes and book a follow-u p appointment for four weeks
Arra nge a CT head and check bloods to exclud e cerebral metastases and
hyperca lcaemia
Arra nge an a ppo intment with a psychiatrist
Detain him under th e Menta l Health Act
m
se
As
Ask to sp eak to his wife alone to find out why he is refusing su rgery
Dr
Respect his wishes and book a follow-up appointment for four weeks
Arra nge a CT head and check bloods to exclude cerebral metastases and
hyperca lcaemia
Arrange an appo intment with a psychiatrist

-
........
Detain him under the Mental Health Act
Ask to speak to his wife alone to find out why he is refusing su rgery
This question is ultimately about autonomy. By being able to understand and retain the
-
........
information you give him the patient has demonstrated that he is competent to make
decisions. It shou ld be noted that the Mental Capacity Act 2005 states that 'a person is not
to be treated as unable to make a decision merely because he makes an unwise decision'.
ACT hea d and bloods may exclude causes that wou ld impair judgement but wou ld you
override his decis ion even if you noticed evidence of a cerebral metastase? As there is no
evidence that th is man is suffering from a mental illness referral to a psychiatrist wou ld be
inap propriate.
By speaking to the wife a lone you are riski ng b rea ching confidentia lity. Detaining him
m
se
under the Menta l Hea lth Act s imply because you disagree with his decision is clearly
wrong As
Dr
Which one o f the following is involved in the degradation of polypeptides?
Peroxisome
Endoplasmic reticulum
Prot easome
Ribosome
m
se
As
Golgi apparatus
Dr
I Peroxisome
I
fD
Endoplasmic reticulum f.D
Prot easome GD
Riboso me f.D
m
se
•
As
Golgi apparatus
Dr
G cells in stomach
m
se
As
Dr
I I ce lls in upper small intestine ED.
G cells in stomach m
K cells in upper small intestine GD
D cells in the pancreas GD
S cells in upp er sma ll intestine CD
m
se
CCK - I cells in upp er sma ll intest ine
As
Dr
Anti-nuclear antibod ies (ANA) are common ly found in patients w ith syst emic lupus
eryt hematosus (SLE). However, they can also b e found in around 9% of peop le w it hout
the condit ion. Therefore, as a t est for diagnos ing SLE, ANA has low:
Positive predictive value
Sensitivity
Specificity
Negative p redictive value
m
se
As
Incidence
Dr
Posit t e predictive value .
(D
Sensitivity CD
I Specificity CD
Negative p redictive value fD
Incidence
•
If a test is fa lsely positive in 9% of the gene ral p op ulatio n the n that test has poor
specificity.
Low specificity tests have ma ny fa lse positives (those without the cond ition test positive).
m
se
As
Low sensitivity tests have ma ny false neg atives (those with the conditio n are missed).
Dr
An 18-yea r-o ld female who is known to have Turner's syndrome is refe rred to ca rdio logy
as she has a mu rmur. On exa mination a soh ejection systo lic murmur is heard . What is the
most li kely cause of this find ing?
Pu lmonary stenosis
m
se
As
Dr
Coa rctation o f the a o rta
Ventricula r septal d efect
F mo nary stenosis
Su prava lvula r a o rtic stenosis
I Bicuspid aortic valve

-
~
m
se
Turner's syndrome - most common cardiac defect is bicuspid aortic valve
As
Dr
A scientist is developing a new test fo r Bovine spongiform encepha lopathy that uses gel
e lectrophoresis to sepa rate native proteins by 3-D structu re. This is an example of:
A microarray
Northern blotting
Southern blotting
m
se
As
Western blotting
Dr
A microarray
Northern blotting
southr n blotting
Western blot ting
Molecu lar biology techniques

• SNOW (South - NO rth - W est)
m
• DROP (DNA - RNA - Protein)
se
As
Dr
A study compa res the sensitivity of two tests fo r colorectal cancer. The first test has a
sensitivity of 85% whilst the secon d test has a sensitivity of 91%. What type of significance
test shou ld be used for co mpa ring the two results?
Wilcoxon matched -pairs
Mann -Whitney test
Student's t -test
Chi-squared test
m
se
As
Pea rson's test
Dr
Wilcoxon matched-pairs GD
Mann-Whitney test GD
Student's t -test a
I Chi-squared test
Pea rson's test

CD
(fD
m
se
As
As percentages are being compared the chi-squared test sho uld be used
Dr
A 52-year-old lady w ith a 6-month history of steatorrhoea, abdominal pain, bloating and
a positive IgA tissue transglut aminase test was referred to gastroenterology for further
investigati on. The diagnosis is confirmed on duodenal bi opsy, w hich reveals subtotal
villous atrophy and crypt hyperplasia.
Which HLA is th is disease most associated with?
HLA-DR2
HLA-DR3
HLA-85
HLA-DQ2
m
se
As
HLA-827
Dr
HLA-DR2 CD
HLA-DR3 GD
HLA-85 (D
HLA -DQ2 GD
HLA-827 fD
Coel iac disease is linked to HLA-DQ2

This patient has coelia c disease. Coeliac disease is linked to HLA-DQ2 and HLA-DQ8.
HLA-DR2 is associat ed with narcolepsy and Goodpasture's.
HLA-DR3 is associat ed with d erm atitis herpeti form is, Sjogren's syndrome and primary
biliary cirrhosis.
HLA-85 is associated with 8ehcet's disease.
m
se
As
HLA-827 is associat ed with ankylosing spondylitis, Reiter's syndrome and anterior uveitis.
Dr
Northern blotting is used t o:
Detect and quantify proteins
Amp lify DNA
Detect RNA
Detect DNA
m
se
As
Amplify RNA
Dr
Det ect and quantify proteins .
CD
Amplify DNA m
I Detect RNA CD
Detect DNA m
Amplify RNA
Molecular biology techniques

• SNOW (South - NOrth - West)
m
se
• DROP (DNA - RNA - Protein)
As
lmportart "or me _ess ;rroc1:o"'lt
Dr
A 78-year-old man p resent ed t o t he eye ca sualty w it h diplopia. He has b een noticing t his
d ou ble vision for t he past two w eeks. On examinat ion, there was horizontal diplop ia and
minimal rest rict ion o f one o f t he extraocu lar muscles in the leh eye. His past medical
hist ory includ es longst anding prost ate cancer and hypertension. Imaging o f the b rain
revealed metastatic lesion in t he clivus encasing the cavernous sinus and ca ro tid artery.
Which one o f t he followin g cran ial nerve palsy leads t o diplopia in this patient?
Right t hird cranial nerve (CN3) palsy
Leh sixth cra nial nerve (CN6) pa lsy
Right sixt h cranial nerve (CN6) palsy
Leh fou rth cranial nerve (CN4) pa lsy
m
se
As
Leh t hird cranial nerve (CN3) palsy
Dr
Right t hird cranial nerve (CN3) palsy CD
I Left sixt h cranial nerve (CN6) pa lsy ED.

Right sixt h cran ial nerve (CN6) palsy GD
Left fourth cran ial nerve (CN4) palsy GD
Left third cran ial nerve (CN3) palsy G'D
CN6 pa lsy manifesting as dip lopia could be the first sign o f brain metastasis
The sixth cranial nerve (CN6) innervates the lateral rectus mu scle which is respons ible fo r
moving the eye laterally. CN6 arises from the pons which sits on the cl ivus. Hence, a
tumour involving the clivus would compress t he CN6 causing its palsy. This lea ds to
restrict ed lateral gaze which results in horizonta l diplopia as seen in this patient. Right
cranial nerve palsies are irrelevant as the question clearly states the involvement of left
m
se
extraocu lar muscle. CN4 palsy causes vertical diplopia. CN3 palsy causes ptosis and
As
involves four extraocular muscles rather than one that is mentioned in the question.
Dr
A stu dy is designed to see whether the d egree of chest pain is linked to the troponin I
value for patients adm itted followin g a myocard ia l infarctio n. The pain is assessed using a
scale of 1-10, with 10 representing the worst pain that the patient has ever experienced.
Which one of the followin g s ign ificance tests is it most appropriate to use to investigate
this link?
Student's t -test
Chi-squared test
Spearma n's rank co rrelation coefficient
Pea rson's p rodu ct-moment coefficient
m
se
As
Mann -Whitney test
Dr
Student's t-test
Chi-squared test
P ,ea rman's ran k corre lation coefficient

-
~
Pearson's p roduct-moment coefficient
Mann-Whitney test
This scenario looks at whether the val ues a re co rrelated. As the d ata is non-parametric,
m
se
pa rticu larly the observation based pain sca le, Spearman's rank co rre lation coefficient
As
should be used.
Dr
You are called to see a patient overnight who had a tota l parathyroidectomy earlier in the
day for primary hyperparathyroidism. The patient is experiencing perioral ting ling and leg
cramps. The nurse tells you that his hand clenched into a claw when she took his blood
pressure. You suspect an electrolyte imbalance. Which ECG finding are you most likely to
see with this electrolyt e disorder?
Tented T waves
Flatt ening of the P wave
Prolongation of the QTc interval
Prolongation of the QRS interval
m
se
As
Torsades de pointes
Dr
Tented T wave s
Flattening of the P wave
Prolongation of the QTc interval
Prolongation of the QRS interval
Torsades de pointes
The most common ECG change in hypocalcaemia is prol ongation of the QTc
interval
The correct answer is a pro longation of the QTc int erval. The patient has the classic
symptoms of acute hypocal caemia. This is common after parathyro idectomy for primary
hyperparathyroidism, due to rapid absorption of calcium into the bones after removal of
excess PTH (often called 'hungry bones syndrome.') QTc pro longation in hypocalcaemia is
mainly due t o prolon gation of the ST segment as a result of the slowing of ventricular
repo larisation.
Torsades de point es can be seen in hypocalcaemia but it is more commonly seen with
hypokalaemia or hypomagnesaemia. Tented T waves and flattening of the P wave are
seen in hyperkalaemia.
m
se
ECG diagnosis: the effect of ionised serum calcium levels on electrocardiogram

As
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951043/
Dr
A 40-year-old man is admitted w ith an Ml and transferred for an urgent PC!. On closer
questioning, he has been complaining o f a severe burn ing sensation o f his hands and
feet. On examination, you notice multiple angiokeratomas in a bathing-suit distribution. A
urine dip reveals prot ein +++. A diagnosis of Fabry disease is suspected. What is the most
likely pathophysiology of the condition?
Deficiency of HGPRT
Deficiency of TPMT
Deficiency of glucocerebrosidase
Deficiency of alpha-galactosi dase A
m
se
As
Deficiency of hexosa minidase A
Dr
Deficiency of HGPRT
Deficie ncy of TPMT
Deficiency of g lucocereb ros idase
~ficiency of a lpha-galactosidase A
Deficie ncy of hexosa minidase A
Fa bry disease is an X-l inked recessive d isorde r cha racterised by a d eficiency of alpha -
g a lactos idase A.
A d eficiency of TPMT is li nked with severe b one marrow fa ilure whe n these p atie nts a re
given azathiop rin e o f 6-merca ptopurin e.
Deficiency o f HGPRT a nd glucocerebrosidase a re associated with Lesch- Nyhan syndrome

a nd Gauche r disease respectively. Hexosaminid ase A d eficie ncy is linked with Tay-Sachs.
Fabry disease
Fa bry disease is an X-l inked recessive d isorde r cha racterised by the d eficie ncy of alpha-
g a lactos ida se A. This lead s to accumu latio n of glycos phingo lip id s, namely
glo botriaosylce ram ide, within the lysoso mes o f cell s. It is the second most p reva lent
lysosomal sto rag e di sord er ah er Gaucher d isease.
Clinical features:
• Seve re neu ro path ic/limb pain b rought on by stress, heat, o r co ld
• Angiokeratomas
• Renal features: proteinu ria, polyuria, polydipsia
• Cardiac: leh ventricu la r hypertro phy, coronary a rtery disease, va lvula r abnorma lities
a nd heart fa il ure
• Cere brovascula r: TIAs/ stro kes
Manageme nt:
• Enzyme rep la cement the rapy with aga ls idase a lfa
s em
As
Dr
A 40-yea r-old ma n is a d mitted to the intensive ca re unit following a severe episode o f
acute pancreatitis. On the third day of his a d mission he becomes pyrexial. A septic screen
is ordered incl uding cultu res taken from both perip hera l blood and the internal jugula r
li ne. There is no s igns of infection on the chest x-ray or urine sample. The microbiology
la boratory p hone to re port s ig ns of bacterial infection in the sample from the centra l line.
What is the most li kely orga nism to be isolated?
Pseudomonas aeruginosa
Escherichia coli
Streptococcus pneumoniae
m
se
As
Dr
Escherichia coli
-
~
I Staphylococcus epidermidis
Most common organism found in central line infections - Staphylococcus
m
se
epidermidis
As
Dr
Each o f the following organ isms commo nly cause respiratory tract infections in patients
with cystic fibrosis, except
Aspergillus
Burkholderia cepacia
Staphylococcal aureus
m
se
As
Strongyloides stercora/is
Dr
I
Aspergillus
.
(D
.
(D
Burkholderia cepacia (!D
Staphylococcal aureus CD
m
se
As
Strongyloides stercora/is CD
Dr
Which of the following is responsible for the early repolarisation phase o f the myocardial
action potential?
Rapid sodium influx
Rapid calcium influx
Slow sodium efflux
Slow efflux of calcium
m
se
As
Dr
Rapid sodium influx fD
Rapid calcium influx tiD
I Slow sodium efflux fliD
Slow efflux of calcium GD
m
se
I
As
Efflux of potassium CiD
Dr
I
A new born female baby is diagnosed with cystic fibrosis following an episode of
meconium ileus shortly after birth. Which one of the followi ng is least like ly to occur as a
consequence of her underlying diagnosis?
Delayed puberty
Nasal polyps
Diabet es mellitus
Rectal prolapse
m
se
As
Arthropathy
Dr
Delayed puberty CD
Nasal polyps f!D
Diab etes mell itus C!D
Recta l pro la pse f!D
Arthropathy GD
m
se
As
Arthro pathy is not a common feature o f cystic fibros is
Dr
Which one of the following cardiac tissue types has the highest conduct ion velocity?
Atrial myoca rdial tissue
Ventricular myocardi al tissue
Pu rkinje fibres
Atrioventricular node
m
se
As
Sinoatrial node
Dr
Atrial myocardial tissue
Ventricular myocardial tissue

•.
(D
I Purkinje fibres
Atrioventricular node
GD
.
(D
m
se
As
Sinoatrial node GD
Dr
Which of the following cond itions is inherited in an autosomal dominant fash ion?
Noonan syndrome
Homocystinuria
Cystinuria
m
se
As
Fanconi anaemia
Dr
I Noonan syndrome CD
Homocystinuria GD
Cystinuria .
CD
Congenital adrenal hyperplasia fD
Fanconi anaemia (D
Autosomal recessive condit ions are 'metabo lic' - exceptions: inherited ataxias
Autosomal dominant condit ions are 'structural' - exceptions: Gilbert's,
m
se
As
Dr
A 24-year-old man who has been discharged fo llowing admission for a spont aneous
pneumothorax ask for advice about flying. During his stay in hospital the pneumothorax
was aspirat ed and a check x-ray revealed no residual air. What is the earliest time he
should fly?
Immediately
24 hours
3 days
2 weeks
m
se
As
2 months
Dr
Immediately tlD
p. hours GD
3 days CD
I 2 weeks ED
2 months CD
m
se
Please see the text below for an explanation about the competing and chang ing
As
gu idelines.
Dr
Type I reaction
Type n reaction
Type mreaction
Type N reaction
m
se
As
Type V reactio n
Dr
Type I reaction m
Type ll reaction CD
P,pe m reaction CD
C!D
.,
Type N reaction
m
se
As
Type V reactio n
Dr
A 74-yea r-o ld female is adm itted with central chest pain. She states that the pain comes
on with exertion and is relived by rest. She has a past med ical history of hypertension.
ECG resu lts:
ECG T wave inversion in V4-V6
Blood resu lts:
Troponin I 0 .02 ng/ml (normal < 0 .07)
Which molecule does tropo ni n I bind to?
Neu rom uscu la r junction
Calcium ions
Actin
Myosin
m
se
As
Sarcoplasm ic reticulum
Dr
Neurom uscular junction
Ca lcium ions
I Actin
Myosin
Troponin I b inds to actin to hol d the troponin-tropomyosin complex in place

Tro ponin I binds to actin to hol d the tro po nin-tropomyosin complex in place.
The clinical features are sugg estive of stab le angina. The T wave inversio n in the lateral
leads gives fu rther evid e nce to ischaemic hea rt disease. The normal tro ponin I ru les out a
myoca rdia l infarctio n.
Cardiac myocytes d o not have a neuromuscu la r junction. They commu nicate with each
other via gap ju nctions.
Tro ponin C binds to calciu m ions.
Myosin is the thick comp onent of muscle fibres. Actin slid es along myosin to generate
muscle contraction.
em
The sarco plasmic reticu lum regulates the calcium io n concentratio n in the cyto plas m of
s
striated muscle ce lls

As
Dr
I • I __ I - ~·
A 64-year-old woman who is reviewed due to multiple non-healing leg ulcers. She reports
feeling generally unwell for many months. Examination findings include a blood pressure
of 138/72 mmHg, pulse 90 bpm, pale conj unctivae and poor dentition associated w ith
bleeding gums. What is the most likely underlying diagnosis?
Thyrotoxicosis
Vita min 812 deficiency
Vita min C deficiency
Diabet es mellitus
m
se
As
Sarcoidosis
Dr
Thyrotoxicosis
Vitamin 812 deficiency

-
" "'
Vitamin C deficiency
Diabetes mellitus
-
~
m
se
As
Sarcoidosis
Dr
Which one o f the fo llowi ng statements regard ing gastrin is true?
Secreted by D ce lls in the stomach
Secretion is inhibited by h igh a ntra l pH
Reduces acid secretion in the stomach
Increases g astric motility
m
se
As
Distension of the stomach inhibits secretion
Dr
Secreted by D ce lls in the stomach
I Secretion is inhibited by h igh a ntra l pH
Reduces acid secretion in the stom ach
Increases gastric motility
Distens ion of the stomach inhibits secretio n

-
""""
m
se
Gastrin - in creases gastric motility
As
Dr
Which one of the following is least associated with Tetralogy of Fallot?
Rig ht ventricular out flow tract obstruction
Overriding aorta
Ejection systolic murmur
Left-to-right shunt
m
se
As
Rig ht ventricular hypertrophy
Dr
Right ventricular outflow tract obstruction
Overriding aorta
Ejection systolic murm r
Left -to-right shunt

-
~
-
Right ventricular hypertrophy
Right-to-left shu nting is characteristic of Fallot's.lt is however known that a small number
m
se
of asymptomatic infants may initially have a degree of left-to-right shunting through the
As
ventricular septal defect
Dr
A 17-year-old male w ith a history of cystic fibrosis presents to cl inic for annual review.
What is the most appropriate advice regarding his diet?
High ca lorie and low fat w ith pancreatic enzyme supplementation for every meal
High ca lorie and low fat w ith pancreatic enzyme supplementation for evening meal
Normal calorie and low fat w ith pancreatic enzyme supplementation for every meal
High ca lorie and high fat with pancreatic enzyme supplementation for evening
meal
m
se
As
High ca lorie and high fat with pancreatic enzyme supplementation for every meal
Dr
High ca lorie and low fat with pancreatic enzyme supplementation for every meal fl'D
High calorie and low fat with pancreatic enzyme supplementation for evening
meal
Normal ca lorie and low fat with pancreatic enzyme supplementation for every
meal
High ca lorie and high fat with pancreatic enzyme supplementation for evening
meal
m
High ca lorie and high fat with pancreatic enzyme supplementation for every
se
As
meal
Dr
Which one o f the following causes of primary immunodeficiency is aT-cell disorder?
Chronic granulomatous disease
DiGeorge syndrome
m
se
As
Dr
Chrot granulomatous disease

-
.....,
I DiGeorge syndrome
DiGeorge syndrome - a T-cell disorder

m
DiGeorge syndrome is a primary immunodeficiency disorder caused by T-cell deficiency
se
and dysfunction. It is an example of a microdeletion syndrome. Patients are consequently
As
at increased risk o f viral and fungal infections.
Dr
Which one o f the following is not a recognised cause of hypocalcaemia?
Hypopa rathyroidism
Bendroflumethiazide
Acute pancreatitis
m
se
As
Acute rhabdomyolysis
Dr
Hypopa rathyroidism CD
Bend roflumethiazide GD
Pseudohypoparathyroidism (D
Acute pancreatitis (D
m
se
As
Acute rhabdomyolysis GD
Dr
Which one of the following congenita l infections is most characteristically associated with
chorioretinitis?
Cytomegalovirus
Treponema pallidum
Rube lla
Toxo plasma gondii
m
se
As
Parvovirus B19
Dr
Cytomegalovirus ED
Treponema paltidum CD
Rube lla fD
I Toxo plasma g ondii ED

Parvovirus B19 m
Congenital t oxoplasmosis
• cerebra l calcification
• chorio retinitis
A form o f 'salt and pepper' chorioretinit is is also seen in congenita l rub ella but this is not
m
a com mon feature.
se
As
Chorioreti nit is is found in around 75% of pat ients wit h congenital toxoplasmosis.
Dr
Which of the following is true rega rding endothelin?
It is a potent vasodilator
It is produced mainly by pulmonary tissue
It acts on target cells by stimu lating guanylate cyclase
Release is stimulated by nitric oxide
m
se
As
Endotheli n antagonists are useful in prima ry pulmonary hypertension
Dr
It is a potent vasodilator
It is produced mainly by pulmonary tissue
It acts on target cells by stimulating guanylate cyclase
Release is stimulated by nitric oxide
m
se
As
Endothelin antagonists are useful in primary pulmonary hypertension
Dr
A 30-year-old man is ref erred to ophthalmology due to deteriorating visual acuity. Both
his brother and uncle on his mother's side have developed similar problems. What is the
most likely mode of inheritance of his cond ition?
Autosomal dominant
Autosomal recessive
X-li nked recessive
X-li nked dominant
m
se
As
Polygenic
Dr
Autosom al d om inant mt
Autosomal recessive fD
I X-linked recessive ED
X- li nked d o minant flD
Polygen ic CD
This first clue is the natu re of the disease - many of the inhe rited eye disorde rs such as
retinitis pi gmentosa and ocula r a lbin ism a re inhe rited in a n x-linked re cessive pattern.
Fo r this d isord e r to b e autosoma l recessive both the patient's pa rents wou ld need to be
m
ca rriers (hete rozygous) as we ll as both his maternal aunt and uncle. Even fo r common
se
a utosomal recessive disorde rs such as cystic fibros is the carrier rate is a round 1 in 25
As
making this statistica lly less likely.
Dr
Which type o f secondary messenger system does nit ric oxide stimulate?
Cyclic GMP
Cycl ic AMP
Phosphoi nositide
Protein kinase
m
se
As
Calcium
Dr
I Cyclic GMP
Cyclic AMP
ED
fD
Phosphoi nosit ide .
(D
I Pr+ ein kinase fiD

Calcium m
m
se
Nitric oxide, second messenger = cGMP
As
Dr
One of you r colleagues confides in you that he has just b een diagnosed with he patitis B.
He has not told anyone e lse as he is wo rried he may lose his job. He is currently wo rking
as a genera l su rgeon in the local hospita l. You try to p ersuad e him to info rm occupationa l
health b ut he re fuses. What is the most ap propriate action?
Keep co nfidentia lity but ask him to sto p taking blood
Send an a no nymou s letter to his employer
Keep co nfidentia lity
Inform your colleague's em ploying body
m
se
As
Conta ct the police
Dr
Keep confidentiality but ask him to stop taking blood
Send an anonymous letter to his employer
Keep confidentiality
I Inform your colleague's employing body
Contact the police
m
se
Whilst th is may seem harsh patient safety has to be paramount. Please see the updated
As
GMC guidelines for further details.
Dr
A 10-year-old male is referred to an oncologist for suspect ed lym phoma. His symptoms
include fever, night sweats, weight loss and lym phadenopathy is present on examination.
Molecular testing and histo logica l analysis of a lymph node biopsy suggest a diagnosis of
Burkitt's lymphoma. Which oncogene is associated with Burkitt's lymphoma?
ABL
p53
n- MYC
c- MYC
m
se
As
HER2
Dr
AB L tiD
I p53 fiD
n-MYC fiD
c-MYC (D
HER2 CD
Burkitt's lymphoma is com monly associated with c-MYC

Burkitt's lymphoma is classically associated w ith the t ranslo cation: t(8;14). Here, the c-MYC
gene is translocated next to t he gene for IgH. lgH is highly exp ressed in t he body (as it
codes for the heavy chain of antibodies), an d t his leads to an overam plification c-MYC.
p53 is a tumour supp ressor gene, not an oncogene. n-MYC comes f rom the same family
m
se
as c-MYC b ut is found in neuroblastoma. HER2 is found in b reast cancer. ABL is found
As
chronic myeloid leukaemia.
Dr
Which one of the following is in direct anatomical contact with the right kidney?
Gallbladder
Liver
Stomach
Dist al part of small intestine
m
se
As
Duodenum
Dr
Gallbladder CD
Liver CD
Stomach m
GD
m
se
As
Duodenum e::£')
Dr
Which one of the following may be used to calcu late the number needed to treat?
1 I (Absolute risk reduction)
(Abso lute Risk Reduction) I (Number of people in t rial)
((Control event rat e) - (Experimental event rate)) I (Control event rat e)
1 I (Relative risk)
m
se
As
1 I (Hazard ratio)
Dr
Ill (Absolute risk reduction) fD
(Abso lute Risk Reduction) I (Number of people in t rial) f.D
I ((Col trol event rate) - (Experimental event rate)) I (Cont rol event rate) f.D
11 (Relative risk) f.D
1 1 (Hazard ratio) m
m
se
NNT = 1 1 Abso lute Risk Reduction
As
Dr
A scientist is developing an assay whereby he heats up a DNA specimen at 95°C then
cools it to 55°C whilst adding primers to specific sequences. Following each primer, heat-
stable DNA polymerase is a dded and the cycle is repeated .
Which molecula r technique has been described?
Southern blot
Western blot
SDS-PAGE
Polymerase Chain Reaction (PCR)
m
se
As
Cloning
Dr
Southern blot .
f!D
Western blot CD
SDS-PAGE CD
I Polymerase Chain Reaction (PCR) (ifD
Cloning m
Polymerase Chain Reaction (PCR) uses denaturation, annea ling and elongation to
amplify a desired fragment of DNA
PCR is a common technique used to amplify a desired fragment of DNA.
Other answers:
• Southern blot: detect ion o f DNA.
m
• Western blot: detect ion o f RNA
se
As
• SDS -PAG E: protein separation by electrophoresis
• Cloning: recombinant DNA p roduction using bacteria
Dr
A study is d esigned to look at the efficacy of a mandible advancement device in reducing
snoring. The severity of snoring was assessed by the partner using a 10 point sca le before
and after using the device. Fifty peop le were invo lved in the study. What is the most
appropriate statistical test to apply to this data?
Unpa ired Student's t-test
Pea rson's p roduct-moment coefficient
Wilcoxon s igned-rank test
Chi-squared test
m
se
As
Mann-Whitney test
Dr
Unpa ired Student's t-test
Pearson's proa uct-moment coefficient
Wilcoxon s igned-ra nk test

-
~
Chi-squared test
Mann-Whitney test
m
The data in this study is non-parametric, paired and comes from the same po pulation.
se
These factors make the Wilcoxon signed-rank test the most appropriate statistical
As
hypothesis test to use.
Dr
The adrenergic recept or is an example o f a:
Gu anylat e cyclase receptor
G p rotein -coupled receptor
m
se
As
Dr
Intracellular receptor CD
Tyrosine kinase receptor tiD
Guanylate cyclase receptor (D.
I G p rotein -coupled receptor
Ligand-gated ion channel

CD
(D.
m
se
Norepinephrine - G protein -coupled recepto r
As
Dr
A 30-yea r-old ma le patient is referred by the GP to the infectious disease team with a 10-
months histo ry o f the gradua l a ppea ra nce of an increasing numb er of pain less nodu les on
the neck, fa ce and arms. He admits to travelling to India 4 months prio r to the app earance
o f the first nodu le. Whil st he was in Ind ia, he stayed with a lo ca l fami ly fo r one month,
d u ring which he was served meat includ ing po rk. On fu rther questio ning, he ad mits that 6
months a go, he noticed passing a noodle- li ke material in his stool but did not seek
med ical attenti on. He a lso a dmits to g enera l we ight loss for the last 8 months b ut he has
been going to the gym. On exam ination, there a re 10 d ifferent subcutaneous nod ules in
total. The skin b iopsy of one of the nod ules on the arm shows the nodule to b e a wh ite
cystic structure.
Given the likely diag nosis, what wou ld b e the most appro priate treatment to start him on?
Praziqua ntel
Benda zoles
Qui nine
Penicillin
m
se
As
Flucloxacill in
Dr
Praziquantel eD
I Bendazoles
Quinine
6D
CD
Penicillin m
Flucloxacill in CD
Cysticercos is can be treated with be ndazoles

Th is patient has disseminated cysticercosis. Cysticercosis can be treated with bendazoles.
Praziquantel is used to treat schistosomiasis.
m
Qu inine is an anti-malarial.
se
As
Pen ici llin and flucloxacilli n are not usually used to treat cysticercosis.
Dr
A 38-year-old male is admitt ed to the Emerg ency Departm ent following a collapse w hile
running a marathon. His blood results are as follows:
Na+ 121 mmol/ 1
K+ 3.4 mmolfl
Urea 3. 2 mmol/1
Creatinine 68 umol/ 1
During assessment he beco mes increasingly obtund ed and goes on to have multiple tonic
clon ic seizu res. What is the most ap propriate treat ment from the list below to improve his
neurological status?
Decompressive craniot omy
Demeclocycline
Intravenous normal saline
Hypertonic saline
m
se
As
Mannitol
Dr
I DL pressive cranioto my
Demeclocycli ne
Intravenous norma l saline
~pertonic saline
Mann ito l
Acute hyponatraemia is that which occurs within a duration of 48 hours.
Ove r consu mption o f fluid s, pro longed race duration a nd inadeq uate tra ini ng all can
p red ispose to acute hyponatraemia in this settin g. When hyponatraem ia deve lo ps o ve r a
s hort d uration the a b ility o f the bra in to ada pt is exceeded and cere bral oed ema can
resu lt which may lead to confusion, seizures and coma. As a resu lt patie nts may d ie from
b ra in herniatio n.
The correct treatme nt to g ive is hypertonic sali ne. Decompressive cran iotomy would help
a ll eviate ra ised intracra nia l pressu re d ue to cereb ra l oed e ma howeve r is not an
a ppro priate first li ne treatme nt. Demeclocycli ne is used fo r SIADH and ma nnitol is mo re
like ly to b e used in the co ntext of trau matic bra in injury.
A s mall, q uick increase in the serum sod ium is requ ired in o rd er to decrease intracranial
m
se
p ressu re. Hypertonic sa line (3%) bo luses (a fte r seeking senio r advice) a re the most
As
a ppro priate treatment to improve neu ro log ical status in such patients.
Dr
You are reviewing a new study on the benefit of omega-3 fish oils in patients with
established ischaemic heart disease. What does the power of the study equate to?
= 1 I p va lue
= stand ard d eviation I sq uare root of sa mple size
= 1 - p robability o f making a type II error
= 1 - p robability of making a type I error
m
se
As
= 1 I probability of making a type I error
Dr
= 1 I p value GD
= st andard deviation I square root of sample size GD
I = 1 - probability of making a type II error CD
= 1 - pro bability of making a type I error CD
= 1 I probability of maki ng a type I error m:t
m
se
Pow er = 1 - the proba bility of a type II erro r
As
Dr
A 34-year-old man is referred to ophthalmology following a deterioration in his vision. He
is noted to be ta ll w ith thin, long fingers and a degree of learning disabilities. Following
review he is suspected as having a displacement of his lens on the right side. What is the
most likely underlying diagnosis?
Ehlers- Danlos syndrome
Homocystinuria
Rapadi lino syndrome
Marfan's syndrome
m
se
As
Crouzon disease
Dr
Ehlers-Da nlos syndrome
Homocystinuria
Rapadilino syndrome
J
Marfan's syndrome
Crouzon disease
m
se
As
The presence o f learning difficu lties points t o a diagnosis o f homocystinuria rather than
Marfan's syndrome.
Dr
You are examining a patient who complains of double vision. Whilst looking fo rwa rd the
patient's left eye turns towards the nose. On looking to the patient's right there is no
obvious squint. However, on looking to the left the patient is unable to abduct the left eye
and double vision worsens. What is the most likely underlying problem?
Right 6th nerve palsy
Right 3rd nerve palsy
Left 6th nerve palsy
m
se
Left 3rd nerve palsy
As
Dr
Right 6th nerve palsy fD
Right 4th nerve palsy CD
Right 3rd nerve palsy CD
Left 6th nerve palsy fZD
m
se
As
Left 3rd nerve palsy C!D
Dr
A 68-year-old man p resents t o t he cl inic w ith his wife. His wife is very concerned about his
behaviour during sleep. She stat es that he ap pears to be lucidly dreaming and act ing out
his dreams, wh ich has resulted in him p hysica lly hurting her a few t imes.
What stage of sleep does t his p henomenon occu r?
Awake
Non -REM st age 1 (N l )
m
se
As
REM
Dr
Awake CD
Non-REM stage 1 (Nl) «!D
I Non-RE L stage 2 (N2) «!D
Non-REM stage 3 (N3) GD
I REM ED
REM sleep is t he d eepest stag e of sleep which is associated w ith dreaming and loss
of muscle tone
During t he REM stag e of sleep t here is normally aton ia to p revent individuals acting out
their dreams. REM sleep behaviou r disorders (REM parasomnias) are characterised by loss
o f t his normal atonia during REM sleep. REM sleep is t he d eepest stag e of sleep where
dreaming occurs. It is believed t hat loss o f muscle tone during this stag e of sleep is partly
a prot ective factor to p revent harm to oneself and others. In REM sleep disord ers, t he
paralysis t hat normally occurs during REM sleep is incomplete or absent, allowing t he
person to 'act out' his or her dreams, which are often vivid, intense, and violent.
m
se
Non-REM stag e 1 (Nl) sleep is t he lightest sleep which is associat ed w ith hypnagogic
As
j erks.
Dr
A 4-year-old female is referred to the paediatricia n due to a swollen abdomen. She has
lost cons iderable weight and says she is never hu ngry. Moreover, he r bowel movements
suggest she is constipated. An MRI reveals a lesion in the a drena l glands. A b iopsy of this
lesi on is taken and undergoes molecula r testing for a n oncogene. Which of the fo llowing
is an oncogene for neuroblastom a?
AB L
c -MYC
n- MYC
BCL-2
m
se
As
Ras
Dr
AB L .
(D
c-MYC f!D
n- MYC GD
BCL-2 CD
Ras 6D
n- MYC is an oncogene for neuroblastoma

n- MYC is an oncogene for neuroblastoma. The number of n-MYC repeats o ften correlates
m
with p rognosis. ABL is an oncogene found in ch ron ic myeloid leukaemia. c-MYC is an
se
oncogene found in Burkitt's lymphoma. Ras is an oncogene found in many cancers, but
As
mostly pancreatic cancer.
Dr
During which o f t he followin g stages o f mitosis does chromatin condense to form
chromosomes?
Telophase
Metap hase
Prophase
Interphase
m
se
As
Anaphase
Dr
Telophase fl'D
Metaphase fD
I Prophase ED.
Interphase f!D
m
se
As
Anaphase GD
Dr
Which one of the following defines the standard error of the mean?
Square root (Standard deviation I number of patients)
Number of patients 1 square root (mean)
Number of patients 1 square root (standard deviation)
Standard deviation 1 square root (number of patients)
m
se
As
Standard deviation 1 square root (mean)
Dr
Square root (St andard deviation I number of patients)
Number o f patients I square root (mean)
Number o f patients I square root (stand ard d eviation)
Standard d eviation I square root (number of pat ients)
Standard deviation I square root (mean)
m
se
Standard error o f the mean = standard deviation I square root (num ber of patients)
As
Dr
A 4-yea r-old boy is brought by his mother to the pediatrician. The chi ld has had a
diagn osis of cereb ra l pa lsy in the past and the mother is aware of this. However, the
mother now complains that the child has been hitti ng himself a nd biting his fingers over
the past few weeks. This behavior has persisted despite the mother giving mo re attention
to the ch ild.
The mother also mentions that her son's stool has been feeling like ora nge-co lored sa nd .
After a b lood test revea led a high level o f uric acid, the pediatrician explai ns to the
mother that her son most li kely suffers from a genetica lly inherited conditio n caus ing a
high level of uric acid in the b lood. The boy is prescri bed allopu rinol.
Which of the followi ng best describes the inhe rita nce pattern o f this patient's condition?
Autosomal recessive
X- li nked recessive
Mitochondrial
Autosomal dominant
m
se
As
X- li nked d o minant
Dr
Autosomal recessive eD
I X-linked recessive ED
Mitochon drial GD
Autosomal d om inant fD
X-linked d ominant fD
Lesch-Nyhan syndrome causing hyperuricemia is g enetically inherited in an X-linked

recessive pattern
This patient present ed with the si gns and symptoms typical of Lesch-Nyhan syndrome.
This disease, also know n as juvenile gout, is characterized by hyperuricemia. It is a genetic
condition w ith an X-linked pattern o f inheritance. It is caused by a d efect in t he purine
salvage pathway due to the absence of the hypoxanthine-guanine
phospho ribosyltransferase (HGPRT) enzyme which catalyzes the conversion of
hypoxanthi ne to inosi ne monophosp hat e (IM P) and guanine to guanosine
monophosphate (GMP). The consequence is an accumulation of uric acid. The typical
f indings supporting this diagnosis in this patient is t he ag gressive b ehavior, self-
mutilation, intellect ual impairment as well as laboratory finding of hyperurice mia. Other
conditions with an X- linked recessive pattern of inheritance are Becker muscular
dystrop hy, Fabry's disease and G6PD deficiency amongst others.
(Fi rst Aid 2017, p34&55-57).
1: Autosomal recessive pattern of inheritance is common for condit ions featu ring enzyme,
ca rrier channels and other b iomolecular deficiencies such as glycogen storage diseases,
phenylketonuria an d Wi lson disease. For an autosomal recessive condit ion to be passed
on to an o ffspring, both the father an d mother must be carriers and the child has a 25
percent chance o f developin g t he condition by inherit ing two copies of t he d efective
g ene.
3: Mitochondrial inheritance depicts condit ions t ransm itted by defective mitochondria.

Si nce mitochon dria are passed on f rom mother t o offsp ring, t hese conditions are always
inherited maternally. Examples are t he mitochondrial myopathies such as the
mitochondrial encephalopathy, lacti c acidosis, and stroke-like episodes (MELAS)
syndrome.
4: Autosomal d om inant pattern of inheritance is co mmon for con dit ions featuring defect
in structural g enes. Examples are condit ions such as Marfan syndrome, Li Fraumeni
syndrome and Von Hippei-Lindau disease. For autosomal dominant conditions, t he
passing of only one copy of t he defective gene f rom either the mother or the father is
sufficient fo r exp ression of the disease.
5: X-linked dominant pattern o f inheritance is usually passed on from both mothers and
fathers to their offspring. Since mothers have two cop ies of the X chromosome, they can
pass it to 50 percent of t heir daughters and sons. However, fathers who have only one
copy of the X chromosome w ill pass it t o all the ir daughters and not t o their sons.
em
Examples of the condit ions w ith this pattern of inheritance are f ragile X syndrome and
s
hypophosphatemic rickets.
As
Dr
A study looks at whether golf a ctu ally increases the risk of media l epicondylitis. Sixty
people who regu larly play golf are matched to s ixty people who do not p lay golf. Thirty of
the golfers had developed medial epicondylitis at some point compa red to ten of the
non -go lfe rs.
What is the odds ratio of developing media l epicondylitis for people who play golf?
0.3
2.5
m
se
As
3.33
Dr
0.3 (!D
3 fD
I 5 CD
2.5 CD
3.33 CD
Remember to calculate the odds, rather than risk, initially:
Odds o f a golfer deve loping medial epicondylitis = 30 I 30 = 1. If we were calculating the

risk, rathe r than the odds that is asked for, it wou ld be 30 I 60 = 0.5.
Odds a non-g olfer developing medial epicondylitis = 10 I 50 = 0.2. Again, the risk wou ld
be 10160 = 0.16.
m
se
As
The odds ratio is therefo re = 1 I 0.2 = 5
Dr
Which one o f t he followin g diseases is most strongly associat ed w ith HLA ant ig en DR2?
Haemochromatosis
Type 1 diabetes mellitus
Goodpasture's syndrome
Behcet's disease
m
se
As
Coeliac disea se
Dr
Haemochromatosis
Type 1 d iabetes mellitus
Behcet's d isease
Coeliac d isease
m
se
Goodpasture's - HLA-DR2
As
Dr
A new anti-epileptic drug is t rialied fo r child ren with absence seizu res. There are 250
children in t he contro l group and 150 children assigned to take the new d rug. After 4
mont hs 100 child ren in t he cont ro l group had had a seizu re compa red to 15 child ren in
the g rou p takin g the new medicat ion. W hat is the relative risk reductio n?
30%
3.33
75%
m
se
As
40%
Dr
4 «D
30% ED
3.33 GD
1 75% tiD
40% .
(D
Relative risk reduction = (EER - CER) I CER

m
Contro l ev ent rat e, CER = 100 I 250 = 0.4
se
As
Relative risk reduction = (E ER - CER) I CER = (0.1 - 0.4) I 0.4 = -0.7 5 o r a 75% reductio n
Dr
Which one of the followin g statements regard ing epidemiological measures is co rrect?
Cross -sect ional surveys can be used to estimate the prevalence of a condition in
the population
In chronic diseases the incidence is much greater tha n the p revalence
Incidence = prevalence* duration of condition
The prevalence is the number of new cases per population in a given time period
m
se
As
Pre-test proba bility = 1 I incidence
Dr
Cross-sectional surveys can be used to estimate the prevalence of a condition in f1'D
the population
In clronic diseases the incidence is much greater than the prevalence
Incidence = prevalence* du ration of condition
The prevalence is the number of new cases pe r population in a given time periodCD
m
se
As
Pre-test probability = 1 I incidence
Dr
A 61-year-old man is seen in cl inic due to numbness and t ingling in his left hand. On
examination he has weakness of elbow extension, metacarpophalangeal joint flexion and
extension and dist al interp halan geal joint flexion w ith all other movements p reserved, all
ref lexes are normal an d sensation is normal apart from reduced p in-prick sensation over
the medial aspect of t he hand. An MRI scan of the cervical spine is performed as a nerve
lesion is sus pected.
Which of the follow ing patholog ies is most likely to be found on the scan based on the
clinical findings?
Disc herniation between CS and C6
Disc herniation between C6 and C7
Disc herniation between C7 and T1
Fa cet joint hypertrop hy between C6 and C7
m
se
As
Fa cet joint hypertrop hy between C7 and T1
Dr
Disc herniation between CS and C6
Disc herniation between C6 and C7
Disc herniation between C7 and Tl
Facet jo int hypertrophy between C6 a nd C7

-~
Facet jo int hypertrop hy between C7 a nd T1
C8 is the ONLY cervical nerve root that comes out BELOW the vertebra
The scenario descri bes someone with a C8 radicu lo pathy evidenced by reduced sensatio n
in the C8 dermato me (the medial sid e of the hand over the little fing er) and weakness of
the C8 myotome (flexion of the di stal interphalangeal and metaca rp opha langea l joints).
The other o ptions available co rrespond to the C6 o r C7 roots a nd these a re unaffected as
evidenced by norma l elbow flexion and thumb sensatio n (C6) and normal sensatio n ove r
the mi ddle finger (C7). Elbow extension is wea k as it has roots fro m b oth C7 and C8 a nd
so cannot b e used a lone to d eci de between the two levels cl inical ly.
The C8 nerve root exits the spine be low the C7 verteb ra, b eing the on ly cervical ne rve
root which exits be low a verteb ra. The rest of the cervical nerve roots d e rive their na me
m
from the vertebra be low them. The most common a cute pathology causing a se
As
radiculopathy is a disc herniation and th erefore this is the co rrect answe r.
Dr
An elderly patient is admitt ed t o hospital following blood in her urine and severe
abdominal pain. She has a blood pressure o f 90/ 60 and a heart rate of 140bpm. Her
respirato ry rat e is 30 breaths per minute with o xygen sats at 90%. She is started on high -
flow oxygen, given antibiotics and a fluid b olus. Moreover, blood cultu res, lactate and
urine output are measu red. Over the next 10 minutes, her heart rate and blood pressure
stabilise. Her fam ily are tol d that she is most likely suffering from sep sis secondary t o a
urinary tract infect ion. Which cytokine is responsible for the chemot axis o f neutrophils?
Il-l
IL-2
IL-5
IL-8
m
se
As
IL-12
Dr
11-1 tiD
IL-2 .
CD
IL-5 GD
I IL-8 tiD
IL-12 CD
IL-8- main functions include: neutroph il chemotaxis

IL-8 is responsible for the chemotaxis of neutrophils. It is secreted from macrophages and
some epithelial tissues.
IL-l is responsible for acute inflammation. IL-2 is secreted from Thl cells and is
responsible for proliferation and differentiation ofT cells. IL-5 stimu lates proliferatio n of
m
se
eosinophils. IL-12 is secreted from antigen presenting cells and encourages the
As
differentiation of ThOcells into Thl cells.
Dr
You review a 29-year-old woma n who is recovering from a fractu re of the rig ht olecranon.
Since the fracture she has noticed that the little finger on her right hand is numb. Wh ich
nerve is likely to have been damaged?
Ulnar nerve
Radial nerve
Axillary nerve
Muscu locutaneous nerve
m
se
As
Median nerve
Dr
Ulnar nerve
Radial nerve
Axillary nerve
Musculocutaneous nerve
m
se
As
Median nerve
Dr
Which one of the following best describes the Bohr effect?
Increase in p02 means C02 binds less well to Hb
Decreasing acidity (or pC02) means oxygen binds less well to Hb
Decrease in p02 means C02 binds less well to Hb
Ra ised 2,3-DPG enhances oxygen delivery to the tissues
m
se
As
Increasing acidity (or pC02) means oxygen binds less well to Hb
Dr
Increase in p02 means C02 binds Jess well to Hb GD
Decreasing acidity (or pC02) means oxygen binds Jess well to Hb tED
I Dec1ease in p02 means C02 binds less well to Hb fD

Raised 2,3-DPG enhances oxygen delivery to the tissues tED
m
se
Increas ing acidity (or pC02) means oxygen binds less well to Hb C!D
As
Dr
A 32-year-old man presents to the sexual health clinic with a painfu l ulcer on his penis.
On further questioning, he also admits to having experiencing recurrent ulcers in the
mouth and joint pains in his elbows and knee. On examination, there is a sma ll ulcer,
about 2 em in diameter, on the gla ns of penis.
Which HLA antigen is associated with this presentation?
HLA 85
HLA DR3
HLA DR4
HLAA3
m
se
As
HLA DQ8
Dr
I HLA BS ED
HLA DR3 CD
HLA DR4 f!D
HLA A3 m
HLA DQ8 CD
Behcet's d isease is associated with HLA-BS

The patient p resents with featu res (oral, genital ulcers and arthritis) w hich are su ggestive
of Behcet's disease. Another feature o f Behcet's disease is eye inflammatio n su ch as
anterior uveitis. Behcet's d isease is associat ed with HLA-BS.
HLA DR3 is associat ed with Sj ogren's syndrome and p rimary biliary cirrhosis.
HLA DR4 is associat ed with rheumat oid arthritis and type 1 d iabet es mellitus.
HLA A3 is associat ed w ith haemochro matosis.
m
se
As
H LA DQ8 is associated with coeliac disease.
Dr
Which one o f the following wou ld invalidate the use of the Student's t-test when
performing a significance t est?
Using it w ith unpaired data
Using it w ith dat a that is not normally distributed
Using it w ith data that has a small sample size
Using it to test whether the slope o f a regression line differs significantly from 0
m
se
As
Using it to test a null hypothesis
Dr
Using it with unpa ired d ata (lD
~ng it with data that is not norma lly d istributed CD
Using it with data that has a small sample size tiD

I Using it to test whethe r the s lope of a reg ression li ne d iffers s ignificantly fro m 0 «D
Using it to test a null hypothesis «D
m
se
As
Dr
Data must be pa rametric, i.e. fo llows a normal distribution
A 64-year-old female patient is referred to the gastroenterology cl inic with a 6-month
history of recurrent epigastric pa in, acid reflux unresponsive to antacids and a trial of
proton -pump inhibitor. Gastroscopy is a rranged which shows an ulcer in the descending
duod enum and a tumou r in the antrum of the stomach.
Which type of cell this does this tumo ur originates from?
S cells
G cells
I ce lls
D cells
m
se
As
H cells
Dr
S cells f.D
G cells 6D
I ce't f.D
D cells m.
H cells m
Gastrin is p roduced by the G cells in the antrum of the stomach

The tumour in this patient is most likely a g astrinoma. Gastrinoma secretes excessive
g astrin which causes increased HCL p roduction, resu lting in peptic u lcers. Gastrin is
usually produced by the G cells in the antrum o f the stomach.
S cells secrete secretin.
I ce lls secrete CCK.
m
D cells secrete somatostatin.
se
There is no such ce ll as H cell in the stomach. As
Dr
You are a STl d octor o n a gastroente ro logy ward. The F2 d octo r has asked you to
su pervise him putt ing in a n ascitic drai n for a patient with live r cirrhos is. He is keen to g et
it s ig ned o ff fo r his portfolio. He has never seen one put in befo re but ha s read a round
the su bject. What is th e most appropriate action?
Yo u d o the p ro ce du re but sign hi m o ff as you know he will do many mo re over the

next 3 mo nths
Get the F2 docto r to insert the dra in und er you r ca reful gu ida nce, avo id telling the
pati ent to p reve nt u nnecessa ry anxiety
Suggest it wou ld be bette r if he watches you insert the d rain befo re a ttempting
one himself
If he is confident ask him to do it so you can spend you r time more efficiently on
o th er wa rd jo bs a nd s ign h im off
m
se
Ask th e patient if he mind s the F2 doctor d o ing the proced u re and g et the F2
As
d octor to insert the dra in under yo ur ca reful g u idance
Dr
Yo u do the p rocedu re but sign him o ff as you know he will do many more over
the next 3 months
Get the F2 doctor to insert the drain under your careful gu id ance, avo id telling
the patient to p revent unnecessa ry a nxiety
I Suggest it would be better if he watches you insert the d rain before a tte mpting
one himself
If he is confident a sk him to do it so you ca n spend your time more efficie ntly o n

other ward jobs and s ign him off
Ask the patient if he mind s the F2 doctor d oing the procedure a nd g et the F2
doctor to insert the dra in under your ca reful guida nce
It used to be said that fo r pro cedures 'see o ne, d o o ne, teach o ne'. These d ays have long
g o ne. Docto rs a re now expected to s how p roof of competency before performing
procedures a lo ne. In this scenario the F2 doctor has never seen one p reviously so it is not
appropriate fo r him to insert the d rain today. The best o ptio n is for him to watch you.
If you are g oing to let the F2 d octo r inse rt the drain you s hould be honest with the
patient about his la ck o f experie nce.
Sign ing h im off without seeing him perfo rm the procedure is a ve ry poor o ption which
cou ld result in a GMC re fe rra l if fou nd o ut. It a lso puts futu re patients at risk
m
se
Letting him insert the d rain today without su pervision is ag ain a ve ry poor o ptio n as it
As
puts the patient at risk.

Dr
A 47 -yea r-old male visits the GP for review and a rou tine blood check. He has a past
med ical history of angina, hypertension, asthma and hyperlipidaemia. You loo k to his
med ications which shows an extensive polypharmacy includ ing fenofibrate. This drug
lowers triglyceride levels and increases high-density lipoprotein (HD L) synthesis.
What is the mechanism of this drug?
Inhibition of hepatic diacylglycerol acyltransferase-2
HMG-CoA reductase inhibitor
Activation of PPAR receptor resulting in increase li poprote in lipase (LPL) activity
Reduction in the rea bsorption of bile acids
m
se
As
Increased production of apo lipoprotein E by the liver
Dr
Inhibition of hepatic diacylglycerol acyltransferase -2
HMG-CoA reduct ase inhibitor
Activation o f PPAR receptor resulting in increase lipoprotein lipase (LPL) activity

-
~
C!ID
Reduction in the reabsorptio n of bile acids
Increased production of apolipoprotein E by the liver
Fibrates work through activating PPAR alpha recept ors resulting in an increase in
LPL activity reducing triglyceride levels
Fibrates are cholest erol-lowering drugs that work throu gh activating PPAR alpha
recept ors resulting in an increase in LPL activity. LPL increases the uptake of triglyceride
fatty acids in muscles resulting in lower levels in the blood.
Statins inhibit HMG-CoA reductase resulting in the reduction of the mevalonate pathway
leading to reduced cho lesterol levels.
Niacin or nicotinic acid (vitamin B3) inhibits hepatic diacylglycerol acyltransferase-2 which
is required for triglyceride synthesis.
Bile acid sequestrants are a class of drugs w hich work by binding to bile salts reducing
reabsorption o f bile acids.
s em
Apolipoprot ein E is a protein involved in the met abolism of fat s it specifically removes
As
chylomicron rem nants.

Dr
A 16-yea r-old g irl atte nds yo ur GP su rgery due to concerns about de layed me na rche. On
histo ry, yo u note that there have been no deve lopmenta l conce rns. She is a t the 65th
percentile for weight and 5th percentile for he ight. On exam ination, you note that she has
a sho rt web bed neck and a broad chest. You p erform karyotype analysis, which is
abnormal. What is the most common ca rd iac cond ition a ssociated with th is pre se ntatio n?
Atrioventricular septa l defect
m
se
As
Tricuspid regurgitatio n
Dr
I Bicuspid aortic valve
Patent ductus a rte riosus
Atrioventricular septa l defect

-
~
I Mitral va lve prola pse
Tricusp id reg u rgitation
Tu rner's syndrome - most common cardiac defect is bicuspid aortic valve

Tu rne r syndrome (45 XO) is associated with:

• Bicusp id aortic valve
m
se
• Aortic root d ilatation
As
• Coa rctation of the aorta
Dr
A 62-year-old man presents t o the cardiology clinic for review some 6 weeks after
suffering an anterior myocardial infarction. His medication has been optimised, his blood
pressure is 122/ 82 mmHg, pulse is 67 beats p er minute and regular. LDL cholesterol is 1.4
mmol/1, hsCRP is lSmg/1.
Which of the follow ing medications has been shown to impact on future risk of
myocardial infarction in patients like this?
Canakinumab
Prednisolone
Infliximab
Rituximab
m
se
As
Methotrexate
Dr
I Canakinumab CD
Prednisolone tED
Infliximab GD
Rituximab (D
Methotrexate GD
Modulating inflammation can reduce ischaemic cardiovascular events

Canakinumab is an anti-Ill monoclona l antibody, which has been shown to reduce

systemic inflammation. In patients who have an elevated CRP of > 2mg/1, (as he re),
patients in the CANTOS trial who had suffered a p revious MI were treated with
canakinumab. Those patients treated with canakinumab in add ition to standard of care
had a 15% reduction in major adve rse card iovascular events ve rsus those treated with
standard of ca re a lone. This tria l has established 'p roof of concept' for modulating
inflammation in those patients at increased risk of cardiovascular disease.
https://www.nejm.o rg/doi/fuii/10.1056/N EJMoa1707914?query=OF
There is some evid ence that use o f anti-TNF agents used in the treatment o f rheumatic
disease may be associated with red uced incidence o f cardiovascular events, a lthough this
is from post-hoc statistical ana lyses. Infliximab is therefore not the correct answer here.
em
There is no evidence o f cardiovascu la r b enefit from any of the other agents listed,
s
(prednisolone, rituximab or methotrexate).

As
Dr
Which one of the following immunoglobulins are present in the lowest concentration in
blood?
IgA
Ig E
IgG
IgM
m
se
As
IgD
Dr
IgA (D
IgE 6D
IgG fiD
L_
IgM f.D
IgD tD
m
se
Whilst the majority of IgA is found in secretions there is a significant quantity present in
As
blood. IgE makes up less than 0.1% of immunoglobulins
Dr
Which one o f the following conditions is NOT an autosomal dominant co ndition?
Retino blastoma
Tuberose sclerosis
Achondroplasia
Myotonic dystrophy
m
se
As
Albinism
Dr
Autosomal recessive condit ions are 'metabolic' - exceptions: inherited ataxias
Autosomal dominant condit ions are 'structural' - exceptions: Gilbert's,
m
se
As
Dr
Which one o f the following statements regarding galactosaem ia is incorrect?
Autosomal recessive inhe ritance
May cause cata racts
Caused by the absence of galactose-1-phosphate uridyl transferase
May cause jaundice
m
se
As
May cause periphera l neuropathy
Dr
May cause cataracts
Caused by the absence of galactose-1-phosphate uridyl transferase
May cause jaundice
m
se
neuropat~~
As
May cause peripheral
Dr
You are speaking to a 24-year-old man who is known to have haemophilia A. His wife has
had genet ic testing and was found not to be a carrier of haemophilia. He asks you what
the chances are of his futu re children develop ing haemophilia. What is the correct
answer?
0%
25%
50%
50% if male, 0% if female
m
se
As
100%
Dr
I 0% CD
25% CfD
50% GD
I 50% if male, 0% if fema le flD

100% m
X-linked recessive cond it ions - there is no male-to-male trans mission. Affected

males can on ly have unaffected sons and carrier daughters.
m
As we now know t hat mother is not a carrier of the disease there is no chance th at any
se
future children cou ld develop haemophilia. You should of course also discuss w ith him
As
that any daughters that he has will be carriers of the cond it ion.
Dr
A 23-yea r-old man is referred to the ophtha lmo logists with visual p roblems which are
found to be caused by a downward dislocation of the len in his right eye. The
ophthalmologist notices his marfarnoid habitus a nd history of learn ing disabilities. A
diagnosis of homocystin uria is suspected. What is the pathop hysiology of this cond ition?
Deficiency of S-adenosyl- methion ine
Deficiency of homocysteine transsulfurase
Excess of cystathionine beta synthase
Deficiency of cystathion ine beta synthase
m
se
As
Excess of homocysteine transsu lfu rase
Dr
Deficiency of S-adenosyl-methionine
Deficiency of homocysteine transsulfurase

-
~
Excess of cystathionine beta synthase
~fi c i ency of cystathion ine beta synthase

Excess of homocysteine transsu lfu rase
Homocystinuria is caused by a d eficiency o f cystathion ine beta synthase

m
se
Interesting ly, patients with Down's syndrome have an excess of cystathionine beta
As
synthase.
Dr
A randomised controlled trial compares two d rugs used in the initia l management of
rheumatoid arthritis. After being assigned to the random ised groups a number of patients
drop out due to a dverse effects of the medication. How shou ld the data be analysed?
Recruit more patients
For each patient who drops out, remove a patient fro m the other ra ndomised
group
Include the patients who drop out in the final d ata set
Remove patients who drop out from final d ata set
m
se
As
Abandon the trial if more tha n 5% of patients d rop out
Dr
Recru it more patients
For each patient who drops out, remove a patient from the other randomised
group
Include the patients who drop out in the fina l data set
Remove patients who drop out from final data set
m
se
As
Abandon the trial if more than 596 of patients drop out
Dr
An 82-year-old male nursing home resident with advanced vascular dementia presents
with worsening confusion t o the Emergency Department. His only regular medication is
d opidogrel. His admission blood test s are as follows:
Na + 121 mmol/ 1
K+ 3.8 mmolfl
Urea 9.4 mmolfl
Creatinine 110 umol/ 1
His confusion screen (including CT brai n) is normal. On examination he has dry mucous
membranes, his blood pressure is 104/58 mmHg, pulse 94/ min and temperature 36.1°C.
With regard to his low sodium what would be the most appropriat e management?
Fluid restrict ion
Demeclocycline
Intravenou s normal saline
Tolvapta n
m
se
As
Furosemide Dr
Fluid restriction GD
Demeclocycline .
(D
I Intravenous normal saline CD

Tolvapt an CD
Furosemid e CD
This case is an example of hypovolaemic hyponatraemia. It is important with

hyponatraemia to ascertain volume st atus as this will determine management. Poor oral
intake due to advancing dementia is the likely cause. This is supported by an elevated
urea suggesting dehydration. Poor oral intake can lead to both hyper or hyponatraemia
depending on the relative proportions of sodium and water deficiency.
The management of each is as follows:
Hypovolaemic hyponatraemia
• rehydration with sodium chloride 0.9% or a balan ced cryst alloid (Hartmann's)
• avoid rapid correction of sodium in order to reduce the risk of osmotic
complications su ch as central pontine myelinolysis
Euvolaemic hyponatraemia
• check urine and serum osmolality. Does the patient meet the criteria for SIADH?
• treat the underlying cause where possible in SIADH
• fluid restriction (S00 -7SOmls/ day)
• monitor fluid balance and perform daily weights
• consider demeclocydine or tolvapt an (under specialist supervision). Both inhibit the
action of antidiuretic hormone.
Hypervolaemic hypon atraemia

• fluid and salt restriction
• consider diuretics
em
• treat the underlying cause (e.g. ca rdiac failure)

s
As
Dr
A case-control study is d esig ned to investigate whether being exposed to passive
smoking as a child is a risk factor fo r asthma. Two hund red patients with asthma a re
recruited. Of these 200, 40 report e ither o ne o r both pa rents smoking in the house whe n
they were a child. A furthe r 200 contro ls who do not have asthma a re recruited. Of these
people 20 repo rt that one o r both parents smoked in the house. What is the odd s ratio o f
asthmatics having been exposed to passive smoking as a child?
2.25
0.66
0 .5
1.5
m
se
As
4
Dr
2.25 ED
0.66 fiD
0.5 .
fiB
1.5 CD
4 CD
Odds - remember a ratio o f the number of peop le w ho incur a particular outcome

t o t he nu mber of people who do not incur the outcome
NOT a ratio of t he number o f people who incur a particu lar out come to the tot al
number o f people
The od ds of asthmatics b eing exposed to passive smokin g is 40 I 160 = 1 I 4
The od ds of the controls being exposed t o passive smoking is 20 I 180 = 1 I 9
m
se
As
The od ds ratio is therefore 114 I 119 = 914 = 2.25 Dr
Which one o f the following diseases is most strong ly associat ed w ith HLA antigen DR2?
Behcet's disease
Coeliac disease
Haemochromatosis
m
se
As
Narcolepsy
Dr
Behcet's disease
Coeliac disease
-
~
Haemochromatosis
Narcolepsy
m
se
Narcolepsy - HLA- DR2
As
Dr
Which one o f the fo llowin g state ments rega rd ing re lative risk is correct?
Relative risk = 1 - a bsolute risk red uctio n
It is the usua l outcome measu re of cohort studies
Risk may b e d efined as the od ds of a n o utco me hap pe ning
Relative risk = 1 I od ds ratio
m
se
If the risk ratio is less than 1 then the rate o f a n eve nt is increased co mpa red to
As
contro ls
Dr
Relative risk = 1 - absolute ris k reduction
I It is the usual outcome measure of cohort studies
Risk may be defined as the odds of an outcome happening
~l ative risk = 1 { odds ratio

If the risk ratio is less th an 1 then the rate of an event is increased compa red to
controls
m
se
Remember that risk and odds are d ifferent. If 20 patients die out of every 100 who have a
As
myocardial infarction then the risk of dying is 20 I 100 = 0.2 whereas the o dds a re 20 I 80
Dr
= 0.25.
A 22-year-old male university student presents to the GP surgery with a 2-week history of
a patch of red and flaky ski n at the corners of the mouth. On examination, angular
cheilitis is evident. On further questioning, he reports that for the last 3-4 months he has
been drinking alcohol excessively and not eating well.
What is the most likely vitamin deficiency to cause this clinical pictu re?
Vita min 82 (riboflavin) deficiency
Vita min A deficiency
m
se
As
Vita min K deficiency
Dr
Vitamin 82 (riboflavin) deficiency

-
~
Vitamin A deficiency
Vita min K deficiency
Riboflavin deficiency causes angular cheilitis

Vitamin 82 (riboflavin) deficien cy is a cause o f angular cheilitis. 3-4 months of inadequat e

int ake of riboflavin is su fficient to lead to depletion and b ecoming sym ptomatic.
Vitamin 86 deficiency causes p eripheral neuropathy.
Vitamin D deficiency causes osteomalacia.
m
Vitamin A deficiency causes visual det erioration and night blindness.
se
Vitamin K deficiency causes easy bruising and bleeding. As
Dr
A 60 yea r-old man with haemop hilia A has just become a grandfather. He wants to know
what the chances a re o f his daug hter's son having haemophilia . His dau ghter's partner is
well with no past med ical history.
What is the p robability that his daughter's son has haemoph ilia A?
Imposs ible to calculate
50%
25%
No increased risk
m
se
As
100%
Dr
I
Imposs ible to calculate
5o%
-
........
25%
No increased risk
100%
Haemophilia A is an X-li nked recessive disease. This mea ns that all female offspri ng of
m
a ffected men will be carriers. There is then a 50% chance of these fema les passing the
se
gene on. If the female's ch ildren are male, they will therefore have a 50% chance of
As
having the condition.
Dr
Which of the following is responsible for the plateau phase of the myocardial action
potential?
Slow calcium efflux
Rapid sodium influx
Slow influx of calcium
m
se
As
Slow sodium efflux
Dr
Slow calcium efflux GD
Efflux of p otassium (fD
Ra id sodium influx (D
Slow influx of calcium

.,
Slow sodium efflux fD
m
se
As
Slow influx of calcium is responsible fo r the plateau phase o f the action potential
Dr
The serum potassium is measured in a 1,000 patients taking an ACE inhibito rs. The mean
potassium is 4.6 mmol/1 with a standard deviation of 0.3 mmol/1. Wh ich one of the
following statements is correct?
95% of values lie between 4.5 and 4.75 mmol/1
95.4% o f values lie between 4.3 and 4.9 mmol/1
m
se
As
Dr
95% of values lie between 4.5 and 4.75 mmol/1 CD
95.4% of values lie between 4.3 and 4.9 mmol/1 fD
I 99.7% o f values lie between 4.0 and 5.2 mmol/1 GD

68.3% of values lie between 4.5 and 4.75 mmol/1 CD
I 68.3% o f values lie between 4.3 and 4.9 mmol/1 fD
m
se
As
We know that 68.3% of va lues of a normally dist ributed variable lie w ithin 1 standard
deviat ion of t he mean. This means t he range is 4.3 to 4.9 mmol/1.
Dr
A 23 -year-old man p resents w ith a three d ay history of g eneral malaise and low-grade
t emperature. Yesterday he develop ed extensive pain ful ulcerat ion of his mout h and gums.
On examinat ion his temperat ure is 37.4°( , p ulse 84 I min and t here is submandibular
lympha denopat hy. What is t he most likely diagnosis?
Epstein Barr virus
Lichen pl anus
HN seroconversion illness
Herp es simpl ex virus infection
m
se
As
Oral Candida
Dr
Epstein Barr virus
Lichen planus
HN seroconversion illness
Herp es simplex virus infection

-
~
Oral Candida
m
se
This man has gingivostomatitis, a charact erist ic feature of primary herpes simplex virus
As
infect ion
Dr
Which one of the following conditions is usually inherited in aX-linked dominant fashion?
Albinism CD
Hurler's syndrome CD
Ataxia telangiectasia f!D.
Homocystinuria GD
m
se
I I
As
Alpert's syndrome CD
Dr
Albinism (!D
Hurler's syndrome (!D
Ataxia te langiectasia GD '
Homocystinuria GD
I Alpert's syndrome CID
m
se
As
Alpert's syndrome is inherited in aX-linked dominant fashion in around 85% o f cases
Dr
A 55-year-old wo man complains of neck and rig ht arm pain for the past two months. The
pain is often triggered by flexing her neck. Her past medical hist ory includes ost eoarthritis
of her knee, obesity and depression. On examination there is no obvious muscle atrophy
o r w eakness of the right arm. There is how ever some sensory loss over the middle finger
and palm of the hand. Which nerve root is most likely to be affected by the impingement ?
C4
cs
C6
C7
m
se
As
C8
Dr
C4 m
cs CD
C6 GD
C7 ED
m
se
As
C8 (D
Dr
A scientist is studying the ro le of regulatory protein s in intracellular trafficking. He has
isolated and identified various intracellular proteins tagged with extensive ubiquitinatio n.
These proteins are destined to which of the following organelles?
Smooth endoplasmic reticu lum
Golgi apparatus
Prot easome
m
se
As
Peroxisome
Dr
Smooth endoplasmic reticu lum
Golgi apparatus
-
"""""'
Prot easome
Peroxisome
Ubiquitin tagging destines p roteins to proteasome for degradation
m
se
As
Ubiquitin ta gs proteins for degradation in p roteasome and lysosome.
Dr
A ra pid finger-prick blood test to help diagnosis deep vein thrombos is is developed.
Com pa ring the test to cu rrent standa rd techniques a study is done on 1,000 patients:
DVT present DVT absent
New test negat ive 20 680
What is the specificity of the new test?
680/880
200/ 220
680/780
680/700
m
se
As
200/300
Dr
6801880 .
(D
2001220 flD
680/780 CiD
680/700 flD
2001300 GD
Specificity = TN I (TN + FP)

Specificity = true negatives I (true negatives + false positives)
m
se
As
= 680 I (680 + 100)
Dr
A 19-year-old man from a travelling com munity presents to the Emergency Department
with breathing difficu lties. On examinatio n he has a temperature of 38.2°C and stridor. A
diagnosis of acute epiglottitis is suspect ed. Which one of the following organisms is most
likely to be responsible?
Epstein Barr Virus
Haemophilus influenzae
m
se
As
Dr
Epstein Barr Virus
Acute epiglottitis is caused by Haemophilus influenzae type B

Patients from travelling communities may not always receive a fu ll cou rse of
immunisation.
m
se
As
Acut e epiglottitis is of cou rse much more common in young children
Dr
A study is performed compa ring two chemotherapy regimes fo r patients with small cell
lung cancer. The end po int of the study is survival time. Wh ich o ne of the following types
statistical measu res is it most appropriate to compa re survival time with?
Odds ratio
Pea rson's product-moment coefficient
Relative risk
Hazard ratio
m
se
As
Absolute risk reduction
Dr
Odds ratio
Pearson's p roduct-moment coefficient
Relative risk
Hazard ratio
m
se
As
Absolute risk reduction ~
Dr
A 55-yea r-old man with a history of type 2 dia betes mellitus, bipolar d iso rder and chro nic
o bstructive pu lmona ry disease has b loods taken as pa rt of his annual d iabetic review:
Na• 129 mmol/ 1
K• 3.8 mmolfl
Urea 3 .7 mmolfl
Creatinine 92 iJmolfl
Due to his smoking history a chest x-ray is ord e red which is re ported as normal. Which
one of the following med ications is most like ly to be responsible?
Metfo rmin
Lithium
Ca rbamazepine
Sodium valproate
m
se
As
Exenatide
Dr
Metformin fD
Lithium CfD
I Carbamazepine tiD
Sodium valproate GD
Exenatide .
CD
SIADH - drug causes: carbamazepine, sulfonylureas, SSR!s, tricyclics

m
Lithium can cause diabetes insipidus but this is generally associated with a high sodium.
se
Lithium only tends to cause raised antidiuretic hormo ne levels following a severe
As
overdosage. Please see the BNF for more details.
Dr
Which one of the following drugs is contra -indicat ed wh ilst breast feeding?
Am inophylline
Carbamazepine
Sodium valproate
Methyldopa
m
se
As
Am iodarone
Dr
Am inophylline CD
Carbamazepine GD
Sodium valproate tiD
Met yldopa fD
Amiodarone CD
m
se
As
Amiodarone in breastfeeding must be avoided
Dr
Which one of the followi ng immu nological changes is seen in progressive HIV infection?
Increase in IL-2 production
Increase in B2-microglobul in levels
Increased type IV hypersensitivity respo nses
Increased natural kill er (NK) cell function
m
se
As
A rise in the CD4/CD8 ratio
Dr
Increase in IL-2 production
I Increase in B2-microglobulin levels
Increased type IV hypersensitivity responses
Increased natural killer (NK) cell function
m
se
As
A rise in the CD4/CD8 ratio
Dr
You review a 30-year-old man shortly aher he is discharged from the Inte nsive Care Unit
aher being admitted with pneumococcal pneumonia. This is his second admission in 18
months with a severe pneumonia. During his first admission Haemophilus influenzae was
grown from his sputum. He also describes having frequent episodes of sinusitis and
recurrent skin abscesses. Which one of the following com plement deficiencies is he most
likely to be suffering from?
Cl
C2
C3
C4
m
se
cs
As
Dr
Cl CD
C2 CD
C3 e:D
C4 GD
m
se
As
cs fD
Dr
A 45-yea r-old man presents to his GP with a severe sore throat and difficulty swallowing.
He is found to have oesophageal candidiasis and an HIV test returns as positive. The
med ica l student attached to the GP practice asks the GP about the HIV virus. Wh ich of the
following is co rrect?
HN is a DNA virus
HN 2 is more pathogenic than HIV 1
HN is an RNA virus
HN leads to d epletion of B cells
m
se
As
HN enters the cells using the CD3 recepto r
Dr
HIV is a DNA virus tiD
HIV 2 is more pathogen ic than HIV 1 a
I HIV is an RNA virus flD
HIV leads to d epletion of B cells m
HIV enters the cells using the CD3 recepto r a
HIV is an RNA retrovirus
The correct answer is 3 - HIV is an RNA virus in t he retrovirus class. It uses a reverse
transcriptase to convert its RNA genome into DNA. which it t hen integrat es into t he host
cell genom e.
The ot her answers are incorrect. HIV 2 is less patho genic t han HIV 1. HIV leads t o
d eplet ion o fT cells. HIV ente rs the cell p rimarily via t he CD4 receptor.
m
se
NICE CKS: HIV infection and AIDS
As
https:/ /cks.n ice.org.u k/ h iv-infection -and -a id s
Dr
Which one of the fo llowing state ments is true regarding interfero n?
Interferon-b eta is produced by leucocytes
Interferon-alpha a nd interferon- beta bind to the same type of receptor
Interferon-gamma has stro nge r a ntiviral actio n than interferon-alpha
Interferon-alpha has been shown to reduce the frequency of exacerbations in

patients with rela psing-remitting multiple scleros is
m
se
As
Interferon-gamma has a role in chro nic hepatitis C
Dr
Interferon- beta is produced by leucocytes
Interferon-alpha and interferon-beta bind to the same type of receptor
Interferon-gamma has stronger antiviral action than interferon-alpha
Interferon-alpha has been shown to reduce the frequency of exacerbations in

patients with relapsing-remitting multiple sclerosis
m
se
Interferon-gamma has a role in chronic hepatitis C
As
Dr
A 20-yea r-old Chine se wom an, who ca me to the UK on holiday, was bro ught into the
em ergen cy department following a road traffic a ccid ent. On physical e xamination, apart
from the traumatic injuries and b ruises, there is a bsent axillary a nd pubic ha ir as well as
min imal brea st d eve lopment a nd hyperpigmentation o f the oral mucosa and axilla. CT
traumagram (head, o cciput to Tl, chest inclu ding aortic arch, a bdo men, a nd pelvis)
revea ls a ce rvica l fracture but a lso bulky adrenal g lan ds and an a tro phic uterus. She
repo rts a histo ry of p rimary amenorrhoea which wa s thought to be d ue to pubertal d elay.
Her basi c o bservations include heart rate 58 beats p er mi nute, b lood pressu re 182/ 102
mmHg, Saturation 99% on room air, resp irato ry rate 18 b reaths per minute. An a rterial
b lood g as(ABG) was d one. Hypoka laemia wa s found with a potassium of 2.9 mmol.
Given the likely diagno sis, what d o you expect the rest o f the ABG result to b e?
pH = 7.34, p02 = 14 kPa, pC02 = 5.2 kPa, bica rbonate = 20 mEq/L
pH = 7. 42, p02 = 14 kPa, pC02 = 3.9 kPa, b icarbonate = 28 m Eq/L
m
se
As
pH = 7.39, p02 = 14, pC02 = 4.9 kPa, b icarbonate = 25 mEq/L
Dr
pH = 7. 42, p02 = 14 kPa, pC02 = 3.9 kPa, bicarbonate = 28 mEq/L
~ = 7.49, p02 = 14 kPa, pC02 = 5.0 kPa, bica rbonate = 32 mEq/L

pH = 7.32, p02 = 7 kPa, pC02 = 6.8 kPa, b ica rbonate = 37 mEq/L
pH = 7.39, p02 = 14, pC02 = 4.9 kPa, b icarbonate = 25 mEq/L

-
~
Congenital adrenal hyperplasia is a cause of metabo lic alkalosis

This patient has sig ns of und iag nosed congenital adrena l hyperplasia. Even thoug h the
classic 21-hydroxylase deficiency co mmo nly presents in infancy, other rarer forms such as
17-alpha-hydroxylase deficiency cou ld rema in und iag nosed till adu lthood, especia lly in
the case of this patient who comes from a country where good paediatric care may not be
easily accessible. Congenital ad rena l hyperp lasia is a cause of metabolic a lka losis. The
ABG rea dings in Option 3 shows meta bolic alka losis.
Option 1 shows metabolic acidosis.
Option 2 shows metabolic acidosis with respiratory compensation.
Option 4 shows Type 2 respi ratory failure, respi ratory acidosis with pa rtia l metabo lic
compensation.
s em
As
Option 5 shows a norma l ABG.

Dr
A 52-yea r-o ld ma n p resents to the medical tea m with a 6 -day history of fever, headache,
rigors, d ia rrhoea and vomiting. Hi s observations includ e temperature 39 •c, heart rate 110
beats per minute, respiratory rate 22, blood pressure 143/92 mmHg. He has been
p revious fit and well and has been worki ng o n a fa rm fo r the last 6 months. A diag nosis o f
Q fever is confirmed via PCR testing.
What is the organ ism implicated in this cond ition?
Rickettsia rickettsii
Coxiella burnetti
Rickettsia typhi
m
se
As
Ehrlichia
Dr
Rickettsia rickettsii .
CED
Coxiella burnetti GD
Rickettsia typhi fD
Rickettsia prowazekii fD
Ehrlichia CD
Coxiella burnetti is the causative o rganism in Q fever

Coxie lla burnetti is the causative orga nism in Q fever.
Rickettsia rickettsii is the causative orga nism in Rocky Mounta in spotted fever.
Rickettsia typhi is the causative o rganism in end emic typhus.
m
Rickettsia prowazekii is the causative organ ism in epidem ic typhus.
se
As
Ehrlichia is the causative o rganism in ehrlichiosis. Dr
Which of the following conditions is not caused by a trinucleotide repeat expansion?
Fragile X syndrome
Huntington's
Myotonic dystrophy
m
se
As
Friedreich's ataxia
Dr
Fragile X syndrome CD
Huntington's CD
Ataxia te langiectasia CI!D
Myotonic dystrophy CD
m
se
Friedreich's ataxia CD
As
Dr
Which one of the fo llowin g is the best definition of the p value?
The probab ility o f obta ini ng a similar resu lt, assum ing th at the null hypothesis is
true
The probability that a rep lica ting experiment wo uld not yield the s ame conclusion
The probab ility o f obta ini ng a resu lt at least as extreme, assuming that the nu ll
hypothesis is true
The pro bab ility that the null hypothesis is true
m
se
The pro bab ility o f obta ini ng a resu lt at least as extreme, assuming that the nu ll
As
hypothesis is false
Dr
The probability of obta ining a s imilar result, assum ing that the null hypothes is is fi!D
true
The pro bab ility that a rep licating experiment would not yield the same conclus ionD
I
The p robab ility of obtaining a resu lt at least as extreme, assu ming that the nu ll
hypothesis is true
The probability that the null hypothesis is true
m
The probability of obta ining a resu lt at least as extreme, assu ming that the nu ll
se
As
hypothesis is fa lse
Dr
A 34-year-old man is stabbed in the back caus ing a hem isection of the spina l cord at the
level TS. You assess the patient's sensory function, with respect to temperature, vib ration,
fine touch. You a lso assess the patient's muscle strength. Wh ich signs would you expect
to see?
Ipsilatera l loss of tem perature, contralatera l loss of fine touch and vib ration,
ipsilate ral spastic pa resis
Contra lateral loss of temperature, ipsilatera l loss of fine touch and vib ration,
contra latera l spastic pa resis
Contralateral loss of temperature, contralateral loss of fine touch and vibration,

contralatera l spastic pa resis
Ipsilatera l loss of tem perature, ipsilateral loss of fine touch and vibration, ipsilateral
spastic pa resis
m
Contra lateral loss of temperature, ips ilatera l loss of fine touch and vib ration,
se
ipsilate ral spastic paresis
As
Dr
Ipsilateral loss of tempe rature, contralateral loss of fine touch and vib ration,
ipsilatera l spastic pa resis
Contra lateral loss of temperature, ipsilateral loss of fine to uch and vibration,
contralateral spastic pa resis
Contralateral loss of temperature, contralateral loss of fine touch and vib ration,
contralatera l spastic pa resis
Ipsilateral loss of tempe rature, ipsilateral loss of fine touch and vibration,
ipsilatera l spastic pa resis
Contralateral loss of temperature, ips ilateral loss of fine to uch and vib ration,
ipsilateral spastic paresis
The spinothalamic tract decussates at the same level the nerve root enters the
spinal cord. The corticospinal tract, dorsal column medial lemniscus, and
spinocerebella r tracts decussate at the medulla
Important for me Less 'mpcrte;nt
The sp inothalamic tract is responsible fo r carrying sensory fibres for pain and
temperature. It decussates at the sa me leve l the nerve root ente rs the spina l co rd, and
hence te mpe rature loss is contra late ral. The dorsal co lumn medial lemn iscus carries
sensory fibres fo r fin e touch and vibration (and unconscious p roprioception). It
d ecussates at the medulla and hence the fin e touch and vibration loss is ipsilateral. The
em
corticospina l tract is a descend ing tract which has a lready decussated (at the medulla). It
s
is respo nsible for inhibiting movement o f muscles. Loss of its function causes an upper
As
motor neuron lesion o n the ipsilatera l side (if affected in the spina l co rd)
Dr
Which part of the renal tubule is impermeable t o water?
Distal convoluted tubule
Connecting tubule
Descending limb of loop of Henle
Thin ascending limb of loop of Henle
m
se
As
Thick ascending limb of loop of Henle
Dr
Distal convoluted tubule
Connecting tubule
Descending limb of loop of Henle

-
~
Thin ascending limb of loop of Henle
Thick ascending limb of loop of Henle

-
~
The thin ascending limb of the loop of Henle is impermeable to water

m
se
As
The thin ascending limb is impermeable to water, but highly permeable t o sodium and
chlo ride ions.
Dr
As part of a research p roject you are trying to asce rtain whether the use of dum mies in
infants is li nked to sudden infant death syndrome. What is the most appropriate form of
study d es ign?
Randomised controlled trial
Cross-over trial
Cross-sectional survey
Case-control study
m
se
As
Coho rt study
Dr
Randomised controlled trial C!D
I Cross-ove r trial fD
Cross-sectional survey CD
I Case-control study CID

Cohort study CD
m
se
As sudden infant death synd rome is re lative ly rare a case-control d esign is more
As
appropriate than a cohort study.
Dr
A study looks at the benefits of adding a new anti platelet drug to aspirin following a
myocardial infarction. The following results are obtained:
Percentage of patients having

further Ml within 3 months
Aspirin 4%
Asp irin + new drug 3%
What is the number needed to treat to prevent one patient having a further myocardial
infarction within 3 months?
0.75
0.33
Cannot calculate without mo re data
m
se
As
100
Dr
0.75 f!D
0 .33 f!D
Cannot calculate wit hout more d ata fD
1 G'D
I 100 GD

NNT = 1 I (cont rol event rat e - exp eriment al event rat e)
m
se
As
= 1 I (0.04-0.03) = 1 I (0.01) = 100
Dr
A 34-yea r-old patient, comes in with weight loss and haemoptysis. On questioning, it is
revealed he has significant night sweats. On examination, he has reduced breath sounds
ove r the apex of his right lung and sign ificant nail clubbing. After referral to the
respiratory physician, he is started on 4 antibiotics: rifampicin, ethambutol, pyrazinam ide,
and isoniazid. What is the mechanism of action of rifampicin?
Inhibit cell wall formation
Inhibit 50S subunit of ribosomes
m
se
As
Dr
Inhibit cell wall formation

-
. ..wl'
Rifa mpici n inhibits RNA synthesis

m
These are the classic presentation o f an individual with tu berculosis. The combination of
se
rifa mpicin, ethambut ol, pyrazinamide and isoniazid is the first line t reatm ent. Rifa mpicin's
As
mechanism of action is to inhibit RNA synthesis.
Dr
Of the following scenarios, which one would indicate it was inap propriate for the patient
to take an airline flight?
A 54-yea r-old woman who had a lapa roscopic cho lecystectomy 5 days ago
A 17-yea r-old flying back to the UK who broke his leg whilst skiing in Canada. Had
a p laster cast applied 24 hours ago
A 59-yea r-old ma n who had a co lonoscopy 2 days ago
A 62-year-old ma n who had an uncomplicated myocardial infa rction 3 weeks ago
m
se
As
A woma n who is 27 -weeks pregnant with twins
Dr
A 54-yea r-o ld wo ma n who had a la pa rosco pic cho le cystectomy 5 d ays ago
I A 17 -yea r-old flying back to the UK who broke his leg whilst skiing in Ca nad a.
Had a plaster cast a p plied 24 hours ag o
A 59-yea r-o ld ma n who had a co lo noscopy 2 days ago

-......,
A 62-yea r-o ld ma n who had a n unco mplicated myocardial infarction 3 weeks
ago
A wo man who is 27 -weeks p regna nt with twins

-
~
m
Fo ll owing the ap plicatio n of a plaste r cast patie nts shou ld wa it 24 hou rs befo re s hort
se
flig hts ( < 2 hou rs) a nd 48 hou rs befo re long e r flights. This is d ue to the fa ct that a ir may
As
be trap ped b eneath the cast
Dr
A 36-year-old former intravenous drug user is to co mmence treatment for hepatitis C
with interferon-alpha and ribavirin. Which of the following adverse effects are most like ly
t o occur when patient s are treated with interferon-alpha?
Diarrhoea an d trans ient rise in ALT
Cough and haemolytic anaemi a
Flu-like sym ptoms and transient rise in ALT
Haemolyti c an aemia and flu-like sympt oms
m
se
As
Depression and flu-like symptoms
Dr
Diarrhoea an d transient rise in ALT CD
Cough and haemolytic anaemia CD
Flu-like symptoms and transient rise in ALT CID
Haemolytic anaemia and flu-like sympt oms GD
m
se
As
Depression and flu-like symptoms eD
Dr
A 61-year-old woman presents to the emergency department w ith morning headaches,
nausea and vomiting. An urgent CT head reveals a mass within the right front al lobe. An
MRI head is performed w hich shows what is likely a glioblastoma su rrounded by oedema.
What medication is used in this context to t reat oedema?
Hydrocortisone
Dexamethasone
Hypertonic sa line
Mannitol
m
se
As
Furosemide
Dr
Hydrocortisone D
I Dexamethasone GD
Hypertonic saline D
Mannitol GD
Furosemide fD
Dexamethasone is used to treat cereb ral oedema in patients with brain tu mou rs
Dexamethasone is a potent steroid with p red ominantly glucocorticoid effect s. It is used to
m
se
treat vasogenic oedema that occurs due to the break dow n of t he blood-b rain barrier. A
As
com mon use within neurosurgery is to treat oedema caused by brain t u mou rs.
Dr
What is the correct formu la t o calculat e the neg ative p redictive value of a screening t est?
TP = true posit ive; FP = false positive; TN = t rue negative; FN = false negative
TN I (TN+ FN)
TP I (TP + FP)
TN I (TN + FP)
Sen sit ivity I (1 - specificity)
m
se
As
TP I (TP + FN )
Dr
I TN I (TN+ FN) GD
TP I (TP + FP) m
TN I (TN+ FP) flD
Sensitivity I (1 - specificity) fD
TP I (TP + FN ) m
m
se
Negative predictive value = TN I (TN + FN)
As
Dr
A 62-yea r-old ma n with mixed hyperlipidaemia, hypertension and ischaemi c heart disea se
comes to the cl inic fo r review. He has suffered a left lower li mb deep vein thrombosis a nd
been started on rivaroxaban fo r 3 months as treatment. there a re no apparent risk facto rs
for deep vein thrombos is a nd he has been fit and active, still wo rking as a landscape
g a rdener.
Which of the following medications that he takes may be associated with increased risk of
deep vein thro mbosis?
Ram ipril
Ato rvastatin
Fenofibrate
Bisoprolol
m
se
As
Indapa mide
Dr
Ram ipril
Ato rvastatin
•fD
Fenofibrate 6D
Bisopro lo l fD
Indapa mide fD
Fibrates may increa se the risk o f venous thro mboembol is m

Questions we re ra ised as to whether fib rates may be associated with venous

thro mboem bo lis m after an imbalance in favou r of co mpa rator therapies with respect to
thro mboem bo lic events. A meta-analysis has now suggested that th is imba lance may
represent a real risk of VTE in patients prescribed fibrates: (OR, 1.58; 95% CI, 1.23-2.02).
https:/ I a cad e mic.ou p.com/ eu rhea rtj/ art icle/ 31/1 0/ 1248/486868
The data from the same meta-analysis for statins suggests, a lthough does not confirm,
that they may be associated with red uced risk of ve nous thro mboembolis m: (OR, 0.81;
95% Cl, 0.66-0.99), a lthou gh the statin data was very heterogenous and may not
m
se
therefo re re present a real findi ng. Beta-blockers, th iazid e li ke d iuretics and ACE inhibitors
As
a re thought to have no impact on risk of venous thromboem bolism.
Dr
A 69-year-old fema le with a history of multiple myeloma is admitted w ith confusion. The
following results are obtained:
Na• 14 7 mmol/ 1
K• 4. 7 mmol/1
Urea 14 .2 mmol/ 1
Adjusted calcium 3.9 mmolfl
What is the most appropriate initial management?
IV 0.45% saline
IV zoledron ic acid
Oral prednisolone
IV pamidronate
m
se
As
IV 0.9% sa line
Dr
IV 0.45% saline GD
IV zoledronic acid CD
Ora l predn isolone (D
IV pam idronate CD
I IV 0.9% sal ine ED.
IV fluid therapy is the first- line management in patie nts with hypercalcaemia
m
se
The ra ised sodium is a function of dehydratio n and will correct once the patient is
As
adequately rehydrated
Dr
T-Helper cells of the Th2 subset typically secrete:
IL-4, IL-5, IL-6, IL-10, IL-13
IFN-gamma, IL-2, IL-3
IL-l, IL-6, TNF-alpha
IFN- beta, IL-4, IL-8
m
se
As
IL-l
Dr
I IL-4, IL-5, IL-6, IL-10, IL-13
IL-l, IL-6, TN F-alpha
IFN-beta, IL-4, IL-8

-
~
m
se
As
Dr
Each one of the following is an acute phase protein, except:
Haptoglobin
Alpha-1 antitrypsin
CRP
Ferritin
m
se
ESR
As
Dr
tED
.,
Haptoglobin
Alpha-1 antitrypsin
ICL CD
Ferritin .
(D
m
I
se
I
As
ESR ED
Dr
Which one o f t he followin g cell types secretes the maj ority of p ulmonary su rfactant?
Type D pneumoncytes
Kupffer cells
Type I pneumoncytes
Macro phages
m
se
As
El ast ocytes
Dr
TypeD pneumoncytes f.ZD
KupffL IIs .
CD
Type I pneumoncytes CD
Macrophages m
m
se
As
Elastocytes CD
Dr
Which one o f t he followin g featu res is not associated w ith Turner's syndrome?
Short st ature
High -arched palat e
Co arctation o f t he aorta
W eb bed neck
m
se
As
Secondary amenorrhoea
Dr
Short statu re
High-arched palate
I Coa rctatio n o f the a o rta
Web bed neck
Secondary amenorrhoea
-
~
m
se
As
Primary, not seco nd ary, a me no rrhoea is seen in Turner's synd rome
Dr
A 32-year-old man with familial hypercholesterolaemia comes to the lipid clinic for review.
Despite 80mg of atorvastati n, his LDL cholest erol is still 3.8 and he su ffered an inferior
myocardial infarction some 3 months earlier. You elect to co mmence evolocumab.
Which of the following reflect s the mode of action of evolocumab?
Activat es lipoprot ein lipase
Blocks absorption of cholesterol in the GI tract
Inhibits PPAR-alpha
Inhibits SGLT-1
m
se
As
Prevents PCSK9-mediated LDL receptor degradation
Dr
Activates lipoprotein lipase
P ,ocks absorpt ion of cholesterol in t he GI t ract
Inhibits PPAR-a lpha
Inhibits SGLT-1
Prevents PCSK9-mediated LDL receptor degraa at ion
Evolocumab prevent s PCSK9-mediated LDL receptor d egrad at ion. Evolocu mab b ind s
selectively t o PCSK9 and prevents circulating PCSK9 from binding to t he low -density
lipoprot ein recept or (LDLR) on the liver cell surface, thus p reventing PCSK9-mediat ed
LDLR degradation. Increasing liver LDLR levels resu lts in associat ed reductions in serum
LDL-cho lesterol. Use of evolocumab is associated w ith a reduction in levels of free PCSK9
and this is taken as a measure of t arget engagement. it lowers LDL cholest erol by more
than 50% in 85% of patients who are t reated .
Fibrates increase lipop rotein lipase activity via PPAR-alpha agonism, and ezetimibe
reduces intestinal absorption of cholest erol. SGLT-1 inhibitors reduce intestinal
abso rpt ion of glucose.
Use of evolocumab is endorsed by NICE under certain con ditions on ly, namely t hat t he
d osage is 140mg every 2 weeks and LDL cho lesterol is p ersistently above 3.5 mmol/1.
m
se
As
https://www.nice.o rg.uk/guid ance/ ta394/chapt er/1 -recommendations
Dr
A 17-year-old girl presents with a 6 week history of nausea and abdominal discomfort.
Routine blood tests reveal the following.
Hb 10.9 g/dl
WBC 6 .7 " 109/1
Platelet s 346 *109/1
Calcium 2 .33 mmol/1
Bilirubin 7 IJffiol/1
ALP 262 u/1
ALT 35 u/1
Alcoholic liver disease
Cholangiocarcinoma
Pregnancy
Gallstones
m
se
Primary biliary cirrhosis
As
Dr
Alcoholic liver disease CD
Cholang ioca rcinoma m
I Pregnancy ED
.
Gallstones CD
Primary biliary cirrhos is fD
m
se
Alkaline phosphatase is significa ntly elevated in pregnancy. This wou ld also explain the
As
borderline anaemia
Dr
A new test to screen for ovarian cance r in patients with a positive fam ily history is tested
on 920 patients. The test is positive in 16 of the 20 patients who are proven to have
ovarian cancer. Of th e remaining pati ents, only 10 have a positive test. What is the
negative predictive value of the new test?
900/920 = 97.8%
890/900 = 98.9%
10/900 = 1.1%
890/894 = 99.6%
m
se
As
890/920 = 96.7%
Dr
A co ntin gency table can be construct ed f ro m the above data, as shown below:
Ovarian cancer No ovarian cancer
Test positive 16 10
Test negative 4 890
m
se
As
The negative pred ictive value = TN I (TN + FN) = 890 I (890 + 4) = 8901894
Dr
What a re funnel p lots primarily used for?
Demonstrate the hetero gene ity of a meta -ana lysis
Demonstrate the existence of p ublication bias in meta-analyses
Provid e a g ra p hical rep resentation o f the relative risk results in a case-control study
Provid e a g ra p hical rep resentation of the relative risk resu lts in a cohort study
m
Provid e a g ra p hical rep resentation o f the p robab il ity o f a patient experiencing a
se
As
pa rticu la r a dve rse e ffect
Dr
Demonstrate the heterogene ity o f a meta-analysis
I Demonstrate the existence of pu blication bias in meta-ana lyses
Provide a g ra p hical rep resentation of the re lative risk resu lts in a case- contro l
study
Provide a g ra p hical rep resentation of the relative ris k results in a coho rt study
raphical rep resentation of the proba bil ity of a patie nt expe riencing a
dverse effect
m
se
Funnel plots - show publ ication b ias in meta-ana lyses
As
Dr
A 13-yea r-o ld g irl presents with pa lp itations, fatig ue and dyspnoea. She has had
symptoms fo r around a year. There is no history of syncope o r chest pa in. On exam ination
s he ha s a pan-systolic murmur associated with g iant V waves in the j ugu lar venous pulse.
Auscu ltatio n of the chest is u nrema rkable. A resting ECG is norma l but a 24 hou r tape
s hows a short burst of supraventricu lar tachycardia . What is the most li kely diag nosis?
Atrial septal d efect
Pulmonary stenosis
Arrhythmogen ic right ventricular card iomyopathy
m
se
As
Ebstein"s ano maly
Dr
Atrial septa l d efect
Pulmonary stenosis
Hypertiophic obstructive cardiomyopathy
Arrhythmogen ic right ventricular card iomyopathy
m
se
As
Ebstein's ano maly
Dr
Which one o f the fo llowin g state ments best d escribes a type I sta tistical e rro r?
The null hypothes is is rejected whe n it is true
The null hypothes is is a ccepted whe n it is false
The p va lue fails to reach statistica l significa nce
The alternative hypothesis is rejected whe n it is true
m
se
As
A stu dy fa ils to reach an a ppro priate powe r
Dr
The null hypothes is is rejected when it is true CD
The null hypothesis is accepted when it is false fiD
The p value fails to reach statistical significance CD
The alternative hypothesis is rejected when it is true CD
m
se
As
A study fails to reach an appropriate power m
Dr
You are a STl docto r in medicine. Whilst on-ca ll you review a 60-year-old woman who is
known to have COPD. She has been admitted with an infective exacerbation and has not
responded to nebulisers and intravenous a minophylli ne. Her most recent blood gases
show a wo rsening respiratory acidosis. You feel that non -invasive ventilation (NIV) is
needed a nd bleep the on-call physio. After discussing the blood g as results over the
p hone she says that NIV is not indicated in her opinion and refuses to set it up. What is
the most a pp ropriate action?
Phone he r back in 30 minutes and exaggerate the clinical pictu re to persuade her
to come in
Accept her p rofessional opin ion and reassess the s ituation in 30 minutes
Set-u p the NIV eq uip ment yourself to avoid any furthe r delay
As there is a disagreement on ma nagement speak to the consultant on-ca ll
m
se
As
Transfer the patient to another hospital
Dr
Phone h~r back in 30 minutes and exaggerate the clin ical p icture t o persuade her m
to come 1n
Accept her professional opinion and reassess the situation in 30 minutes
Set-up the NIV equip ment yourself to avoid any further delay
As there is a disagreement on management speak to the consult ant on-call
Transfer the patient to another hospital
By fa r the best option here is to speak to the consultant on-ca ll. The physio may be
experienced in p roviding NN but it is ult imately a medical decision about whether to start
a treatment.
Accepting her opinion is a poor option as she has not reviewed the patient herself and is
on ly giving an op inion on the basis of b lood gases.
Setting up NN equipment requ ires t raining. If done incorrectly it could potentially harm a
m
se
patient. Transferring an acutely unwell patient simply because the physio won't come in is
As
not appropriate. Lying about cl inical info rmation is a very poor option.
Dr
You are advisi ng a patient who has recently been diagnosed w ith ch ron ic kidney disease
stage 4 with regards to her diet. Which one o f the following foods should she eat in
moderation due to the high potassium content?
Tomatoes
Plums
Cra nberry j uice
Grapes
m
se
As
Green beans
Dr
Tomatoes
.,
Plums .
(D
Cranber j u ice «D
Grapes fiD
m
se
Green beans «D
As
Dr
You are working in the palliative ca re unit. A 65-year-old female has severe neuropath ic
pain secondary to spinal co rd met astasis. It has been unresponsive to titration of opioid
and neuropathic agent s. Your consu ltant decides to use ketam in e.
What is the mechanism of action of ketam ine?
GABA agonist
GABA analogue
Modulation of voltage-gated calcium channel
NMDA receptor antagonist
m
se
As
Sodium channe l blocker
Dr
GABA agonist CD
GABA ana logue CD
Modulation of voltage-gated calcium channel CD
I NMDA receptor antagonist 6D

Sodium channel blocker fD
Ketamine is an NMDA recepto r antagonist

Ketamine is an NMDA recepto r antagonist. It can be used in neuropath ic pain poorly

responsive to titrated opioids and oral adjuvant analgesics (e.g. antidepressant and/or
anticonvulsant) particularly when there is abnormal pain sensitivity (e.g. allodynia,
hyperalgesia or hyperpathia).
Gabapentin acts by modu lation of the vo ltage-gated calcium channel.
Pregabali n is a GABA analogue.
m
Benzodiazepines are GABA agon ists.
se
As
Local anaesthetics (e.g. lidoca ine) are sodium channel blockers.
Dr
What level of evidence does a study offer which is obtained from a meta -analysis of
randomised controlled t rials?
Ia
Ib
IIa
lib
m
se
As
IV
Dr
!a ED
Ib f!D
I!a CfD
lib f!D
m
se
As
IV f!D
Dr
A 59-year-old man is investigated for exertional chest pain and is found t o have extensive
coronary artery disease on an giogram. Which of the following cell types is most
implicated in the development of co ronary artery pla ques?
Lymphocytes
Plat elet s
Macrophages
Neutrophils
m
se
As
Basophils
Dr
Lymphocytes CD
Platelets .
ctD
Macrophages (iD
Neutrophils a
Basophils CD
m
se
Although platelets are clearly central to the thrombotic cascade which develops following
As
plaque ruptu re macro phages play a greater role in the initial development of the plaque.
Dr
Which one o f the followin g statements rega rd ing sig nificance tests is incorrect?
Parametric data is usually norma lly distributed
Student's t -test may be paired o r unpa ired
Pearson's prod uct-moment coefficient is used to assess correlation between two

va riables
Chi-squa red test is used to compare pa rametric data
m
se
As
Paired data refers to data obtained from a single group o f patients
Dr
Which one of the fo llowing statements regard ing significance tests is incorrect?
Parametric d ata is usu ally no rmally distributed
Student's t -test may be paired or unpai red
Pea rson's p rodu ct-moment coefficie nt is used to a ssess co rrelation between two f!D
va riab les
m
Chi-squared test is used to com pare parametric data
se
As
Paired d ata refers to data o btained from a single gro up o f patie nts
Dr
Which one o f the fo llowin g statements rega rd ing vita mi n D-resistant rickets is fa lse?
Ma nag e ment includ es the use o f high-d ose vita min D supp lements
Is aX- li nked d ominant condition
X-ray changes include cu pped metaphyses
Fa il ure to th rive may be seen
m
se
As
Decrea sed urina ry phosp hate is cha racteristic
Dr
Management includes the use of high-dose vitamin D supplements CD
Is aX-linked dominant condition tiD
X-ray changes include cupped metaphyses CD
Failure to thrive may be seen CD
m
se
As
Decreased urinary phosphate is characteristic CD
Dr
A two-yea r old boy p resents with an abdom inal mass. Which of the following is
associated with Wilm's tumour (nephroblastoma)?
Deletion on short arm of chromosome 12
Tuberose sclerosis
Beckwith-Wiedemann synd rome
Autosomal d ominant polycystic kidney d isease
m
se
As
Autosomal recessive polycystic kidney disease
Dr
Deletion on short arm of chromosome 12
Tuberose sclerosis
I Beckwith-Wiedemann syndrome
Autosomal dominant polycystic kidney d isease
Autosomal recessive polycystic kidney disease
m
se
Beckwith-Wiedemann synd ro me is a inherited condition associated with o rgano megaly,
As
macrog loss ia, abdom inal wall defects, Wilm's tumour and neonata l hypoglycaemia.
Dr
Which part of an antibody do immune cells bind t o?
Disulfide bridge
Heavy-chain of antigen binding site
Light -chain of antigen binding site
Fe region
m
se
As
Light -chain hypervariable region
Dr
Disulfide bridge m
Heavy-chain of antigen binding site CD
Light -chain of antigen binding site (tD
I Fe region GD
Light -chain hypervariable region CD
Immune ce lls bind to the crystallising reg ion (Fe) of immunoglobulins

Important for me Less impcrtc.nt
Antibodies (immunoglobulins) may be divided into 2 main pairs:
m
• Fab region: antigen-binding fragment - the region that binds t o antigens
se
As
• Fe region: fragment cryst allizable region - the ta il region of an antibody that
int eract s with ce ll surface receptors
Dr
A scient ist is invest igating Chron ic Myeloid Leukaem ia (CML). He d evelops a fluorescent
DNA probe to b in d to BCR-ABL fusion g ene for direct visua lisation of Philadelphia
translocation.
Which molecu lar t echnique is he using?
Southern blot
DNA Microarray
Fluorescence In Situ Hybridisation (FISH)
Northern blot
m
se
As
Flow cytometry
Dr
Southern blot
DNA Microarray
Fluorescence In Situ Hybridisation (FISH)
Northern blot
Flow cytometry
-
~
Fluorescence in situ hybridization uses fluorescent DNA or RNA probe t o bind to

specif ic gene site of inte rest for direct visualisation of chromoso mal anomalies
m
se
Fluorescence in situ hybridization uses fluo rescent DNA or RNA p robe to bind to specific
As
gene site of interest for direct visua lisation of ch romosomal anomalies.
Dr
A patient comes into the GP due to a d ry cough. He mentions that he beco mes very easily
short of b reath and feels feverish. He admits to being an intravenous drug user. He is
referred to the sexua l health clinic and is d iag nosed with HIV after blood tests. Which cell
su rface protein does HIV use to enter cell s?
CD3
CD4
CDS
CD8
m
se
As
CD14
Dr
CD3 CD
I CD4 GD
CDS CD
CD8 fi!D
CD14 fD
HN uses CD4 to ent er cells

The patient in t his scenario has Pneumocystis pneumonia, a lung infection from t he
fungus Pneumocystis jiroveci, which affects immunocomprom ised patient s. HIV uses CD4
t o enter cells - t his is why specifically T helper cells are reduced in patients w ith HIV.
CD3 is a cell su rface p rotein found on all T cells. CDS is a cell su rface marker commonly
m
se
found in mantle cell lymphomas. CD8 is a cell su rface marker fou nd on cytotoxic T cells.
As
CD14 is a cell surface marker found on macrophages.
Dr
You a re a STl docto r working on a med ica l ward . You a re struggling to cope with the
workload and often leave the wa rd late. Who is the most app ropriate action to take?
Ta ke time o ff-sick until the situation is sorted to protect patient care
Speak to the med ical director
Arrive one-hour ea rly every morning to give yourself extra time
Sp eak to your consultant
m
se
As
Sp eak to the postg raduate d ean
Dr
Ta ke time o ff-s ick until the situation is sorted to p rotect patient care
Speak to the med ical d irecto r
Arrive one-hour ea rly eve ry morning to g ive yourself extra time
Speak to your consultant

-
~
Spea k to the postg raduate d ean
Sp eaking to you r co nsultant is the first action to ta ke in th is scenario . They a re best

placed to be a ble to ta ke actio n to try a nd a me nd the situatio n. As the consulta nt is
ultimately res ponsible fo r patie nt care they also have a rig ht to know if you are struggling
to cope as this may a ffect patient care.
The medical directo r may a lso b e a ble to ass ist but wo uld end up s pea king to the
consu ltant and hence is not the first cho ice.
m
se
Arrivin g early may seem a n o ption but does not ultimate ly a ddress the cause o f the
As
p ro b le m. Ta king time o ff sick is the worst o ptio n - it d oesn't a ddress the pro blem and is
Dr
unp ro fess io nal.
A 55-yea r-old lady with known metastatic b reast cance r p resents to the acute medical
take with hypercalcaem ia. She has no other co- morbid ities, is a non-smoke r an d wo rks in
a n office based job. She is treated with intravenous fluid a nd b isphosphonates, aher
which her calcium norma lises and she is discha rged.
At d ischarge, she is referred to the endocrinology d epartment for outpatient follow-up,

a longside regular b lood ca lcium monito ring. What ve rba l a dvice is it most important to
give her on discha rge from hos pita l?
Avoid excess exercise until treated
Low calciu m diet
Reduce a lcohol intake
Ensu re adeq uate sun light exposure
m
se
As
Increase fluid intake
Dr
Avo~ excess exercise until treated
Low calcium diet
Reduce a lcohol intake

-
. .wr
Ensure ad eq uate su nlight exposure
Increase fluid inta ke
In the context of hyperca lcaemia se co nda ry to malig nancy the below advice is suggested
by NICE:
• Advice a bout maintaining good hydration (drinkin g 3 -4 L of fluid per d ay), provid ed
there are no contraindica tions (s uch as severe renal impairment o r heart failure).
• Reass ure that a low calci um diet is not nece ssa ry, a s inte sti nal a bsorption of calcium
is usually reduced.
• Advise the perso n to avoid any drugs or vitamin supplements that could exa cerbate
the hyperca lcae mia.
• Encourage mo b ilization where possib le to avoid exa cerbating the hypercalcaemia.
• Advise the perso n to repo rt any sympto ms o f hypercalcaemia .
m
se
NIC E Gu id elines: Hyperca lcaemia- http://cks.nice.org.uk/hypercalca em ia)
As
Dr
Patients with deficiencies o f which one of the following complement protein(s) are
predisposed to im mune complex diseases?
Cl-INH
Clq, Clrs, C2, C4
CS-9
C3
m
se
As
C3bBb
Dr
Cl-IN H .
(D
I Clq, Clrs, C2, C4 ED

CS-9 CD
C3 GD
m
se
•
As
C3bBb
Dr
Each one of the following statements regarding atrial natriu reti c pe ptide a re true, except:
Lowers blood pressure
Degrad ed by e ndopeptid ases
Promotes excretio n of sodium
Secreted mainly by the left atrium
m
se
As
Antago nises actions of angiotensin II and a ldosterone
Dr
Lowers blood pressure
Degraded by endopeptidases
-
....,
Promotes excretion of sodium
I Secre ted mai nly by the left atrium
m
se
As
Antagon ises actions of ang iotensin II and aldosterone
Dr
A 32-year-old female patient is referred by GP t o the urology cl inic for 6-months non-
specific pain in the right lower back and the abdomen, urinary frequency and haematuria.
She is originally fro m Ghana and moved to the UK 3 months ago. Ultrasound of the
kidney uret ers and bladder (KUB) shows th icken ing of the bladder wa ll. CT KUB shows
linear calcification of the entire surface area of the bladder wall as well as part of the left
uret er. On further question ing, the patient reports when she was living in Ghana, she has
been swimming in the local lake on a regu lar basis.
Given the likely diagnosis, w hat wou ld be the most appro priate treatment?
Linezolid
Amoxicillin
Co -tri moxazole
Bendazole
m
se
As
Praziquantel
Dr
Linezolid (D
Amoxicillin CD
I Co -tri moxazole CD
Bendazole CD
I Praziquantel eD
Schistosoma haematobium can be treated w ith praziquantel

This patient likely has Schistosoma haematobium, which can be treated with praziquantel.
Helminth infections are not usually treatable with antibiotics such as linezolid and
amoxicillin.
Co -tri moxazole is not usually used for the treatment of helminth infections.
m
se
Bendazole is used to treat a variety of helminth infections but not Schistosoma
As
haematobium.
Dr
A 14-yea r-old gi rl is a dmitted to hospita l following a ru ptured ecto pi c preg na ncy. She
comes from a fam ily of Jehova h's Witnesses. Her haemoglobin on admission is 6.9 g/dl.
She consents to a bl ood tra nsfusion but he r mothe r refuses. What is the most a ppro priate
course o f action?
Advise the pa re nts she will have to get a High Court injunct io n in o rde r to stop the
transfusio n
Give the blood tra nsfusion
Transfer the patient to a hos pital run by Jehovah's Witnesses
Respect pare nta l wishes a nd withhold the blood transfusio n
m
se
As
Ask the hospita l lawye r to co me in a nd decid e upo n the correct course of action
Dr
Advise the pa rents she will have to get a Hig h Cou rt injunct ion in orde r to stop
the transfusi on
Give the blood transfusion
Tra1sfer the patient to a hospital run by Jehovah's Witne sses
Respect pare nta l wishes a nd withhold the bloo d transfusion
Ask the hospital lawyer to come in a nd decide upon the correct course o f action f!D
The GMC gives the fo llowing gu id ance:

'You shou ld e ncou rage you ng people to invo lve thei r pare nts in maki ng important
d ecisio ns, but yo u s hou ld usually ab ide by a ny d ecision they have the capacity to make
themselves'
With respect to Jehovah's witnesses:

'You should not ma ke assumptions about the d ecisio ns that a Jehovah's Witness patient
mig ht make about treatme nt with b lood o r blood products. You shou ld ask for and
respect their views and a nswe r the ir q uestions ho nestly and to the best of you r ability.
Yo u may a lso wish to contact the hospital liaison committees estab lished by the Watch
Towe r Society (the g ove rning body of Jehovah's Witnesses) to support Jehovah 's
Witnesses fa ced with treatment d ecisions involving b lood. These com mittees ca n a dvise
o n current Society po licy reg arding the accepta bil ity o r otherwise o f pa rticu la r blood
products. They also kee p deta ils of hospitals a nd docto rs who a re experienced in
'bloodless' med ica l p rocedu res.'
A blood tra nsfusio n is clea rly in the patient's best inte rests a nd in the scenario described
a bove may potentially be life-saving. Whilst a child cannot refuse treatment they a re a ble
to provide consent. Giving the blood transfusion is there fo re both clin ica lly and ethically
the rig ht cou rse o f action.
s em
Not g iving the b lood transfusion not only fails to respect the patie nt's wishes b ut also
As
causes pote ntia l ha rm.

Dr
Which one of the followin g statements is true regarding the radial nerve?
Damage at the axilla would lead to wrist drop
Damage at the wrist leads to wasting of the thenar muscles
It supplies the latera l 2 lumbrica ls
m
It supplies sensation to the lateral one and a half fingers
se
As
It is derived from C6-8 and Tl
Dr
Damage at the axilla would lead to rist dro p
Damage at the wrist leads to wasting of the then ar muscles
It supp lies the lateral 2 lumbrica ls
It supplies se nsation to the late ral one and a half fingers
m
se
As
It is d erived from C6-8 and T1
Dr
You are a STl d oct or in General Medicine. During an on -call you are in A&E seeing a
pat ient w ho has a p neumot horax. On arriving you find t he A&E ST2 doctor att empt ing t o
perform an aspiration. He appears t o about t o insert t he needle at t he wrong landmark.
What is t he most ap propriate action?
Tell you r colleagues about what hap pened in t he mess to ensu re t hey are aware o f
the doctors limitations
Say noth ing, stay w ith the patient and t ake over when he asks for help
Go and g et t he A&E consu ltant
Say noth ing at t he t ime but f ill in a cl inical incid ent form
m
se
As
Immediat ely vo ice you r concerns and ask him to stop
Dr
Tell you r colleagues about what hap pened in the mess to ensure they are aware
of the doctors limitations
Sa L oth ing, stay with the patient and take over when he asks for help
Go and get the A&E consu ltant
Say noth ing at the time but fill in a cl inical incident fo rm
Immed iate ly voice your concerns and ask him to stop
If you have concerns rega rdi ng the management of a patient it is important to act on
them.lt may b e that you a re wrong - the ST2 docto r may actually b e p erforming the
aspiration using a recognised, safe techniq ue. This s hou ld not however sto p you voicing
your concerns - fa iling to d o so may put the patient at risk.
If you feel una ble to do you shou ld d iscuss you r concerns with someone who is in a
position to act. Saying nothing puts the patie nt at pote ntia l harm. Filli ng in a cl inica l
incident form after the event will not alte r this.
m
se
Sp rea ding rumours in the mess a bout a docto rs ab ility is unprofessiona l and unlike ly to
As
lead to a resolution of the p roblem.
Dr
Which one o f the followin g is associated with increased lung compliance?
Kyphosis
Pulmonary oedema
Emphysema
Pulmonary fibrosis
m
se
Pneumonectomy
As
Dr
Kyphosis .
(D
Pulmonary oedema fD
I Emphysema ED
Pulmonary fibrosis CD
m
se
6D
As
Pneumonectomy
Dr
Which one o f the followi ng stat ement s regarding interleukin 1 (IL-l} is t rue?
It is released mainly by macrop hages/mono cytes
It causes vasoconstriction
It reduces expression of selectin molecu les on the end othelium
IL-l anta gon ists are cu rrent ly lice nsed for use in co lo rect al ca ncer
m
se
As
It inhibits t he release o f nit ric oxid e by the endothelium
Dr
I It is released mainly by macrophages/monocyte_s_ ____.
It causes vasoconstriction
-
P ,educes expression of selectin molecules on the endothelium
IL-1 antagonists are currently licensed for use in colorectal cancer

-
m
se
As
It inhibits the release of nitric oxide by the endothelium
Dr
Which of the following is not a tumour suppressor gene?
p53
APC
NF-1
Rb
m
se
As
myc
Dr
p53 f!D
APC CD
NF-1
- f!D.
I
Rb CD
I
myc CD
m
se
As
myc is an oncogene which encodes a tra nscri ption factor
Dr
A 74-year-old male is admitt ed to the Emergency Department after routine b lood tests by
his GP showed t he fol lowing results. The pat ient has a background of stable essential
thrombocytosis.
Na+ 139 mmol/ 1
K+ 6 .6 mmolfl
Urea 4. 2 mmolfl
Creat inine 68 umol/ 1
Hb 13.5 g/dl
Pit 800 * 109/ 1
WBC 6 .6 *109/ 1
His ECG was normal and he was given calcium gluconat e along with an insulin/dextrose
infusion. Following this his potassium improved to 6.1, however over the next few days he
remained persist ently hyperkalaemic.
What wou ld you suspect is the cause of his high potassium given h is high cell counts?
Pseudohyperkalaemia
Tu mour lysis syndrome
Hypomagnasaemia
Conn's syndrome
s em
As

Dr
Pseudohyperkalaemia
Tumou r lysis syndrome
Hypomagnasaemia
Conn's syndrome
m
se
As
High cell counts and high potassium: consider pseudohyperkalaemia
Dr
A new screen ing test is developed fo r colo recta l cancer. It is a b lood test which detects a
p ro te in; the higher the level of the protein, the more likely a patient is to have colo rectal
cancer. If the cut-off for a positive test is increased, which o ne of the fo llowing will a lso be
increased?
The p va lue
Specificity
Like lihood ratio for a negative test resu lt
Sensitivity
m
se
As
Dr
The p value
Specificity
Likelihood ratio for a negative test result
Sensitivity
Specif icity = TN I (TN + FP)

m
se
As
Increasing the cut-off of a pos itive test result will decrease the number o f fa lse positives
and hence increase the specificity
Dr
A study is carried out to assess the potentia l of hip protectors to reduce fe mo ra l neck
fractu res in elderly nu rsing home patients. The average ag e of the patie nts was 82 years.
Ove r a two -yea r perio d 800 patients we re recruited a nd assig ned rand omly e ither to the
hip protector gro up or sta nda rd ca re g roup.
The results:
Hip p ro tector g rou p: 400 patients - 10 of whom had a femora l neck fractu re ove r the two
year pe riod
Contro l gro up: 400 patients - 20 of who m had a fe mo ra l neck fract ure over the two yea r
pe riod
What is the absolute risk red uct ion?
0.025
0.05
10
m
se
0 .5 As
Dr
I 0.025 CD
0.05 CD
2 G'D
10 CD
0.5 fJ!D
Ab solute risk reduction = (Control event rate) - (Experimental event rate)

The absolute risk reduction = CER-EER, where:
Control event rate (CER) = (Nu mber who ha d particular out come with the control/ (To tal
number who had the control)
Experimental event rate (EER) = (Number w ho had particular outcome with the
intervention) I (Total number who had the intervention)
CER = 20 I 400 = 1 I 20 = 0.05
m
EER = 10 I 400 = 1 I 40 = 0.025
se
As
ARR = CER - EER = 0.05 - 0.025 = 0.025
Dr
A 4 -month -o ld female infant was admitted to hospital fo r diarrhoea a nd abdom ina l
distension. She had a complicated b irth with resuscitation attempts necessary. On
exa mination, it is apparent s he appears to be malnourished, has axial hypoto nia and she
has abnormal facia l features. Blood tests elevated long-chain fatty acids levels. Which
organelle is responsible for the catabolism of long chain fatty a cids?
Rough endoplasm ic reticu lum
Nu cleus
Proteasome
Peroxisome
m
se
As
Lysoso me
Dr
Nucleus
Proteasome
Peroxisome
Lysosome
Peroxisomes are responsible for t he catab olism o f long chain fatty acids
This patient is p resenting w ith sym ptoms o f Zellweger syndrome a genetic disease w hich
causes peroxisome dysfunction. Peroxisomes are the p rinciple organelle res ponsible for
the catabolism of long chain fatty acids.
Rough endoplasmic reticulum is responsible for the t ranslation and folding of new
p roteins. The nucleus is res ponsible fo r conta ining and mainta ining DNA. and the
transcription of RNA Proteasomes are responsible for t he breakdown o f proteins tagged
m
se
wit h ubiquitin. Lysosomes are responsible for the catabolism o f polysaccharides and
As
p roteins.
Dr
Whil st reviewing a patient's drug card you notice that you prescribed the wrong dose of
a tenolol when the patient was initially cle rked. Instead of 25m g ate no lol o d you
p rescribed SOmg ateno lol od. She has received the incorrect d ose on two occasio ns. On
exa mining Mrs Smith you note her blood pressu re and pulse a re normal. Mrs Smith has a
past history of anxiety and describes herself as a 'worrie r'. What is the most appropriate
action?
Complete an entry in your e-portfolio
Apolog ise to the patient + complete a clinical incident form
Complete a cl inica l incident form + avo id tell in g patient to prevent unnecessary

anxiety
Fi ll out a 'yellow card'
m
se
As
Keep her on the higher dose as she is su ffering no ill effects
Dr
Comp lete an entry in your e-portfolio
I Apologise to the patient + complete a clinical incident form
Comp lete a cl inica l incident form + avoid tellin g pat ient to prevent unnecessary f!D
anxiety
Keep her on the higher d ose as she is su ffering no ill effects
In t his scenario the patient ap pears to have come t o no harm follow ing t he error. This
should not however change you r approach to t he sit uation. The pat ient shou ld be
informed o f what has happened, an apology shou ld be made and reassurance give t hat
there ap pears to b e no ill effects. By com pleting a clinica l incident form you add to a bo dy
o f d ata w hich may in the long term change to practice.
An entry to you r e-portf olio at least shows that you both acknowledge and are w illing to
learn f rom t he error. The yellow ca rd syst em is int ended t o report side-effects from drugs
rat her t han prescription errors and hence is fairly point less.
m
se
The dose of a drug a pat ient takes shou ld b e based on clinical need rather t han a
As
reluctance t o acknow led ge an error. Dr
A 68-yea r-old man is admitted with central chest pai n wh ich is crushing in character. He
has associated flushing.
ECG results:
ECG T wave inve rsion in II,III and AVF
Blood results:
Troponin T 0 .9 ng/ml (normal <0.01)
Which substance does troponin T bind to?
Calcium io ns
Tropomyosin
Actin
Myosin
m
se
As
Dr
Calcium io ns fD
Tropomyosin GD
Actin f!D
Myosin C!D
Sarcoplasmic reticulum m
Troponin T b inds to tro pomyosin, forming a troponin-tropo myosin com plex

The clinical and e lectrog raphic featu res ra ise concerns over an inferior myoca rdial
infarction which is confirmed by the raised troponin. Troponin T b inds to tropo myosin,
forming a troponin-tropomyosin complex. It is specific to myocardial damage.
Troponin C binds to calcium ions. It is re leased by damage to both skeletal and card iac
muscle ma king it an insens itive marke r for myoca rdial necrosis.
Troponin I binds to actin to hol d the troponin-tropomyosin complex in place. It is specific

to myocardial damage.
Myosin is the thick component of muscle fibres. Actin slid es along myosin to generate
muscle contraction. em
s
The sarcoplasm ic reticu lum regulates the calcium ion concentration in the cytoplas m of
As
striated muscle cells

Dr
A 49-year-old man comes into clinic. One of his friends has recently had a myocardial
infarctio n and he is concerned about his own risk of co rona ry heart disease. He has no
past medical history of note o t her tha n anxiety for which he is not currently taking any
medication. He does however smoke around 20 ciga rettes a day. Ca rdiovascu lar
examination is unremarkable. His BMI is 26 kg/m 2 and blood pressu re is 126/82 mmHg.
You strongly advise him to stop smoking. What is the most appropriate fu rther cou rse o f
action?
Reassure him that he has a very low risk of coronary heart disease given his age
Arra nge a 24 hour blood p ressure monitor
Arra nge a lip id profile then calculate his QRISK2 score
Start orlistat
m
se
As
Refer him for an exercise tolerance test
Dr
Reassure him that he has a very low risk of coronary heart disease given his age CD
Arra nge a 24 hour blood pressure monitor
Arrange a lipid profile then calcu late his QRISK2 score
l tart orlistat
Refer him for an exercise tolerance test
If we feed his age, gender and smoking history into QRISK2 this gives a 10-year-risk of
m
se
cardiovascular disease (CVD) of 13.9%. He is therefore an appropriate person to have a
As
'formal' assessment of CVD risk using a lipid profile to further inform the QRISK2 score.
Dr
How is t he left ventricular ejection f raction calculated?
End systolic LV volume I end diastolic LV volume
End diastolic LV volume I end systolic LV volume
End diastolic LV volume I stroke volume
End systolic LV volume - end diastolic LV volume
m
se
As
Stroke volume I end diastolic LV volume
Dr
End systolic LV volume I end diastolic LV volume fD
End diastolic LV volume I end systolic LV volume CD
End diastolic LV volume I stroke volume fD
End systolic LV volume- end diastolic LV volume f!D
m
se
vol~me
As
Stroke vo lume I end diastolic LV CD
Dr
A 60-yea r-old man presents to the clinic with breathlessness. An urgent chest X-ray is
arranged. Sputum cultures reveal that he has pneumonia. He is started on erythromycin.
What is the mecha nism of action of erythromycin?
Inhibit 30S subu nit of ribosomes
Inhibit prote in wall synthesis
m
se
As
Dr
Inhibit protein wall synthesis
Macrolides inhibit the 50S subunit o f ribosomes

Erythromycin is a macrolide, w hich w orks by inhibiting the 50S subunit of ribosomes. This
m
se
prevents the production o f prot eins from bacte ria. Macrolides are co mmonly confused
As
with tetracycl ines, which inhibit the 30S subunit of ribosomes.
Dr
A 45-yea r-old female presents with ptosis and muscle weakness which worsens towa rds
the end of the day. She has a past medica l history of hypothyroidism. On exam ination you
note fatigable ptos is and proximal limb weakness. You suspect a diagnosis of myasthen ia
graVIS.
Which rece ptor is involved in the pathophysiology?
Muscarinic acetylcho line receptors
Nicotinic acetylcholine recepto rs
Beta 1 ad renocepto r
Beta 2 ad renocepto r
m
se
As
Alpha 1 adrenoceptor
Dr
Musca rinic acetylchol ine receptors
Nicotinic acetylcholine receptors
Br a 1 ad renoceptor
Beta 2 ad renoceptor
Alpha 1 ad re noceptor
Ske leta l muscle contraction is d epend ent on acetylcho li ne which activates nicotinic
acetylcho li ne receptors
Skeletal muscle contraction is d epend ent on acetylcholi ne which activates nicotinic

acetylcholi ne receptors.
Stimulation of the muscarinic acetylcholi ne receptor results in a variety of d ifferent e ffects

d ependent upon the subclass of receptor. For exa mple stimu lation of M2 receptors wou ld
resu lt in a decreased heart rate which could worsen the compensation.
Stimulation o f b eta 1 adrenergic receptors result in increased heart rate and cardiac
contra ctil ity.
Stimulation o f b eta 2 adrenergic receptors result in smooth muscle dilation e.g .

bronchodi lation.
Stimulation o f alpha 1 ad renergic receptors result in vasoconstriction of the skin, gut and
kidney arterio les. This helps increases total peripheral resistance and mean arterial
pressure, as well as facilitate p erfusion of the brain, hea rt and lu ngs which a re key organs
em
o f use in the flight or fright response.

s
As
I•• I •• I tt I
Dr
Discuss Imp ro ve J
A study looks at adding a new antiplatelet drug in addition to aspiri n to patients who've
had a stroke. One hundred and seventy patients are enrolled for the study with 120
receiving the new drug in addition to aspiri n and the remainder rece iving just aspirin.
After 5 years 18 people who received the new drug had a further stroke compared to 10
people who just received aspirin. What is the number needed to treat?
15
1.8
20
m
se
10
As
Dr
8 (fD
ps GD
1.8 (D.
I 20 CD
10 GD

Control event rat e = 10 I 50 = 0.2

Exp erimental event rate = 18 I 120 = 0.1 5
m
se
Absolute risk redu ction = 0.2 - 0.15 = 0.05
As
Dr
Yo u a re a STl docto r in g e nera l medicine. A 19-yea r-old female who has type 1 diabetes
mell itus is adm itted with her fourth e pisode of dia betic ketoacid osis in the past two
months. You sus pect she runs he r sugars high to keep he r weight down. She is g eneral ly
no n-com pliant and often self-d ischarges a fte r 24 hours. What is the most a ppropriate
respo nse?
Ta ke he r o n a tour of the wa rd showing her patie nts with amputated legs o r those
on dialys is as an incentive to get better control
Have a ch at a fter the wa rd rou nd about why she thinks he r contro l is so bad
Write a letter to her GP advising him/her of your conce rns
Take no a ction as it is her d e cision whether she ta kes he r med ication o r co mplie s
with treatment
m
se
Te ll her she is wasting NHS resources a nd you d o not want to s ee her tu rn up at
As
your hosp ital ag ain
Dr
I
Take her on a tou r of the ward showing her patients with amputated legs or
those on dialysis as an incentive to get better control
Have a chat a fter the ward rou nd about why she thinks her control is so bad
-
...wr
Write a letter to her GP advising him/her of your concerns
r:k
I
e no action as it is her decision whether she takes her medication or complies
witi treatment
CD
Tell her she is wasting NHS resources and you do not want to see her turn up at
your hospital again
Managing young diabetic patients may be frustrating but needs to be approached in an

empathetic manner. Taking time to explore why her control is so bad is the best response
in th is scena rio. The GP shou ld hopefu lly have a long term relationship with the patient
and may be in a pos ition to a ddress these p roblems.
Taking no action igno res the problem. Trying to scare her by showing her patients with
complications is a poor option not least because it fa ils to respect the privacy o f the other
patients.
m
se
Te ll ing her she is wasting NHS resources is uncaring a nd unprofessiona l. Tell ing her not to
turn up at hospital again is indefensible from an ethical an d medicolega l perspective.As
Dr
A patient d evelops an eczematous, weeping rash on his wrist fo llowing the pu rchase o f a
new watch. In the GelI and Coom bs classificatio n of hype rsensitivity reactions this is a n
example of a:
Type I rea ct io n
Type II rea ction
Type Ill reactio n
Type IV rea ct io n
m
se
As
Type V reaction
Dr
Type I reaction CD
Type ll reaction GD
Type lli reaction CD
I Type N reaction ED
Type V reactio n m
Type N hype rsensitivity reaction - allerg ic contact d e rmatitis
m
se
As
This patient has a llergic contact de rmatitis, which is commonly p recipitated by nickel
Dr
Which one o f the fo llowing statements best d escribes a type n statistical e rro r?
The p va lue fa ils to reach statistica l significa nce
A study fa ils to reach an ap pro priate power
The null hypothes is is rejected whe n it is true
The null hypothes is is a ccepted whe n it is false
m
se
As
The alternative hypothesis is rejected whe n it is false
Dr
The p va lue fails to reach statistica l sig nificance
A study fa ils to reach a n a ppro priate powe r
The null hypothes is is rejected when it is true

-
'""""
I The null hypothesis is accepted when it is false
m
se
As
The alternative hypothesis is rejected when it is fa lse
'""""
Dr
A new o ral- hypoglycaemic is being developed. A number of different study types are
considered t o demonstrate efficacy in reduci ng the HbAl c. Which one of the following
study designs would require the most patients t o produ ce a significant result?
Equivalence trial
Non -inferiority trial
Superiority trial
Pla cebo- controlled trial
m
se
As
Stu dy design would not affect the number of patients required
Dr
Equivalence trial
Non -inferiority trial
I Superiority trial
Placebo-controlled trial
Stu dy design would not affect the number of patients required
m
se
As a superiority trial co mpares the new drug with an existin g treatment, w hich wou ld also
As
lower HbAlc, a large sample size is required to demonstrat e a significant difference.
Dr
A new drug is trial led for the treatm ent of lung cancer. Drug A is given to 500 people with
early stage non-small cell lung cancer and a placebo is given t o 450 people with the same
condition. After 5 years 300 people who received drug A had survived compa red t o 225
who received the placebo. What is the number needed t o treat to save one life?
3.33
75
10
m
se
As
2
Dr
3.33 f!D
75 CD
I 10 ED
5 f!D
2 CD

The quest ion asks about t he number need ed t o treat to save one life. The 'event' is
therefore survival.
Exp eriment al (drug A) event rate = 300 I 500 = 0.6

Cont rol (placebo) event rat e = 225 I 450 = 0.5
m
se
Absolute risk redu ct ion = 0.6 - 0.5 = 0.1
As
Dr
A patient diagnosed with ch ronic primary hype rparathyro idism was treated by
parathyro idectomy and you are seeing him in clinic as a follow-up. His post-operative
bloods are available to you in clinic:
Parathyroid hormone 1.8 pmoi/L (1.6 - 6 .9 pmoi/L)
Corrected C<llcium 1.7 mmoi/L (2 .1 - 2.6 mmolfl )
Phosphat e 0 . 1 mmoi/L (0 .1 - 0 .8 mmoi/L)
What is the most likely explanation for this?
Osteomala cia
Hungry bone syndrome
Rickets
Scurvy
m
se
As
Parathyroid adenoma
Dr
Osteoma lacia fD
~ngry bone syndrome GD
Rickets m
Scu rvy m
Pa rathyroid ad e noma f.D
Hung ry bone syndrome is the result of a sud den d ro p in previously high

pa rathyro id ho rmone levels
This question tests you r knowled ge of the complications of a parathyro idectomy

following chro nic hype rpa rathyro id is m.
Osteomala cia -this is not the correct answer. Osteomalacia is a chro nic conditio n which is
not consistent with this patient's history.
Hung ry bone syndrome -this is the correct answer. This p resentation is a typical
presentation of hu ng ry bone syndrome, a rare b ut sign ifica nt condition following a
pa rathyro idectomy following chronic hyperpa rathyroidism. It causes hypocalcaem ia .
Rickets -this is not the correct answer. Rickets is a conditio n in ch ildren.
Scu rvy - this is not the correct answe r. Scu rvy is a vitam in d eficiency which wou ld not
cause this picture .
s em
Pa rathyroid ad enoma - this is not the correct answe r. This is mo re li kely to cause
As
hyperca lca emia.

Dr
A 35 -year-old gent leman has attended his GP due to j oint pains and reported skin
changes.
On examinat ion, you note a brown ish/bluish pigment to his ears. On closer inspection,
you also note a similar disco lou ration of his sclera bilaterally. His past history includes a
prior knee j oint replacement. A specialist urine sample is sent away, which ult imately
shows elevated levels of homogent isic acid. What is the most likely unifying diagnosis?
Alkaptonuria
Wilson disease
m
se
As
Phenylketonuria
Dr
Osteogenesis imperfecta f.D
I Alkaptonuria ED
Porphyria cutanea t arda CfD
Wilson disea se CD
Phenylketonuria GD
Alkapto nu ria is an autosomal recessive diso rder t hat is a resu lt of a d eficiency of

homoge nt isic acid dioxygenase leading to elevat ed levels o f homogentisic acid (HGA).
HGA then polymerises and forms a pigment t hat is deposited in connective t issue
throughout the b ody (o chronosis). Clinica lly f eatures include brown/bluish p igment o f t he
ear ca rtilag e or sclera, arthro pathy, renal stones, cardiac valve involvement and coronary
calcif ication.
Osteogenesis imperfecta causes blue sclera b ut is not associated wit h elevat ed HGA.
m
se
Porphyria cutanea t arda, Wilso n disease and p henylket onuria d o not cause cartilag e
As
discolou ration nor elevat ed HGA.
Dr
A new b iochemical marker ha s been found which is increased in mothers who are carrying
fetuses w ith Down 's syndrome. The new blood test is trialled in 1,000 women over the age
o f 35 years. Of these women 20 were found to be carrying a fetus with Down's syndrome
as assessed usin g standard measures. The new test was positive in 15 of t he 20 cases but
was also positive in 30 of the remaining 980 women. What is the positive predict ive value
o f t he test?
0.66
950/980
0.33
0.8
m
se
As
0.5
Dr
0.66 C!D
9501980 CD
I 0.33 GD
0.8 GD
0.5 CD
A contin gency table can be co nstructed from t he above dat a, as shown below:
Down's Not Down's
Test positive 15 30
Test negative 5 950
m
se
As
Positive predictive value = TP I (TP + FP) = 15 I (15 + 30) = 0.33
Dr
In t erms of the cell cycle, which one of the following phases det ermine the length of the
cell cycle:
MO
Gl
m
se
As
G2
Dr
M C!D
MO tiD
~ CID
s fD
m
se
G2 .
(D
As
Dr
T-Helper cells of the Thl subset typically secrete:
IFN-beta, IL-4, IL-8
IL-l, IL- 6, TN F-alpha
IL-l
m
se
As
IL-4, IL-5, IL-6, IL-10, IL-13
Dr
IFN- beta, IL-4, IL-8 fD
I IFN-gamma, IL-2, IL-3 ED

IL-l, IL-6, TNF-alpha e'D.
IL-l CD
m
se
As
IL-4, IL-5, IL-6, IL-10, IL-13 GD
Dr
A scientist is investigating pote ntia l targets for anti-HN drugs. What is the ro le of reve rse
transcriptase in HIV infection?
Inhibits topoisomeras II (DNA gyrase) and topoisomerase IV
Prevents sup erco iling during replication
Unwinds the DNA double helix at the re plication fork
Transcribes viral RNA to host DNA
m
se
As
Produces viral RNA in host cells from DNA template
Dr
Inhibits t opoisomeras II (DNA gyrase) and topoisomerase IV CD
Prevent s supercoiling during replication (D
Unwinds the DNA double helix at the replication fork m

I Transcribes viral RNA to host DNA CD
m
se
CID
As
Produces viral RNA in host cells from DNA template
Dr
A 23-yea r-old female patient presents to the eme rgency d e partment with a 24- hou r-
history of gra dua l-onset globa l headache, feve r a nd photopho bia . On exam ination, there
is neck stiffness an d an a rea of non- blanching rash on the rig ht sh in. She ha d 3 e pisodes
o f menin gococca l men ingitis in the past. She was started on ceftriaxone for susp ected
mening itis. In the mean time, you sus pect that the patient may have an
im munodeficiency.
Which immunod eficiency is she like ly to have?
Cl q, Clrs, C2, C4 d eficiency
ClO deficien cy
CS d eficiency
Cl inh ibitor (Cl-INH) p rotein d eficiency
m
se
As
CS-9 d eficiency
Dr
Clq, Clrs, C2, C4 d eficie ncy
ClO deficien cy
CS d eficiency
Cl in hibitor (Cl-INH) p rotein d eficiency
CS-9 deficiency
CS-9 deficiency pred isposes to Neisseria meningitidis infections

CS-9 d eficiency pred isposes to Ne isseria mening itidis infectio ns.
Clq, Clrs, C2, C4 d eficie ncy (classic pathway com pone nts) p redi sposes to SLE.
CS d eficie ncy pre d isposes to Le ine r d isease (recu rrent d iarrhoea, wasting and se borrhoeic
d e rmatitis).
m
Cl inh ibito r (Cl-INH) p rote in d eficiency causes he reditary a ng ioed ema.
se
As
The re is no ClO com plement.
Dr
Which of t he following conditions is inherited in an autosomal dominant fash ion?
Familial Mediterranean Fever
Homocystinuria
Tuberous sclerosis
m
se
As
Friedreich's ataxia
Dr
Homocystinuria
~berous sclerosis
Ataxia te langiectasia
Friedreich's ataxia
Autosomal recessive condit ions are 'metabolic' - exceptions: inherited ataxias
m
Autosomal dominant condit ions are 'structura l' - exceptions: Gilbert's,
se
As
Dr
A 52-year-old has a fasting lipid profile checked as part of an an nual occupational health
check. Combined with his blood pressu re and current smoking status his 10-year risk of
ca rdiovascu lar disease is calcu lat ed to be 23% percent. Following appropriate counselling
he chooses to start atorvastatin 20mg. He is followed up 3 months later when a fu ll lipid
p rofile is repeated. What shou ld his t arget be?
A greater than 40% reduction in non-HDL cholesterol
Total cholesterol < 5 mmol/1
Ta rget cholesterol is inappropriate in t his situation
Total cholesterol < 4 mmol/1
m
se
As
Total cholesteroi:HDL ratio < 4
Dr
I A greater than 40% reduction in non -H DL cholesterol
Tot al cho lesterol < 5 mmol/1

-
~
p .rget t olesterol is i nappro priate in t his situation
Tot al cho lesterol < 4 mmol/1
Tot al cholesteroi:HDL ratio < 4

-
~
In the primary prevention of CVD using statins aim for a reduction in non -HD L
m
se
cholesterol of > 40%
As
Dr
Where is secretin secreted f rom?
I ce lls in upper small intestine
G cells in stomach
K cells in upper sma ll intestine
m
se
As
S cells in upp er sma ll intestine
Dr
G cells in stomach

-
~
m
se
Secretin - S cells in upper small intestine
As
Dr
A 43-yea r-old homeless lady has been refe rred to gastroenterology as the GP was
concerned of a possible malabso rption syndrome. She compla ins of weakness and
longstand ing d ia rrhoea. On examination you note en la rged an d bleeding gums. She takes
no medications.
Which of the following deficiency syndromes can lead to gum hypertrop hy?
Pellagra
Beri-Beri
Menkes Disease
Scurvy
m
se
As
Osteoma la cia
Dr
Pellag ra «ED
Beri-Beri CD.
Menkes Disease m
Scurvy GD
Osteomalacia m
Scurvy causes gum hypertrophy

The answer is scurvy - caused by vitamin C deficiency. Patients classically can present with
gingivitis, non -healing ulcers, mya lgia and even convulsions.
Other important causes of gingivitis include pregnancy, acute promyelocytic leukaemia

and drugs such as phenytoin, ciclosporin and nifedipine.
Pellagra is niacin (83) deficiency, classically causing dermatitis, diarrhoea and dementia.
Beri-Beri is caused by thiamine deficiency (Bl) and is further categorised into wet
(predomina ntly hig h output heart failure) and dry (predominantly neu ropathic). Menkes
m
se
Disease is a rare congenital disorder of copper metabolism leading to copper deficiency
and osteomalacia is vitami n D deficiency. As
Dr
A 1-month old ma le baby p resents to the paediatric eme rgency department with an
e p isod e of tonic-clonic seizure p receded by a 1-week history of poor feeding, wheezing
and g eneral failure to thrive. The baby was born at term with no complication. There is no
s ignificant past medical history. On exam ination, the baby has a small jaw and mouth, low
set ears and long face. Chest X-ray s hows opacification in the right lowe r zone . An
echoca rdiogram confirms a larg e ventricular septal d efect.
What other pathology is th is patient likely to have?
B lym phocyte deficiency
T and B lymphocyte deficiency
T lymphocyte deficiency
Granu locyte deficiency
m
se
As
Com p lement deficiency
Dr
B lymphocyte d eficiency
T and B lymphocyte d ef iciency
T lymphocyte def iciency
Granulo cyte deficiency

I
Complement d eficiency
-
~
DiGeorge syndro me - a T-cell diso rder

Important for me Less ·moc rte;nt
The baby's presentation suggests DiGeorge syndrome. The seizure episod e is likely
caused by hypocalcaemia from hypoparathyroidism. He also has syndrom ic feat ures of
DiGeorge syndro me and congenital heart disease. There is evidence o f infection which
indicat es t hat immuno def iciency is likely. T-lymphocyte d eficiency in DiGeorg e syndrome
m
is usually due to t hymic hypoplasia.
se
As
The ot her options are not co rrect as t hey are not consistent w ith DiGeorge syndrome.
Dr
A 27 -yea r-o ld fe male presents to her Genera l Practitioner with severe morn ing headaches
associated with nausea. She is referred fo r a n MRI head scan that revea ls a la rge tumou r
a rising fro m the fa lx cerebri a nd pushing on the brain. The re is a well -d efined borde r
between the tumou r and the bra in pa renchyma.
What is the most li kely diag nosis?
Glioblastoma
Metastas is
Low-gra de g lioma
Men ingioma
m
se
As
Cra niopha ryngio ma
Dr
Glioblastoma fD
Metastasis m
Low-grade glioma m.
I Meningioma
Craniopharyngioma
mt
(D
Meningiomas are typ ical ly benign tumours t hat develop from the dura mat er o f the
menmges
Meningiomas are typ ica lly benign tumours t hat arise from the cap cells of the dura mater
m
of t he meninges. They are extra-axial lesions, meaning they do not arise from the brain
se
parenchyma . They do not invade t he b rain substance, but rather cause symptoms by
As
compression.
Dr
In 2015 The New Eng land Journa l of Med icine re ported that that the sodi um-g lucose co-
transporter 2 inhibitor, em pagliflozin, resulted in a redu ct ion in ca rdiovascular d eaths,
non - fata l myocardia l infa rction a nd no n-fatal stroke when add ed to standa rd ca re in
patie nts with type 2 dia betes at hig h risk of cardiovascula r events. They expressed the
result per 1000 patient yea rs, with em pagliflozin having an event rate o f 37.3/ 1000 patient
years a nd p lacebo a n event rate o f 43.9/ 1000 patie nt yea rs. Using this info rmation,
a pproximate ly how ma ny patients at high risk of adverse ca rdiovascular outcome need to
be treated with empag liflozin to p revent one cardiovascula r death, non -fata l myocard ia l
infarction or non-fata l stro ke?
1000
150
200
50
m
se
As
100
Dr
1000 .
(D
I 150 €D
200 «D
50 GD
100 f!D
It is impo rta nt to be able to interp ret cli nical papers correctly so that information can be
expressed in a clin ically meaningful way. The num ber need ed to treat (NNT) is one such
metho d and is the inve rse of the absolute risk red uction:
NNT= 1/ Absolute risk red uction
The absolute risk redu ct ion is the change in the risk o f an outcome of a given treatm ent
in relation to the compa rison treatment. It is th e d ifference between the treatment event
rate and the contro l event rate.
The tricky p art of th is question is that the data is exp ressed per 1000 pati ent yea rs. When
a study outcome is based on time o f exposu re (patie nt-years), the NNT is calculated
based on cumulative event proportions. This requires some complex ca lculations which
you would neve r be exp ected to perfo rm in an exa m (you are n't a llowed calcu lato rs);
however, a q uick way to get a n estimate of the number needed to treat is by performing
the following calculation:
ARR=(Contro l event rate expressed per 1000 patient years) - (Expe rimenta l event rate
expressed per 1000 patient yea rs)
Fo r the a bove q uestion:
ARR=43.9-37.3
ARR= 6.6/1000 patient years
NNT=(Patient years)/ARR
NNT= 1000/ 6.6
em
NNT= 151.5 (which is closest to 150, the corre ct answer here)

s
As
Dr
A 56-year-o ld female presents with a breast lu mp in her right breast. Following further
investigations she has been diagnosed with breast cancer and genetic ana lysis shows a
mutation in the p53 gene. Targeted chemotherapy agents are developed towards p53.
Which phase in t he cycle is influenced by p53 and determines the cell cycle length?
GO
S1
G1
S2
m
se
Submit answer
As
Dr
GO GB
51 CD.
I G1
52
Gl
CD
M CD
G1 phase determines cell cycle length

Importa nt fo r me less important
G1 determines the length of t he cell cycle. p53 is an important protein involved in DNA
repair and init iation of apoptosis to name a few. Thus if this important protein is mutated
the likelihood of cancer is increased.
[ .. I at tt Discuss Improve ]
Next question )
Cell cycle
The cell cycle is regulated by proteins called cyclins which in turn control cycl in-
dependent kinase (CDK) enzymes.
Phase Notes Regulatory proteins
Go • 'resting' phase
• quiescent cells such as
hepatocytes and more
permanently resting cells such
as neurons
• Gap 1, cells increase in size Cyclin D I CDK4, Cyclin D I CDK6

• determ ines length of cell cycle and Cyclin E I CDK2: regulates
• under influence of p53 transition from G1 to S phase
5 • Synthesis of DNA, RNA and Cyclin A I CDK2: active in S phase

histone
• centrosome duplication
• Gap 2, cells continue to Cyclin B I CDK1: regulates t ransit ion

. . .
mcrease 1n s1ze from G2 to M phase
M • M itosis -cell d ivision

em
• the shortest phase of the cell

s
As
cycle
Dr
A 22-year-o ld female patient presents with a 48 hour history of headache, fever and
photophobia. She has a 3-year o ld child who has had a recent diarrheal illness. Serum
blood g lucose was 4 mmoi/L.
A lumbar puncture reveals the following:
Fluid Clear & colourless
White cell count 16 cel ls/~ L ( 100% lymphocytes)
Protein 0.8 g/L
Glucose 3mmoi/L
What is the most appropriate treatment option?
Ceftriaxone
Chloramphenicol
No treatment indicated
Immunoglobulins
Ganciclovir
m
se
As
Submit answer
Dr
Ceftriaxone CD
Chloramphenicol CD
I No treatment indicated GD
Immu nog lobulins
Ganciclovir GD
•
Antivirals are of no benefit in t he treatment of confirmed viral meningitis
Importa nt for me Less important
Viral meningitis does not require any treatment and is usually a self-lim iting infection. This
should be differentiated from viral encephalit is, wh ich has a different presentation and
does need treat ment. Care should be taken with the clinical history as t he same organism
can cause both presentations e.g HSV.
The history here is suggestive of a mening itis picture, t his combined wit h the CSF results
suggests a viral meningitis.
Most cases of viral mening itis are caused by enterovirus. There are no current t reatments
of proven benefit that should be used in vira l meningitis.
Ganciclovir is not accepted first line treatment for either meningitis or encephalit is.
Refer to T he UK joint specialist societies guideline on the diagnosis and management of

acute meningitis and meningococcal sepsis in immunocompetent adu lts'. (2016)
[ .. I a' tt Discuss Improve ]
Enteroviruses
Enteroviruses are positive-sense single stranded RNA viruses. The family contains the
Coxsackievirus, echovirus and rhinovirus as well as others. It is the most common cause of
viral men ingit is in the adult population but can cause a range of different diseases, in
both adults and children. Although the range of d iseases caused by these viruses is broad,
em
notable disease entities include Hand, Foot and Mouth disease, herpangina and
s
As
pericarditis.
Dr
A 67 -year-old man who is a retired builder presents following the development of a
number of red, scaly lesions on his leh temple. These were initially small and flat but are
now erythematous and rough to t ouch. What is the most likely diagnosis?
Pityriasis versicolor
Seborrhoeic keratosis
Polymorphous light eruption
Actinic keratoses
m
se
As
Malignant melanoma
Dr
Pityriasis versicolo r
-
-
. .wl'
Polymorphous light eruption
Actinic keratoses
-
"""'
. .wl'
m
se
As
Malignant melanoma . .wl'
Dr
A 15-yea r-old male retu rns to the d ermatology clin ic for review. He has a past history of
acne and is cu rrently treated with ora llymecycline. The re has b een no resp onse to
treatment and exam ination revea ls evid ence of scarring on his face. What is the most
su itab le treatment?
Oral d oxycycline
Oral cyprotero ne a cetate
Oral isotretinoin
IV retinoin
m
se
As
Topical retinoids
Dr
A 15-year-old male ret u rns to the d ermat ology cl inic for review. He has a past hist ory of
acne and is current ly t reated w it h orallymecycli ne. There has b een no resp onse to
treatment and examination reveals evid ence of sca rring on his face. What is t he most
suitab le t reatment?
Oral d oxycycline
Oral cyproterone acet at e
Oral isotretinoin
IV retinoin
-
~
m
se
As
Topica l retinoids
Dr
A 55-year-old female is referred to dermatology due to a lesions over both shins. On
examination symmetrica l erythematous lesions are found with an orange peel textu re.
Pretibial myxoedema
Pyoderma gangrenosum
Necrobiosis lipoidica diabeticorum
Erythema nodosum
m
se
As
Syphilis
Dr
I Pretibial myxoedema CiD
Pyoderma gangrenosu m CD
Necrobiosis lipoidica diabeticorum CD
Erythema nodosu m GD
m
se
m
As
Syphilis
Dr
A 23-year-old man with very severe Crohn's disease has been put on comp lete bowel rest
for an indefinite period of time whilst he continues his inpatient recovery. He has been
receiving t otal parent eral nutrition for the past few weeks. Recently he has noticed his
skin becoming dry and scaly with mouth ulcers and lip swelling.
What is the likely cause of these changes?
Selenium deficiency
Iron deficiency
Zinc deficiency
m
se
As
Folate deficiency
Dr
Selenium d eficie ncy
Iro n d eficie ncy
~c defici ency
Folate d eficiency
-
~
Zinc d eficiency caused by total parentera l nutrition (TPN) can resu lt in

a crodermatitis herpetiformis
Various s ma ll bowe l diseases that ca use destruction o r ma lfunction of the gut mucosa
a nd malabso rption lea d to zinc d eficiency. Th is has sim ilarly been noticed in patie nts o n
total parentera l nutritio n (TPN) who d o not rece ive zinc- resulting in acrodermatitis
he rpetifo rm is causing peri-orificia l d e rma titis a nd a lop ecia.
Selenium deficie ncy ca n co ntribute to fatigue, ha ir loss, weig ht ga in, joint and muscle
pa in.
Iro n d eficiency ca n contribute to fatigue, weakness, pale skin, chest pa in, shortness o f
b reath, heada che, dizziness and cold peripheries.
Vita min 812 deficie ncy ca n cause a smooth tongue, nerve pro b le ms like numbness o r
ting li ng, pa le skin and weakness.
em
Fo late deficie ncy ca n cause a la ck of energy, pale skin, pa lpitations, head aches and loss of
s
As
a ppetite.
Dr
A 43-yea r-old man comes for review. A few months ago he develo ped redness around his
nose and cheeks. This is worse after d rinki ng alco hol. He is concerned as one of his work
colleagues asked him if he had a drink p roblem despite him drinking 14 un its per week.
On exam ination he has erythema as described above with some pustu les on the nose and
telangiectasia on the cheeks. What is the most like ly dia gnosis?
Mitral stenosis
Seborrhoeic dermatitis
Alcoho l-related skin changes
Acne rosacea
m
se
As
Systemic lupus erythematosus
Dr
Mitral stenosis
Alcoho l-related skin changes

-~
Acne rosacea
~temic lupus erythematosus

-
.....,
m
se
As
This is a typical history of acne rosacea
Dr
A 35-year-old female p resent s tender, erythematous nodules over her forearms. Blood
t ests reveal:
Calcium 2.78 mmolfl
Granuloma annulare
Erythem a nodosum
Lupus pernio
Erythem a multiforme
m
se
As
Necrobi osis lipoidica
Dr
Granuloma annu lare CD
Erythema nodosum GD
Lupus pernio CD
Erythema multiforme .
(D
Necrobiosis lipoidica CD
m
se
As
The likely underlying diagnosis is sarcoidosis
Dr
A 29-year-old man consults you regarding a rash he has noticed around his groin. It has
been present for the past 3 months and is asymptomatic. On examination, a symmetrica l
rash around the groin is noted cons isting of well-defined pink/brow n patches with fine
scaling and superficial fissures.
Erythrasma
Pityriasis versicolor
Secondary syphilis
Acanthosis n ig ricans
m
se
As
Candida intertrigo
Dr
I
Erythrasma CD
Pityriasis versicolor fD
Secondary syphilis m
Acanthosis n ig rica ns GD
m
-
se
As
Candida intertrigo
Dr
A 78 year-old woman presents with a poorly healing area of skin on her ankle. She has a
history of d eep vein thromb osis 20 years ago following a hip replacement. She currently
t akes Adcal D3, and no other medications. On examination there is a shallow ulcer
anterior to the medial malleolus. She is otherwise very well.
What investigation wou ld b e most useful in d et ermining f urther management?
Serum calcium
Ankle-brachial pressure index
CT venogram
C-reactive protein
m
se
As
Lower limb d opp ler
Dr
Serum calcium
Ankle-brachial pressu re index
CT venogram
C-reactive protein
Lower li mb Clopp ler
This patient has the classic appearances of a venous ulcer. She is syste mically well with no
evid ence to suggest infection. The most appropriate management of venous ulcers is with
m
se
compression d ressings, however it is important to make sure the patient's a rterial supply
As
is good enough to a llow some compression.
Dr
Which of the following conditions is most associated with onycho lysis?
Bullous pemphigoid
Raynaud's disease
Oesophageal cancer
m
se
As
Scab ies
Dr
Bullous pemphigoid
p .ynaud's disease
-
~
Oesophageal cancer
Scabies
m
se
As
Raynaud's disease causes onycholysis, as can any cause of impa ired circulation
Dr
A 54-year-old man with significant psoriasis and related arthritis comes to the
rheumat ology cl inic for review. despite both NSAIDs and corticosteroids, his symptoms
continue t o worsen . On examination you can see both extensive plaque psoriasis, and
deforming polyarthropathy leading to significant loss of function affecting both hands.
Investigations
Hb 123 g/ 1 Na• 140 mmol/ 1
Platelet s 32 1 * 109/1 K• 4 .2 mmolfl

8
WBC 10.1 109/1 Urea 6 .7 mmol/1
Neuts 6 . 1 * 109/ 1 Creatinine 105 ~mol/1
Lymphs 1.9 * 109/ 1 CRP 104 mg/1
Eosin # * 109/1 ESR 70 mm/hr
Which of the following is the most appropriate next st ep?
Azathioprine
Brodalumab
Et anercept
Rituximab
m
se
As
Toclizumab
Dr
Azathio prine f1'D.
Broda luma b CD
Etanerce pt CD
Rituximab f!D.
Toclizumab fD
In this situatio n with uncontro ll ed pso riasis a nd pso riatic a rthritis, ea rly instigation of a
bio lo gica l is recom mend ed. TN F a lpha is a pro- infla mmatory cytokine closely linked to
the seve rity of psoriasis, and eta nercept, a TNF alp ha antag o nist is the most ap propriate
inte rve ntio n. Tubercu losis a nd vira l hepatitis shou ld be ruled out prior to starting thera py.
Althou gh azathio prine d oes impact o n d isease severity in pso riasis, in this situation it's
more im portant to g a in disease contro l early, and therefo re eta nercept is the prefe rred
inte rve ntio n. Brodaluma b is a n anti -Ill? mono clo na l antibody which has completed
m
registration trials for psoriasis. It's like ly to be reserved however fo r patie nts who fa il to
se
g a in control on other interventions. Rituximab is an anti-CD20 antibody more commonly
As
used in the treatme nt of rheumatoid arthritis, as is tocl izumab which ta rgets IL6.
Dr
A 54-yea r-old lady attend s with a rash. She describes a facial rash p resent for seve ra l
weeks associated with flushing . On exam inatio n, the re is erythematous pa pulopustular
rash with telang iectasia across both cheeks and nose. Given the likely d iagnosis, which
associated com plication may she also have?
Blepharitis
Parotitis
Vu lvovaginitis
Pancreatitis
m
se
As
Pericarditis
Dr
Ble pharitis (D
Parotitis .
(D
Vulvovaginitis fD
Pancreatitis .
(D
Pericarditis CD
Acne ro sacea
• chronic skin condition which causes pers istent fa cia l flush ing, erythema,
te lang iectasia, pustules, pap ules and rhinop hyma
• It can a lso affect the eyes causing b le pha ritis, keratitis, conjunctivitis
• It is treated with top ical antibiotics e .g . metronidazole gel o r o ra l tetracycline
m
se
(especially if ocu lar symptoms).
As
Dr
A 45-yea r-old man with a history of sebo rrhoeic dermatitis p resents in late winter due a
fla re in his sym ptoms, affecting both his face and scalp. Which one of the following
agents is least likely to be beneficial?
Topical ketoconazole
Selenium sulph ide sha mpoo
Topica l hydrocortisone
Ta r sha mpoo
m
se
As
Aqueous cream
Dr
Topical ketoconazole CD
Selenium sulphide shampoo m.
Topical hydrocortisone flD
Ta r shampoo .
GD
I Aqueous cream CD
m
se
As
There is less of a ro le fo r emollient s in the management of seborrhoeic dermatitis than in
other ch ron ic skin disorders
Dr
A 59-year-old patient presents to dermatology outpatients cli nic with a three- month
histo ry of discolouration of the skin on his back. On examination, there are patchy areas
of mild hypo pigmenta tion covering large areas of the back. You suspect a diagn osis of
p ityriasis versicolor. What is the li kely causative organism?
Epidermophyton
Histoplasma capsulatum
Micosporum
Trichophyton
m
se
As
Malassezia
Dr
Epidermophyton m
Micosporum
•
CD
Trichophyton GD
I Malassezia GD
Pityriasis versicolo r is caused by Malassezia furfur

Pityriasis ve rsicolou r is caused by infection with Malassezia fungus. Initial treatment is with
topical anti-fu ngals such as ketoconazole shampoo.
Microsporum, Trichophyton and Epidermophyton are dermatophytes and cause fun gal nail
m
se
infecti ons and ringworm. Histoplasma is a fungi that can cause pneumo nia in immune -
As
compromised patients.
Dr
A 62-yea r-old woman mentions in d iabetes cl inic that she has a 'volcano' li ke spot on he r
left cheek, wh ich has app eared over the past 3 months. She initially thought it may b e a
simp le spot but it has not gone away. On exam ination she has a 5 mm re d, raised lesion
with a centra l keratin filled crate r. A cl inical d ia gnos is of p robab le keratoacantho ma is
ma de . What is the most suitable mana gement?
Reassure will spontaneously involute within 3 months
Urgent referra l to dermatology
Topica i S-FU
Non-u rgent referral to d e rmatology
m
se
As
Ora l predn isolone
Dr
Reassure will sp ontaneously invo lute within 3 months
~ent referral to dermatology

Topica l 5-FU
Non-u rg ent referral to d e rmatology
Ora l p redn isolo ne
m
se
As
Whilst keratoacanthoma is a benign lesion it is d ifficult clinically to exclud e squamous cell
ca rcinoma so urgent excision is advised
Dr
A 36-year-old wo man is reviewed. She p resented 4 weeks ago w ith itchy dry skin on her
arms and was diagnosed as having atopic eczema. She was prescribed hydrocortisone 1%
cream with an emollient. Unfortunat ely t here has b een no improvement in her symptoms.
What is the next st ep in management, alongside cont inued regular use of an emollient?
Betamethasone valerate 0.1%
Clobet asone butyrate 0.05%
Clobet aso l propionate 0.05%
Topical tetracycline
m
se
As
Regular wet w raps
Dr
Betamethasone va lerate 0.1% ED
I Clobetasone butyrate 0.05% CD

Clobetasol propionate 0.05% f!!D
Topica l tetracycline m
Regu la r wet wraps m
Topica l ste ro ids
• moderate: Clobetasone butyrate 0.05%
• potent: Betamethasone valerate 0.1%
• very potent: Clobetasol propionate 0.05%
Clobetaso ne butyrate 0.05% is a moderately potent top ica l stero id and would be the most
su itable next step in manage ment. It is important to note the potency d ifference between
m
se
two very simila r sound ing stero id s - Clobetasone butyrate 0.05% (moderate) and
As
Clobetasol propionate 0.05% (very potent)
Dr
Yo u are working in dermato lo gy. A 72-yea r-old lady has b een refe rred to you by the GP.
She says she can feel a firm patch o f ro ughened skin ove rlying the left cheek which has
been getting gra dua lly la rger in size. She thinks it has been there fo r at least a year. Her
GP was not a ble to see any external featu res of ulceration, b ut felt there was a ro ugh a rea
o ve r the left cheek. On examinatio n there is a firm waxy a rea a bout 3 x 3 em in size
o ve rlying the left cheek with ill-defined ed ges. How wo uld you manage this lesion?
Mohs s urgery
Radiotherapy
Excis ion biopsy
Reassure the patient a nd discharge her back to the GP
m
se
As
Monitor in clinic eve ry s ix months
Dr
I Mohs surgery
Radioth erapy
Excision biopsy
Reassure the patient and discharg e her back to the GP
Monitor in clinic every six months
The diagnosis is a morphoeic basa l cell carcinoma. These are a type of BCC which present
wit h firm/ rough/waxy patches often on the chee ks. They o ften have poorly d efined edges.
Whilst radiotherapy can be used t o manage so me basal or squamous cell carcinomas,
Mohs su rgery is the gold standard for treating these lesions.
As t his lesion is a basal cell carcino ma it should be removed. Therefore answers 4 and 5
are wrong. An excision b iopsy is not necessary as it is a clinical diagnosis. Mohs su rgery
m
se
will also confirm t his diagnosis as well as treat the lesion by removing it f ully until clear
As
margins are p resent.
Dr
A 64-yea r-old woma n presents with severe mucosal ulceration associated with the
d evelopment of b listering lesions ove r her torso a nd a rms. On exam ination the blisters
are flaccid and easily ru ptu red when touched . What is the most like ly diag nosis?
Pemp higu s vulgaris
Pemp higoid
Dermatitis herpeti formis
Psorias is
m
se
As
Ep idermolysis b ullosa
Dr
I Pemphigus vu lgaris CD
Pemphigoid CD
Dermatit is herpeti formis CD
Psoriasis m
Epidermolysis bullosa (D
Blisters/ bullae
• no mucosal involve ment: bullous pemphigoid
m
• mucosal involvement: pemphigus vulgaris
se
As
Dr
A 43-yea r-old woman is referred to psychiatry following repeated episodes of
hypoman iac behaviour interspersed with period s of depress ion. Her past medical history
includes psoriasis and a deep vein thrombosis 11 yea rs ago. Which one o f the following
med ications is most like ly to worsen he r psoriasis?
Sodium valproate
Quetiapine
Lith ium
Valproa ic acid
m
se
As
Fluoxetine
Dr
Sodium valproate CD
Quetiapine .
(D
Lithium (D
Valp oa ic acid fD
Fluoxetine CD
m
se
As
Psoriasis: lithium may trigger an exacerbation
Dr
A 24 -yea r-old stu dent p resents d ue to some lesions on his lower a bdomen. These have
been p resent fo r the past s ix weeks. Initia lly, there was o ne lesion but since that time
more lesions have a ppeared. On exa minatio n around 10 lesions a re seen; they a re ra ised,
a rou nd 1-2mm in diameter and have an u mbilicated a ppea rance. What is the most likely
diagnosis?
Genital warts
Lichen planus
Keratosis pilaris
Mo lluscum contag iosum
m
se
As
Foll iculitis
Dr
Genital warts
Lichen planus
Keratosis pilaris
Molluscum contagiosum
-
.......,
Folliculitis
m
se
As
This is a classical description of molluscum contag iosum, although it is most commonly
seen in ch ildren.
Dr
A 62-year-old female is referred to dermatology due to a lesion over her shin. It initially
started as a small red papule which lat er became a deep, red, necrotic ulcer with a
violaceous border. What is the likely diagnosis?
Syphilis
Erythem a nodosum
Pretibial myxoedema
m
se
As
Dr
Syphilis
Erythema nodosum
Pr~tibial myxoedema
-
~
m
se
As
This is a classic description of pyoderma gangrenosum
Dr
A 78-year-old man is admitt ed from a nursing home wit h multi-infarct d ement ia, chronic
o bst ructive pulmonary disease and b ivent ricu lar failure. You are as ked t o assess his risk o f
pressure sores and need for referral to t he t issue viab ility t eam during his inp atient stay.
Which o f t he follow ing is most useful in det ermining t he risk of p ressure so res?
Glasg ow criteria
Rankin scale
Ransom crit eria
Waterlow sca le
m
se
As
Townsend sca le
Dr
Glasgow criteria
Rankin scale
•
CD
Ransom criteria CD
Waterlow scale .
GD
Townsend scale CD
The Waterlow scale was develo ped in 1985 to assess the risk of pressure sore
develop ment, helping to drive level of nursing intervention and use of special mattresses
to reduce risk. Potential scores range from 1-64. A score greater than 10 indicates an
increased risk of pressu re sore development, with scores > 15 indicating high risk and > 20
indicating very high risk. A num ber of factors are taken into account when assessing
patients using the scale including body habitus, co ntinence status, malnutrition, mobil ity,
neurological status a nd presence of major trau ma.
The Glasgow and Ransom crite ria were d rawn up to stratify risk in patients presenting
with acute pa ncreatitis, with respect to identifying those at increased risk of mortality, and
those who need to be trea ted in a hig h dependency a rea.
m
se
The Ra nkin scale relates to the degree of d isabil ity in patients post stro ke, and the
Townsend sca le is an in dicator of deprivation. As
Dr
A 25-yea r-o ld ma le presents with extensive patches of a lte red pig mentatio n o n his front,
back, fa ce and thig hs. There is mild p ruritus. A d iagnosis of exte nsive pityrias is ve rsico lo r
is ma de. What is the most appropriate ma nag e me nt?
Ora l metronid azo le
To pical terbinafine
To pica l ketoco nazole 2% sham poo
To pica l selenium sulphide
m
se
As
Ora l te rb inafine
Dr
Oral metronidazole
Topica l terbinafine
-
~
r Topical ketoconazo le 2% shampoo
Topica l selenium sulp hide
Oral terbinafine
Ketoconazole s ham poo is used to treat pityriasis ve rs icolo r

m
se
Topica l ketoconazo le 2% shampoo shou ld be tried first -line. If there is a failure to respond
As
then systemic the rapy may be indicated in this case
Dr
A 50-yea r-old man p resents with shiny, flat-topped papu les on the palmar aspect o f the
wrists. He is main ly bothered by the troublesome and persistent itching. A diagnosis o f
lichen planus is sus pected. What is the most appropriate treatment?
Refer for punch biopsy
Emollients + o ral antihistam ine
Topical dapsone
Topical clotrimazole
m
se
As
Topical clobetasone butyrate
Dr
Refer for punc h biopsy CD
Emollients + oral antihistamine GD
Topical dapsone GD
Topical clotrimazole CD
m
se
As
Topical clobetasone butyrate ED
Dr
A 65 -yea r-o ld woman with blistering lesions on her leg is diag nosed as having bullous
pe m phigo id. What is the most a pp ro priate in itia l manag ement?
Reassu rance
Topical corticostero ids
Ora l itraconazole
Screen fo r solid -tumou r malignancies
m
se
As
Ora l corticostero id s
Dr
Reassurance CD
Topical corticosteroids tiD
Ort raconazo le a
Screen for solid-tumour malignancies .
(D
m
se
I
As
Oral corticosteroids
I
ED
Dr
Each of the following drugs may b e used in pso riasis, except:
Interferon alpha
Infliximab
Retinoids
Methotrexate
m
se
As
Ciclosporin
Dr
I Interferon alpha CD
Infliximab (tiD
Retinoids fD
Methotrexate fD
m
se
Ciclosporin (tiD
As
Dr
A 25-yea r-o ld man presents with a widespread rash over his b ody. The to rso a nd limbs
a re covered with mu ltiple e rythematous lesions less than 1 em in d iamete r which in parts
a re covered by a fine scale. You note that two weeks ea rlier he was seen with a so re
throat when it was noted that he had exudative tonsill itis. Other than a history of asthma
he is norma lly fit and well. What is the most li ke ly diagnosis?
Pityriasis rosea
Syphilis
Disco id eczema
m
se
As
Guttate psoriasis
Dr
Pityriasis rosea (D
Pityriasis versicolor .
(D
Syphilis CD
Discoid eczema .
(D
m
se
Guttate psoriasis GD
As
Dr
Which one o f the following factors wou ld predispose a patient to form ing keloid scars?
Having white skin
Incisions along relaxed skin t ension lines
Being aged 20-40 yea rs
Being female
m
se
As
Having a wound on the lower back
Dr
Having white skin
Incisions along rel axed skin tension lines
Being aged 20 -40 years
Being female
Having a wound on the lower back
m
se
As
Keloid scars - more com mon in young, black, male adu lt s
Dr
A 35-year-old man p resents with an itchy, sca ly rash that has gradually developed over
the past few months. He is normally fit and well and the only past medica l history of note
is genera lised anxiety disorder. On examination he has a number of ill-defined, pink
colou red patches with a yellow/brown scale.The main affected areas a re the sternum,
eyebrows and the nasal bridge. What is the most likely diagnosis?
Acne rosacea
Atopic dermatitis
Pityriasis rosea
m
se
As
Psoriasis
Dr
Acne rosacea
Atopic dermatitis
Sebo rrhoeic de rmatitis
Pityriasis rosea
Psorias is
-
~
An itchy rash affecting the face and sca lp d istribution is commonly caused by
seborrhoeic dermatitis
The d istribution is very typical for seborrhoeic d ermatitis. Atopic dermatitis p resents mo re
commo nly in the flexura l a reas and does not have the same cha racte ristic scale.
Pityriasis rosea typica lly presents with a hera ld patch (usually on trunk) fo llowed by
m
erythematous, oval, scaly patches which follow a characteristic d istribution with the
se
long itudinal diameters o f the oval les ions ru nning pa ra lle l to the line o f Langer. This may
As
p roduce a 'fir-tree' app earance.
Dr
A 24-year-old female with a history of anorexia nervosa presents with red crusted lesions
around the corner of her mouth and below her lower lip. What is she most likely to be
deficient in?
Zinc
Tocopherol
Pantothenic aci d
Thiamine
m
se
As
Magnesium
Dr
I Zinc CD
Tocopherol CD
I Pantot henic aci d CD

Thiamine tiD.
Magnesium CD
m
se
As
Vita min 82 (riboflavin) deficiency may also cause angu lar cheilosis.
Dr
A 36-year-old female with a history of ulcerative colitis is diagnosed as having pyoderma
gangrenosum. She presented 4 days ago w ith a 1 em lesion on her right shin w hich
rapidly ulcerated and is now painful. What is the most appropriate management?
Topical hydrocortisone
Oral prednisolone
Surgica l debridement
Topical tacro limus
m
se
As
Infliximab
Dr
Topical hydrocortisone CD
Oral prednisolone ED
Surgical debridement CD
Topical t acrolimus CD
Infliximab .
(D
Topical therapy does have a role in pyoderma gangrenosum and it may seem intu itive to
m
try this first before moving on to syst emic treatment. However, pyoderma gangrenosum
se
has the potential to evolve rapidly and for this reason oral prednisolone is usually given as
As
initial treatment. For a review see BMJ 2006;333:181-184
Dr
A 72-year-old man is invest igated for oral ulceration. A biopsy suggests pemphigus
vu lgaris. Th is is most likely to be caused by antibodies directed against
Hemidesmosomal BP180
Occludin-2
Desmoglein
m
se
As
Adherens
Dr
Occludin-2
Hemidesmoso al BP230
Desmoglein
-
~
m
se
As
Adherens
Dr
A 35-year-old man presents with anaemia. On further questioning, you find that he has a
lifelong hist ory of recurrent, severe nosebleeds and characteristic erythematous spot s
around his lips, which blanch when pressed. What is the most likely diagnosis?
von Hippei-Lindau
Peutz-Jeghers syndrome
Neurofibromatosis type 1
Heredit ary haemorrhagic tel angiectasia
m
se
As
Granulomat osis with polyangiitis
Dr
I von Hippei- Lindau
Peutz-Jeghers synd rome
Heredita ry haemorrhagic telang iectas ia
Granu lomatosis with polyang iitis
The key is in the recognition of the telang iectas ias, which a re o h e n found on the skin o f
the lips, nose and fingers. With this and the epistaxis, two of the three crite ria to diag nose
Heredita ry Haemorrhagic Telang iectasia (H HT) a re met. Anaem ia is a co mmon complai nt
in those with HHT. It is d ue to epistaxis o r otherwise asymptomatic GI tract b leedin g.
Another finding could be hypoxia due to pulm onary a rte riovenous malformatio ns. The
exact features vary, d epending on where the arte riovenous malformations a re located.
Von Hippei- Lin dau disease is caused by a faulty tumour suppresso r gene resu lting in the
d evelop me nt of mu ltiple unusual tumou rs includi ng haema ngio blastoma,
phaeochromocytoma o r renal cell carcinoma. At least two tumou rs must be present to
make the diag nosis in someone without a fa mily history (compa red to just one when a
fam ily histo ry is present).
Peutz Jeg hers syndrome is a d iso rder causing larg e numbers of po lyps in the intestine
which become cancerous in a majority of patie nts. They have pigmented lesions a rou nd
the lips which a re not telang iectasia. There is no history of ep istaxis .
Neurofibromatosis Type 1 is benign tumou r d isorder. Despite the non -mal ig nant natu re
of the tumou rs, they can have severe co nseque nces dependi ng on the location. Optic
gliomas can lea d to blind ness, neu rofibromas (found in the peripheral nervous system)
can lead to learning disabilities and epilepsy. Othe r characteristic findi ngs include caf-au -
la it spots (flat, hyperp igmented, brown cutaneous les io ns), axillary freckling, Lisch nodules
(on the iris) and derma l neuro fib romas (small, rubbery, cutaneous lumps).
Gra nulomatos is with po lyangi itis is a s ma ll- and medium-vessel vascu litis which p rimarily
a ffects the s inuses, kid neys and lungs. Sinus dysfunctio n is the most common initia l
em
s
symptom causing nasa l congestion o r epistaxis. If a rash is present, it is usua lly made up
As
of palpable purpura from small vessel infla mmation.

Dr
A 41-year-old man d evelops itchy, po lygonal, violaceous papules on the f lexor aspect o f
his forearms. Some o f t hese papules have coalesced to form plaques. What is t he most
likely diagnosis?
Lichen planus
Scabies
Lichen sclerosus
Morp hea
m
se
As
Psoriasis
Dr
Lichen planus CD
Scabies m
Lichen sclerosus GD
Morp hea
Psoria sis
•
flD
Lichen
• planus: purp le, p ruritic, pap ular, polygonal rash on flexor su rfaces. Wickham 's
striae over surface. Oral involvement com mon
• sclerosus: itchy white spot s typica lly seen on t he vulva of elderly wo men
m
se
As
Dr
A 74 -yea r-old woman d evelops tense, itchy b listers o n her inner th ig hs and upper a rms.
Given the likely diag nosis, what will immunofluorescence of the skin b iopsy demonstrate?
Loss o f fibrino gen a t the basement membra ne
Granular Ig G along the basement membrane
Ig M crystallization at the d e rma l juncti ons
Linear IgA deposits at the dermoepiderma l junction
m
se
As
IgG and C3 at the dermoep idermal junction
Dr
Loss of fibrinogen at the basement membrane
Granu la r IgG along the basement membrane

-
~
Ig M crysta llization at the dermal junctions
Linear IgA depos its at the dermoepidermal junction
m
I
se
As
IgG and C3 at the dermoepidermal junction
Dr
A 72-yea r-old woman is diagnosed with a num be r of erythematous, rough lesions on the
back of her hands. A diagnosis of actinic ke ratoses is ma de. What is the most app ropriate
management?
Reassu rance
Urgent referral to a d e rmatolog ist
Topica l fluorouracil cream
Review in 3 months
m
se
As
Topical betnovate
Dr
Reassura nce
Urgent referral t o a d ermat olo gist
Topical f luorou racil cream
Revir in 3 months
-
~
m
se
Topica l betnovate
As
Dr
A 26-year-old male presents with a rash. Exam ination reveals erythematous ova l lesions
on his back and uppe r arms wh ich have a slight scale just in side the edge. They vary in
size from 1 to 5 em in diameter. What is the most like ly d iagnosis?
Lichen planus
Guttate psoriasis
Lichen sclerosus
Pityriasis rosea
m
se
As
Dr
Lichen planus fi!D
Guttate psoriasis CD
Lich~ n sclerosus fD
Pityriasis rosea eD
Pityriasis versicolo r GD
m
se
The skin lesions seen in pityriasis rosea are generally larger than those fou nd in guttate
As
psoriasis and scaling is typically confined to just inside the edges
Dr
A 43-yea r-old p resents with itchy lesions on the soles o f both feet. These have been
p resent fo r the past two months. On examination small b listers are seen with surrounding
dry and cracked skin. What is the most likely d iagnosis?
Pustular psoriasis
Pompholyx
Bullous pemphigoid
m
se
As
Pemph igus
Dr
Porphyria cutanea tarda flD
Pustular psoriasis (fD
Pompholyx aD
Bullous pemphigoid CD
m
.
se
Pemphigus (D
As
Dr
A 25 -yea r-o ld man presents with bloating and a lte ration in his b owe l hab it. He has been
keeping a food diary a nd feels his sympto ms may be seconda ry to a food a ll ergy. Blood
tests show a norma l full b lood count, ESR and thyro id fu nctio n tests. Anti- endomys ia!
a ntibodies a re neg ative . What is the most suitable test to investigate p ossible food
a ll erg y?
Total lgE levels
Ha ir a na lysis
Skin patch testing
Skin prick test
m
se
As
Jeju nal biopsy
Dr
TotallgE levels (D
r~air ana lysis fD

Skin patch testing fD
~n prick test CD
Jejunal b iopsy (D
m
Skin prick testing wou ld be first- li ne here as it is inexpens ive and a large number of
se
allergens can be investigated. Wh ilst there is a role fo r lg E testing in food allergy it is in
As
the form of specific lgE antibodies rather than tota l lg E levels.
Dr
A 54-yea r-old woman is prescribed topica l fusidic acid fo r a small patch of impetigo
around her nose. She has recently been discha rged from hospital fo llowing varicose vein
surgery. Seven days after starting treatment the re has been no change in her symptoms.
Examination revea ls a persistent small, crusted a rea a round the right nostril. Whilst
awa iting the resu lts of swabs, what is the most appropriate management?
Ora l vancomycin
Ora l erythromycin
Topica l metronidazo le
Topica l mupirocin
m
se
As
Ora l flu cloxacillin
Dr
Oral vancomycin m
Oral erythromycin CD
Topical metronidazole CD
Topica l mupirocin CfD
Oral flucloxacillin ED
m
se
MRSA should be considered given the recent hospita l stay and lack of response to fusidic
As
acid. Topical mupirocin is therefore the most appropriate treatment.
Dr
A 39-year-old female has a pigmented mole removed fro m her leg which histology shows
to be a malignant melanoma. What is the single most important prognostic marker?
Number of episodes of sunburn before the age of 18 years
Age of patient
Diameter of melanoma
Depth of melanoma
m
se
As
Mutation in th e MClR gene
Dr
A 39-year-old fema le has a pigmented mole removed from her leg which histology shows
to be a malignant melanoma. What is the single most important prognostic marker?
Number of episodes of sunburn before the age of 18 years
Age of patient
Diameter of melanoma
Depth of melanoma
Mutatio n in the MClR gene

-
........
Melanoma: the invasion depth of the tumou r is the single most importa nt
m
se
prognostic facto r
As
Dr
Which one of the following conditions is least likely to be associated with pyoderma
gangrenosum?
Ulcerative colitis
Syphilis
Lym phoma
IgA monoclonal gammopathy
m
se
As
Dr
Ulcerative colitis
Syphilis
Lymp1Lo_m_a__
IgA monoclonal gam mopathy
m
se
As
Syphi lis is not commonly associated with pyoderma gangrenosum
Dr
A 33-year-old male patient with a history of recurrent nose bleeds, iron-deficiency
anaemia and dyspnoea is fou nd to have a pulmo na ry AV malfo rmation on pulmonary
angiogra phy. What is the likely underlying diagnosis?
Haemophilia A
Hereditary haemorrhagic telang iectasia
m
se
As
Down's syndrome
Dr
Haemophilia A
•
I Hereditary haemorrhagic telang iectasia CD
•
«D
m
se
•
As
Down's syndrome
Dr
A patient who is suspect ed of having dermatitis herpetifo rm is undergoes a skin biopsy.
Which one o f the following antibodies is most likely to be found in the dermis?
Ig M
IgA
IgD
Ig E
m
se
As
IgG
Dr
IgM .
(D
IgA GD
Ig D CD
IgE CD
IgG GD
m
se
Dermatitis herpetiformis - caused by IgA deposition in the dermis
As
Dr
An elderly, f ra il woman is admitted to the ward follow ing a fall at home. What is the most
appropriate way to assess her risk o f developing a pressure sore?
PSST-6 score
PAST score
MUST score
Waterlow score
m
se
As
Honeywell score
Dr
PSST -6 score .
(D
IPA~T score m
MUST score .
(D
Waterlow score f.D

Honeywell sco re CD
m
se
Waterlow score - used to ident ify patient s at risk of pressure sores
As
Dr
A 45-year-old woman presents for review. She has noticed a number of patches of 'pale
skin' on her hands over the past few weeks. The patient has tried using an emollient and
topica l hydrocortisone with no resu lt. On examination, you note a number of
depigmented patches on the dorsu m of both hands. Her past medical history includes
thyrotoxicosis for w hich she t akes carbimazole and thyroxine.
What is the most likely cause of her symptoms?
Vitiligo
Carbimazole-induced hypopigmentation
Leukopaenia -induced fungal infection
Idiopathic guttat e hypomelanosis
m
se
Addison disease
As
Dr
Vitiligo
Carbimazole-induced hypopigmentation
Leukopaenia -induced fungal infection
Idiopathic guttat e hypomelanosis
Addison disease
m
se
Vitiligo is more common in patients with known autoimmune conditions such as
As
thyrotoxicosis. There is nothing else in the history to suggest Add ison's disease.
Dr
A 25-year-old female patient presents t o the dermatology clinic complaining of
distressing symptoms of excessive facial hair growth. She has a history of the polycystic
ovarian syndrome and has been on Yasm in. She has not found it to have significant
benefit in her facial hair growth. This has caused her to lose her self-esteem greatly.
What medication would you recommend?
Topical minoxidil
Oral metformin
Topical eflornithine
Topical spironolactone
m
se
As
Topical psoralen
Dr
Topical minoxidil «D
Oral metformin ED
Topical eflornithine .,
Topical spironolactone m
Topical pso ralen m
Topica l eflornithine is the t reatment of choice for facial hirsut ism

Topical eflornithine is the t reat ment of choice for facial hirsutism.
Minoxidil causes hypertrichosis.
Oral metformin does not affect hirsutism.
Spironolactone ca n be used to t reat hirsutism but usually in oral form.
m
se
As
Psora len is not used t o treat hirsut ism.
Dr
A 38-year-old woman with a history of rheumatoid arthritis and epilepsy presents with
generalised increased hair growth over her trunk and arms. Which one of the following
drugs is associated with hypertrichosis?
Sodium valproate
Prednisolone
0 Phenytoin
Ciclosporin
m
se
As
Methotrexate
Dr
Sodium valp roate tiD
Prednisolo ne m
Phenytoin .,
Ciclosporin CiiD
Methotrexate m
m
se
As
Phenytoin is associated with hirsutism rathe r than hypertrichos is
Dr
A 41-yea r-old ma n p resents with a persistent itch rash that has been present for the past
few weeks. On exa minatio n he has e rythematous, scaly lesions underneath the eyebrows,
arou nd the nose and at the top o f his chest. He a lso has a histo ry of dandruff which is well
contro ll ed with over the counter sha mpoos. What is the most appropriate treatme nt for
his face a nd trunk lesio ns?
To pical metron idazo le
Oral oxytetracycline
Oral isotretino in
To pical ketoco nazole
m
se
As
To pical hydrocortiso ne
Dr
Sebo rrhoeic dermatitis - first-line trea tment is to pical ketoconazole
m
se
The com bination of a p eri-o rbita l and naso la bia l sca ly rash associated dand ruff is a
As
classical history for seborrhoeic d ermatitis.
Dr
A 62-yea r-old female is referred due to a long-stand ing ulcer a bove the right medial
mal leolus. Ankle -brachia l pressu re index readi ngs a re as fo llows:
Right 0 .95
Left 0 .95
To date it has been managed by the District Nurse with stand ard d ressing s. What is the
most app ropriate mana gement to maximize the likel ihood of the ulcer healing?
Com pression bandaging
Interm ittent pneumatic compressio n
Hydrocolloid dressin gs
Refer to vascula r surgeon
m
se
As
Topical flucloxa cill in
Dr
Compression bandaging
lntert ttent pneumatic compression
Hydrocolloid dressin gs
Refer to vascular surgeon
Topica l flucloxacill in
Management of venous ulceration - compression bandag ing

m
se
The ankle -b rachia l pressu re index readi ngs indicate a reasonable arteria l supp ly and
As
suggest the ulcers are venous in nature.
Dr
A 63-year-old man who is known to have type 2 diabet es mellitus presents with a number
of lesions over his shins. On examination there are a number of 3-4 mm smooth, firm,
papules which are hyperpigmented and centrally depressed. What is the most likely
diagnosis?
Lupus vulgaris
Guttate psoriasis
Gran uloma annulare
m
se
As
Dr
Lupus vulg aris
Guttate psoriasis
Granuloma annulare
m
se
As
Pyo derma g angreno sum
Dr
A 34-year-old man presents with a three week history of an intensely itchy rash on the
back of his elbows. On examination he has a symmetrical vesicu la r rash on the extensor
aspects of his arms. Which one of the following antibod ies is most likely to be positive?
Anti-mitochond rial antibody
Anti-gliad in antibody
Anti-nuclear antibody
Anti-neutrophil cytoplasm ic antibody
m
se
As
Anti-Jo -1 antibody
Dr
Anti-mitochond rial antibody
Anti-gliadin antibody
-
~
Anti-nuclear antibody
Anti-neutrophil cyto plasm ic antibody
m
se
As
Anti-Jo-1 antibody
Dr
A 17-yea r-old female presents with mu ltiple comedones, pustules and pa pules on her
face. Wh ich one of the following is least likely to improve her cond ition?
Topica l retinoids
Dietary advice
Washing her face using a mild soap with lukewarm water twice a d ay
Oral trimethoprim
m
se
As
Ethinylestradiol with cyproterone acetate
Dr
Topical retinoids
Dietary advice
Washing her face using a mild soap with lukewarm water twice a d ay
Oral trimethoprim
Ethinylestradiol w ith cyproterone acetate
There is no role for dietary modification in patients wit h acne vulgaris. Ethinylestradiol
wit h cyproterone acetate (Dianett e) is usef ul in some fema le patients w ith acne
m
se
unresponsive to standard t reat ment. Oral t ri methop rim is usef ul in patients on long-term
As
antibiotics who develop Gram negative folliculitis
Dr
A 54-yea r-old woman with a history of type 1 diabetes mellitus presents with unsightly
toenails affecting the lateral three nai ls of the left foot. On examination the nails and
b rown and b reak eas ily. Nail scrapings demonstrate Trichophyton rubrum infection. What
is the treatment of choice?
Oral terb inafine for 12 weeks
Oral itraconazole for 4 weeks
Topical itraconazole for 2 weeks
Topical amorolfin e for 6 weeks
m
se
As
Oral itraconazole for 1 weeks
Dr
Oral t erb inaf ine for 12 weeks ED
Oral itraconazole for 4 weeks CD
Topica l itraconazole fo r 2 w eeks GD
Topical amorol fine for 6 weeks CD
Oral itraconazole fo r 1 weeks CD
m
se
Dermatophyte nail infect ions - use oral t erbinafine
As
Dr
You review a 50-year-o ld man who has a history of ischaemic heart disease and psorias is.
Ove r the past two weeks he has experienced a significant worsening o f the plaque
psoriasis a ffecting his elbows and knees. His medications have recently been a ltered at
the card iology clinic. Which one of the following medications is most likely to have
exacerbated his psoriasis?
Nico rand il
Simvastatin
Verapamil
Atenolol
m
se
As
Dr
You review a 50-year-old ma n who has a history of ischaemic heart disease and psoriasis.
Over the past two weeks he has experienced a significant worsening of the plaque
pso riasis a ffecting his elbows and knees. His medications have recently been a ltered at
the ca rdiology clinic. Which one of the following medications is most likely to have
exacerbated his psoriasis?
Nicorandil GD
Simvastatin CD
Verapamil f!D
I Ateno lol ED
Isosorbide mononitrate CD
m
se
Beta-blockers are known to exacerbate plaque pso riasis
As
Dr
An 84-yea r-old woma n with a history o f ischae mic heart disease is reviewed in the
d e rmatology clinic. He r current medication inclu des a spirin, simvastatin, b isoprolol,
ram ipril a nd isoso rb ide mononitrate. She has d eve lo ped tense blisterin g lesions on her
legs. Each lesion is aro und 1 to 3 em in d iameter and she reports that they a re slightly
pruritic. Exa mination of her mouth a nd vulva is unrema rkable . What is the most like ly
diagnosis?
Pem phigu s
Drug reaction to asp irin
Epidermolysis b ullosa
Sca b ies
m
se
As
Bullous pemphig oid
Dr
Pemphigus
Drug reaction to aspirin
Epidermolysis bullosa
Scabies
Bullous pemphigoid
Blisters/ bullae
• no mucosal involvement (in exams at least~): bullous pemphigoid
m
• mucosal involvement: pemphigus vulgaris
se
As
Dr
A 43-year-old man is admitted to the Emergency Department with a rash an d feeling
generally unwell. He is known t o have epilepsy and his medication was recently changed
t o phenytoi n three weeks ago. Around one week ago he started t o develop mouth ulcers
associated w ith malaise and a cou gh. Two days ago he started to develop a widespread
red rash which has now coalesced to form large fluid -filled bliste rs, covering aroun d 30%
of his body area. The lesions separate when slight pressure is applied. On examination his
t emperature is 38.3°C and pulse 126 I min. Blood result s show:
Na• 144 mmol/ 1
K• 4 .2 mmol/1
Urea 13.4 mmol/ 1
Creatinine 121 )Jmol/ 1
Phenytoin-induced neutropaenia
Drug-i nduced lupus
Kawasaki disease
Toxic epidermal necrolysi s

m
se
As
Staphylococcal Scalded Skin syndrome

Dr
Phenytoin-induced neutropaenia (iD
Drug -i nduced lupus f.D

Kawasaki disease CD
I Toxic epidermal necrolysis fD
m
se
As
Staphylococcal Scalded Skin syndrome CD
Dr
A 19-year-o ld man is started on isotretinoin for severe nodulo-cystic acne. Which one o f
the following s ide -effects is most likely to occu r?
Low mood
Th rombocytopaen ia
Ra ised plasma triglyce rides
Reversible alopecia
m
se
As
Dry skin
Dr
Low mood
Thrombocytopaen ia
Ra ised plasma triglycerides
Reversible alopecia
Dry skin
-
~
m
se
Dry skin is the most com mon sid e-effect of isotreti noin
As
Dr
Which one of the followi ng featu res is least associated with zinc deficiency?
Acrodermatitis
Alopecia
Short statu re
Perioral dermatitis
m
se
As
Gingivitis
Dr
Acrodermatitis fi!D
Alopecia CD
Short stature 6D
Perioral dermatitis fD
I Gingivitis CD
m
se
As
Gingivitis is more commonly seen in vitamin C deficiency
Dr
A 67 -yea r-old retired gardener presents to the dermato logy department with a suspicious
evolvin g freckle on his face, which he first noticed 10 yea rs ago. On exa mination, he has a
3cm asymmetric pigmented patch on his cheek, co mprised of multiple shad es of brown
and black, and with asymmetrica l th ickening o f the lesion. Which subtype of me lanoma is
this gentleman most likely to have?
Su perficial spreading melanoma
Desmoplastic melanoma
Lentigo maligna melanoma
Acral lentig inous melanoma
m
se
As
Nodu la r melano ma
Dr
Superficial spreading melanoma fD
Desmoplastic melanoma CD
Lent igo maligna melanoma CD
-.
Acra l lentiginous melanoma CD
Nodular melanoma (fD
Lentigo maligna melanoma: Suspicious freckle on face or sca lp of ch ron ical ly sun-
exposed patients
Lentigo maligna is a precursor to lent igo maligna melanoma. It begins as a suspicious flat
freckle which can grow over 5-20 years to develop into melanoma. It typically occu rs in
older people on chronically sun-exposed skin (e.g. with a ca reer in gardening) and
develops the characteristics of typical melanoma (asymmet ry, border irregularity, colou r
variation, diameter >6mm, evolving). Once it has become melanoma, parts of the lesion
may thicken as occu rred in this gentleman, the re may be increasing numbers of co lours,
ulceration, b leeding, itching and stinging.
Whilst nodular melanoma also presents on the face and neck, it is less likely given the
p resentation and the slow growth of the lesion.
Superficial spreading melanoma wou ld also be a differential t o consider in t his

gentleman, however, the location of the lesion and the ch ron ic mild nat ure of the sun
exposure better fits lentigo maligna.
s em
(De rmNet NZ)

As
Dr
A 65-year-old woman present s with bullae on her forearms follow ing a recent holiday in
Spain. She also notes that the skin on her hands is extremely fragile and tea rs easily. In
the past the patient has been referred to dermatology due to troub lesome hypertrichosis.
Pellagra
Pemphigus vulgaris
Epidermolysis bullosa
Bullous pemphigoid
m
se
As
Dr
Pellagra
Pemphigus vu lgaris
•
f!D
Epidermolysis bullosa CD
Bullous pem phigoid GD
Porphyria cutanea tarda 6D
Porphyria cutanea tarda

• blistering photosensitive rash
• hypertrichosis
m
se
• hyperpigmentation
As
Dr
A 26-year-old man with a history o f heredita ry haemorrhagic telangiectasia is planning to
start a family. What is t he mode o f inheritance?
Autosomal dominant with incomplete penetrance
Autosomal codom inant
Autosomal recessive w ith incomplete penet rance
Autosomal dominant
m
se
As
Autosomal recessive
Dr
Autosomal d ominant with incomplete penet rance
Autosomal codominant
Autosomal recessive w ith incomplete penet rance

-
"""
I Autosomal dom inant
Autosomal recessive
m
se
Heredit ary haemorrhagic telang iectasia - aut osomal d om inant
As
Dr
An 18-yea r-o ld female is reviewed in the dermatology clinic comp la ining of scalp hair
loss. Wh ich one of the fo llowing cond itions is least likely to be responsible?
Disco id lupus
Tinea capitis
Alopecia areata
m
se
As
Telogen effluvium
Dr
Discoid lupus
Tinea capitis
Alopecia areata
-
""""
Telogen effluv1~m
m
se
As
Porphyria cutanea ta rda is a recogn ised cause o f hypertrichosis
Dr
Which one of the following complications is most associated with psoralen + ultraviolet A
light (PUVA) thera py?
Squamous cell cancer
Osteoporosis
Basal cell cancer
Dermoid cysts
m
se
As
Malignant melanoma
Dr
I Squamous cell cancer
Osteoporosis
GD
m
I Basal cell caner
Dermoid cysts
flD.
CD
Malignant melanoma m:t
m
se
The most significant complication of PUVA therapy for psoriasis is squamous cell skin
As
cancer.
Dr
A 25-year-o ld man presents with a pru ritic skin rash. This has been p resent for the past
few weeks and has responded poorly to an e mo llient cream. The p ruritus is d escribed as
'intense' a nd has resu lted in h im having trou ble s leeping. On inspecting the skin you
notice a com bination of pa pules a nd vesicles on his buttocks and the extensor aspect o f
the knees and elbows. What is the most likely diagnosis?
Lichen planus
Chronic plaque psoriasis
Henoch-Schonle in pu rpu ra
Dermatitis herpetiformis
m
se
As
Scabies
Dr
Dr
As
se
m
A 34-year-old man with a history of polyarthralgia, back pain and diarrhoea is found to
have a 3 em red lesion on his shin which is starting to ulcerate. What is the most likely
diagnosis?
Syst emic Shigella inf ection
Syphilis
Metast atic colon ca ncer
Erythema nodosum
m
se
As
Dr
Systemic Shigella infection
Syphilis
Metastatic colon cancer
Erythema noCiosu m
m
se
This patient is likely to have ulcerative colitis, wh ich has a known association with large-
As
joint arthritis, sacroilitis and pyoderma gangrenosum
Dr
A 47 -yea r-old lorry driver presents following the development of a wide spread urticarial
rash. This is associated with p ruritus. What is the most a pp ropriate medication to help
re lieve the itch?
Cetirizine
Lo ratadine
Chlorphenamine
Ran iti dine
m
se
As
Alimemazine
Dr
Cetirizine fD
I Loratad ine fD
Chlorphenam ine tiD
j ,nitidine CD
Alimemazine m
m
se
The o bvious concern in a lo rry drive r is drows iness. Of the non -sed ati ng antihista mines
As
the re is some evid ence that cetirizine causes mo re drows iness than loratad ine
Dr
A 54-yea r-old ma n is referred to the d ermatology o utpatient d e partment due to a facial
rash which has p e rsisted fo r the past 12 months. On exam inatio n the re is a symmetrica l
rash consisti ng of extens ive pustu les and pa pules which affects his nose, cheeks a nd
fo rehea d. What is the most a p prop riate treatment?
Ciprofloxacin
Isotretinoin
Oxytetracycline
Hydroxychloroqu ine
m
se
As
Prednisolone
Dr
Ciprofloxacin m
Isotretinoin tiD
I Oxytetracycline
Hydroxychloroqui ne
ED
.
(D
Prednisolo ne ctD
Acne rosacea treatment:

• mild/m oderate: top ical metronid azole
• seve re/resistant: ora l tetracycline
m
se
As there is extensive invo lvement o ral oxytetra cycline s hould pro bably b e used rather
As
than topical metronidazole
Dr
Which one o f t he followin g antibiotics is most associated with the development of
Stevens-Johnson syndrome?
Co -tri moxazole
Ethambutol
Chloramphenicol
Ciprofloxacin
m
se
As
Gentam icin
Dr
Co-trimoxazole CiD
Ethambutol CD
Chloramphet ol flD
Ciprofloxacin GD
m
se
As
Gentamicin .
(D
Dr
A 69-year-old woman with a history of learning difficu lties is reviewed in cl inic. She is
known to have erythema ab igne on her legs but according to her carer still spends long
hours in front of her electric fire. Which one of the following skin lesions is she at risk of
developing?
Squamous cell carcinoma
Cutaneous T-cell lymphoma of the skin
Dermatofibrosarcoma protuberans
Basal cell carcinoma
m
se
As
Malignant melanoma
Dr
Squamous cell carcinoma GD
Cutaneous T-cell lymphoma of the skin f!D
Dermatof ibrosarcoma protuberans tiD
Basal cell carcinoma fD
m
m
se
Malignant melanom a
As
Dr
A 63-year-old ge ntleman presents to his general practitioner. He has recently been
diag nosed with melanoma aher being referred to the derm atolog ist with a suspicious red
lu mp on his face. He is awaiting further imag ing to see if the melanoma has metastasised.
Aher being told his subtype of melanoma, he resea rched further online. He is now very
concerned as he has rea d that his subtype is the most aggressive subtype and that it
metastasises ea rly. Which subtype of mela noma is he like ly to have?
Actinic keratosis
Lentigo maligna
Acral lentig inous
Nodu la r
m
se
As
Superficial spreading
Dr
Nodular melanoma: Invade agg ressively and met astasise early
The presentation of th is lesion is most consist ent w ith nodular melanoma. Nodular
melanoma is the most aggressive form o f melanoma. This is because it tends to grow
rapidly, downwards into the d eeper layers of skin, increasing in thickness fast er t han in
diamet er.
The ot her forms of melanoma typica lly take longer to grow and met astasise. These are
described in further detail in t he notes below. Actinic keratosis is not a form of melanoma,
but rather a p re-cancerous lesion.
m
se
(DermNet NZ)
As
Dr
Which of the following skin cond itions is not associated with diabetes mellitus?
Necrobiosis lipoidica
Sweet's syndrome
Granuloma annulare
Vitiligo
m
se
As
Lipoatrophy
Dr
Necrobiosis lipoidica m
Sweet's syndrome eD '
Granuloma annulare (fD
Vit iligo f!D

Lipoatrophy fD
m
se
As
Sweet's syndrome is also known as acute febrile neutrophilic dermatosis has a st rong
associat ion with acut e myeloid leukaemia. It is not associat ed w ith diabetes mellitus
Dr
A 23-yea r-o ld stu de nt is investigated fo ll owing a n anap hylactic reaction sus pected to b e
seconda ry to a wasp sting . Wh ich o ne of the fo llowi ng is the most a ppro p riate first- line
test to investigate the cause o f the reactio n?
Hair a na lysis
Radioalle rgoso rbent test (RAST)
Desens itiza tion therapy
Skin patch test
m
se
As
Skin prick test
Dr
Ha ir ana lysis CD
Radioallergosorbent test (RAST) CD
Defensitization therapy CD
Skin patch test (D
Skin prick test
m
se
As
Given the history of anaphylaxis it would not be approp riate to perform a skin prick test
Dr
A 19-year-old student presents with a three day history of a 1 em golden, crust ed lesion
on the border o f her lower lip. What is th e most suitable management ?
Oral co-amoxiclav
Oral penicillin
Oral flucloxacillin
Oral flucloxacillin + penicillin
m
se
As
Topical fusidic acid
Dr
Oral co-amoxiclav
Oral penicillin
Oral flucloxacillin
Oral flucloxacillin + penicill in
Topical fusidic acid
Impetigo - t opica l fusidic acid is first-line

m
se
This history is typica l of impetigo. As the lesion is small and localised to pical fus idic acid is
As
recom mended
Dr
A 49-year-old man is reviewed in the dermatology clinic complaini ng of losing hair.
Examination revea ls generalised scalp hair loss that does not follow the typical male-
pattern distribution. Which one of th e following medications is least likely to be
responsible?
Colchicine
Cyclophosphamide
Heparin
Carbimazole
m
se
As
Phenytoin
Dr
Colchicine GD
~clophysphamide t!D
Heparin fD
Carbimazole CD
I Phenytoin eD
m
se
As
Phenytoin is a recognised cause of hirsutism, rather than alopecia
Dr
A 22-yea r-old woman presents due to hypopigmented skin lesions on her chest and back.
She has recently returned from the south of Fra nce and has tanned skin. On examination
the lesions are slightly scaly. What is the most likely d ia gnosis?
Tinea corporis
Pityriasis ve rsicolor
Lym e disease
m
se
As
Psoriasis
Dr
Tinea corporis m.
I Pityriasis versico lor GD
Porphyria cutanea tarda CD
Lyme disease
•m
m
se
Psoriasis
As
Dr
Pellagra is caused by a deficiency in:
Vitamin 812
Th iamine
Nicotinic acid
Vitamin 82
m
se
As
Vitamin 86
Dr
Vita min B12 m
Th iamine CiD
Nicotinic acid ED.
Vit amin B2 GD
Vitamin B6 mt
m
se
Deficiency of niacin (B3) causes pellagra
As
Dr
A 45-year-old man has been referred to dermatology cl inic due to a new rash. He is a
keen gardener and has spent the majority of the summer tend ing to his outdoor plants.
His background is notable for hepatitis C, COPD and hypertension. He notes this rash is
worst on his hands, face and shoulders.
On examination you note blisters and erosions on his hands, forehead and upper back.
Which of the following tests wou ld be most helpful in ascertaining a diagnosis?
Direct immunofluorescent staining
Varicella antibodies
Urine uroporphyrinogen
Serum porphobilinogen
m
se
As
Anti tissue transglut aminase antibodies
Dr
Direct immunofluo escent staining
Varicella antibodies
Urine uroporphyrinogen
Serum porphobilinogen
Anti tissue t ransglut aminase antibodies
Hepatitis C may lead to porphyria cutanea ta rda

This blistering condition is porphyria cutanea ta rda (PCT). It is associated w ith chronic
hepatitis C and results in blisters and erosions in sun exposed areas. High levels o f urine
uroporp hyrinogen are diagnostic. Serum (and urine) porpho bilinogen are useful fo r the
diagnosis of acut e intermittent porphyria (AlP), an autosomal dominant condition t hat is
characte rised by neurolog ica l symptoms and abdominal pain.
m
se
Other conditions that can cause acantholysis include pemphigus vulgaris (for w hich
As
answer 1 is useful) and dermatit is herpetiform is (for w hich answer 5 is useful).
Dr
A 45-yea r-old wo man presents with itchy, violaceous pa pules on the flexor aspects of her
wrists. She is normally fit an d well and has not had a si milar rash previously. Given the
likely diagnosis, what other feature is she most li kely to have?
Onycholysis
Ra ised ESR
Mucous membra ne involvement
Pain in small joints
m
se
As
Microscopic haematu ria
Dr
I Onycholysis
Raised ESR
I Mucous membrane involvement
Pain in small joints
Microscopic haematuria
Lichen
• p lanus: pu rp le, p ruriti c, pap ular, p olygonal rash on flexor surfaces. Wickham's
st riae over surface. Oral involvement com mon
• sclerosus: itchy white spot s typi cally seen on the vulva of elderly women
m
se
As
Mucous membrane involvement is common in lichen planus
Dr
A 26-year-old man who is HIV positive is noted to have developed seborrhoeic dermatitis.
Which of the following two complications are most associated with this condition?
Alopecia and otitis externa
Blepharitis and otitis externa
Photosensitivity and alopecia
Photosensitivity and blepha ritis
m
se
As
Blepharitis and a lopecia
Dr
Alo pecia and otitis externa CD
I Blep haritis and otitis externa CD

Photosensitivity and alopecia
Photosensitivity and b lep ha ritis

•
CD
Blepharitis and a lopecia «D
Otitis externa and blepharitis a re common complications of sebo rrhoeic d e rmatitis

m
se
Alopecia is not com monly seen in seborrhoeic dermatitis, but may develop if a severe
As
secondary infection d evelo ps
Dr
A 45-year-old man who p resented with itchy lesions on his hands is diagnosed w ith
scabies. It is decided to t reat him with permet hrin 5%. You have explained the need to
treat all members o f the househo ld and hot wash all bedd ing and clothes. What advice
should be given about applying the cream?
From neck down + leave for 12 hours
All skin including scalp + leave for 12 hours + retreat in 2 d ays
From neck down + leave for 4 hours
m
se
As
From neck down + leave for 12 hours + retreat in 7 d ays
Dr
From neck d own + leave for 12 hours

-
~
All skin including scalp .,. leave for 12 hours + retreat in 7 d ays
From neck d own + leave for 4 hou rs
From neck down + leave for 12 hours + retreat in 7 d ays
Scabies - pe rmethrin treatment: all skin includ ing scalp + leav e for 12 hours +
retreat in 7 days
m
se
The BNF advises to apply the insecticide to all areas, including t he face and scalp, contrary
As
to the manufactu rer's reco mmendatio n (and commo n p ractice).
Dr
A 78-year-old wo man asks you for cream to treat a lesion on her left cheek. It has been
present for the past nine months and is asymptomatic. On examination you find a 2 * 3
em area of flat brow n pigment ation with a j ag ged, irregular edge. The pigmentation on
the anterior aspect of the lesion is a darker brown. What is th e most likely diagnos is?
Solar lentigo
Dermatofibroma
Lentigo maligna
Bowen's disease
m
se
As
Dr
Solar lentigo GD
Dermatofibroma CD
Lentigo maligna 6D
Bowen's disease f!D
Seborrhoeic keratosis CD
m
se
These lesions often present a diagnost ic dilemma. The asymmetrica l nature o f t he lesion
As
wou ld however point away from a diagnosis of solar lent igo.
Dr
A 26-year-old fema le, o f Han Chinese origin, with new ly diagnosed partial ep ilepsy is
commenced on ca rbamazep ine and has an HLA B*1502. Two weeks later, she d evelops a
ma culopapu lar rash, purpuric macules and targetoid lesions; f ull -thickness epid ermal
necrosis, and mu cous membrane involvement .. What is t he pred om inant cell type
involved in this reaction?
T cells
IgG
Complement
IgE
m
se
As
B cells
Dr
T cells .,
IgG f.D
Comp lement GD
IgE tiD
B cells .
(D
m
HLA allele B* 1502 as a marker for carbamazep ine-induced Stevens-Johnson syndrome
se
and t oxic epid ermal necrolysis in Han Chinese. Stevens-Johnso n syndrome and toxic
As
ep id ermal necrolysis is a d elayed -hypersensit ivity reaction, thus involving T -cells.
Dr
A 34-yea r-old ma n attends the eme rgency depa rtment with a rash on his legs which he
says has been getting worse over the past two weeks. His GP started him on flucloxacillin
one week ago. At the weekend he visited the emergency department as the rash was
spreadi ng; he was d ischarged with the addition of clarithromycin.
He has a past medical history of well-controlled asthma. He suffers occasional aches and
pains in mu ltiple joints but has never ha d a ny forma l investigations fo r this problem. He
takes no regular med ications.
On exam ination his o bservations are stable and he is afebrile. He has a series of raised
purple-red lumps on the anterior aspect of both his shins. They are pai nful and tender to
touch.
The resu lts of investigations are as follows:
Hb 144 g/ 1
Platelets 30 1 * 109/ 1
WBC 9 .6 * 109/ 1
CRP 15 mg/L
Na• 139 mmol/ 1
K• 4 .5 mmol/1
Ca 2 + 2.5 mmol/1
The on call radiolog ist has authorised this report:
Chest X-ray No focal consolidation seen, clear lung fields. Some bilateral hilar lymphadenopathy.
What is the most like ly diag nosis?
Sa rcoidos is
Cellu litis caused by MRSA
Necrotising fasciitis
Scrofuloderma (cutaneous tu berculosis)

s em
Erysipelas
As
Dr
Sarcoid os is
Cellulitis caused by MRSA
r :ecrotising fasciitis
Scrofulo derma (cutaneous tu berculo sis)
Erysipelas
m
The descriptio n of this gentle man 's rash is a classic picture of erythema nodosu m.
se
As
Tog ether with bilate ra l hila r lymp had enopathy, this ma kes sarcoid the most p laus ible
diag nosis.
Dr
A 67 -year-o ld man with a history o f Pa rkinson's disease p resents due to the development
o f an itchy, red rash o n his neck, be hi nd his ears and a round the nasolabia l folds. He had
a simila r fla re up last winter but did not seek medical attention. What is the most like ly
diag nosis?
Levo do pa associated dermatitis
Sebo rrhoeic dermatitis
Flexu ral psoriasis
Acne rosacea
m
se
As
Fixed drug reaction to ropinirole
Dr
Levo dopa associated d e rmatitis C!D
I Seborrhoeic dermatitis
Flexu ra l psoriasis
6D
CD
Acne rosacea f!D
Fixed drug reaction to ropinirole .
(D
Parkinson's disease is associated with seb orrhoeic d e rmatitis
m
se
As
Seborrhoeic dermatitis is more co mmon in patients with Pa rkinson's disease
Dr
A 30-year-old man presents w ith painf ul, purple coloured lesions on his sh ins. Some o f
these lesions have started t o heal and no evid ence o f scarring is seen. These have been
present for the past 2 weeks. There is no past medical hist ory of note and he takes no
regular medicat ions. What is t he most usef ul next investigat ion?
Liver function t est s
Ant i-nuclear antibody
ECG
HIV t est
m
se
As
Chest x-ray
Dr
--
Liver function tests CD
Anti-nuclear antibody GD
ECG m
HNtest GD
I Chest x-ray CD
The likely d iagnosis here is erythema nodosum (EN) . All these tests may have a place but
m
se
a chest x- ray is important as it helps exclude sarcoidos is and tubercul osis, two im portant
As
cause of EN
Dr
A 60-yea r-old man is ad mitted to hos pital with acute pneumon ia. He has a past medical
histo ry of chro nic o bstructive pulmona ry d isease, alco ho l excess and hypertension, and
has b een ho me less fo r the last 12 years. On the post-take wa rd ro u nd, you notice that he
has a brown-red discolou ration of his fa ce, neck, fo rearms and lower legs, with scaling
a nd c racking of the skin . He co mpla ins that he is struggli ng to eat and drink and has
persistent vo miting and diarrhoea. He seems a little diso rientated . Which vitam in
d eficiency is most like ly to be causing these symptoms?
B2 (riboflavin)
B3 (niacin)
B6 (pyridoxi ne)
Bl (thia mine)
m
se
As
B12 (cya nocobalam in)
Dr
B2 (riboflavin) CD
B3 (niacin) GD
B6 (pyridoxine) CD
Bl (thiamine) GD
B12 (cyanocoba lamin) m
Deficiency of niacin (B3) causes pellagra
The correct answer is B3 - niacin. The patient has some of the sym ptoms of pellagra, which
is classically cha racte rised by the tria d of dermatitis, diarrhoea and d ementia. The
'd e mentia' more commonly presents subtly with low mood, irritability, apathy and anxiety,
progressing to delusions, psychosis, drowsiness and coma.
m
se
Derm Net NZ:
As
https:/ ;www.dermnetnz.org/top ics/ pellag ra/
Dr
A 14-year-old male is reviewed due t o a patch of scaling and hair loss on the right side o f
his head. A skin scraping is sent which confirms a diagnosis o f tinea ca pitis. Which
o rganism is most likely to be responsible?
Trichophyton t onsurans
Microsporum dist ortum
Trichophyton verrucosum
Microsporum audouinii
m
se
As
Microsp orum canis
Dr
I Trichophyton tonsurans CD
Microsporum dist ortum m
Trichophyton verrucosum fD
Microsporum audouinii m
m
se
As
Microsporum ca nis GD
Dr
You review a 24 -yea r-o ld man who has recently presented with la rge psoriatic pla ques on
his e lbows and knees. He has no history of skin p roble ms a lthough his mother has
psoriasis. You recommend that he uses an emollient to help control the scaling. What is
the most a p propriate fu rther prescription to use a s a first-line treatment on his plaq ues?
Topica l ste roid
Topical ste roid + topical calcipotriol
Topical coal ta r
Topical calcipotriol
m
se
As
Topica l dith rano l
Dr
Topical steroid
~pical ste ro id + topical calcipotriol
Topica l coa l ta r
Topica l calcipotriol
Topica l dithranol
m
NICE recom mend a potent corticosteroid applied once da ily p lus vitam in 0 analogue
se
applied once da ily (applied separate ly, one in the morni ng and the other in the even ing)
As
for up to 4 weeks as initial treatment.
Dr
Which one of the fo llowin g statements regard ing al lergy testing is incorrect?
Both irritants and a llergens may be tested for using s kin patch testing
The ra dioa llergosorbent test d etermines the level of Ig E to a s pecific allergen
Skin prick testing is easy to perform and inexpens ive
Skin prick testing should be rea d a fter 48 hours
m
se
As
Skin prick testing no rma lly includes a h istami ne contro l
Dr
Both irritants and a llergens may be tested for using s kin patch testing
The ra dioa llergosorbent test d etermines the level of Ig E to a s pecific alle rgen
Skin prick testing is easy to perfo rm and inexpens ive

-
. .wr
Skin prick testing should be rea d a fter 48 hours
Skin prick esting normally includes a h istami ne contro l
m
se
Skin prick testing can be read after 15-20 minutes. Skin patch testing is read after 48
As
hou rs
Dr
A 34-year-old man presents for the removal of a mole. Where on the body are keloid
scars most likely to form?
Sternum
Lower back
Abdomen
Flexor surfaces of limbs
m
se
As
Scalp
Dr
Sternum GD
Lower back m
I Abdomen CD
Flexor surfaces of limbs CD
Scalp CD
m
se
Keloid scars are most common on the sternum
As
Dr
A ma n p resents with a n area of d ermatitis on his left wrist. He thinks he may be alle rgic to
nickel. Which one of the following is the b est test to investigate this possibility?
Skin patch test
Radioallergosorbent test (RAST)
Nickel Ig G leve ls
Skin prick test
m
se
As
Nickel IgM levels
Dr
Skin patch test em
Radical ergosorbent test (RAST) tiD
Nickel IgG levels CD
Skin prick test GD
m
se
As
Nickel IgM levels CD
Dr
An 85-year-old lady presents to dermatology cli nic com plaining of itchy white plaques
affecting her vulva. There is no history of vaginal discharge or bleeding. A similar plaque is
also seen on her inner thig h. What is the likely diagnosis?
Candida
Lichen planus
Lichen sclerosus
Herp es simplex
m
se
As
Dr
Candida
Lichen pl anus
Lichen sclerosus
Herp es simplex
Lichen
• p lanus: purp le, pruritic, pap ular, polygonal rash on flexor surfaces. Wickham's
st riae over su rface. Oral involvement com mon
• sclerosus: itchy white spot s typically seen on t he vulva of elderly wo men
m
se
As
The correct answer is lichen sclerosus. Candida may cause pruritu s and w hite plaques but
lesions would not also be seen on her inner t high
Dr
A 20-year-old man presents with acute gingivitis associated with oral ulceration. A
d iagnosis of primary herpes simplex infection is suspected.
Which one of the following types of rash is he most likely to go on to develop?
Erythema ab igne
Erythema nodosum
Erythema chronicum migrans
Erythema marg inatum
m
se
As
Erythema multiforme
Dr
Erythem a ab igne CD
Erythema nodosum .
(D
Erythe a chronicum migrans CD

Erythema marginatum .
f!D
m
se
I
As
Erythema multiforme 63
Dr
A 62-year-old male is referred t o dermatology with a lesion over his shin. On examination
shiny, painless areas of yellow skin over the shin are found with abundant telangiectasia.
Pretibial myxoedema
Erythema nodosum
m
se
As
Syphilis
Dr
Pretibia l myxoedema
Necrobiosis lipo idica diabeticorum
Erythema nodosum
-
~
m
se
Syphilis
As
Dr
A woman p resents w ith painfu l erythematous lesions on her shins. Which one of t he
following is least associated wit h this presentation?
Pregnancy
Behcet's syndrome
Streptococcal infect ion
Penici llin
m
se
As
Amyloidos is
Dr
A woman presents with painfu l erythematous lesions on her shins. Wh ich one of the
following is least a ssociated with th is presentation?
Pregnancy GD
....___
Behcet's synd rome f1D
Streptococcal infection CD
Penicillin I GD
m
se
As
Amylo id osis CD
Dr
Which one of the fo llowing statements regard ing scabies is fa lse?
All me mbers of the household s hould b e trea ted
Typically a ffects the fingers, interdigital webs an d flexor as pects of the wrist in
a dults
Sca b ies causes a delayed type N hypersensitivity reactio n
Patients who co mplain o f pruritus 4 weeks following treatment should be retreated
m
se
As
Ma lathion is suita b le for the erad ication of scabies
Dr
All members o f the household shou ld be treated
Typically affects the fingers, interdigital webs and flexor aspects of the wrist in
adults
Scabies causes a delayed type IV hypersensitivity reaction
Patients who complain of pruritus 4 weeks folloJ ng treatment should be

retreated
Malathion is suitable for the eradication of scabies
m
se
As
It is normal for pruritus to persist for up to 4-6 weeks post eradic<~tion
Dr
Which of t he following skin di sorders is least associated w ith tubercu losis?
Scrofuloderma
Erythem a nodosum
Lu pus vu lgaris
Verrucosa cutis
m
se
As
Lu pus pernio
Dr
Scrofuloderma GD
Erythema nodosu m tiD
Lupus vulgaris CD
Verrucosa cutis tED
I Lu pus pernio CD
m
se
As
Lupus pernio is sometimes seen in sa rcoidosis but is not associated w ith tube rcu losis
Dr
A 23 -year-o ld man presents as he is concerned over recent ha ir loss. Exa mination revea ls
a d iscrete area of ha ir loss on the left temporal reg io n with no obvious abnorma lity o f the
underlying scalp. What is the most likely d iagnosis?
Te logen effluvium
Alopecia areata
Tinea capitis
Male-pattern ba ldness
m
se
As
Disco id lupus erythematous
Dr
Telogen effluvium
Alo pecia areata
Tinea ct pitis
Male-pattern ba ldness
m
se
As
Disco id lupus erythematous
Dr
A 17 -year-old man p resents w ith a 2 week h istory of abdom inal pain, diarrhoea and
repeated episodes of flushing. Exa mination revea ls urticarial skin lesions on t he trunk.
What t est is most likely to revea l t he diagnosis?
Chest x-ray
Urinary catecholamines
Serum amylase
Urinary 5-HIAA
m
se
As
Urinary hist amine
Dr
Chest x- ray CD
Urinary catecholamines GD
SeLum amylase a
Urinary 5-HIAA ED
I Urinary histamine mt
Urinary histamine is used to diagnose systemic mastocytosis

Given the history of diarrhoea and flushing a diagnosis of carcinoid syndrome should be
considered, which wou ld be investigated with urinary 5-HIAA levels. This would not
however explain the urtica rial skin lesions. In a yo ung person a diagnosis of systemic
m
se
mastocytosis should be considered. Another factor against carcinoid syndrome is the age
As
of the patient - the average age of a patient with a carcinoid tumo ur is 61 yea rs
Dr
A 30-year-old female in her th ird trimester of pregnancy mentions during an antenatal
appointment that she has noticed an itchy rash aroun d her umbilicus. This is her secon d
pregnancy and she had no similar problems in her first pregnan cy. Examination reveals
blist ering lesions in the peri -um bilical region and on her arms. What is the likely
diagnosis?
Pompholyx
Polymorphic eruption of pregnancy
Lichen planus
m
se
As
Pemphigoid gestation is
Dr
Pompt o lyx
Polymorphic eruption of p regnancy
Lichen pl anus
Pemp higoid g estation is
Polymorphic e ruption of p regnancy is not associated with b listering

m
se
Pemphigoid gestation is is the correct answer. Polymorphic eruption of pregnancy is not
As
associated with b listering
Dr
A 17-year-old male is reviewed six weeks after starting an oral antibiotic for acne vulgaris.
He stopped taking the d rug two weeks ago due to perceived alteration in his skin co lour,
and denies been exposed to strong sun light for the past six mo nths. On examination he
has generalised increased skin p ig mentation, includ ing around the buttocks. Which one of
the following antibiotics was he likely to be taking?
Doxycycline
Oxytetracycline
Tetracycline
Erythromycin
m
se
As
Minocycline
Dr
Minocycline can cause irreversible skin pigmentatio n and is now considered a second line
m
drug in acne. Photosensitivity secondary to tetracycline/doxycycline is less likely given the
se
generalised distributio n of the pigment ation an d the failure to improve following drug
As
withdrawal
Dr
A 58-yea r-old woman presents with a pe rsistent erythematous rash on her cheeks and a
'red nose'. She describes occasiona l episodes of facia l flushing. On exa mination
erythematous skin is noted on the nose and cheeks associated with occas ional
telangiectasia. What is the most approp riate management?
Topical metronidazo le
Topica l isotretinoin
Benzyl peroxide
m
Daktaco rt
se
As
Dr
Topical metronidazole GD
Topical isotretinoin CD
Benzyl peroxid e .
(D
Dakt acort
Topica l hydrocortisone
•
flD
Acne rosacea treatment:

• mild/ moderate: top ical metronid azole
• severe/resistant: ora l t etracycline
m
se
As
Given that t his woman has mild sympt oms, topica l metron idazole shou ld be used first line
Dr
A 34-yea r-old man p resents to dermatology clinic with an itchy rash on his palms. He has
a lso noticed the rash a rou nd the site o f a recent scar on his fo rea rm. Examination reveals
pa pules with a white-la ce pattern o n the surface. Some isolated white streaks are also
noted on the mu cous membranes of the mouth. What is the diagnosis?
Lichen pl anus
Sca bies
Lichen sclerosus
Morp hea
m
se
As
Pityriasis rosea
Dr
Lichen planus GD
Scabies
I
a
Lichen sclerosus tiD.
Morphea fD
Pityriasis rosea CD
Lichen
• p lanus: pu rp le, pruritic, pap ular, polygonal rash on flexor surfaces. Wickham's
striae over su rface. Oral involvement com mon
• sclerosus: itchy white spot s typica lly seen on t he vulva of elderly wo men
m
se
As
This is a typical history of lichen p lanus.
Dr
A 78-year-old nu rsi ng home res ident is reviewed due to the development of an intensely
itchy rash. On examination red linear les ions are seen on the wrists and elbows, and red
papules a re present on the penis. What is the most appropriate management?
Topica l permethrin
Referral to GUM clinic
Topica l betnovate
m
se
As
Topica l selenium sulph ide
Dr
Topical permethrin
Referra l to GUM clinic
Topical betnovate
-
~
Topical selenium sulphide
m
Lichen planus may give a similar pictu re but the intense itching is more cha racteristic of
se
scabies. It is also less com mon for lichen planus to present in the elderly - it typical affects
As
patients aged 30-60 years.
Dr
A 40-year-old man complains of widespread pruritus for the past two weeks. The itching
is particula rly b ad at night. He has no history of note and works in the local car factory.
On examination he has not ed to have a number of linear erythemat ous lesions in
between his fingers. What is the most likely diagnosis?
Polyurethane dermatitis
Fibreglass exposure
Cimex lectularius infestation (Bed-bugs)
Scabies
m
se
As
Langerhans cell histiocytosis
Dr
A 40-year-old man com plain s o f widespread p ruritus fo r the past two weeks. The itching
is particula rly bad at night. He has no history of note and works in the local car factory.
On examination he has not ed to have a number of linear erythemat ous lesions in
between his fingers. What is the most likely diagnosis?
I Polyurethane dermatitis
Fibreglass exposure
Cimex lectularius infestation (Bed-b ug s)
I Scabies
-
~
m
se
As
Lang erhans cell histiocytos is
Dr
A 31-year-old woman develops with pa inful, purple lesions on her shins. Which one of the
following med ications is most likely to be responsible?
Montelukast
Lansoprazole
Combined ora l contraceptive pill
Sodium valp roate
m
se
As
Carbimazole
Dr
Mo ntelukast m
Lansoprazole D
I Combined oral contraceptive pill GD

Sodium valproate CfD
m
se
As
Carbimazo le GD
Dr
A 24 -yea r-old woman presents due to a rash on her neck and forehead. She returned
from a holiday in Cyprus 1 week ago and had her hair dyed 2 days ago. On examination
there is a weepy, vesicu lar rash around he r ha irlin e although the sca lp itself is not bad ly
a ffected. What is the most likely diag nosis?
Cutaneous leishmaniasis
Allergic contact dermatitis
m
Syphilis
se
As
Photocontact d e rmatitis
Dr
Cutaneous le ish man iasis m
Irritant contact dermatitis CID
Allergic contact d e rmatitis ED
Syphilis m
m
se
As
Photocontact dermatitis (D
Dr
A 29-year-o ld man presents due to the development of 'ha rd skin' on his scalp. On
exam ination he has a 9cm circular, white, hyperkeratotic lesio n o n the crown of his head.
He has no past history of any skin or sca lp disorder. Skin scrapings a re reported as
follows:
No fungal elements seen
Psorias is
Dissecting cellulitis
Kerion
m
se
As
Dr
Psorias is
Dissecting cellulitis
Kerion
Sebo rrhoeic dermatitis
As the skin scra ping is negative fo r fungi the most like ly diagnosis is psoriasis. Scalp
psoriasis may occur in isolation in patients with no history of pso riasis elsewhere. Please
see the link fo r more information.
m
se
The white appearance of the lesion is secondary to the 'silver scale' covering the psoriatic
As
p laq ue.
Dr
A 21-year-o ld woman who is 16 weeks p regnant present with worsening acne which s he
is finding d istressing. She is currently usin g topical benzyl peroxid e with limited effect. On
exa mination there is wid espread no n-inflam matory lesions and pustu les on her face.
What is the most appropriate next manageme nt step?
Ora l trimethoprim
Ora l lymecycline
Ora l erythromycin
Topical retinoid
m
se
As
Ora l doxycycline
Dr
Ora l trimethoprim .
(D
Ora l lymecycline tlD

Oral erythromycin CD
Topical retinoid fD
Ora l doxycycline (D.
Acne vulgaris in pregnancy - use ora l erythromycin if treatment needed

m
se
Oral erythromycin may be used for acne in pregnancy. The other drugs are
As
contrain dicated
Dr
A 81-year-old man is investigated after he develops a number of itchy blisters on his
trunk. A skin biopsy suggests a diagnosis bullous pemphigoid. This is most likely to be
caused by antibodies directed against:
Ad herens
Desmoglein-3
Hemidesmosomal BP antigens
Occludin-2
m
se
As
Desmoglein-1
Dr
Adherens
Desmoglein-3
Hemidesmosomal BP antigens
Occludin-2
m
se
Desmoglein-1
As
Dr
A 26-year-old lady presents to you distressed due to the presence of a rash over her
thorax and abdomen fo r the last th ree weeks. On examination, you note nu merous
t eardrop lesions on her b ody.
She has no know n past medical hist ory and denies exp osure to any new irritants. She
states that she is going t o be married in 2 weeks and wants to know if there is anything
that can be done to hasten the disap pearance of her rash.
Which t herapy could th is lady b e commenced on?
Photochemotherapy (PUVA) A
Ora l p rednisolone
Dermovate
Ultraviolet B phototherapy
m
se
As
Methotrexate
Dr
Photochemotherapy (PUVA) A
Oral p rednisolone
Dermovate
~raviolet B phototherapy
Methotrexate
This patient has a class ic d escription of gutta te psoriasis. Wh ilst th is will usually self-
m
se
resolve, ultraviolet B p hotothe ra py has been known to accelerate resolution. The other
As
treatments have no ro le in the acute management o f g uttate psoriasis.
Dr
A 33-year-old lady presents complaining of facial disco lou ration. She is 26 weeks
pregnant. So far it has been an uncomplicated preg nancy. She has a background of
rheumat oid arthritis but has been o ff treatment for 2 years.
On examination she has a large, flat, symmetrical, brow n-pigmented patch across her
cheeks, forehead, nose and upp er lip.
Syst emic Lupus Erythematosus (SLE)
Melasma
Polymorphic eruption of pregnancy
Rosa cea
m
se
As
Vitiligo
Dr
System ic Lupus Erythematosus (SLE)
r-::lasma
Po lymo rphic e ruptio n of preg nancy
Rosacea
Vitilig o
-
~
m
se
Melas ma is a b enign but re latively com mo n s kin condition which ca n ap pear in
As
pregnancy. In this situatio n it may reso lve a few mo nths aher de livery.
Dr
A 17-year-old female orig inally from Nigeria presents due to a swell ing around her
earlobe. She had her ears pierced a round three months ago and has noticed the gradua l
development of an erythematous swelli ng since. On examination a keloid scar is seen.
Intra lesional d iclofenac
Advise no treatment is available
Intralesional triamcino lone
Advise will spontaneously reg ress within 4-6 months
m
se
As
Intralesional sclerothe rapy
Dr
Intralesio nal d iclofenac
Advise no treatment is ava ilab le
I lntra les ional triamcinolone
Advise will sponta neously reg ress within 4-6 months

-
"""'
m
se
As
Intra lesional scle rothe rapy
Dr
A 33-year-old woman is reviewed in the dermatology clinic with patchy, well demarcated
hair loss on the scalp. This is affecting around 20% o f her tota l scalp, and causing
s ignificant psycholog ica l distress. A d iagnosis o f alopecia areata is sus pected . Which one
o f the following is an appropriate manage ment pla n?
Topicai S-FU crea m
Autoimmune screen
Topical corticoste ro id
m
se
As
Autoimmune screen + topical ketoconazole
Dr
Topical 5-FU cream
Autoimmune screen
Topica l ketoconazole
I Topica l co rticost eroid
Autoimmune screen + top ical ket oconazole
Watchfu l wa iting for spontaneous remission is another option. Neit her the British
m
se
Associat ion o f Dermato logist s or Clinica l Knowledge Summaries recommend screen ing
As
for autoimmune disease
Dr
Each one of the fo llowing is associated with hypertrichosis, except:
Anorexia nervosa
Psoriasis
Minoxidil
m
se
As
Ciclosporin
Dr
Anorexia nervosa
Porphyria cutanea tarda
Psoriasis
Minoxidil
m
se
Ciclosporin
As
Dr
A 62-year-old with a history of acne rosacea presents fo r advice regarding t reat ment.
Which one o f t he followin g int erventions has t he least role in management?
Camouflage creams
Topical metronidazole
Low -d ose topical corticosteroid s
Laser t herapy
m
se
As
Use o f high -facto r sun block
Dr
Camouflage creams
Topical met onidazole
Low-dose top ical corticosteroids
Laser therapy
m
se
Use of high-facto r sun block
As
Dr
A 9 -yea r-o ld child with a history o f atopic eczema p resents with a sudden worsening of
her skin. Her eczema is usually well contro lled with emollients but her pa rents are
concerned as the facia l eczema has got significantly worse overnight. She now has pa infu l
clustered blisters on both cheeks, a round her mouth on her neck. Her temperature is
37.9°C. What is the most appropriate ma nagement?
Advise paraceta mol + e moll ients and reassure
Intravenous aciclovir
Potent topica l stero id
Intravenous flucloxaci llin
m
se
As
Ora l fluconazo le
Dr
Advise paraceta mol + e moll ients and reassure
r : :avenous aciclovir
Potent topical steroid
Intravenous flucloxacillin
Oral fluconazole
-
~
m
se
As
Eczema herpeticum is a serious cond ition t hat requ ires IV antivira ls
Dr
Which one of the fo llowin g statements regard ing vitil igo is true?
It is seen in a ro und 0.1% of patients
The average age of onset is 40-50 years
Skin trauma may p recipitate new skin lesions
It is rare in Cauca sia n people
m
se
As
The torso te nds to be a ffected first
Dr
It is seen in a round 0.1% of patients
-
I
The average age of onset is 40-50 years
Skin trauma may precipitate new skin lesions

-
"""
"""
It is rare in Caucasian p eo ple
The torso tends to be a ffected first
m
se
As
This is known as the Koebner p henomenon
Dr
Which one o f t he followin g statements regarding acne vu lgaris is incorrect?
Foll icular epidermal hyperp roliferation resu lts in obstruction of t he p ilosebaceous

follicle
Acne vulga ris affects at least 80% of teenagers
Propionibacterium acnes is an anaerobic bacterium
Typica l lesions include comedones and pust ules
m
se
As
Beyond the age o f 25 yea rs acne vulga ris is more common in males
Dr
Foll icular ep id ermal hyperproliferation results in obstruction of the pilo se baceou s G
fo llicle
Acne vulgaris affects at least 80% of teenagers
P ,o pionibacterium a cnes is an anaerobic bacterium
Typical lesions inclu de comed ones a nd pustu les
Beyond the age of 25 years acne vulgaris is ore com mon in males
m
se
As
Acne is actua lly mo re com mo n in fe males after the age of 25 years
Dr
A 50-year-old man with a history o f ulcerative co litis comes for review. Six yea rs ago he
had an ileostomy formed which has been functioning well until now. Unfortunately he is
currently suffering significant pain around the stoma site. On examination a deep
erythematous ulcer is not ed w ith a ragged edge. The surrounding skin is erythematous
and swollen. What is the most likely diagnosis?
Munchausen's syndrom e
Dermatitis artefacta
m
se
As
Stomal granuloma
Dr
Munch ausen's syndrome
Dermatitis artefacta
Stomal gra nuloma
Pyo de rma g angrenosum is asso ciated with infla mmatory bowel d isease a nd may be seen
arou nd the stoma site. Treatment is usually with imm unosuppressants as surgery may
worsen the p roblem
m
A differentia l diag nosis wo uld be ma lignancy and hence lesions s hould be refe rred for
se
specia list opi nion to evaluate the need fo r a b iopsy. Irritant contact d e rmatitis is co mmon
As
but wo uld not be expected to cause s uch a dee p ulcer.
Dr
Each one of the following is associated with yellow na il syndrome except:
Chronic sinus infections
Bronchiectasis
Azoospermia
Congenital lymphoedema
m
se
As
Pleural effusio ns
Dr
Chronic sinus infections
Bronchiectasis
Azoospermia
-
........
Congenital lymphoedema
-
~
m
se
As
Pleural effusions
Dr
A 34-year-old man co mes for review. Over the past two weeks he has develop ed a
number o f painf ul, erythemat ous lesions on his shins. He has no dermatologica l history of
note and is usually f it and well. On examination the lesions are consistent w ith erythema
nodosum. You arrange some baseline investi gations. He asks w hat is likely to happen.
What is the most app ropriate response?
Heal w ithout scarring if st eroids are given with in 2 weeks
Heal w ithout scarring within 6 -12 mont hs
Heal w ithout scarring within 1-2 months
Heal w ith sca rring within 1-2 months
m
se
As
Heal w ith sca rring within 6 -12 months
Dr
I Heal wit ~out scarring if steroids are given within 2 weeks
Heal without scarring within 6-12 months
I Heal without scarring within 1-2 months
Heal with scarring within 1-2 months
m
se
Heal with scarring within 6-12 months
As
Dr
Which one of t he followin g conditions is least associated wit h p ruritus?
Pemphigus vulgaris
Iron -d eficiency anaemia
Polycythaem ia
Chronic renal failure
m
se
As
Scabies
Dr
I Pemphigus vu lgaris CD
Iron -deficiency anaemia CD
Polycythaem ia m.
R onic renal failure m
Scabies m
m
se
Pemphigus vu lgaris is an auto immune bullous disea se of the skin. It is not commonly
As
a ssociated with p ruritus
Dr
Which of the following conditions is least likely to exhibit the Koebner phenomenon?
Vitiligo
Molluscum co ntag iosum
Lichen planus
Psoriasis
m
se
As
Lupus vulgaris
Dr
Vitiligo CD
Molluscum contag iosum &D
Lichen planus CD
Psorias is CD
Lupus vulgaris ED
m
se
As
Lupus vulgaris is not associated w ith the Koebner phenomenon
Dr
Which one o f t he followin g is least recog ni sed as a cause o f erythrod erma in t he UK?
Lymphoma
Drug eruption
Lichen planus
Psoriasis
m
se
As
Eczema
Dr
Lym phoma fD
Drug eruption .
(D
Lichen planus CD
Psoriasis fiD
m
se
As
Eczema fiD
Dr
A 45-year-old man develops toxic epidermal necrolysis following a cha nge in his epilepsy
medication. He is syst emically unwell and is admitted to ITU for supportive ca re. What is
the most appropriate treatment?
Cyclophosphamide
Supportive care only
Pulsed methylprednisolone
m
se
As
Pla smapheresis
Dr
Intravenous immunoglobulin GD
c r clophosphamide CD
Supportive care only tD
Pulsed methylprednisolone f!D
m
se
As
Plasmapheresis CD
Dr
A 74-yea r-old lady with a history of hypothyroidism presents in January with a rash down
the right side of her body. On examination an erythematous rash with patches of
hyperpigmentation and telangiectasia is fou nd. What is the likely diagnos is?
Erythema marginatum
Herpes zoster
Pretibial myxoedema
Erythema ab igne
m
se
As
Xanthomata
Dr
Erythema ma rginatum fD
IH~rpes zoster CD
Pretibial myxoedema CfD
I Erythema ab igne ED
Xanthomata CD
This is a classic presentation of erythema ab igne. Desp ite the name, p retibial myxoedema
is associated with hyperthyro idism rather than hypothyroidism.
m
se
Hypothyroidism can make patients feel co ld and hence more likely to sit next a heater I
As
fire .
Dr
A 78-year-old man asks you to look at a lesion on the right s ide of nose which has been
gett ing slowly bigger over the past 2-3 months. On exa mination you observe a rou nd,
raised, flesh colou red lesion wh ich is 3mm in diameter a nd has a central depression. The
edges o f the lesion appear ro lled an d contain some tela ngiectasia.
What is the single most like ly diag nosis?
Molluscum contag iosum
Actinic keratosis
Malignant melanoma
m
se
As
Basal cell ca rcinoma
Dr
Molluscum contagiosum tiD
Actinic keratosis m.
Squamous cell carcinoma f!D
Malignant melanoma m
I Basal cell carcinoma CD
m
se
I
As
This is a classic description of a basal cell carcinoma.
Dr
A 54-year-old man present s w ith a brown velvety rash on the back of his neck arou nd his
axilla. A clinica l diagnosis o f acanthosis nigricans is made. Which one of the fo llowing
conditions is most associated with this ki nd of rash?
Hypothyroi dism
Psoriasis
Tub erculosis
Ulcerative colitis
m
se
As
Acute pancreatitis
Dr
I Hypothyroidism 6D
Psoriasis fD
Tuberculosis D.
Ulcerative colitis GD
m
se
As
Acute pancreatitis GD
Dr
A 54-yea r-old man presents with a two month history of a rapidly growing lesion on his
right forearm. The lesion initially appea red as a red papu le but in the last two weeks has
become a crater filled centrally with yellow/brown mate rial. On examination the man has
skin type II, the lesion is 4 mm in diameter and is morphologically as described above.
Keratoacanthoma
m
se
As
Maligna nt melanoma
Dr
Seborrhoeic keratosis CD
I Keratoacanthoma CD
Pyoderma gangrenosum G'D
Basal cell carcinoma CD
m
se
As
Malignant melanoma CD
Dr
~
A 64-year-old female is referred to dermatology due to a non-healing skin ulcer on her
lower leg. This has been present for around 6 weeks and the appearance didn't improve
following a cou rse of oral flucloxacillin. What is the most importa nt investigation to
perform first?
MRI
Rheumatoid factor titres
Swab of ulcer for culture and sensitivity
m
se
As
X-ray
Dr
MRI
Rheumat oid fact or titres
Swab of ulcer for cu lture and sensitivity
X-ray
An ankle-brachial pressure index measurement would help exclude arterial insufficiency

as a contributing facto r. If this was abnormal then a referral to the vascu lar surgeons
should be considered.
If the ulcer fa ils to heal with active management (e.g. Compression bandaging) then
referral for consideration of biopsy to exclude a malignancy should be made.
m
se
As
Ongoing infection is not a common cause of non-healing leg ulcers.
Dr
A 52-year-old African-American woman p resents to the dermatology department. She
has noticed a patch of pigmented skin on her toe, which has been s lowly en larg ing over
the past five months. On exam ination, she has pigmentation of the nail bed of her g reat
toe, affecting the adjacent cuticle and p roxima l nail fo ld. Wh ich subtype of melanoma
wou ld you expect to p resent in this manner?
Superficial spreading melanoma
Acral lentig inous melanoma
Nodu la r melano ma
m
se
As
Ame lanotic melano ma
Dr
Superficial spreading melanoma
Acra l lentiginous melanoma
Nodular melanoma
Ame lanotic melanoma
Acral lentiginous melanoma: Pigmentation of nail bed affecting proximal nail fold
suggests melanoma (Hutchinson's sign)
Acra l lentiginous melanoma is the rarest form of melanoma overall, but the commonest
fo rm of melanoma in people with darker ski n. Hence it is important to be able t o
recognise.
Acra l lentiginous melanoma mostly affects people over the age of 40 and is equally
common in males and females. It is not related to sun exposure. It typically present s as an
enlarging discoloured ski n patch on the palms, fingers, soles or toes with the
characteristics of other flat forms of melanoma. It can arise in the nail unit, appearing as
general discolouration or irregular pigmented bands runn ing longitudinally along the nail
plate and is called subungual melanoma when it arises in the matrix.
This patient has subungual acral lentiginous melanoma with an important clin ica l clue of
this called 'Hut chinson's nail sign'. This sign is characterised by ext ension of the nail bed,
matrix and nail plate pigmentation t o the adjacent cuticle and proximal o r lateral nail
folds.
The other forms of melanoma are less likely to present in this way and are described in
more detail in the not es below
s em
As
(DermNet NZ)
Dr
A 22-year-old male is referred to dermatology clinic with a longst anding problem of
bilateral excessive axillary sweating. He is otherwise well but the condition is affecting his
confidence an d limiting his social life. What is the most appropriat e management?
Non -sedating antihistamine
Topical hydrocortisone 1%
Perform thyroid function t est s
Topical aluminium chloride
m
se
As
Trial of desmopress in
Dr
Non -sedating antihistamine
Topical hydrocortisone 1%
Perform thyroid fu netion tests
Topical aluminium chloride
m
se
As
Trial of desmopressin
Dr
Which one o f the following featu res is least likely to be seen in a patient w ith pellagra?
Diarrhoea
Depression
Dysphagia
Dermatitis
m
se
As
Dementia
Dr
Diarrhoea m
Depression D.
Dysphagia fD
Dermatitis
Dementia
•m
m
se
As
Depression is quite a common early find ing in patients with pellagra
Dr
Which one o f the fo llowin g side -e ffects is least recogn ised in patie nts ta kin g isotreti noin?
Hypertension
Te ratogenicity
Nose bleed s
Depress ion
m
se
As
Ra ised trig lycerid es
Dr
I Hypertension CI!D
Teratogenicity fD
Nose bleeds CD
Depression GD
Raised trig lycerides GD
Isotretinoin adverse effects

• t eratogenicity - females MUST be t aking contraception
• low mood
• dry eyes and lips
• raised trig lycerides
• hair thinning
• nose b leeds
m
se
As
Hypertension is not listed in the Brit ish National Formulary as a side-effect
Dr
A 3 -yea r-o ld girl is ta ken to her doctor due to a rash on the rig ht uppe r a rm. On
exam ination mu ltiple raised les io ns o f a bout 2 mm in diamete r are seen. On close
inspection a centra l dimple is present in the majo rity o f lesions. What is the like ly
diag nosis?
Roseola infant u m
Molluscum contag iosum
Kawasaki disease
Viral warts
m
se
Pityriasis rosea
As
Dr
Roseo la infantum
Molluscum contagiosum
Kawasaki disease
Viral warts
m
se
As
Pityriasis rosea
Dr
A 48-year-old presents with diarrhoea and co nfusion. He is known to be alcohol
dependent, having p reviously had several admission with alcoho l toxicity. He consumes
45 units of alcohol per week, and has had previous a dmissions for aspiration pneumonia.
He denies head trauma. On exam ination he appears confused and anxious, and there is a
rash a rou nd his neck which appears to be in sun exposed areas. It appears pigmented. A
CT scan of the head is normal. What deficiency would most like ly explain his
presentation?
Thiamine
Vita min A
Vita min C
Nia cin
m
se
As
Riboflavin
Dr
Thiamine ED
Vitamin A m
m
Niacin GD
Riboflavin
•
The correct answer is niacin. Niacin d eficiency, or pellagra, typica lly presents as the triple
com bin ation of d ementia, diarrhoea and d ermatiti s. The d ermatitis is a p hotosensitive
pigment ed dermatitis. The significant alcohol histo ry makes niacin deficiency very likely.
Thiamine d ef iciency causes beriberi and Wernicke-Korsa koff syndrome, neithe r w hich
wou ld exp lain his rash. Vitamin C deficiency causes scurvy which is associat ed w ith
bleeding and gum ulceration.
Source:
m
se
Pzirand eh, Sassan, and David L. Burns. 'Overview of W ater-soluble Vitamins.' UpToDate.
As
N.p., OS Jan. 2017
Dr
A 55-year-old man presents with multiple erythematous target lesions two days aher
starting a new medication. Which one of the fo llowing d rugs is most like ly to have been
started?
Levetiracetam
Olanzapine
Carbamazepine
Fluoxetine
m
se
As
Diazepa m
Dr
Levetiracetam .
(D
Olam apme .
(D
Carbamazepine GD
Fluoxetine
•
Diazepa m
•
m
se
This patient appears to have erythema multiforme which is a known complication of
As
carbamazepine use
Dr
A 26-yea r-old newly qualified nu rse p resents as she has d eve loped a bilatera l
erythematous rash on both hands. She has recently em igrated from the Phil ipp ines a nd
has no past medical history of note . A diagnos is of contact d e rmatitis is susp ected. What
is the most suitab le to test to identify the underlyi ng cause?
Radioa llergoso rbent test (RAST)
Latex Ig M levels
Skin prick test
Urina ry porphyrins
m
se
As
Skin patch test
Dr
Radioallergosorbent test (RAST) .
(D
Latex IgM levels CD
I Skin ~rick test CD

Urinary porphyrins CD
I Skin patch test GD
m
se
The skin patch test is usefu l in th is situation as it may also identify for irritants, not just
As
allergens
Dr
A 34-year-old patient who is known to have psoriasis p resents with erythematous skin in
the groin and genita l a rea. He also has erythematous skin in the axilla. In the past he has
expressed a dislike o f messy o r cumbersome creams. What is the most appropriate
treatment?
Topical stero id
Topical d ith rano l
Topica l clotrimazole
Coa l tar
m
se
As
Topical calcipotrio l
Dr
Topical ste roid 6D
Topical a ithranol flD
Topical clotrimazole CD
Coal tar (fD
Topical calcipotriol .
ED
Flexural psoriasis - top ical steroid

m
This patient has flexural psoriasis which responds well to topical steroids. Topical
se
As
calcipotriol is usually irritant in flexu res. Mild tar preparations are an option but may be
messy and cumberso me.
Dr
A 34-yea r-old fema le is reviewed in the dermatology clinic with a skin rash under he r new
wrist watch. An al lergy to nickel is suspected. What is the best investigation?
Skin prick test
Skin patch test
Skin biopsy
Serum IgE
m
se
As
Serum nickel antibodies
Dr
Skin prick test (fD
I Skin patch test GD

Skin biopsy a
Ser m IgE CD
m
se
m
As
Serum nickel antibodies
Dr
A 22-year-old male sex worker co mes t o the Emergency department wit h an
erythematous skin rash. He t ells you t hat it b egan on his sca lp, and is now spreading to
involve his face, neck, and t he flexor surfaces of his arms and legs. He has no significant
past medical hist ory and takes no regular medication. Blood pressure, pulse and
t emperat u re are all normal. Respirat ory and abdom inal examination is unremarkab le.
There are extensive erythematous scaly plaques, the o verlying skin is greasy and there are
areas of yellow I brow n crust ed material.
Which o f the follow ing t est s is most important in t his sit uation?
Autoimmu ne prof ile
Herp es PCR
HN t esting
Skin scrapings for microsco py and culture
m
se
As
Syphilis serolo gy
Dr
Autoimmune profile
Herp es PCR
•m .
I HN t esting ED
Skin scrapings for microscopy and culture fD
Syphilis serology GD
HN is associated w ith seborrhoeic dermatitis

Th is man's presentation is consistent with seborrhoeic dermatitis, and given his

occupation as a male sex worker, there is a high risk this may be associated w ith HIV
inf ection. p 24 antigen t esting may be useful in the early st ages of HIV infection for
screening, in the later st ages of inf ection serology for anti-HIV antibodies is most useful.
The ext ensive plaques count against this being a fungal infection, which would usually be
confined t o one area, ruling out taking skin scrapings as b eing useful. Seborrhoeic
dermatitis may be associated w ith aut oimmune thyroid disease, although we're g iven no
m
evidence t o support a diagn osis o f thyroid dysfunction here. Syphili s is unlikely given
se
there is no hist ory of primary syphilis infection, and herp es PCR is not useful in
As
determining the underlying cause of seborrhoe ic dermatitis.
Dr
A 50-year-old chronic alcoholic present s with a persistent skin ras h on his hands, arms,
neck and face. The rash is red -brown in colour, symmetrica l and scaly. He also complains
of a poor appet ite, nausea and diarrhoea. Which vitam in d ef iciency is most likely to have
caused his sym ptoms?
Niacin
Folic acid
Thiamine
Vitamin 86
m
se
As
Zinc
Dr
Niacin CD
Folic acid D
Th iamine CD
Vita min B6 m
Zinc (D
m
Niacin (B3) deficien cy is ch aracterised by d ermatit is, diarrhoea and dement ia, a
se
condition known as pellagra
As
Dr
A 54-yea r-old woman who has had a hysterecto my presents for a dvice about hormone
re placement therapy. Wh ich one of the following would result from the use of a
combined oestrogen-progestogen preparation compared to an oestrogen-only
p reparation?
Decreased risk of venous thromboembolism
Increased risk of a stroke
Increased risk of b reast cancer
Increased risk of endometrial cancer
m
se
As
Better control of symptoms
Dr
Decreased risk of venous thromboembolis m
Increased risl< of a stroke
Increased risk of breast cancer
Increased risk of endometrial cancer
Better control of symptoms
HRT: adding a prog estogen increases the risk of brea st cancer

This is the rationale behind giving women who 've had a hysterectomy oestrogen-only
m
se
treatment. The BNF states that the stroke risk is the sa me reg a rdless o f whether the HRT
As
p reparation contains progesterone.
Dr
Which one of the following increases the risk of developing peripheral oedema in a
patient taki ng pioglitazone?
Concomitant use with g liclazide
Serum sodium < 140 mmol/1
Concomitant use with insulin
Concomitant use with metformin
m
se
As
Serum potassium < 4.0 mmol/1
Dr
Concomitant use with gliclazide fD
Serum sodium < 140 mmol/1 fD
Concomitant use with insulin tD
Concomitant use with metformin f!D
m
se
Serum potassium < 4.0 mmol/1 fD
As
Dr
A 54-year-old man has a routine medical for wo rk. He is asympt omatic and clinical
examination is unremarkable. Which of the following results establishes a diagnosis of
impaired fasting glucose?
Fasting glucose 7.1 mmoi/L on one occasion
Fasting glucose 6.8 mmoi/L on two occasions
Glycosuria + +
75g o ral glucose t olerance t est 2 hour value of 8.4 mmoi/L
m
se
As
HbAlc of 6.7%
Dr
Fasting g lucose 7.1 mmoi/L on one occasion
I Fasting g lucose 6.8 mmo i/L on two occasions
Glycosuria + +
175g o ra l glucose tolerance test 2 hour value of 8.4 mmoi/L

HbAlc of 6.7%
-
........
m
se
A 75g o ral g lucose to lerance test 2 hou r value of 8.4 mmoi/L wou ld imply impa ired
As
g lucose to le rance rather than impaired fasting g lucose
Dr
A 45 -year-old man presents with bitempora l hemianopia and spade-li ke hands. What is
the definite t est to confirm the diagnosis?
Early morning growth hormone
Insulin tolerance test
Ora l glucose tolerance test with growth hormone measurements
Rando m insulin-like growth factor 1 (IGF-1)
m
se
As
Short ACTH test
Dr
Early morning g rowth ho rmone
Insu lin tole rance test
F l g lucose to lerance test with growth ho rmone measu rements
Random insulin -like g rowth factor 1 (IGF-1)
Short ACTH test

-
. .wr
The d iagnostic test for acromegaly is an oral g lucose to lerance with growth
m
se
hormone measurements
As
Dr
Which one o f the following is least associated wit h gynaecomastia?
Klinefelter's syndrome
Seminoma
Liver disease
Puberty
m
se
As
Hypothyroidism
Dr
Klinefelter's syndrome tiD
Seminoma f.D
Liver disease CD
Puberty tiD
Hypothyroi dism ED
m
se
As
Gynaecomastia is seen in up to a th ird of men with t hyrot oxicos is, but is not a feature of
hypothyroidism
Dr
A 73-yea r-old female p resent with urge inco ntinence having a sign ificant impact on he r
qua lity o f life. She has undergone supervised bladder tra ini ng with no improvement in
sympto ms a nd is keen to tria l medication. She has a past medical history of atrial
fibrillation, well -controlled hypertension and recurrent urinary retention.
What wou ld be the most app ropriate first -li ne treatment?
Mirabegron
Oxybutyn in
Pelvic floor exercises
Tolterodine
m
se
As
Su rgical re pai r
Dr
I Mirabegron eD
Oxybutynin fD
Tolte rodine
•
fD
Surgical repair CD
~
Ant icho linergics fo r u rge incontinence are associated with co nfus ion in eld erly
people - mirab egro n is a preferable alt ernative
The key to t his question is to recognise that antimuscarinics the usual treatm ent for urge
incontinence are contraindicated in patient s with a history of urin ary retention. As such
mirabegron is the correct answer.
Oxybutynin is an antim uscarinic and would be contraindicated in this patient.
Pelvic floor exercises are used in the treatment of stress incontinence and are unlikely to
have an effect in patients with pure urge incontinence.
Tolterodine is also an antimuscarinic and shou ld not be used in a history of u rinary

ret ention.
em
Surgical repair would be used in patient s with stress incontinence that has not improved
s
As
with pelvic floor exercises and as such is not the correct answer.
Dr
A 36-yea r-old wo ma n who p resented with a goitre is diag nosed with autoimmu ne
thyro iditis. Which one of the fo llowing types o f thyroid cancer is she predisposed to
d eve loping?
Ana pla stic
Lym phoma
Medullary
Foll icular
m
se
As
Pa p illary
Dr
Anapla stic CD
Lym phoma ED.

Medullary flD
Follicular .
f!D
Papillary CD
m
Hashimoto's thyroiditis is associated with thyro id lymphoma
se
As
Dr
An 80-year-old man is adm itted with a 3 month history of gradua l decline and dizziness
on standing, followed by a 3 day history of inability to mobilise, general weakness and
nausea. The medical consultant asks you to perform a short synacthen test which returns
as no rmal. Which cause of adrenocortical insufficiency has not been excluded?
Infiltration of the adrenal gland by amyloidosis
Enlarging pitu itary mal ignancy
Haemorrhage into the adrenal gland
Autoimmu ne adrenal failure
m
se
As
Infiltration of the adrenal gland by tuberculosis
Dr
Infiltration of the adrena l g land by amylo id osis
~arging pitu ita ry malign ancy

Haemorrhage into the a drena l gland
Autoimmu ne ad re nal failure
Infiltration of the adrena l g land by tuberculosis
A norma l short synacthen test does not exclud e ad renocortical insufficiency due to
p itu itary failure
The sho rt Synacthen test is a metho d of excluding adrenal insufficie ncy. A b aseline
cortisol level is ta ken, IV synthetic ACTH is the n ad ministe red a nd a second cortiso l level is
ta ken 30 mi nutes late r. If the co rtiso l post ACTH rises to > 420 nmoi/L at 30 mi nutes, the
a d rena l response to ACTH is ad eq uate and Addison's disease (adrenal fa ilure) can b e
excluded .
Howeve r, this exclud es only primary ad renal fa ilure a nd d oes not exclude cortisol
d eficiency second a ry to fa ilure o f the p ituitary to pro duce ACTH. The correct a nswe r is
the refo re pit uitary fa ilure d ue to d a mag e by an e nlarg ing ma lig nancy. The othe r a nswe rs
a ll cause da ma ge to the adrenal gla nd.
m
se
NICE CKS: Ad dison's disease
As
https:/ / cks.n ice.o rg .u k/ a dd isons-d isease

Dr
A 36-yea r-o ld fe male with a BMI of 34 kg/m" 2 is reviewed after ma na ging to lose 3 kg in
the past month. She asks about the poss ibility o f starting a drug to help her lose weig ht.
What is the p rimary mode o f action of orlistae
Leptin antagon ist
Pancreatic lipase inhibito r
Prevents intestinal a bso rption of low-density lipoproteins
HMG-CoA reductase inhibitor
m
se
As
Centrally-acting appetite su ppressant
Dr
Leptin antagonist
I Pancreatic lipase inh ibito r
Prevents intestina l absorption of low-density lipoproteins
HMG -CoA reductase in hibitor

-
~
Centra lly-acting appetite supp ressant
m
se
The primary mod e of action of o rli stat is to inhib it pancreatic lipases, which in turn wil l
As
d ecrease the absorption of lipids from the intestine
Dr
A 45-yea r-old woman presents with weight gain and recu rrent 'dizzy' episodes. Over the
past four mo nths she has gained 20 kg . The episodes occur on a n a lmost da ily basis and
are characterised by blurred vision, sweating, headaches and palpitations. Her GP checked
a blood suga r during one of these episodes which was reco rd as being 1.4 mmol/1. What
is the single most useful test?
Glucagon stimu lation test
Oral glucose to lerance test with growth hormone measu rements
Insulin + C-peptid e levels durin g a hypoglycaem ic episode
Short ACTH test
m
se
Insulin tole rance test
As
Dr
Gluj'agon stimulati on test
Oral gluco se tolera nce test with growth ho rmone measu rements
~ulin + C-peptide levels during a hypoglycaemic epiJ de
Short ACTH test
This patient has sympto ms typical o f a n insul inoma. Whi lst supervised fasti ng is normally
m
se
the investigatio n of choice if this option is not given then insulin + C-peptid e levels
As
d u ring a n acute hypog lyca em ic e pisod e are useful.
Dr
A 32-year-old woman who is 24 weeks pregnant w ith her third child comes to the clinic
for review. She has b een diagnosed w ith gest ational diabetes mellitus, an d a fasting
plasma glucose following 2 weeks of adherence to lifestyle changes is still elevated at 6.8
mmol/1. Her blood pressure is 122/ 82 mmHg, and her body mass index is 25 kg/ m 2• She is
reluctant to start insulin initially because her sister has Type 1 diabet es and suffers from
frequent hypoglycaem ia.
Which o f the follow ing is the most appropriate next int ervention?
Metformin
Glibenclamide
Insu lin glargine
Dapagliflozin
m
se
As
Insu lin pump therapy
Dr
I Metformin GD
Glibenclamide
Insulin glargine
•
(D
~apagliflozin CD
Insulin pump therapy f.D
Metf ormin is the first line therapy of choice for diabetes in pregnancy
Metformin has been evaluated in a large Australasian trial for the treatment of gestational
diabetes mellitus. Versus insulin initiation at the point of diagnosis, those patient s treated
with metformin gained less weight during pregnancy and su ffered slightly fewer episodes
of hypoglycaemia. There was no difference in the primary endpoint of adverse foet al
outcomes, and women treated with metformin first preferred this option, even though
most eventually progressed to insulin in addition to oral therapy. This has precipitat ed
NICE to recommend metformin as a first line option where fasting glucose is less than 7.0
mmol/1despite diet ary modification.
https://www.nejm.org/doi/fuii/10.1056/ NEJMoa0707193
https:/ /www.nice.o rg.uk/gu idance/ng3
Althou gh glibenclamide is safe in pregnancy it does not limit weight gain and control is
inferior t o insulin therapy. It's therefore only an option in patients who refuse metformin
and insulin. Out of the insulin options listed, insulin pump the rapy is preferred, althou gh
many women find it more difficu lt to comply with pump therapy and are therefore treated
with a basal bolus regimen. There is no evidence to support the use of SGLT-2 inhibitors
em
such as dapagliflozin in pregnancy. One problem which leads to diabet es is relative insulin
s
As
resistance, which SGLT-2 inhibitors will not significantly impact upon.

Dr
An elderly male of no f ixed abode with a history of alcohol dependency and chronic liver
disease is taken to the Emergency Department w ith reduced consciousness (GCS 5) and a
blood glucose of 1.3 mmoi/L.
What is the correct management of his hypoglycaemia?
I M Glucagon STAT
Lucozad e
lOOm I IV Normal Saline
lOOm I IV Dextrose 5%
m
se
As
lOOm I IV Glucose 20%
Dr
IM Glucagon STAT fD
Lucozad e m
l OOm I IV Normal Saline m
lOOm I IV Dei rose 5% (f.D
lOOm I IV Glucose 20% ED
Hypoglycaem ia in patie nts with a lco ho lic liver disease d oes not respo nd to
gluca gon
Patients with alcohol ic live r d isease have depleted glycogen sto res, therefore, treatment
with g lucagon does not improve b lood g lucose.
It is not safe to use the o ral route when the patient is GCS 5, there fo re, adm inistering
Lucozade is not appropriate.
Norma l sali ne d oes not correct hypoglycaemia.
5% d extrose is a ma intenance flu id and not appropriate for acute treatment of

hypoglycaemia.
m
se
As
Therefore, the correct a nswer is lOOm I IV Glucose 20%.

Dr
What is the mechanism of action of exenatide?
Glucagon inhibitor
Dipeptidyl peptidase-4 (DPP-4) inhibit or
Glucagon-like peptide-1 (GLP-1) mimetic
Increti n inhibitor
m
se
As
Alpha-glucosidase inhibitor
Dr
Glucagon inhibitor fD
Dipeptidyl peptidase-4 (DPP -4) inhibit or GD
I Glucagon-like peptide-1 (GLP-1) mimetic fiD

Incretin inhibitor m
Alpha-glucosidase inhibitor fD
m
se
Exenatide = Glucagon- like peptide-1 (GLP-1) mimetic
As
Dr
An 85-year-old comes fo r review. She has recently had private health screen ing and has
been advised to see a doctor reg ard ing he r thyroid function tests (TFTs).
TSH 9.2 m U/ L
Free t hyroxine 14 pmoi/L
She is currently we ll and asympto matic. What is the most ap propriate management?
Sta rt levothyroxine
Sta rt carb imazole
Ord er a thyroi d ultrasou nd scan
Sta rt levothyroxine + ca rb imazole ('blo ck and re pla ce ')
m
se
As
Repeat TFTs in a few months time
Dr
I Start levothyroxine
Start carb imazole
Order a thyroi d ultrasound scan
Start levothyroxine + carb imazole ('block and replace')
Repeat TFTs in a few months time
m
se
This patient has subclinica l hypothyro idism. By both the TSH and age criteria advocated
As
by NICE Clin ical Knowledge Summa ries she shou ld be mon ito red for now.
Dr
What chromosome abnorma lity is associated w ith Klinefelter's syndrome?
47, XO
47, XXV
46, XXV
47, XYY
m
se
As
47, xxo
Dr
47, XO fD
I
47, XXV
46, XXV
GD
GD
47, XYY CD
47, xxo CD
m
se
Klinefelter's - 47, XXV
As
Important for me Less · moc rtC~nt
Dr
A 51-year-old wo man who is known to have poo rly contro lled type 1 diabetes mellitus is
reviewed. Her main presenting complaint is bloati ng and vo miting after eating. She also
notes that her blood glucose readings have b ecome more erratic recently. Which one o f
the following medications is most likely to be beneficial?
Helicobacter pylori eradication therapy
La nsoprazole
Am itriptyline
Metoclopramide
m
se
Cyclizine
As
Dr
Dr
As
se
m
A 33-year-old woman presents with weight loss and excessive sweating. her pa rtner
reports that she is 'on edge' all the ti me and d uring the consu ltation you noti ce a fine
tremor. Her pu lse rate is 96/ mi n. A large, non-tender goitre is noted. Examination of her
eyes is un rema rkable with no evidence of exophthalmos.
Free T4 26 pmolfl
Free T3 12.2 pmol/1 (3.0- 7.5)
TSH < 0 .05 mu/1
Toxic mu ltinodu lar goitre
Hashimoto's thyroiditis
T3-secreting adenoma
De Querva in 's thyroiditis
m
se
As
Graves' disease
Dr
I Toxic multinodu lar goitre GD
Hashimoto's thyroiditis m '
T3-secreting a denoma fD
fD
..
De Querva in's thyroid itis
I Graves' disease
Graves' disease is the most co mmon cause of thyrotoxicos is

m
se
Only aro und 30% of patients with Graves' d isease have e ye disease so the absence of eye
As
signs does not exclude the d iagnosis.
Dr
Which one of the following drugs is least likely to cause gynaecomastia?
Spironolactone
Sodium valp roate
Digoxin
Cimetidine
m
se
As
Anabolic stero ids
Dr
Spironolactone CD
I Sodium valproate ED
Digoxin tiD
Cimetid ine GD
Anabolic steroids CD
m
se
Whil st sodi um va lproate may rarely causes gynaecomastia it is much more co mmon after
As
ta king the othe r listed drugs.
Dr
A 56-year-old female is admitted to ITU wit h a severe p neumonia. Thyroid f unction tests
are most likely to show:
TSH normal; thyroxine high; T3 high
TSH normal I low; thyro xine low; T3 low
TSH high; thyroxine low; T3 low
TSH low; thyroxine high; T3 high
m
se
As
TSH high; thyroxine normal; T3 high
Dr
TSH normal; thyroxin e high; T3 high GD
I TSH normal I low; thyroxi ne low; T3 low CD

TSH high; thyroxine low; T3 low GD
TSH low; thyroxin e high; T3 high m.
m
se
GD
As
TSH high; thyroxine normal; T3 high
Dr
What is the mechanism o f action of thiazolidinedi ones?
PPAR-gamma receptor a ntagonist
PPAR-alpha receptor antagon ist
PPAR-alpha receptor agonist
PPAR-gamma receptor ago nist
m
se
As
Increases endogenous in su lin secretion
Dr
PPAR-gamma receptor ant ag onist
PPAR-alpha receptor antag onist
PPAR-alpha re eptor agonist
PPAR-gam ma receptor agonist

-
~
Increases end ogenous insu lin secretion
Glitazones are agonists of PPAR-gamma recepto rs, reducing peripheral insulin
m
se
resistance
As
Dr
A 45-yea r-old man is reviewed in the d ia betes cl inic. The following resu lts are obta ined:
Urinal ysis NAD
HbA lc 69 mmoljmol
Gl iclazide is ad ded to the metformin he already takes. What is the minimum time period
after which the HbAlc s hould be repeated?
6 months
1 month
2 weeks
3 months
m
se
As
4 months
Dr
I 6 months CD
1 month
2 weeks
•m
3 months fD
4 months m
m
se
A more accu rate answer wou ld p roba bly be 2 months but this is not given as an optio n.
As
See the exp la nation below
Dr
A 34-yea r-o ld fema le p resents with feve r a nd lowe r abdom ina l pain. Ove r the past five
d ays she has noticed d eep dyspareu nia and some po st-co ita l bleed ing . Her last period
beg an 10 days ago . She is diffusely tender in the suprap ubic area an d vag ina l exam ination
revea ls cervical e xcitation. Endocervical swabs a re take n. A d ia gnos is of pelvic
inflammatory d isease is suspected . What is the most ap pro p riate management?
Oral doxycycline
Await endocervical swab resu lts
Oral amoxicill in + ciprofloxacin
Oral doxycycline + cip rofloxacin
m
se
As
Oral o floxacin + metro nid azo le
Dr
Ora l doxycycline
Await endocervical swab results
Ora l amoxicillin + ciprofloxacin
Oral doxycycline + cip~ofloxacin

Oral ofloxacin + metronidazole
-
~
m
se
Consensus guidelines reco mmend treatment on ce a diagnosis of pelvic inflammatory
As
disease is su spect ed, rather than waiting for the results of swabs
Dr
A middle-aged man with type 2 diabetes mellitus is reviewed. Despit e wei ght loss,
metformin and gliclazide his HbAl c is 68 mmol/mol (8.4%). The patient agrees to start
insu lin therapy. According t o NICE guidelines which type of insu lin should b e tried
initially?
Basal bolus regime
Isophane (NPH insu lin)
Biphasic insulin
Glargine
m
se
As
Detemir
Dr
Basal bolus reg ime ED
lsophane (NPH insulin) ED.
Biphasic insulin CD
Glargine f!D
Detemir m
rom NICE Clinica l Knowledge Summaries:
'he National Institute for Health and Care Excellence (NICE) recommends that in adults
vith type 2 diabetes:
• Neutral Protamine Hagedorn (NPH) insulin [also known as isophane insulin] (injected
once or twice daily according to need) should be offered.
• NPH plus a short-acting insulin should be considered (particularly if the person's
HbAlc is 75 mmoVmol [9.0%] or higher). This may be administered either separately
or as a pre-mixed (biphasic) human insulin preparation.
• Insulin detemir or insulin glargine should be considered as an alternative to NPH
insulin if.·
• - The person needs assistance from a carer or healthcare professional to inject insulin
and the use of insulin detemir or insulin glargine would reduce the frequency of
injections from twice to once daily, or
• - The person's lifestyle is restricted by recurrent symptomatic hypoglycaemic
episodes, or
• - The person would otherwise need twice-daily NPH insulin injections in combination
em
with oral antidiabetic drugs.

s
As
Dr
A 68-year-old female with a backgrou nd of stage four chron ic kidney disease (CKD)
presents w ith the follow ing blood results to the nephrology cli nic. She has had
progressive CKD over many years following a diagnosis of IgA nephropathy in her third
decade.
PTH 19.1 pmol/ 1 (1.05- 6 .83)
Adjusted calcium 2.84 mmol/1 ( 2. 1-2.6)
What endocrine abnormality is she most likely to have given her background?
Tertiary hyperparathyroidism
Secondary hyperparathyroidism
Multiple endocrine neoplasia 1 (MENl)
m
se
As
Dr
I Tertia ry hyperparathyroidism
R ltiple endocrine neoplasia 1 (M ENl)
The correct answer is tertiary hyperparathyro idism. The PTH level is inappropriate given
the high calcium level indicating autonomous hypersecretion o f PTH. Although such
results coul d be possible w ith primary hyperparathyroidism, the long history of renal
impairment points t owards te rtiary hyperparathyroidism as the hypertrophied parathyroid
glands no longer respond to serum calcium levels. Tertiary hyperparathyroidism occurs
after long t erm secondary hyperparathyroidism.
• PTH over-secretion usually from a parathyroid adenoma
• both PTH an d calcium are elevated
• surgery t o remove the adenoma is the most effective treatment
• conservative measures such as bisphosphonat es can be used
• occurs in chron ic kidney disease typically
• can be secondary to vitamin D deficiency
• PTH released due to low calciu m, high phosphate and lack of vitam in D activation
by diseased kidneys
• PTH level high with calcium levels being low or normal
• medica l management primarily: phosphat e binders, calcium and vit amin D
supplementation
Tertiary hyperparathyroidism
• autonomous hypersecretion of PTH due to hypertrophied parathyroid glands
• occurs after a p eriod o f long standing secondary hyperparathyroidism
• treatment involves pa rathyroidectomy
Pseudohypoparathyroidism is caused by PTH resistance and is associat ed with low

em
calciu m and high PTH levels. MENl is a rare hereditary disorder involving multiple types
s
As
of endocrine tissue neoplasia.

Dr
Yo u have b ee n asked to review a 52-year-o ld wom an in the e me rgency department with
dyspnoea accompanied by nausea and vom itin g. She tells yo u that she initially attributed
this to a flu -like illn ess but as s he fou nd herself beco ming in creasingly short o f breath she
was take n to hosp ita l by he r concerned husba nd. He r past med ical history is s ignifica nt
fo r type 2 d iabetes mellitus, hypertensio n and ob esity. Her cu rre nt medi cations include
metfo rmin lg ram bd, ca na gliflozin lOOmg od, ram ipril l Omg od a nd am lod ipine Smg od .
On exam ination she has a res pirato ry rate o f 25 b reaths/ min, blood pressure 130/ 67
mmHg, pu lse 105 b pm a nd oxyge n saturatio n of 98% on room a ir. The only finding yo u
elicit on p hysica l exa mination is mild te nd e rness in the ep igastric a rea. He r ECG shows a
s inus tachycardia . Routine blood results a re s hown below:
Hb 167 g/ 1 Na• 132 mmol/ 1 Bilirubin 22 IJmOI/1 pH 7.14
Plat elet s 410 * 109/ 1 K• 5.5 mmol/1 ALP 100 u/1 Pa0 2 12 KPa
8
WBC 11.2 109/ 1 Urea 10.4 mmol/ 1 ALT 55 u/1 PaC0 2 1.9 KPa
8
Neuts 10.0 109/ 1 Creatinine 111 IJmOI/ 1 yGT 23 u/1 HC0 3- 111JmOI/ I
Lymphs 1. 1 * 109/ 1 Amylase 32 1 U/ 1 Albumin 33 g/1 Lactat e 3.0 mmoljl
Eosin 0 . 1 * 109/ 1 Cl' 101 mmol/ 1 Urine Ketones 3+ Glucose 11mmoi/L
Sma ll bowel obstruction
Metfo rmin induced lactic acidos is
Sta rvation ketos is
Eug lycaem ic d iabetic keto acidosis

s em
As
Pancreatitis
Dr
Sma ll bowel obstruction
Metformin induced lactic acidosis
Sta~vation ketosis
Eug lycaemic diabetic ketoacidosis
Pancreatitis
This lady has euglycaem ic diabetic ketoacidosis (EuDKA) secondary to her sodium-
glucose co-tra nspo rter 2 (SGLT2) inh ibito r, canagliflozin. EuDKA is a n important to
recognise s ide effect of th is novel class o f oral hypoglycaem ic agents and should be
thought of in any patient with an unexpla ined ra ised anion gap acidos is an d norma l
blood sugar level who is on one of these med ications.
Exactly how these agents cause EuDKA has yet to be d ete rmi ned. However, it is
hypothesised that as these agents lower blood sugar levels by increasing the excretion of
glucose the resu ltin g reduction in plasma glucose results in reduced insu lin secretion
from pancreatic beta-cells and these patients enteri ng a state of re lative insu lin d eficiency.
This lead s to a lowering of the antilipo lytic activity of insu li n, and the conseq uent
stimu lation of the production of free fatty acids, which are then converted to ketone
bodies by beta-oxidatio n in the liver. Mo reover, insu lin stimulates the activity of acetyi-
CoA carboxylase, which p rod uces malonyi-CoA, a potent inh ibito r of carn itine
palmitoyltransferase (CPT-I). Given that CPT-I p romotes the transport of fatty acids into
mitochondria an d hence increases the rate of beta -oxidation, the decrease in the
em
circulating leve l o f insulin promotes the production of ketone bod ies through activation
s
o f CPT-I.
As
Dr
I • I __ I
A 53-year-old female with a hist ory of p rimary atrop hic hypothyroidism is assessed two
mont hs foll ow ing a change in her d ose o f levothyroxine. Which one of t he follow ing best
d escribes w hat the TSH shou ld id ea lly b e?
Between 0.5 to 1.0 mU/ 1
m
se
As
Dr

-
........
m
se
A TSH value between 0.5 to 2.5 mU/1 is now cons idered preferable. Dosage changes
As
should o f cou rse also take account of symptoms
Dr
A 45-year-old wo man is investigated for we ight gain. She had had b een unwell for around
four months and described a co mbination o f symptoms including depression, facial male-
pattern hair growth and reduced libido. During the work-up she was found to be
hypertensive with a blood pressure o f 170/100 mmH g. Which one of the following t est s is
most likely t o be diagnostic?
Renin:aldost erone levels
High-dose dexamethasone suppression test
Pelvic ultrasound
Overnight dexam ethasone suppression test
m
se
As
24 hr urinary free co rtisol
Dr
Renin:aldosterone leve ls CD
High-d J e dexamethasone suppression test GD
Pelvic ultrasound GD
I Overnight dexamethasone suppression test CD

.
24 hr urinary free cortisol C!D
The overnight dexamethasone suppress ion test is the best test to diagnosis
Cushing's syndrome
Important for me Less 'mpcrte;nt
This patient has Cush ing's syndrome as evid enced by the weight gain, hirsutism,
m
se
d epression and hypertension. Po lycystic ova rian syndrome may give some of these
As
featu res but would not cause such an e levated blood pressure.
Dr
Which of the fo llowing statements is true rega rding the pathophysiology of diabetes
mell itus?
Concord ance between identica l twins is higher in type 2 d iabetes mellitus than type
1
Patients with type 1 diab etes mellitus a re rarely HLA-DR4 positive
Type 2 diabetes me llitus is associated with HLA-D R3
Haemochro matosis is a n exa mple of p rima ry d iabetes
m
se
Type 1 diabetes me llitus is thought to b e inhe rited in an autosoma l d om inant
As
fashion
Dr
Concordance between identical twins is higher in type 2 d iabetes mel litus than
type 1
Patients with type 1 diabetes mellitus a re ra re ly HLA-DR4 positive
Type 2 diabetes mellitus is associated with HLA-DR3
Haemochromatosis is an exa mple of primary diabetes
Type 1 d iabetes mellitus is thought to b e inherited in an autosoma l dominant

fashion
Type 1 d iabetes me llitus is caused by autoimmune destruction of the Beta -cells of the
pancreas. Id e ntica l twins show a genetic co nco rda nce of 40%. It is associated with HLA-
DR3 a nd DR4. It is inherited in a polygen ic fashion
Type 2 d iabetes me llitus is thought to be ca used by a re lative d eficiency of insu lin and the
phenomenon of insu li n resistance. Age, obesity and ethnicity a re impo rtant aetiologica l
factors . There is a lmost 100% concordance in ide ntica l twins and no HLA associations.
m
se
As
Haemoch romatosis is an exa mple of seconda ry d ia betes
Dr
The fasting glucose for a patient is reported as follows:
Glucose (fasting) 6.3 mmol/ 1
What is the most li kely underlying pathophysiological change?
Beta-cell hyperplasia
Beta-cell atrophy
Muscle insuli n resistance
Hepatic insuli n resistance
m
se
As
Ad ipose tissue insulin resistance
Dr
I Beta, cell hyperpla sia .
(D
Beta-cell atrophy .
(D
Muscle insulin resistance CD
I Hepatic insulin resistance CD
m
se
As
Adipose tissue insulin resistance fD
Dr
A 35-year-old female is referred to the endocrine cli nic due to weight loss and
palpitations. The following results are obtained:
TSH < 0 .05 m u/1
T4 178 mmol/ 1
Which one of the following featu res wou ld most suggest a diagnosis of Grave's disease?
Atrial fibrillation
Lid lag
Family history of radioiodine treatment
Pretibial myxoedema
m
se
As
Multinodular goitre
Dr
Atrial fibrillation
Lid lag
Family history of rad ioiodine treatment

-
~
Pretibial myxoedema
Multinodular goitre
m
se
Pretibial myxoedema is not seen in other causes of thyrotoxicosis and points towa rds a
As
diagnosis of Graves'
Dr
A 26-year-old obese female is investigat ed for menst rual disturbance. A diagnosis of
polycystic ovarian syndrome is made. Wh ich of the following finding s is mo st consistently
seen in polycystic ovarian syndrome?
Obesity
Hirsuti sm
Ovarian cyst s on ultrasound
Raised LH:FSH rati o
m
se
As
Clitoromegaly
Dr
Obesity «D
Hirsutism CD
I Ovarian cysts on ultrasound CD

Raised LH:FSH rati o fi!D
Clitoromegaly
•
Polycystic ovarian syndrome - ovarian cysts are the most consistent feat u re
m
se
Whilst all of t he features listed above may b e seen in polycystic ovarian syndrome, ovarian
As
cyst s are the most co nsistent f eature.
Dr
Each one of the following is seen in Klinefe lte r's syndrome, except:
Sma ll, firm testes
Lack of seconda ry sexu al characte ristics
Infertility
Increased incide nce of brea st cancer
m
se
As
Reduced g ona dotro phin leve ls
Dr
Small, firm testes
-
~
I
Lack of secondary sexual characteristics
Inferti/!lit_
- Y_ _ _ __
-
~
Increased incidence of breast cancer
I Reduced gonadotrophin levels
m
se
Klinefelter's syndrome - elevated gonadotrophin levels
As
Dr
You review a 68-yea r-o ld man who has chronic obstructive pulmonary d isease (COPD).
Each year he typically has a round 7-8 cou rses o f o ra l pred nisolone to treat infective
exacerbations of his COPD. Which one of the fo llowing adverse effects is linked to long-
term steroid use?
Osteomalacia
Eno phtha lmos
Leucopaen ia
Avascular necrosis
m
se
Constipation
As
Dr
Osteomala cia fD
Eno phtha lmos m
Leuco paen ia .
(D
Avascula r necrosis GD
Constipation CD
m
se
Long -term corticostero id use is linked to osteopaenia and osteo po rosis, rath er tha n
As
osteomalacia.
Dr
Each one of the following is a featu re o f pseudohypo parathyro idism, except:
Short fou rth and fifth metacarpals
Rou nd fa ce
Norma l ca lcium and p hosp hate leve ls
Cogn itive impairme nt
m
se
As
Short statu re
Dr
ISho~ fourth and fifth metacarpals CD
Round face fiD
INormal calcium and phosphate levels ED
Cognitive im pairment fD
m
se
As
Short statu re CD
Dr
A 48-year-old male presents to t he clinic. He com plains of excessive flatulence following
starting a new agent for management o f his type 2 diabetes mellitus. He has no other
past medical hist ory.
What drug is most likely implicat ed?
Metformin
Gliclazide
Acarbose
Sitagliptin
m
se
As
Em pag Iiflozi n
Dr
I Metfo rmin ED
Gl iclazide fD
I Aca rb ose CD
Sitagliptin fD
Em pag Iiflozin fD
Excessive flatu lence is an extremely co mmon sid e effect of acarbose which is often
poorly to le rated
Aca rbose is a n inhibito r of intestinal alpha g lucosidases, which results in decreased

abso rpti on of starch and sucrose. Sin ce aca rbose p revents the degradation and
abso rpti on of complex carbohyd rates into g lucose, an increased carbohydrate load will be
delivered to the colon. In the colon, bacteria d igest the complex carbohydrates, caus ing
gastro intestina l side -effects such as flatulence and diarrhoea. Excessive flatulence is the
most common ly reported side effect and is often the reason for discontinuation of the
drug.
Metformin can also cause gastrointestinal s ide effects, however it is often diarrhoea rather
than excessive flatulence, making acarbose the better answer.
Gliclazide is a su lphonylurea agent. The su lfonylureas act mainly by augmenting insul in

secretion and consequently a re effective on ly when some residual pa ncreatic beta-cell
activity is present; during long-te rm administration they also have an extra pancreatic
action. Sid e effects include hypoglycaem ia, cholestatic jaundi ce and diarrhoea.
Sitagliptin is a dipeptidyl peptidase -4 (DPP-4) inhibitor. Side effects include pe riphera l

oedema and diarrhoea.
Empagliflozin is an inhibitor o f the sodium glucose co-transporter-2 (SG LT-2). It cause

s em
increased g lucose excretion in the urine which p redisposed to recurrent urina ry tract
As
infections.
Dr
A 35-year-old gentleman is followed up in genera l practi ce after a routine health check at
work has identified high blood pressu re. He has been started on initial anti- hypertensive
therapy whilst awaiting investigation. He is otherwise well with no past medical history of
note.
He reports that his grandfather had been previously diagnosed with Conn's syndrome at
an early age.
Which of the following can interfere with t esting for primary hyperaldosteronism?
Digoxin
Am lodipine
Ivabradine
Bisoprolol
m
se
As
Ram ipril
Dr
I Digt in fD
Am lodipine .
(D
Ivabradine fD
Bisoprolol .
(D
~mipril GD
The answer here is ramipril. The reason behind th is is due to its int erference with the
renin-angiotensin-aldost erone syst em, for which the other medications do not.
Medications that can cause false negative renin:aldosterone ratio results are the following:
• Angiotensin-converting enzyme inhibitors (e.g. ram ipril or lisinopril).
• Angiotensin receptor blockers (e.g. losartan).
• Direct renin inhibitors (e.g aliskiren).
m
se
• Aldosterone antagonists (e.g. spironolactone or eplerenone).
As
Dr
An 18-year-old man presents to the nurse at the local health centre with a third episode
of balanitis over the past 3 months. He also has vague symptoms of tiredness. His father
and grandfather were diagnosed with type 1 diabet es and t ake a basal-bolus insulin
regimen. He is slim w ith a body mass index of 22 kg/m 2 . He is not ed to have glycosuria
on urine dipsti ck testing.
Investigatio ns:
Na• 140 mmol/ 1
K• 3 .9 mmol/1
Urea 6 . 1 mmol/1
Glucose 9 .2 mmol/1
Latent autoimmune diabet es o f adults (LADA)
Maturity onset diabetes of the you ng (MODY)
Renal glycosuria
Type 1 diabetes
m
se
As
Type 2 diabetes
Dr
Late nt autoimmune dia betes o f adults (LADA)
Maturity onset diabetes of the yo ung (MODY)
Renj' glycosuria
Type 1 diabetes
Type 2 diabetes
MODY is a utosoma l dom ina nt diabetes mell itus which often p resents for the first time in
young s li m individu als without symptoms of polyuria and po lyd ipsia . Insid ious onset with
for insta nce with recurrent ba lanitis as here is usual. It's important to recognise the
diagnosis because many patients with MODY includ ing those with the HNF-1 alpha form
o f the disease can be managed with su lp honylureas for many yea rs before needing to
start insulin therapy. Evaluation of fam ily history and testing for antibod ies fo r type 1
diabetes can help to d ifferentiate MODY from other forms of d iabetes mell itus.
Type 1 d iabetes isn't associated with such strong heritability as that seen he re, and g iven
this patient's body ha bitus, type 2 d iabetes is very unlikely. LADA is associated with a
body ha bitus simi la r to the overweight I obese pictu re seen in type 2 diabetes for many
patients, although p rogressio n to insu li n therapy occurs more quickly. Renal g lycosuria is
m
se
ruled out by the e levated fasting glucose seen he re .
As
Dr
A 21-year-old with type 1 diabetes was admitted with abdominal pain and vomiting. She
had been having dysuria and urine dip showed + + nitrites and + + leu cocytes. Her heart
rate was 90 bpm and b lood pressure was 112/80 mmH g. Cap illary glucose was 28 mmol/1
and capi llary ketones were 5.1 mmol/1. A venous gas was obtained which showed:
pH 7.25
Bicarbonate 12 mmolfl
Base excess -3.8
Lactate 2.9 mmolfl
She was st arted on IV f luid s and fixed -rate IV insu lin. Her cap illary glucose and ketones
had improved significantly after 24 hours of treatment, however she gradually st arted to
beco me con fused, irritable and was slurring her words. A repeat venous gas showed:
pH 7.32
Bicarbonate 17 mmolfl
Base excess -2.0
Lactate 2.3 mmol/1
Potassium 3. 1 mmolfl
What is the most likely cause of her new neurolog ical symptoms?
Stroke
Encephalopathy
Cerebral oedema
Sepsis
sem
As
Hypokalaemia
Dr
~~troke m
Encephalopathy CD
I Cerebral oedema CD
Sepsi s
Hypokalaemia
•
tED
Cerebral oedema is an important comp lication of flu id resuscitation in DKA,

especially in young patients
Children/young adult s are particu larly vulnerable t o cerebral oedema following fluid
resuscitation in DKA and ohen need 1:1 nursing to monitor neuro-observations,
headache, irritability, visual disturbance, focal neurology etc.
It usually occurs 4-12 hours following commencement of treatment but can be present at
m
any time.
se
As
If any suspicion, request a CT head and ca ll senior immediately.
Dr
One o f you r patients is diagnosed with having the metabolic syndrome. Which one o f the
following is associated with this condition?
Endometriosis
Hypothyroi dism
Asymptomatic rise in amylase levels
El evated albumin levels
m
se
As
Ra ised uric acid levels
Dr
Endometriosi s
Hypothyroi dism
Asympt omatic rise in amylase levels

r-
EI vated albumin levels
m
se
As
Raised u ric acid levels
Dr
A 46-year-old woman is ref erred to endocrine with a tender neck swelling. Blood results
are as follows:
TSH < 0 . 1 mU/1
T4 188 nmol/ 1
Hb 14.2 g/dl
Pit 377 * 109/ 1
WBC 6 .4 * 109/ 1
ESR 6 5 mm/hr
Technetium thyroid scan shows decreased uptake gl obally
Sick thyroid syndrome
Acute bacterial thyroiditis
Subacute thyroiditis m
se
As
Toxic multinodular goitre

Dr
Sick thyroid synd rome fD
~
Acute bacterial thyro id itis fiD

Hashimoto 's thyroiditis ED
Subacute thyroiditis CD
Toxic mu ltinodu la r goitre GD
m
se
Su bacute thyroiditis is suggested by the tender goitre, hyperthyro id ism and raised ESR.
As
The g lo bally reduced uptake on technetium thyroid scan is also typical
Dr
Which one o f the following processes is responsible for keto ne p roducti on during
diabetic keto acidosis?
Glycogenolysis
Exchange with hyd rogen ions in the collecting ducts
Gluconeogenes is
Decreased plasma bicarbonate levels
m
se
As
Lipolysis
Dr
Glycogenolysis
Exchange with hyd rogen ions in the collecting d ucts
I Gluconel genesis
Decreased plasma bicarbonate levels
I Lipolys is
The low-insu lin cond itions seen in d iabetic ketoacidosis stimulate the p rocess of lipolysis
m
se
and the p roduction of the ketone bodies, beta-hydroxybutyrate and acetoacetate, which
As
can be used as metabolic fuel.
Dr
A 28-yea r-old woma n with po lycystic ova rian syndrome consults you a s she is having
p roblems beco ming p regna nt. She has a past history of olig omenorrhea and has
p reviously recently stopp ed taking a co mbined oral contra ce ptive pill. Despite stop ping
the p ill 6 months ago s he is still not having regu la r pe riod s. Her bo dy mass index is 28
kg/m" 2. Apa rt from advisi ng her to lose wei ght, which o ne of the following inte rventio ns
is most effective in in creasing her chan ces of conceiving?
Metformi n
Bromocriptine
La parosco pic ova ria n cautery
Clom ife ne
m
se
As
Orl istat
Dr
Metf ormin
Bromocriptine
Laparoscopic ovarian cautery
Clomifene
Orlistat
Inferti lity in PCOS - clomifene is superior to met formin

Whilst metformin has a role in the management of infertility it should be used second -line
m
se
t o anti-oestrogens such as d omifene. Similar questions to this chen app ear in which
As
d omifene is not an option, in this case metformin is clearly the right answe r.
Dr
A 39-year-old woman is reviewed in the clinica l pharmacology cl inic following referral by
her GP for management o f her hypertension. She has a blood pressure of 159/90 mmHg
despite 3 oral anti-hypertensive medications including full dose ramipril. Examination in
the clinic confirms the elevat ed blood pressure. Her pulse is 72 and regular. Her chest is
clear an d her abdomen is soft and non -t ender with no palpable masses. Her body mass
index is 28 kg/m 2 •
Hb 130 g/ 1
WBC 6 .0 * 109/ 1
Na• 141 mmol/ 1
K• 3.1 mmol/1
urea 4.1 mmol/1
CT abdomen: Right adrenal adenoma, thick walled gallbladder with a solita ry stone
Which of the follow ing is the most likely diagnosis?
Conn's syndrome
Cushing's syndrome
Essential hypertension
Phaeochromocytoma
sem
As

Dr
Conn's syndrome CD
Cushing's syndrome f!D
Essential hypertension m
Phaeochromocytoma GD
Renal a rte ry stenosis m
The relatively norma l weight, coupled with hypertension and hypokalaemi c meta bolic
alkalosis fits well with a dia gnos is of Conn's syndro me, (primary hyperaldoste ronism). The
right adrena l ad enoma is the like ly source of excess ald osterone production. In the
p resence o f an ACE inhib itor prescribed fo r hypertension, significant hypokalaem ia is very
likely to be related to Conn's.
Cushing's syndrome is un like ly given that the body mass index is only slightly elevated,
and the p resence o f an adrenal adeno ma and biochemical abnormalities effective ly rules
out essential hypertension. Phaeochromocyto ma may be associated with hypokalaemia,
but is more li kely to be associated with episod ic hypertension associated with bu rsts o f
m
se
catecholamine release. In renal artery stenosis, a significant rise in creatinine wou ld be
As
expected in association with the introduction of the ramip ril.
Dr
A 53 yea r man presents as his wife has noticed a change in his appearance. He has also
noticed his hands seem la rger. On exam ination blood pressu re is 170/94 and he is noted
to have bitempo ral hem ianop ia. What is the most appropriate first- line treatment?
Octreotide
External irradiation
Pegvisomant
Trans-sphenoida l surgery
m
se
As
Bromocriptine
Dr
Octreotide
External irradiation
Pegvisomant
Trans-sphenoidal surgery
Bromocriptine
m
se
Trans-sp henoidal surgery is the t reatment of choice in acromeg aly. There is no significant
As
evidence base supporting t he use of p re-o perative oct reotide
Dr
A 49-yea r-old woman is investigated for thyrotoxicosis. On exam ination she is noted to
have a goitre conta ining multip le irregular nodules. Nuclear scintig raphy with technetium
99m reveals patchy uptake. What is the treatment of choice?
Corticosteroids
Radioiodine
Block-and-re place regime
Su rgery
m
se
As
Anti-thyroid drug titration regi me
Dr
Corticosteroids m
Radioiodine CD
Block-ant replace reg ime f!D
Su rgery ED
m
se
As
Anti-thyroid drug titration regi me G'D
Dr
A 45-yea r-old woman with Graves' disease comes fo r review. She has recently b een
diagnosed with thyro id eye disease and is b eing cons idered fo r ra diothera py. Over the
past three days her rig ht eye has become red and pa inful. On exa mination there is
p ro ptosis and e rythema of the right eye. Visual acuity is 6/ 9 in b oth eyes. What
comp lication is she most like ly to have developed?
Exposure keratopathy
Optic neuropathy
Carb imazole-related neutropaenia
Centra l reti nal vein o cclusion
m
se
As
Sjogre n's Syndrome
Dr
Exposure keratopathy
Optic neuropat hy
~bimazole-related neutropaenia
Centra l retinal vein occlusion
Sjogren's Syndrome
m
se
As
Dr
Which one o f the following types o f thyro id ca ncer is associated with the RET oncogene?
Anapla stic
Lym phoma
Follicular
Medullary
m
se
As
All types of thyroid cancer
Dr
Ana pla stic
Lym phoma
Foll icular
Medullary
All types of thyroid cancer
The RET o ncog ene encod es a recepto r tyrosine kinase and is a ssociated with MEN type 2.
m
se
As
Pa pillary thyroid cancer also appea rs to be associated with the RET oncogene
Dr
The first -line treatment in remnant hyperlipidaemia (dysbetalipoprot einaemia) is:
Ursodeoxycholic acid
Vitamin A
Statins
Fish oil
m
se
As
Fibrates
Dr
Ursodeoxycholic acid (!D
Vitamin A CD
Statins ED
Fish oil fD
m
se
Fibrates CD
As
Dr
A 20-year-old woman with a history of type 1 diabetes since the age of 8 comes to the
Emergency department with nausea, vomiting, weight loss and frequent episodes of
hypoglycaemia. She has been treat ed with a basal bolus regime of insulin since diagnosis
and usually has very stable diabetes contro l. On examination, her blood pressure is
105/70 mmHg with a postural drop of 15 mmHg. Her pulse is 74 beats per minute and
regular. Her body mass index is 21 kg/m 2 .
Investigations
Na• 127 mmol/ 1
K• 5.0 mmol/1
Urea 11.2 mmol/ 1
Glucose 4 .8 mmol/1
TSH 10.2 IU/ 1
Free thyroxine 7 pmol/1
Which of the following is the most important int ervention?
Fluid restriction
IV hydrocortisone
IV normal saline
Oral fludrocortisone
sem
As
Oral thyroxine
Dr
Fluid restrict ion m
I IV hydrocortisone
.,
IV normal saline GD
Oral fludrocorti sone .
(D
Oral thyroxine fi!D
The hyponatraemia and potassium towards the upper end of the normal ra nge, coupled
with hypoglycaemia, fit well with a diagnosis of Addison's disease. Although features of
hypothyroidism may co-exist with hypoadrenalism, corticosteroid replacement is the most
important first step in therapy because commencing thyroxine may worsen any adrenal
crisis.
Fluid restrict ion is not appropriat e given signs of volume depletion an d the likelihood of
Addison's being the primary diagnosis. Althou gh fluid replacement with normal saline
may be useful in relieving symptoms of volume depletion, it is unlikely to be effective
without commen cing hydrocortisone therapy. Oral fludrocortisone is added to
m
se
hydrocortisone in patients who are co rticost eroid replet e but still suffer from symptoms
As
of hyponatraemia or volume depletion.
Dr
What causes increased sweating in patients with acromega ly?
Increased sodium content in sweat
Raised basal meta bolic rate
Episod ic hypoglycaem ia
Low-grade chronic pyrexia
m
se
As
Sweat gland hypertrophy
Dr
Increased sodium content in sweat
Raised basal metabolic rate
Ep isodic hypog lycaemia
Low-gra de chron ic pyrexia
Sweat g Ia nd hypertrophy
m
se
Acromeg aly: increa sed sweating is caused by swea t gla nd hypertrophy
As
Dr
A 52-yea r-old ma n has a set of fastin g bl oods as part of a work-up for hype rtension. The
fasting glucose comes back as 6.5 mmol/1. The test is repeated and reported as 6.7
mmol/1. He says he feels constantly tired but denies any po lyuria o r polydipsia. How
s hould these resu lts be inte rp reted?
Impaired fasting g lycaemia
Suggestive of diabetes mellitus but not d iagnostic
Diabetes mellitus
Normal
m
se
As
Dr
A 52-yea r-old ma n has a set of fastin g bl oods as part of a work-up for hype rtension. The
fasting glucose comes back as 6.5 mmol/1. The test is repeated and reported as 6.7
mmoljl. He says he feels constantly tired but denies any po lyuria or polydipsia. How
s hould these resu lts be inte rp reted?
Impa ired fasting glycaemia
Suggestive of diabetes mellitus but not d iagnostic
Diabetes mellitus
Norma l
-
.....,
m
se
As
Dr
A 40-yea r-old man p resents to the GP concerned about his risk of developing cancer. You
notice that he has la rge spade-l ike hands, a prom inent forehead and nose, and thick skin.
Which of the following cancers is he at increased risk of d eveloping?
Colorecta l carcinoma
Ad renal ca rcinoma
Malig na nt melanoma
m
se
As
Lu ng ca ncer
Dr
I Colorectal carcino ma
Adrena l ca rcinoma
Malignant melanoma
Lung cancer
Patients with acromegaly have an inc reased risk of colorectal carcinoma

Patients with acrom egaly have an increased incidence of colorectal polyps and carcinoma.
This is a fairly recent find ing, now that patients with acrom egaly are survivin g longer due
to better management o f thei r other co mplications, particularly d iabetes and
ca rdiovascular disease. It is recommended that patients with acromegaly have an initial
colonoscopy at age 40, and enter a surveillance progra m based on the results of the
colonoscopy.
Gu idel ines for colorectal cancer screening and surveillance in moderate and hig h risks.
m
se
Update
https:/jwww.ncbi .nlm .nih.gov/ pu bmed/20427 401
As
Dr
A 16-year-old male is reviewed in the endocrinology clin ic due to lack of pubertal
d evelopment. On examination his testes are undescended and t here is only scanty pub ic
hair. What is t he most likely diagnosis?
Down's syndrome
Kallman's syndrome
Dubin-Johnson syndrome
Turner's syndrome
m
se
As
Klinefelter's syndrome
Dr
Down's syndrome
•
I Ka llman's syndrome CD
Dubin-Johnson syndrome CD
Tu rner's syndrome CD
Klinefelter's syndrome GD
m
se
As
Cryptorchid ism is more suggestive of Ka llman's than Klinefelter's syndrome
Dr
Which of the following results establishes a diagnosis of diabetes mellitus?
Asym ptomatic patient with fasting glucose 7.9 mmoi/L on one occasion
Sym ptomatic patient w ith fasting glucose 6.8 mmoi/L on two occasions
Glycosuria+ ++
Asym ptomatic patient with random glucose 22.0 mmoi/L on one occasion
m
se
As
Symptomatic patient w ith random glucose 12.0 mmoi/L on one occasion
Dr
Asymptomatic patient with fasting g lucose 7.9 mmoi/L on one occasion
Symptomatic patient with fasting g lu cose 6.8 mmoi/L on two occasions
Glycosuria+ ++
Asymptomatic patient with random glucose 22.0 mmoi/L on one occasion
I Symptomatic patient with random glucose 12.0 mmoi/L on one occasion

-
~
Diabetes diagn osis: fasting > 7.0, rando m > 11.1 - if asympto matic need two
m
se
readings
As
Dr
A 61-yea r-old wo man is investigated fo r hoarseness and dyspnoea which has got
p rogressive ly wo rse ove r the past month. In the past she has been diagnosed with toxic
mu ltinod ular g o itre which was successfully treated with ra dio io dine . On exam ination she
has a firm, asymmetrical swel li ng of the thyroid g land . La ryngosco py d emonstrates a right
vocal co rd pa ra lysis and apparent externa l com pression of the trachea. What is the most
li kely diagnosis?
Foll icular thyroid ca ncer
Pa pillary thyro id cancer
Medullary thyroid cancer
Lym phoma of the thyroid gla nd
m
se
As
Ana plastic thyroid cancer
Dr
Foll ic ~lar thyroid cancer .
(D
Pap illary thyroid cancer GD

Medullary thyroid cancer fD
Lym p homa of the thyroid gland .
(D
I Anaplastic thyroid cancer GD
m
Ana plastic thyroid cancer- ag g ressive, difficu lt to treat and ohen causes p ressure
se
sympto ms
As
Dr
Which one of the following statements regarding maturity-onset diabetes of the young
(MODY) is true?
There is usually a strong family history
Body mass index is typically > 30
Doesn't respond to glimepiride
m
se
As
Frequent episodes of diabetic ketoacidosis are typical
Dr
I There is usually a strong fam ily history
Body mass in dex is typically > 30
~~esn' t respond to glimepiride

-
""""
m
se
As
Frequent e pisodes of diabetic ketoacidosis a re typ ica l
Dr
What is the most commo n cause of primary hyperaldosteronism?
Pituitary tumour
Ad renocortical adenoma
Ad renal carcinoma
Ectopic secretion
m
se
As
Bilateral idiopathic adrenal hyperplasia
Dr
Pituitary tumou r
Ad renocortical adenoma
Ad renal carcinoma
Ectopic secretion
Bilateral idiopathic adrenal hyperplasia
m
Bilat eral idiopathic adrenal hyperplasia is the most common cause of primary
se
As
hyperaldosteronism
Dr
A 60-year-old man who is known t o have lung cancer comes for review. For the past three
weeks he has lost his appetite, has been feeling sick and generally feels tired. On
examination he appears to be mildly dehydrated. You order some blood tests:
Calcium 3. 12 mmol/ 1
Albumin 40 g/1
Glucose (random) 6.7 mmol/1
Urea 10.2 mmol/1
Creatinine llS I,Jmol/ 1
Which one o f his existing medications is most likely to be contributing to his

presentation?
Am lodipine
Simvastatin
Bendroflumethiazide
Aspirin
m
se
As
Lisinopril
Dr
Am lod ipine m
Simvastat in m
I Bendroflumethiazide em
Aspirin m
Lisinopril
m
se
As
Thiazides cause hypercalcaemia
trrportart "or me _ess ·rr-:>c'1!'1t
Dr
An 18-year-old male is reviewed due to concerns about delayed pubertal development,
despite being 1.77m ta ll. On exa mination he has scant pubic hair a nd reduced testicu la r
volume. The following blood results a re obta ined:
Test ost erone 6 .7 nmoljl (9 - 30)
LH 3 . 1 mu/1 (3 - 10)
FSH 5.7 mu/1 (3 - 10)
Klinefelter's synd rome
Testicular feminisation syndrome
Primary testicular fa ilure
m
se
Ka llman's syndrome
As
Dr
I Klinefelter's synd rome

-.J CiD
m
Testicular feminisation syndrome CD
Primary testicular failure (fD
I Kallman's syndrome ED
Klinefelter's - LH & FSH raised

Ka llman's - LH & FSH low-normal
The LH and FSH levels are inappropriately low-normal given the low testosterone
m
se
concentration, which points towards a diagnosis of hypogonadotrophic hypogonad ism. In
As
Klinefelter's syndrome the LH and FSH levels are raised
Dr
A 55-yea r-old woman is investigated following an osteopo rotic hip fracture. The fo llowing
resu lts a re obtained:
TSH < 0 .05 mu/1
Free T4 29 pmol/ 1
Which one of the fo llowing autoantibo dies is most like ly to be p resent?
TSH receptor stimulating autoantibodies
Anti-nuclear antibod ies
Anti-thyroglobulin autoantibodies
Anti-m icrosomal a ntibod ies
m
se
As
Anti-thyro id peroxid ase a utoantibodies
Dr
I TSH recepto r stimulating autoantibodies
Anti-nuclear antibodies
Anti-thyroglobulin autoantibodies
Anti-m icrosomal antibodies
Anti-thyroid peroxidase autoantibodies
m
TSH recepto r stimulating autoantibodies (often ref erred to as Thyroid Stimulating
se
Immunoglobulins) are almost diagnostic of Graves' disease, the most common cause of
As
thyrotoxicosis in the UK
Dr
At w hich point in the menstrual cycle do p rogesterone levels peak?
Luteal phase
Ovulation
Follicular phase
Levels rema in constant throughout cycle
m
se
As
Menstruation
Dr
Luteal phase
Ovulation
~licular ph~se
Levels remain constant throughout cycle
Menstruation
m
se
As
Progesterone is secreted by the corpus luteum following ovulation.
Dr
Which one of the following is not part of the diagnostic criteria for the metabolic
syndrome?
High triglycerides
Low HDL
High LDL
Central obesity
m
se
As
Hypertensi on
Dr
High triglycerides GD
Low HDL .
fiB
I High LDL CD
Central obes ity m
Hypertension «fD
m
se
High LDL levels are not part of the World Health Organization or Internati onal Diabetes
As
Federati on diagnost ic criteria
Dr
A 25-year-old woman presents fo r her first cervical smea r. What is the most important
aetiological fact or causing cervical cancer?
Human papilloma virus 6 & 11
Herp es simplex virus 2
Smoking
Combined oral contraceptive pill use
m
se
As
Dr
A 25 -year-old woman present s for her first cervical smear. What is the most important
aetiological factor causing cervical cancer?
Herpes simplex virus 2
Smoking
Combined ora l contraceptive pill use
Cervical cancer: Human papillomavirus infection (particularly 16,18 & 33) is by fa r

the most important risk factor
m
se
Whilst a number of the above are known to contri bute to the development o f cervical
As
cancer infection w ith human papilloma virus 16 & 18 is by far the most important factor.
Dr
A 43 -yea r-o ld man presents to his GP with tired ness, low mood a nd unintentiona l we ig ht
g a in o f 13kg ove r the past 4 months. Prio r to feeling li ke this he recall s havin g a flu -like
illness fo llowing which he had a two -week pe riod of feeli ng very a nxious, sha ky and
ene rgetic. He wo nd ers if this is connected.
On exam ination he has a heart rate o f 68 bpm, his blood pressu re is 147/ 83 mmHg and
his te mpe ratu re is 37.1°C. Exa mination of his abdomen and chest a re unremarka ble and
he d oes not have a g oitre o r any palpab le lymphad eno pathy. He has no family history o f
note a nd no pa st medica l histo ry.
Blood tests to look at hi s thyro id function show the fo ll owing:
Thyroid stimulating hormone (TSH ) 6 .1 mu/1 (0. 5-5 .5 mu/1)
Free T4 6 pmol/1 (9-18 pmol/1)
What is the most li kely cause of this man's symptoms?
Grave's d isea se
Hashimoto's thyro iditis
Pa pillary ca ncer of the thyro id
De Querva in's thyro id itis

em
Toxic multinodu la r goitre
s
As
Dr
Grave's disea se
Pa pillary cancer of the thyroid
De Quervain's thyroiditis
Toxic multinodu lar goitre
Subacute thyroiditis ca uses hyper- then hypothyroid ism

Important for me l ess im;>crtc.nt
This g entle man has a cl inica l picture of hypothyro idism with what a ppea rs to be a b rief
period of hyperthyro id ism prio r to this. The most common cause o f this is De Quervain's
thyro iditis and this wo uld be in keeping with the histo ry o f a viral infect io n b efo re the
initial hyperthyro id episode. The re is a rare fo rm of Hashi moto's in which the patient has
an initia l phase of hyperthyro id ism before becoming hypothyro id, howeve r the p erio d o f
hyperthyro id ism is pro longed in those cases a nd the cl inical p icture is often
indistingu is hable from Grave's disease. In ad d itio n it ha ppens far mo re com mo nly in
wo men than me n (a rou nd 5 times) a nd has a stro ng association with other auto -i mmune
diseases. The key to this question is what is most li kely a nd given the re lative ly brief
period of hyperthyro id ism (in Ha shimoto 's it wo uld be in the o rder of 6-12 months rath er
tha n a few weeks) and the preceding vira l infection, De Quervain's is far more like ly.
Grave's disea se a nd toxic multino dula r goitre wou ld b oth p resent with hyperthyro idism
s em
and pa pilla ry thyroid ca ncer does not p ro d uce thyroxine so wou ld not cause any system ic
As
symptoms.
Dr
Which one of t he followin g stat ement s reg arding t he normal menstrual cycle is incorrect?
A number of follicles d evelop in the fo llicu lar phase under the inf luence of FSH
The lut eal p hase is also known as t he secretory phase
The follicu lar p hase follows menstruat ion and occurs around day 5 - 13
A su rge of FSH causes o vulation
m
se
As
Progesterone levels are low in the follicular phase
Dr
A number of follicles d evelop in the follicu lar phase under the inf luence of FSH G)
The lut eal p hase is also known as t he secretory phase CD

The follicular phase follows menstruation and occu rs around day 5 - 13 tiD
A su rge of FSH causes ovulation GD
Progesterone levels are low in the follicular phase f!D
m
se
LH surge causes ovulation
As
Dr
A 71-year-old woman wit h a history of type 2 diabetes mellitus presents wit h lethargy and
polyuria. A diagnosis of hyperosmolar hyperglycaemic state is co nsidered. Which one of
the following findings wou ld be least consistent with this dia gnosis?
pH of 7.38
Ketones 1 + in urine
Serum osmolality of 310 mosmol/kg
Serum bicarbonat e of 19 mmol/1
m
se
As
Glucose of 45 mmol/1
Dr
pH of 7.38
Ketones 1 + in urine
r:um osmolality of 310 mosm o l/kg
Serum bica rbonat e of 19 mmol/1
Glucose of 45 mmol/1
m
se
A t race of ket ones may be found in hyperos molar hyperg lycaem ic st ate. Serum osmolality
As
is typically > 320 m osm o l/kg
Dr
A 49-yea r-old woman with type 2 diabetes mell itus is bein g considered for exenatide
thera py. Which one of the following is not part of the NICE criteria for starting or
continuing this drug?
BMI > 35 kg/m"2
Greater than 1.0 percentage point HbAlc reduction after 6 months
Has fa iled with insu li n therapy
Has type 2 diabetes mellitus
m
se
As
Weight loss > 3% at 6 months
Dr
BMI > 35 kg/m"2
Greater than 1.0 percentage point HbAlc reduction after 6 months

-
"""
I Has failed with insuli n thera py
Has type 2 diabetes mellitus
Weight loss > 3% at 6 months
m
se
As
Patients do not need to have been on insulin p rior to using exenatide
Dr
Which one of t he followin g is least characteristic of Ad dison's disease?
Hypoglycaemia
Metabolic alkalosis
Hyponatraemia
Hyperkalaemia
m
se
As
Po sitive short ACTH test
Dr
Hypoglycaemia
Metabolic alkalosis
-
Hyponatraemia
Hyperkalaemia
Positive short ACTH test
m
se
As
Addison's disease is associated with a metabolic acidosis
itt"portart "or me _ess -,.. :lc"tcnt
Dr
A 23-year-old woman is admitted to the intensive care unit following an episode of
diabetic ketoacidosis. On admission her Glasgow co ma scale was 7/ 15. Collateral history
revealed long-st anding type 1 diabetes mellitus with poor glycaemic control.
Arterial blood gases:
pH 7.12
paC02 3.1 k Pa
pa02 12.2 kPa
HC0 3 3 mmol/1
Capillary Glucose: 33mmoi/L
Urine dip:
glucose +++
ketones +++
protein
nitrites
Leucocyte esterase
The patient was intubated an d successfully treated with intravenous fluids, insulin and
venous thromboembolism prophylaxis.
On discharge her GP undertook a routine screen of blood tests.
Which of the following thyroid function t ests results would be in keeping with her
presentation?
TSH - high, T4 - Low, T3 high
TSH - high, T4 - normal, T3 normal
TSH - low, T4 - Low, T3 high
TSH - low, T4 - normal, T3 normal

s em
TSH - normal, T4 - Low, T3 low

As
Dr
TSH - high, T4- Low, T3 high
TSH - high, T4- norma l, T3 norma l

-
~
TSH - low, T4 - Low, T3 high

r----.
TSH - low T4 - normal, T3 normal
TSH -normal, T4- Low, T3 low
Sick euthyroid syndrome is a reversible stat e of abnormal thyroid function t ests due to a
non -thyroi dal illness, w ithout p re-existing hypotha lamic-p ituitary or thyroid gland
dysfunction. By definition, after recovery of the non -thyroidal illness, thyroid function
t ests should revert back to normal.
Causes of sick euthyroid include: myocardial infa rctions, starvation, burns, t rauma,
su rgery, malignancy, diabetic ketoacid osis, any organ failure and inf lammatory conditions.
The pathology postulated is the dow n regu lation of type 1 d eio dinase, reducing t he
peripheral conversion o f T4 to T3 and t hus reducing t he basal met abolic rate during
m
periods of st ress. Upregulat ion of type 3 d eiodinase to inactive (reverse) T3 also aids to
se
reducing basal metabolic rat e.
As
Dr
A patient with type 2 diabetes is reviewed in clinic. He is currently taking metform in but
his diabetes control remains poor. As he has an erratic lifestyle co nsideration is given to
starting repagl inide. What is the mechanism of action of this drug?
Dipeptidyl peptidase -4 (D PP-4) inh ibito r
Agonist to the PPAR-gamma receptor
Glucagon-like peptide-1 (G LP-1) mimetic
m
se
Activates an ATP-dependent K• channel on the cell membrane of pancreatic beta
As
cells
Dr
Dipeptidyl peptidase-4 (DPP-4) inhibito r
Agonist to the PPAR-gamma receptor
Glucagon-like peptid e-1 (GLP-1) mimetic

-. .wl'
Activates an ATP-dependent.channel on the cell membrane of pancreatic beta
m
se
K cells
As
Dr
You a re ca lled to see a 34 year-old man in the late afternoon while you a re on -call. He
suffe rs with type 1 dia betes mellitus and was a d mitted afte r bein g d iagnosed with
diabetic ketoacidosis. He has been treated with a fixed-rate insu lin infusion with
potassium replacement. He usua lly takes Lantus glargine and Novorapid insu lin s, but the
nu rses have not been adm inistering these while he has been on his insu lin infusion. His
latest a rte ria l blood gas is shown:
pH 7.37
pC02 4. 3 kPa
p0 2 11.9 kPa
Bicarbonate 26 mmoi/L
Glucose 5. 2 mmol/l
What is the best course of action?
Stop insu li n infusion now and restart normal insulin regimen
Give Novo rap id insulin, then sto p insulin infusion with next meal
Continue insulin infusion overnight
Give l Og o ral g lucose
m
se
As
Give Lantus g largine, then stop insu lin infusion with next meal
Dr
Stop insulin infusion now and restart normal insulin regimen
Give Novorapid insulin, then sto p insulin infusion with next meal
Continue insulin infusion overnight

-
Give lOg oral glucose
Give Lantus glargine, then stop insulin infusion with next meal
-
"""'
"""'
Stopping an insulin infusion in the context of an insulin-dependent diabetic needs to be

done with care. Long -acting insulins should be continued throug hout the duration of any
insulin infusion, but in this case this has not occurred - a not-uncommon problem on the
wa rds.
The key focus here is that an insulin-dependent diabetic should never be without insulin
as they risk precipitating diabetic ketoacidosis (DKA). Option A will leave a gap in insulin
therapy (the patient's next insulin dose wi ll be novo rapid due with dinner) and risk
recurren ce of DKA. Option B gives only a short acting insulin, which will have worn off by
the time the patient has his next meal. Option C is a safe choice, but this patient no
longer requires an insulin infusion as evidenced by his normalised pH and blood glucose
and continuing the infusion (with the attendant hourly blood glucose checking) overnight
is not in the patient's best inte rests. Option D is inappropriate as the patient's blood
m
glucose is in the normal range. Option E is therefore the co rrect option - it allows the
se
As
patient's long-acting insulin to take effect before stopping the insulin infusion. He should
also resta rt his Novo rapid insulin with his next meal.
Dr
Which one of the fo llowing statements regard ing g lucagon- like pepti de-1 (GLP-1) is
incorrect?
Secreted in response to a n oral glucose load
Increased leve ls are seen in type 2 diabetes me llitus
Slows ga stric emptying
Secreted by the small intestine
m
se
As
Responsible fo r the incretin effect
Dr
Secreted in response to an oral g lucose load
r Increased levels are seen in type 2 diabetes mellitus
Slows gastric em ptying
I Secreted by the small intestine
Responsible for the incretin effect
m
se
As
Decreased levels of GLP-1 a re seen in type 2 diabetes mellitus
Dr
A 54-year-old woman presents t o the Emergency Department with confusion and fever.
She has a past hist ory of thyrotoxicosis previously treated with radioiodine therapy. On
examination she has a pulse of 120/min regular, blood pressure 150/ 90 mmHg,
t emperature of 39.1°C and a respiratory rate of 18/ min. Examinatio n of the
cardiorespiratory system is unremarkable and urine dipstick is clear. Blood results showed
the following:
Free T4 8 4 pmol/1 (norm al range 10-22 pmolfl)
Free T3 29 pmol/ 1 (2. 5-5 .5 pmolfl)
TSH < 0 .0 1 mU/ 1 (0.5-4.0 mU/1)
Which one of the following does not have a role in the subsequent management?
Lug ol's iodine
Propranolol
Propylthio uracil
Bicarbonate
m
se
As
Dexamethasone
Dr
Lugol's iodi ne GD
I Pr} pranolol m
Propylthio uracil (D
'
I Bicarbonate CD
Dexamethasone GD
m
se
As
There is no indication for giving bicarbonate in this scenario.
Dr
A 59-yea r-old woman co mes to the diabetes clin ic fo r review. Cu rrent medication includ es
metformin and sitagliptin, b ut her HbAlc has continued to rise and ad ditio na l thera py is
required. He r bo dy mass index is 35 kg/ m 2 • Blood pressu re is 132/ 82 mmH g, her pulse is
74 beats per minute and regular. A decision is mad e to sta rt her on d egludec li rag lutide
combination therapy.
Which o f the fo llowing shou ld you warn her a bout?
Patients ofte n g et s kin no dules arou nd the injection s ite
Pancreatitis is commonly associated with treatment
Risk of hypo glycaem ia will increase when s he starts treatme nt
She will lose approximately Skg in wei ght when she starts treatment
m
se
As
She will g a in app roximately 6kg in the first yea r o f treatment
Dr
Patients often get skin nodules around the injection s ite
Pancreatitis is commonly associated with treatment
I Risk of hypoglycaem ia will jncrea se when s he starts treatment
She will lose approximately Skg in weight when she starts treatment
She will gain app roximately 6kg in the first year of treatment
-
~
insu li n and GLP-1 fixed dose comb inations are in creasingly attractive as a treatment
option for diabetologists because they combine the potent glucose-lowering effect of
GLP-1 agonists and long-acting insul in analogues in one preparation. They are however
associated with increased risk of hypog lycaemia, Rates of confirmed hypoglycaemia ( <3.1
mmol/1), run at between 1.8 and 3.5 per patient year of exposure.
Skin nodules are most often seen arou nd injection sites when modified release systems
are used for delivering GLP-1, such as those used in weekly exenatide, (microsphe res).
Pancreatitis features in case reports associated with the use of GLP-1 agonists, a lthough
no cons istent link has been established. Modest weight loss is seen when patients start
deglu dec I liraglutide against a ba ckg round of oral agents, but this is less than that seen
for patients who start liraglutide alone.
m
se
https:/jwww.evide nee .nhs.u k!formu Ia ry/ bn f/ curre nt/ 6-en doerine-system/61-d rugs-used-
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in-diabetes/ 612-antidiabetic-drugs/ 6123-other-antidiabeti c-drugs
Dr
A 58-yea r-o ld wo man presents to the e me rg ency d e partment with co nfusion. She is
found to have a raised te mpe ratu re, tachyca rdia a nd is hypotens ive. Ah er furthe r
investigation, she is fo und to b e in a thyro toxic sto rm.
Given he r presentation what is the best first line treatme nt?
Adre na li ne a nd hydrocortisone
Beta blocke rs and p ro pylthiou racil
Adre na li ne, pro pylthiou racil a nd hydrocortiso ne
Beta blocke rs, p ropylthio ura cil a nd hyd rocortisone
m
se
As
Pro pylthiou racil and hydro co rtisone
Dr
Ad renali ne a nd hyd rocortisone
Beta blocke rs and propylthiou racil
Adrenali ne, propylthiouracil a nd hydrocortisone
Beta blockers, propylthiouracil and hydrocortisone
Propylthiou racil and hydrocortisone
Thyrotoxic sto rm is treated with beta b loc ke rs, pro pylth iouracil and hydrocortisone
This questio n is asking a bout a woman presenting with confusion, ta chyca rd ia,
hypotension and a raise temperature who is fo und to b e in a thyro toxic storm (also
known as a hyperthyro id crisis). You a re asked fo r the best first-line treatment in this ca se
which is option 4, beta b lo ckers, pro pylthiou ra cil a nd hyd rocortisone.
Beta b lockers a re used to treat the tachycard ia, however, these a s always wou ld be
co ntra in dicated in patie nts suffe ring from a sthma.
Propylthiouracil is used as a n anti -thyroid treatment to help reduce the effect o f ra ised
serum thyro id ho rmones that a re causing he r sympto ms.
Hydrocortisone is used to treat a ny unde rlyin g adre na l insufficiency which is more

m
se
com mon in patients su ffe ring from hyperthyro idism a nd can a lso help to red uce seru m
As
thyro id hormone levels.

Dr
You are reviewing a 24-year-ol d man who has recently been diagnosed with type 1
diabetes mellitus. He has no comorbidities and works as an accountant. What HbAlc
target should he aim for initially?
42 mmol/mol
45 mmol/mol
48 mmol/mol
50 mmol/mol
m
se
As
52 mmol/mol
Dr
42 mmol/mol f!D
45 mmol/mol f!D
48 mmol/mol eD
50 mmol/mol .
(D
52 mmol/mol CD
m
se
In type 1 diabetics, a general HbAlc target of 48 mmol/mol (6.5%) should be used
As
Dr
Which one o f the following features is least co mmonly seen in Gitelman's syndrome?
Hypokalaemia
Hypertension
Met abolic alkalosis
Hypocalciuria
m
se
As
Hypomagnesaemia
Dr
Hypokalaem ia .
(D
Hypertension eD
Metabolic alka losis GD
Hypocalciuria C!'D.
Hypomagnesaemia CD
m
se
Gitelman's syndrome: normotension with hypoka laemia
As
Dr
A 20-yea r-old man presents with a nine month history of weight gain. Prior to this he was
of a no rmal weight and cannot identify any obvious lifestyle changes that wou ld account
for his obesity. On exa mination he is noted to have abdominal striae and a d egree of
proximal myo pathy. Blood pressu re is 130/ 80 mmHg. Bloods show the followin g:
Na• 141 mmol/ 1
K• 3.3 mmol/1
Urea 3.3 mmolfl
Creatinine 72 IJmolfl
What is the most appropriate next test?
High-d ose dexamethasone suppression test
Plasma ACTH
Short ACTH test
24 hour urinary free cortisol
m
se
As
Renin:a ldoste rone ratio
Dr
High-dose d examethasone suppression test
Plasma ACTH
Short ACTH test
124 hour urinary f ree cortisol

Renin:aldosterone rat io
The overnight dexamethasone suppress ion test is the best test to diagnosis
Cush ing's syndrome
There is some debate as to whether a 24 hour urinary f ree cortisol o r an overnight

dexamet hasone suppression test shou ld be used to screen patients fo r Cush ing 's. The
overnight (not high -dose) dexamet hasone suppress io n test has however been shown to
be more sens itive and is now much more common ly used in clinical practice. As t his is not
o ffered t hen 24 hour urinary free co rtiso l is the next best answer
For a review compa ring diagnostic methods see 'Specif icity of first-line t ests for the
diagnosis of Cus hing's syndrome: assessment in a large series, J Clin Endocrino l Meta b.
2007 Nov;92(11):4123 -9'
The high -dose dexamet hasone suppressio n test is used to help different iate the cause of m
se
Cushing's syndrome
As
Dr
Discuss 7 Improve J
A 36-year-old man presents to a genitourinary clinic with multiple keratinized genital
warts. You commence treatment with cryotherapy and in the ensuing conversation about
HPV, he asks you about w hether there are any preventive measures that could have
stopped him from contracting the virus.
Which of the following individuals is it most appropriate to offer the HPV (Gardasil)
vaccination?
A 34-year-old man who has sex with women
A 24-year-old heterosexual male who has never had sex
A 35-year-old sexually active fema le w ith abnormal smears
A 21-year-old bisexual man who currently has 3 regu lar sexual partners
m
se
As
A 22-year-old transgender man who was previously vaccinated as a teenager
Dr
~4-year-old man who has sex with women
A 24-year-old heterosexua l male w ho has never had sex
A 35-year-old sexually active female w ith abnormal smea rs
I A 21-year -old bisexual man who current ly has 3 regular sexual partners
A 22-year-old t ransgender man who was previously vaccinated as a teenager
HPV vaccination shou ld be o ffered t o men who have sex with men und er the ag e of
45 to protect against anal, throat and penile cance rs
HPV vaccination is cu rrent ly recommended to men who have sex with men under 45 -
year-old to reduce their risk of anal, throat and penile cancers as well as genital warts. It is
also recom mended for girls, usually age 12-13, p rior to t heir first sexual exposure; the re is
currently no catch-up vaccination programme for women w ho were not offered the
vaccine at that age.
Transgender men (who were assigned female at birth) w ho have sex with men are also
m
eligible (although do not require it if previously vaccinated). From 2019,12 and 13 year old
se
boys will also be offered vaccination; PHE does not currently suggest a catch up p rogram
As
for heterosexual men.
Dr
Which one of the following is the most common non -iatrogenic cause of Cushing's
syndrome?
Ectopic ACTH production
Adrena l adenoma
Micronodular adrenal dysplasia
Adrena l ca rcinoma
m
se
As
Pituitary tumou r
Dr
Ectopic ACTH production
Ad renal adenoma
-
~
I MiJ onodu lar adrenal dysplasia
Ad renal carcinoma
Pituitary tumou r
m
se
As
Cushing's d isease is the most common, non -iatrogenic, cause o f Cushing's syndrome
Dr
A 55-year-old female is reviewed in the diabetes clinic. The following results are obtained:
Urinalysis protein +
HbA lc 86 mmol/mol ( 10.0%)
What average blood glucose level for the past 2 months is this most likely t o represent?
10
11
15
m
se
As
There is no relation between HbA1c and average blood glucose
Dr
9 CD
10 mt
..
CD
11
15
m
se
As
There is no re lation between HbA1c and average blood g lucose CD
Dr
A 25-year-old male develops type 2 diabetes mellitus. Which one of the fo llowing genes
is most likely to be responsible?
Glucokinase
HNF-1 alpha
HNF-4 alpha
HNF-1 beta
m
se
As
IPF-1
Dr
Glucokinase GD
HNF-1 al pha CiD
HNF-4 alpha fiD
HNF-1 beta «D
m
se
As
IPF-1 .
(D
Dr
A patient with type 2 diabet es mellitus is st arted on sitagliptin. What is the mechanism of
action of sitagliptin?
Incretin inhibitor
Dipeptidyl peptidase -4 (DPP -4) inhibit or
Glucagon inhibitor
m
se
As
Glucagon-like peptide-1 (GLP-1) mimetic
Dr
Incretin inhibitor
Dipeptidyl peptidase-4 (DPP-4) inhibito r
-
~
n Giucagon inhibitor
Glucagon -like peptide-1 (GLP-1) mimetic
m
se
Gliptins = Dipeptidyl peptidase-4 (DPP-4) inhibit ors
As
Dr
A 34-year-old female with a history of Addison's disease presents for review in
endocrinology cl inic. She is generally well but complains of a decrease in her libido. On
examination there is a slight loss of pubic hair. What is the most likely cause?
Adverse effect of hydrocortisone therapy
11-hydroxyla se deficiency
Diethylstilbestrol deficiency
Oestrogen deficiency
m
se
As
Dehydroepiandrosterone (DHEA) deficiency
Dr
Adverse effect o f hydrocortisone therapy
I Dietr ylstilbestrol deficiency
Oestrogen deficiency
Dehydroepiandrosterone (DHEA) deficiency
Dehydroepiandrost erone is the most abundant circu lati ng adrenal st eroid. Adrenal glands
are the main source o f dehydroepiandrost erone in females - loss o f funct ioning adrenal
m
tissue as in Addison's disease may result in sympt oms secondary t o androgen deficiency,
se
such as loss of libido. Research is ongoing as to whether routin e replacement o f DHEA is
As
beneficial
Dr
Which one of the fo llowing statements regard ing impa ired g lucose regu lation is co rrect?
All patient should have a re peat o ral g lucose tolera nce test eve ry 2 years
Patients with impaired g lucose tolera nce are more likely to deve lop d ia betes tha n
patients with impaired fasting glycaemia
Impa ired g lucose tolera nce OGT) is defined as a fasting g lucose greater than or
equa l to 6.1 b ut less tha n 7.0 mmol/1
Aro und 1 in 20 adu lts in the UK have impaired glucose regu latio n
m
Patients should b e offered p iog litazone if lifestyle cha nges fa il to imp rove their
se
As
glucose profile
Dr
All patient should have a repeat oral glucose tolerance test every 2 years
Patients with impaired glucose tolerance are more likely t o develop diabetes
than patients with impaired fasting glycaemia
Impaired glucose to lerance (IGT) is defined as a fasti ng glucose greater than or

equal to 6.1 but less than 7.0 mmol/1
Around 1 in 20 adults in the UK have impaired glucose regulation
m
Patients should be offered pioglitazone if lifestyle changes fa il to improve their
se
As
glucose profile
Dr
A 68-yea r-old wo man is found to have the following blood tests:
TSH 0.05 mu/1
Free T4 19 pmol/ 1 (range 9-25 pmol/1)
Free T3 7 pmol/1(range 3-9 pmol/ 1)
If left untreated, what are the most like ly possible conseq uences?
Sup raventricul ar arrhythmias and osteoporosis
Sup raventricu lar arrhythmias and hyperl ipidae mia
Hypothyroidism and impaired glucose tolera nce
m
Myasthe nia gravis and hypothyroidism
se
As
Impa ired g luco se tolera nce a nd hyperlipid aemia
Dr
I Supraventricular arrhythmias and osteoporosis
Supraventricular arrhythmias and hyperlipidaemia
~pothyroidism and impaired glucose tolerance

Myasthenia gravis and hypothyroidism
-
~
m
se
As
Impaired glucose tolerance and hyperlipidaemia
Dr
A 24-year-old woman is found to have a blood pressure of 170/100 mmHg during a
routine medical check. She is well and clinical examination is unremarkable. Blood test s
show:
Na• 140 mmol/1
K• 2.6 mmolfl
Urea 3.4 mmolfl
Which one of the following investigations is most likely to be diagnostic?
Renal ultrasound
Overnight dexametha sone suppression test
Renin:aldosterone ratio
MR angiography
m
se
As
21-hydroxylase estimation
Dr
Renal ultrasound
Overnight dexamethasone suppression test
Renin:a ldosterone ratio
MR angiography
21-hydroxylase estimation
Conn's syndrome is the likely diagnosis - a renin:aldosterone ratio wou ld be an
m
se
appropriate first-line investigation. A normal clin ical examination makes a diagnosis of
As
Cushing's syndrome less likely
Dr
Liddle's syndrome is associated wit h each one o f t he following, except:
Alkalosis
Response t o t reatment w ith amiloride
Hypertension
m
se
As
Hypoka laemia
Dr
Alkalosis
Response to treatment w ith amiloride

-
~
I
Hypertension

-
~
m
se
Hypokalaemia
As
Dr
A 73-year-old ma n is seen in incontinence clinic by a specia lity doctor. He has a past
med ical history of urge in co ntinence. He has tried oxybutyn in in the past but did not find
it helpful. He did n't tolerate tolterodine either due to his longstanding constipation. The
doctor prescribes a 6- week course of mirabeg ron.
What is the mecha nism o f action of mirabegron?
Beta-2 agonist
Beta-1 agon ist
Beta-3 agon ist
Alpha -1 agonist
m
se
As
Alpha -1 anta gonist
Dr
Beta -2 agonist CD
Beta -1 agonist CD
I Beta-3 agon ist CiD

Alpha-1 agonist «ED
Alpha-1 anta gon ist fD
Mirabegro n is a beta-3 a gonist

Mirabegro n is a beta-3 a gon ist used in the mana gement o f urge incontinence if the othe r
drugs such as oxybutynin fail to work o r a re contraindicated.
Sal buta mo l is a beta-2 receptor a gonist and ca uses bron chial s mooth muscle relaxatio n.
Beta -2 receptors are p red om ina ntly found in the lung s.
Beta -1 agonists, su ch as do buta mine, a re used as inotropic age nts in congestive hea rt
failure.
Doxazos in is a n alpha -1 a nta gonist, used in the manag eme nt of hypertension.
m
se
As
Phenylep hrine is an alpha-1 a gon ist. It a cts as a vasoco nstrictor a nd is used as a nasal
Dr
d eco ngestant.
An e lde rly male with T2DM wa s ta ke n to the Emerg ency Department with confusi on,
sweating, and ataxia. He is prescribed thia mine, metfo rmin, g liclazide, and atorvastatin.
BM was measured as 1.3 mmoi/L with para medics and, a fter administration o f l OOm l IV
d extro se 20%, returned to 5.4 mmo i/L.
You are ca lled to see the patie nt in the acute med ical unit as his BM has d ropped to 1.8
mmoi/L.
What is the most likely underlying cause?
Low g lycogen sto res second ary to chro nic a lco holism
Metfo rmin associated lacti c acidosis
Sta rvation
Sulfo nylu rea -i nduced hypoglycaemia
m
se
As
Wernicke's e ncep halopathy
Dr
Low glycog e n sto res seconda ry to chron ic alcoh olism
I Metformin associated lacti c a cidos is
Starvatio n
Su lfonylurea-induced hypoglycaemia
Wernicke's encephalopathy
In su lphonylu rea overdoses, patients are at ris k of recurre nt hypoglycaem ia

Sulphonylureas a re long -a ct ing a nti-g lycaem ic a ge nts with the potentia l to cause
recurre nt hypog lycaem ia .
m
Glycogen sto res a re low in chron ic a lcoholism p reve nting the use of g lucagon as an
se
As
e ffective treatment fo r hypog lycaemia. Wernicke 's ence pha lo pathy may be preci pitated
by ad min istration o f gl ucose be fo re thia mi ne.
Dr
A 45-year-old woman who has a history of Graves' disease presents with visual problems.
She is known to have Graves' ophtha lmopathy and does not cu rrently smoke. Her most
recent thyroid function tests are shown below:
Free T4 15 pmol/ 1
TSH 1.6 mu/1
Which one of the followin g featu res is the strongest indicator of the need for urgent
ophthalmo logy review?
Sensitivity of eyes to light
Diplopia
Troublesome eyelid retraction
Awareness of change in intensity or qu ality of colour vision
m
se
As
Erythema of the conjunctiva
Dr
Sensitivity of eyes to light
Dip lopia
Troublesome eye lid retraction
I Awareness of change in intensity or quality of colour vis ion
Erythem a o f the conjunctiva
m
se
The othe r symptoms/ signs indicate the need for non-urgent review by an o ptha lmologist.
As
Please see the EUGOGO gu ide lines fo r mo re d etails.
Dr
Which one of the following is not associat ed with primary hyperparathyroidism?
Hypotension
Multiple endocrine neoplasia type 1
Multiple endocrine neoplasia type 2a
Depression
m
se
As
Pancreatitis
Dr
Hypotens ion
Mu ltiple endocrin e neoplasia type 1
Multip le endocrin e neoplasia type 2a

-
. .wr
~ression
Pancreatitis
m
se
As
Primary hyperparathyroidis m is a ssociated with hype rtension
Dr
Dynamic pituitary function tests may be used to assess each one of the fo llowing, except:
Cortisol
Prolactin
Growth hormone
Follicular stimulating hormone
m
se
As
Antidiuretic hormone
Dr
Cortisol
Prolactin
Growth hormone
Follicl lar stimulati ng hormone

-
~
m
se
Antidiuretic hormone
As
Dr
A 68-year-old woman present s wit h letharg y and generalised aches. As part of a b lood
screen the following results are obtain ed:
Albumin 42 g/1
ESR 26 mm/hr
What is the most likely cause of these b lood results?
Mult ip le myeloma
Sarcoid os is
Normal
Breast cancer metastases
m
se
As
Dr
Multiple myeloma
ISarco~dosis
Norma l
-
~
Breast cancer metastases
Primary hyperparathyro idism
Malignancy and primary hyperparathyroid ism account for 90% of hypercalcaemia

cases
This question tests whether you have an understanding of the incidence of common
disorders. All of the above may cause hypercalcaemia but cancer and primary
m
se
hyperpa rathyroidism are the most common causes in this age group. A norma l ESR (given
As
her age) points towards a diagnosis of primary hyperparathyroidism.
Dr
A 53-yea r-old man with a history of type 2 diab etes me llitus is reviewed in the diab etes
clinic. Twelve months a go his HbAl c was 9.7% desp ite maxima l o ra l hypoglycaem ic
the rapy. Insu lin was started and his most recent HbAl c is 8.2%. He is considering applying
for a HGV licence and asks for advice. What is the most ap propriate advice?
He cannot drive a heavy goods vehicle if he is ta king insulin
He may be a ble to apply for a HGV licence if he meets strict criteria relating to
hypoglycaemia
He should stop insulin a nd start meg litin id e
As unde r 55 years of age there is no requirement to inform the DVLA
m
se
As
He needs to have been stable on insu li n for at least 5 yea rs before applying
Dr
He cannot drive a heavy goods vehicle if he is taking insulin fiD
may be able to apply for a HGV licence if he meets strict criteria relating to
poglycaemia
CD
He should stop insulin and start meglitinide Q3
As under 55 years of age there is no requirement to inform the DVLA 8

He needs to have been stable on insulin for at least 5 years before applying (D
m
se
Patients on insulin may now hol d a HGV lice nce if they meet strict DVLA criteria
As
Dr
A 53 -year-old male presents to the Emergency Department com plaining o f extreme
fatigue. He has a background of treated Graves disease. On examinat ion his blood
p ressure is 103/ 58 mmH g, p ulse 64/ min an d t emperature 36.3°C. The follow ing results are
o bt ained:
Na + 135 mmol/ 1
K+ 5.4 mmolfl
Urea 5.2 mmol/1
Creatinine 42 umol/1
TSH 3.5 mu/1
Free thyroxine (T4) 12 pmolfl
You arrange for a ran dom cortiso l t est however whilst await ing the result he becomes
unresponsive. In addition t o giving intravenous steroid an d f lu id, what test is it imperative
t o check first given the likely diagnosis?
Serum calcium
ECG
Arterial pH
Prola cti n
m
se
Glucose
As
Dr
I I I .um
seru ~ .
(D
ECG GD
Arterial pH CD
Prolactin m
Glucose GD
This question is alludi ng to a diagnosis of Add ison's disease. The auto immune history,
ra ised potassiu m, fatigue an d low blood pressu re a re all clues to this.
Patie nts with Ad d ison's disease a re pro ne to d eveloping hypog lycaemia d ue to loss of the
g lucogenic effect o f g lucocorticoid s. Give n the sudden d eterio ration in GCS, a glucose
level must be checked .
Addison's disease:
Addison's is adre nocortical insufficie ncy d ue to the dysfunctio n/destruction of the ad renal
cortex. It affects both gl ucocorticoid (metabo lis m of gl ucose etc.) a nd min era locorticoid
(sa lt ba lance) functio n. The commonest cause in the d eveloped wo rld is auto immune
a d rena litis. Other causes includ e d estructio n o f the co rtex by infections such as TB, o r
metastasis.
Sig ns/ sympto ms of Addisonian cris is:
Neuro logi ca l
• syncop e
• confusion
• letha rgy
• convu lsions
Haemodyna mic
• hypote nsion
• hypothe rmia
Biochem ica l
• hyponatraem ia
• hyperka laemia
• hypoglycaemia
Manageme nt of Ad disonian cris is (med ical e me rgency):

• intravenous fluids
• corticostero id s (e.g iv d examethasone)
em
Note: iv d examethasone is often p re ferred as this will not interfe re with cortisol assays
s
need ed fo r a short synacthe n test, unlike hydroco rtisone.

As
Dr
,. . ., I T
An 81-year old female is admitted with a 6-week history dysphagia to both solids and
liquids. She describes odynophagia, weight loss and night sweats.
On examination there was firm irregular mass in the right side of the anterior triangle of
the neck. It was fixed, cold and painless. The mass moved w ith swallowing and you note a
faint stridor like sound on inspiration. There was a fu rther 3 irregular lymph nodes of note
on palpation.
Bloods:
Thyroid stimulating hormone 4. 5 mu/1
Free T4 12 pmol/ 1
Total T4 99 nmol/1
An ultrasound-guided biopsy is likely to reveal which histological tumour?
Papillary
Follicular
Medullary
Anapla stic
m
se
As
Lym phoma
Dr
Pap illary GD
Foll icular f!D
Medullary GD
Anaplastic ED
Lym phoma tiD
Anapla stic thyroid cancer is a highly aggressive, locally invasive tumour. It typically
presents in old er patients with a rapidly increasing mass or lym p h node. Anapla stic
tumours invades loca l surrounding tissues caus ing compression sympto ms in cluding:
pain, shortness o f breath and dysphagia. The aggression of the tumour often lead s to
lymphovascular invasion and subsequent bone and lung metastasis. The cancer origi nates
from follicula r cells, which are poorly d ifferentiated and have a high mitotic rate . The
m
prognosis is poor with a 5-year survival rate quoted b etween 7% and 14%. Treatment is
se
As
usually pa lliative, with a combination of radiotherapy and che motherapy.
Dr
A 33-yea r-old man with tingling in his thu mb, ind ex a nd mid d le finger has b een refe rred
fo r end ocrine consu ltation. He a lso complains of waking up incredibly tired and says his
wife complains that he sno res. On examination, he is noted to have a p rominent brow
ridge. Looking at o ld p hotos, it becomes clear that his facia l ap pearance has drastically
changed ove r time. After some blood tests and an MRI scan, he is prescribed octreotide.
What is the mechanism of action of this drug?
Somatostatin an alogue
Growth hormone receptor anta gonist
Do pam ine ag onist
Do pam ine antagonist
m
se
As
Insu lin-growth facto r 1 a nta gonist
Dr
I Somatostatin analogue GD
Growth hormone receptor antagonist (fD
Dopamine agonist CD
Dopamine antagonist CD
Insu lin-growth facto r 1 antagonist CD
Acromeg aly is caused by excess ive growth hormone. Somatostatin directly inh ibits
the re lease of growth hormone, and hence somatostatin analogues a re used to
treat acromeg a ly
This question is two-fo ld. First, one has to recog nise the sym ptoms of acromega ly. Carpal
tunnel syndrome and sleep apnoea are classic complications of acromegaly. The chang ing
natu re of his face over time is another clue. The second part of the question was to
acknowledge that octreotide, a useful treatment fo r acromega ly is a somatostatin
analogue.
Dopamine agon ists were initially used to treat acromega ly but have fallen out of favou r
due to superior treatments. Dopamine antagonists have never been a treatment for
m
se
acromegaly. An example of a g rowth hormone antagonist is pegvisomant. Growth As
ho rmone stimu lates insu lin growth factor-1 re lease from the liver, but antagonists have
Dr
not been developed yet.

A 41-yea r-old ma n p rese nts with recurre nt head aches. These typica lly occu r 2-3 times a
d ay an d a re associated with sweating and palpitations. As he was concerned that it may
be due to b lood p ressure he borrowed his fathe rs home monitor. During these episo des
his blood pressure is a round 210/ 110 mmHg . Given the likely dia gnos is, what is the most
appropriate next test?
MRI adre nals
Phenoxybe nza mine suppression test
24 ho ur urina ry collection o f va nillylma ndelic acid
24 ho ur urina ry collection o f metanephrine s
m
se
As
24 ho ur urina ry collection o f catecho la mines
Dr
MRI adrenals
l 7 enoxybenzamine suppression test
24 hour urinary coll ection o f vanillylmandelic acid
124 hour urinary collection of metanephrines

24 hour urinary collection o f catecholamines
Phaeochromocytoma: do 24 hr urinary metane phrines, not catecholam ines

m
se
As
Three 24 hour col lections are needed as some patients have inte rmittently raised levels.
Dr
Each one of the fo llowing is associated with pseudohypoparathyroidism, except:
Low calcium levels
Low PTH leve ls
Shortened 4th and 5th metaca rpa ls
Low!Q
m
se
As
Short statu re
Dr
Low calcium levels tiD.
I Low PTH levels ED

Shortened 4th and 5th metacarpa ls tiD
Low !Q t!D
m
se
Short stature fD
As
Dr
A 34-yea r-o ld wo man presents with palpitations, tremo r and heat into lerance. She is
diagnosed with Graves' disease and started o n carbimazo le. What is the mechan ism of
actio n of this drug?
Inhibits 5 '-d eio dinase reducing production of T3
Increases renal excretion o f ca rb imazole
Blocks uptake o f iod ine to thyroi d gland by red ucing levels of hydrogen peroxide
Blocks thyro id peroxid ase from coupling a nd io dinating the tyrosine residues o n
thyroglo bulin
m
se
As
Increases rate of thyroxine brea kdown by thyroid peroxidase
Dr
Inhibits 5 '-deiodinase reduci ng p roducti on of T3
r
Increases renal excretion of carbimazole
Blocks uptake of iodine to thyroid gland by redu cing levels of hydrogen

peroxi de
I
Blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on
thyroglobulin
fZD
m
se
As
Increases rate of thyroxine breakdown by thyroid peroxidase
Dr
A 52-yea r-o ld woman with suspected d ia betes mellitus has an oral gl ucose tolera nce test,
following the standard WHO p rotocol. The following resu lts are o bta ined:
Time ( hours) Blood gl ucose (mmol/1)
0 5.9
2 8.4
How shou ld these resu lts be interpreted?
Impa ired fasting g lucose and impaired glucose tolerance
Norma l
Diabetes me llitus
Impa ired g lucose to le rance
m
se
As
Impaired fasting g lucose
Dr
Impaired fasting g lucose and impaired glucose tole rance
Normal
Diabetes mellitus
Impa ired g lucose tolerance
m
se
As
Impa ired fasting g lucose
Dr
A diabetic man is diagnosed as having painfu l diabetic neu ropathy in his feet. He has no
other medical history of note. What is the most suita ble first-li ne treatment to relieve his
pain?
Duloxetine
Sodium valproate
Carbamazepine
Referral to pain management clinic
m
se
As
Trama dol
Dr
Duloxetine
Sodium valproate
-
~
I Carbamazepine
Referra l to pain mana gement clinic
m
se
As
Tramadol
Dr
A 30-year-old woman who is investigated for obesity, hirsutism and ol igomenorrhoea is
diagnosed as having polycystic ovarian syndrome (PCOS) following an ultrasound scan.
She is hoping to start a fa mily and her docto r starts metformin to try and im prove her
fertility. What is the mechanism of action of metformin in PCOS?
Stimulates the release of insulin from the pancreas
Blocks the insulin mediated deve lopment of multiple immatu re follicles in the
ovanes
Increases peripheral insu li n sensitivity
Blocks the conversion o f oestradiol to testosterone
m
se
As
Increases hepatic g luconeogenesis
Dr
Stimulates the release of insulin f rom the pancreas
Blocks the insulin mediated development o f multiple immature follicles in the

ovaries
~reases peripheral insulin sensitivity

Blocks the conversion o f oestradiol to testosterone
Increases hepatic gluconeogenesis
The majority of patients wit h polycyst ic ovarian syndrome have a degree of insulin
m
se
resistance w hich in t urn can lead to complicated changes in t he hypothalamic-pituita ry-
As
. .
ovana n ax1s.
Dr
A 25-yea r-old man with a fami ly history of multiple endocrine neoplas ia type 1 is
reviewed in clinic. What is the single most useful investigatio n to monitor such patients?
Short synacthen test
Serum calcium
Thyroid fun ction tests
m
se
As
Serum prolactin
Dr
Short synacthen t est
~umcalcium
Thyroid fu nction tests
Serum prolactin
-
' UI;IIl'
Peptic ulceration, galactorrhoea, hypercalcaemia - multiple endocrine neoplasia

type I
m
se
The high incidence of pa rathyroid tumo urs and hypercalcaem ia make serum calcium a
As
useful indicator o f MEN type 1 in suspect ed individuals
Dr
A 78-year-old nu rsi ng home res ident is a dm itted to the acute medi cal un it after being
found collapsed in his room. A carer from the nursing home is p resent and reports that he
has had regular 'hypos' recently. On admission he was d rowsy and the blood glucose was
1.8 mmol/1. Following intravenous dextrose the patient's condition sign ificantly improved.
His medication on admission is as follows:
Metformin l g bd
Gliclazide 160mg od
Pioglitazone 4 Smg od
Aspirin 7Smg od
Simvastatin 40mg on
What is the most appropriate initial actio n?
Stop metformin
Stop pioglitazone
Stop gliclazide
Make no changes to the med icatio n
m
se
As
Stop all o ral antid iabetic medications
Dr
Stop metformin m
-
Stop p ioglitazone CD
I Stop gliclazid e GD
Make no cha nges to the med ication CD
Stop a ll oral antid iabetic medi catio ns GD
Neither metfo rmin nor p ioglitazone cause hypoglycae mia. The g liclazi de dose is therefo re
m
se
responsible and should be stopp ed whilst d eciding upon lo nge r te rm chang es to his
As
med icatio n.
Dr
A 31-year-old female with polycystic ovarian syndrome consu lts you as she is troubled
with excessive facial ha ir. Switching her combined oral contraceptive pill to co-cyprindiol
has had no effect. On exam ination she has hirsutism affecting her moustache, beard, and
temple areas. What is the most app ropriate treatment?
Topica l sa licyl ic acid
Topical a dapalene
Ora l clom ifene
Topical eflornithine
m
se
As
Topica l taza rotene
Dr
Topical salicylic acid m
Topical adapalene f.D
Oral clomifene ED
Topical eflornithine 63
m
se
Topical tazarotene f.D
As
Dr
An 18-year-old g irl is a dmitted to the Emergency Department with an episode o f
sweating and dizziness. She is bro ught in by her father who has type 2 diabetes mellitus
a s he is worried she may be diab etic. He d escribes a number of sim ila r episodes for the
past two weeks. Her BM on adm ission is 1.9 mmol/1so the fo llowin g blood s a re taken:
Plasma glucose 1.8 mmoljl
I nsulin 15 mg/ml (6- 10 mg/ml)
Proinsulin 22% ( 22-24%)
C-peptide 0 . 15 nmol/ 1 (0 .2-0.4 nmol/1)
Diabetes mellitus
Insu linoma
Nesidiobl astos is
Insu lin a buse
m
se
As
Sulfonylurea abuse
Dr
Diabetes mellitus m
Insulinoma (fD
Nesidioblastosis CD
I Insulin abuse GD
Sulfonylu rea abuse CfD
m
se
The ra ised insulin with low c-peptide level points to a diagnosis of insu li n abuse.( -
As
peptide levels wou ld be ra ised in a patient following sulfonylurea abuse
Dr
A 31-year-old wo man present s fo r review. For the past few months she has been feeling
generally tired and has not had a normal period for around 4 months. Prior t o this she
had a regular 30 day cycle. A pregnancy t est is negative, pelvic examination is normal and
routine bloods are ordered:
FBC Normal
U&E Normal
TFT Normal
Follicle-stimulating hormone 41 iu/1 ( < 35 iu/1)
Luteinizing hormone 33 m!U/ 1 ( < 20 miU/ 1)
Oestradiol 70 pmol/ 1 ( > 100 pmol/1)
Ovarian cancer
Gonad otropin- producing pitu itary adenoma
Tu rner syndrome
Premature ovarian failure
m
se
Aromatase enzyme deficiency As
Dr
Ovarian cancer m
Gonadotropin-producing pituitary adenoma (D
Turner syndrome m
I Premature ovarian failure GD
m
se
Aromatase enzyme deficiency CD
As
Dr
A 93-yea r-old female who lives alone comes to see you regarding troublesome urge
incontinence. Over the past yea r, you have noted a steady decline and she is becoming
increasingly frail. She has had a number of falls while rushing to the bathroom, resu lting
in attendance at the loca l emergency depa rtment. She p reviously underwent a course of
bladder retra ining with no significant improvement in symptoms.
What wou ld be the most app ropriate treatment of her urge incontinence?
Immediate release oxybutyn in
Mirabegron
Doxazosin
m
se
As
Su rgical repai r
Dr
Immediate release oxybutynin
~a begron
Doxazosin
Surgical repair
Oxybutynin should not be used in f rail older women w ith urinary incontinence due
to the risk of impairment of daily functioning, confusion and acute delirium
The correct answer here is mirabegron. According t o the latest NICE guidance, first line
medica l t reatment of urg e incontinence aher b ladder retraining can be with oxybutynin,
t olterodine or d arifenacin. NICE has issued a 'do not use' st atement on the use of
oxybutynin in f rail eld erly women due t o the risk of cognit ive impairment, falls an d
general decline. Th is is particu larly the case with immediate release preparat ions. There is
no similar st atement fo r tolterodine or darifenacin. A t rial o r tolterodine or darifenacin,
may have been an app ropriat e answer if this option was given, although these are also
associated w ith anticho linergic side effects. Given t he patients' history o f g eneral d ecline
and recu rrent falls, avoidance of an anticho linergic and t reatment with mirabegron wou ld,
therefore, be a more appropriat e choice than oxybutynin.
Oxybutynin is normally the ant i muscarinic of choice in urge incontinence, however, has a
high anticholinergic burden. Per NICE guid ance it shou ld b e avoid ed in frail older women
due to an increased risk of d elirium, confusion an d impaired function. Given the patients'
age, history of gradual d ecline and recurrent falls, o xybutyn in shou ld be avoided. Th is is
particu larly the case, given that she lives alone and so increased confusion or d elirium
may not b e picked up straight away, increasing her risk of falls.
Pelvic floor exercises are used in conservative management of stress incontinence not
urg e incontinence.
Doxazosin is used in the t reatm ent of hypertension and urinary ret ention. It is like ly to
worsen her symptoms of urge incont inence.
s em
As
Surgery is indicated in stress as op posed to urge incontinence.

Dr
A 42-year-old man presents t o his GP feeling generally unwell. For the past three months
he ha s been experiencing daily frontal headaches which have not been helped by regular
pa racet amol. He has also noticed some unusual symptoms such as his wedding ring no
longer fitting, his shoe size apparently increasing and a small amount of milky discharge
from both nipples. On examination his blood pressure is 168/ 96 mmHg. What is the most
likely diagnosis?
Phaeochromocytoma
Cushing·s syndrome
Diabetes in sipidus
Macroprolacti noma
m
se
As
Acromegaly
Dr
Phaeochromocytoma m
Cushing's syndrome m
Diabetes in sipidus f.D
Macroprolactinoma GD
m
se
I I
As
Acromegaly fiD
Dr
A 67 -year-old man who has a history of type 2 diabet es mellitus and benign prost atic
hypertrophy presents with burning pain in his feet. This has been present for the past few
months and is getting gradually worse. He has tried taking duloxetine but unfortunat ely
has received no benefit. Clinical examinatio n is unremarkable other than diminished
sensation to fine touch on both soles. What is the most suitable initial management?
Carbamazepine
Am itriptyline
Pregabalin
Fluoxetine
m
se
As
Sodium valproate
Dr
Carbamazepine m
Am itriptyline eD
I Pregabalin ED.
Fluoxetine m
~
Sodium valproate m
m
se
Am itriptyline would norma lly be first choice but given his history of benign prostatic
As
hyperplasia it is better to avoid amitriptyline due to the risk of urinary retention.
Dr
A 61-yea r-old man p resents as he develop ed enlargement of his b reast tissue. He has
become ve ry self-conscious a nd is wo rried about go ing on holiday in the summe r. Which
one of the following drugs is most like ly to be res ponsible?
Amitriptyline
Iso niazid
Verapa mil
Methyld opa
m
se
Spironolactone
As
Dr
Amitriptyline
Ison iazid
•
fD
Verapamil fD
Methyldopa CD
Spironolactone CD.
m
se
All the above drugs may cause gynaecomastia but spironolactone is the most common
As
cause.
Dr
A 35-year-old female has recently been diagnosed with Addison's disease due to
autoimmune adrenal fa ilure after presenting w ith a 3 -month histo ry of lethargy, nausea,
weight loss and fainting. Which of the following physical signs may you find in this
patient?
Stretch marks on her abdomen
Multiple bruises on her limbs
Frontal balding
Thinning of the axillary hair
m
se
As
Cafe au lait spots
Dr
Stretch marks on her abdomen
Multiple bruises on her limbs
Fronta balding
Thinning of the axillary hair
Cafe au lait spots
Thinning of pubic and axillary hair is seen in females with Addison's disease due to
reduced production of t estosterones fro m the adrenal gland
The correct answer is thinning of the axillary hair. The patient has failure of the adrenal
gland due to auto immune attack. As well as deficiency o f glucocorticoids and
mineralocorticoids, she will have lower levels of androgens, which are usually produced in
females by the zona reticularis of the adrenal cortex. Th is leads to thinning of hair grown
at puberty, which is androgen dependent. The scalp hair is unaffected.
Stretch marks, skin th inning, easy bruising and poor wound healing are found in
Cushing's disease or in patients given longterm exogenous steroids. Cafe au lait spots are
m
seen in neurofibromatosis type I.
se
As
NICE CKS. Addison's disease.
Dr
A 43 -year-old man is found to have a phaeochromocytoma. Which anti-hypertensive
medication should be started first?
Propranolol
Ramipril
Ateno lol
Phenoxybenzamine
m
se
As
Doxazosin
Dr
Propra nolo l GD
Ram ipril CD
Atenolol GD
Phenoxybenzamine CiD
Doxazosin GD
PH aeochromocyto ma - give PHenoxybenzamine before beta-b lockers

Phenoxybe nzami ne is a non-selective a lp ha-ad renocepto r anta gonist and should be

started b efo re a beta-b lo cke r is intro duced
The re is ongoing debate about the optima l medical management of

phaeochro mo cytoma, with the su ggestion that antihypertensive treatment regimes othe r
m
se
than non specific a lpha-b lockade a re just as effective and safe. The re are however no
As
trials to p rovide an answer to this question yet
Dr
A 49-year-old man with type 2 diabetes mellitus is reviewed. Despit e weight loss and
therapy with metformin and gliclazide his la st HbAlc is 7.2%. Which one of the following
factors woul d suggest that the patient may benefit from a meglitinide?
Obesity
Not adhering to diabetic diet
Problems with hypoglyca emia from gliclazide
Erratic lifestyle
m
se
As
El derly and frail patients
Dr
Obesity
Not adhering to diabetic diet

-
~
Problems wit r hypoglycaemia from gliclazide
Erratic lifestyle
El derly and frail patients

-
~
Meglitinides - stimulate in su lin release - good for erratic lifestyle

m
Meglitinides stimulate insulin release and are particularly useful for post-prandial
se
As
hyperglycaemia or an erratic eating schedule, as patients t ake them shortly before meals
Dr
A 18-year-old man with a background of Marfan syndrome presents to the emergency
department with palpitations and sweating. He was hypertensive on admission at 198/101
mmHg. He is also complaining of the development of nodules on his torso and cheek
which provide a pins and needle like sensation. A 24 hour urinary catecholam ine has been
sent and is currently pending.
Thyroid carcinoma
MEN type 2A
MEN type 1
MEN type 2B
m
se
As
Pheochromocytoma
Dr
hyroid carcinoma fD
MEN type 2A GD
MEN type 1 CD
~Ntype2B GD
Pheochromocytoma .
f!D
Medullary thyroid cancer, phaeochromocytoma, marfanoid body habitus - multiple

endocrine neoplasia type lib
When differentiating between MEN 2A and 2B, it is worth remembering that M EN 2B has
similar charact eristics as MEN 2A (Thyroid carcino ma's, Adrenal tumours, Parathyroid
hyperplasia) but in addition typically have a Marfanoid appearance and mucosal
neuromas, as well as the absence of hyperparathyroidism.
m
MEN type 1 is characterised by pancreatic neuroendocrine tumou rs, pituitary adenoma
se
and parathyroid hyperplasia.
As
Dr
A 33-yea r-o ld white male attends his GP with a two month history of weight loss, letha rgy
and polydipsia. He has a past med ical history of a thyroidectomy fo r Grave's disease, no
significant fa mily history and currently takes levothyroxine. The GP does a capilla ry
glucose measurement, which is 18.lmmoi/L a nd does a urina lys is revea ling 2+ glucose
and 2 + ketones. His blood p ressure is 134/86mm Hg. What is the most likely diagnosis?
Type 2 d iabetes mellitus
Addison's disease
Latent Autoimmune Diabetes of Adulthood
Maturity Onset Diabetes o f the Young
m
se
As
Levothyroxine-induced diabetes mellitus
Dr
Type 2 d iabetes me llitus
Addison's disease
Latent Autoimmune Diabetes of Adulthood
Maturity Onset Diab etes of the Young
Levothyroxine-induced dia betes mellitus
Latent autoimmune d iabetes of ad ulthood (LADA) is a diso rder in which, d esp ite the
p resence o f islet antibod ies at diagnosis of dia betes, the p rog ression o f autoi mmune -cell
failure is slow.
In contrast to type 2 diabetes, patients a re typically younger and without an increased

body ha bitus. In contrast to type 1 d iabetes, insulin is not usually required in the ea rly
stages of the disease.
Diagnosis may be aided through a Glutam ic Acid Decarboxylase (GAD) Autoa ntibo dies
test and evidence of o ther autoimmune diseases.
Levothyroxine is not associated with inducing d iabetes. In patients with diabetes starting
thyroxine, doses o f antidia betic d rugs in clud ing insu lin may need to be increased .
m
se
As
Addison's disease is associated with hypog lycaemia.
Dr
A 44-year-old woman presents to her GP as she is feeling 'hot all the time ' and is
consequently worried she is going throu gh an early menopause. Her husba nd has a lso
noticed a 'fu llness' of her neck which has become a ppa rent over the past few weeks. On
examination her pu lse is 90/minute and she has a small, non-tender go itre. Blood tests
are a rran ged:
TSH < 0 .05 mu/1
Free T4 24 pmol/ 1
Anti-thyroid peroxidase antibodies 102 IU/ml ( < 35 IU/ml )
ESR 23 mm/hr
Toxic mu ltinodu la r goitre
Thyro id cancer
De Quervain 's thyroid itis
m
se
Graves' disease As
Dr
Hashimoto's thyro iditis fiD
I T(OXIC
. mu Itmo
. d u Iar g01tre
.
CD
Thyroid cancer m
- De Querva in's thyroid itis fD
I Graves' disease CD
The thyrotoxic symptoms and blood tests, g oitre and anti-thyro id peroxidase a ntibodies
sug gest a d iagnosis of Graves' d isea se.
Whilst a nti-thyro id peroxidase a ntibod ies are seen in 90% of Hashimoto's disea se they are
also seen in 75% of patie nts with Graves' disease. Ha shimoto 's thyroiditis is also g enera lly
a ssociated with hypothyro idism, which is not in keep ing with this p resentation.
m
se
As
The ESR result is within norma l range.
Dr
A 54-yea r-old fema le presents to the Emergency Depa rtment concerned about double
vision. She is noted to have exophtha lmos a nd conjunctival oedema on exam ination a nd
a dia g nosis of thyro id eye disease is suspected . What can be said reg arding he r thyro id
status?
Hyper- o r euthyroi d
Hypothyroid
Hyperthyro id
Hypo- or euthyro id
m
se
As
Eu -, hypo- o r hyperthyroid
Dr
Hyper- o r euthyroid CD
Hypothyroi d m
Hyperthyroid ED.
Hypo- or euthyro id m
I Eu -, hypo- or hype rthyroid CD
Whilst thyroid eye disease is mostly associated with hyperthyro id ism secondary to Graves'
disease the re is not a lways an association. A minority of patients will e ithe r be euthyro id
o r hypothyroi d.
m
se
It is a lso known that the severity o f thyroid eye d isease is not re lated to the d egree of
As
thyrotoxicosis in Graves' d isease.
Dr
A 62-year-old man is investigated for hypertension and proximal myo pathy. On
examination he is noted to have abdomina l striae. Which one of the following is most
associated with ectopic ACTH secretion?
Carci noid tumou r
Cardi ac myxoma
m
se
As
Adrenal carcinoma
Dr
Carcinoid tumou r
Card iac myxoma
Adrena l ca rcinoma
Small cell lung cancer account s 50-75% of case o f ectop ic ACTH

m
se
Ad renal carcinoma and card iac myxoma are causes of ACTH independent Cushing 's
As
syndrome
Dr
A 40-year-old woman complains of feeling tired all the time and putting on w eight. On
examination a diffuse, non-tender goitre is not ed. Blood tests are ordered:
TSH 15.1 mU/1
Free T4 7. 1 pmol/1
ESR 14 mm/hr
Anti-TSH receptor stimulating antibodies Negative
Anti-thyroid peroxidase antibodies Positive
Pituitary fa ilure
Primary atrophic hypothyroidism
De Quervain's thyroiditis
m
se
As
Grave's disease
Dr
Pituita ry fa ilure CD
Pril)lary a trophic hypothyroidism CD
De Q uerva in 's thyro id itis fD
I Hashimoto's thyroiditis fD
Grave 's disea se GD
Hashimoto's thyro iditis= hypothyroidism + goitre + a nti-TPO

This patient has Hashimoto's thyro iditis, as evidenced by the hypothyroid ism, g o itre a nd
anti-thyroid peroxidase a ntibodies. De Que rvain's thyro iditis typica lly ca uses a pa inful
m
se
g o itre a nd a ra ised ESR. Aro und 90% of patients with Grave's disease have anti-TSH
As
recepto r stimu lating antibod ies.
Dr
A 54-year-old man with type 2 diabetes mellitus is reviewed in clinic. He is currently
t aking pioglitazone, metfo rmin, aspirin an d simvastatin. Which one of the following
problems is most likely to be caused by pioglitazone?
Photosensitivity
Thrombocytopaenia
Myalgia
Peripheral oedema
m
se
As
Hyponatraemia
Dr
Photosensitivity tiD
Thro mbo cytopaenia D.
Mya lg ia CD
~ipheral oedema CD
Hyponatrae mia tiD
m
se
Piogl itazone may cause flu id retention
As
Dr
Each one of the following is associated with Pendred's syndrome, except:
Goitre
Short 4th and 5th metacarpals
Sensori neural d eafness
m
se
As
Euthyroid status
Dr
.
..
Goitre (D
I Short 4th and 5th metaca rpa ls
Autosomal recessive inhe ritance (fD
I Sensl ri neu ra l d ea fness fD
m
se
As
Euthyro id status fD
Dr
A 23-year-old woman is diagn osed with Graves' disease. Wh ich o ne of the fo llowing
statements rega rding treatment is correct?
Block-and-replace reg imes are usua lly of a shorter du ration than carbimazo le
titration therapy
Concu rrent adm inistration of p ropranolol and carb imazole should be avoided
Patients on b lock-and -rep lace reg im es have fewer side-effects than those using
titration therapy
Carb imazo le should be sta rted at no higher than lO mg/day for patients
commencing a titration regim e
m
se
In the block-and -replace regime levothyroxine should be sta rted at the same time
As
as ca rb imazole
Dr
Block-and-replace regimes are usually of a shorter duration than carbimazole
titration therapy
Concurrent administration of propranolol and carbimazole should be avoided
Patients on block-and-replace regimes have fewer side-effects than those using

titration therapy
C!D
Carbimazole should be started at no higher than lOmg/day for patients

commencing a titration regime
In th e block-and-replace regime levothyroxine should be started at the same
m
se
time as ca rbimazole
As
Dr
A 45-yea r-old who is currently being investigated for lethargy and reduced libid o presets
for fo llow-u p. He initially p resented after requesting a testosterone b lood test due to his
reduced sexua l drive. This was repo rted as follows:
Test ost erone 5.4 nmoljl (> 9.0)
Su bsequent blood tests s how the following:
Prolactin 4 50 mU ( < 400)
Cortisol ( Sam) 120 nmoi/ L ( 130-690)
FSH 0 .8 IU/l {1 -8)
Addison's disease
Testicular cancer with brain metastases
Non -functioning pituita ry adenoma
Prola cti noma
m
se
Cra niopharyngioma As
Dr
Addison's disease
Testicular cancer with brain metastases
Non-functioning pituitary adenoma
Prolactinoma
Craniopharyngioma
Non -functioning pituitary tumours present with hypopituit arism and pressure
effects
Whilst the prolactin level is slightly raised this ca n be caused by the pressure effect s of the
m
se
tumou r preventing dopamine (which inhibits prolactin release) from reaching the normal
As
prolactin- producing cell s. Much higher levels wou ld be expected w ith a prolactinoma.
Dr
A 45-year-old female is admitted to the Emergency Department with abdominal pain
associated w ith vomiting. She has a past medical hist ory of hypothyroidism and t akes
thyroxine. On examination she is pyrexial at 37.6°C. Pulse is 110 bpm with a blood
pressure of 100/ 64 mmHg. Blood results show the following:
Na• 131 mmol/ 1
K• 4.9 mmol/1
Urea 8.1 mmol/1
Glucose 3.3 mmolfl
What treatment should be given first?
Ceftriaxone + benzylpenicillin
Glucagon
Propranolol
Triiodothyronine
m
se
As
Hydrocortisone Dr
m
se
This is a typical history of Addison's. Patients may have a history of other autoimm une
As
conditions such as thyroid disorders. Steroids shou ld be given as soon as possible
Dr
A 32 year-old man presents compla ining of pers istent headaches. He was diagnosed with
hypertension 4 months ago and started on perindop ril. On exam ination, heart his rate is
75 beats per mi nute and blood pressure is 185/llSmmHg.
Investigations:
Serum pot assium 1.9 mmoljl (3.5-5 .0)
Plasma aldosterone ( after 30 minutes supine) 700 pmoljl ( 135-400)
Plasma renin activity (after 30 minutes supine) 0.4 pmoljmljhr (l.l -2.7)
What is the most likely cause of his hypertension?
Addison d isease
Bilateral re na l artery stenosis
Phaeochromocytoma
m
se
As
Pri mary hyperaldosteronism
Dr
Addison disease
Bilatera l rena l artery stenosis
Phaeochromocytoma
Primary hyperaldosteron ism
Primary hyperaldosteronism is typically caused by an aldosterone producing adenoma

(Conn's syndrome), other causes include: bilatera l adrenocortical hyperp lasia and adrena l
carcinoma.
Primary hyperaldosteronism and b ilateral renal artery stenosis are associated w ith
hypoka laemia due raised serum aldosterone, which causes increased sodium reabsorpt ion
and potassium excretio n.
Aldosterone is elevated in bilat eral renal artery st enosis due to reduced renal perfusion.
Aldosterone is high in primary hyperaldoste ronism, however, serum renin is usually low in
primary hyperaldosteronism due t o the resulting hypertension causing excessive renal
perfusion, which results in decreased renin production (negative feedback mechanism).
High renin levels are seen in renal artery stenosis as renal perfusion is permanently
reduced, despite hypertension, due to t he stenotic renal arteries.
m
se
As
(Reference: Oxford handbook o f clinical medicine, 8th ed.pg.220)
Dr
An 24-year-old woman is reviewed due to facial hirsutism. You suspect a diagnosis o f
polycystic ova rian syndrome (PCOS). Which one o f t he followin g features wou ld suggest
the need for further investigations before confidently making a diagnosis o f PCOS?
Cl ito romegaly
Acanthosis nigricans
Obesity
Amenorrhoea
m
se
As
Acne
Dr
Clitoromegaly eD
Acanthosis nigricans f!D
Obesity CD
Amenorrhoea fD
Acne CD
Clito romegaly is seen occasionally in PCOS but is normally associated with very high
m
se
androgen levels. If clitoromega ly is found then fu rther investigations to exclude an
As
ovarian or adrenal androgen secreting tumour are required.
Dr
Which one of the following hormones is under continuous inhibition?
Growth hormone
Prolactin
Thyroid releasing hormone
m
se
As
Ad renocorticotrophic hormone
Dr
Growth hormone
I Prola ct in
I Thyroid releasing hormone
Adrenocorticotrophic hormone
Prolactin - under continuous inhibition

m
se
Prolactin is unique amongst the pituitary hormones in being tonically inhibited by the
As
hypothalamus
Dr
A 49-year-old female was admitted to t he emergency department with confusion. A
history is unobtainable due to this confus ion, with a Glasgow co ma scale sco re of 13/15.
Hosp ital records note a 2-month backgrou nd of recurrent urin ary t ract infect ions (UTI's)
and recent admission for urosepsis. Her past medical history includes: Type 2 diabetes
mellitus, hypertension, hypercholesterolaemia and a hiatus hernia.
On examinat ion the patient is cool peripherally with a cap refill of 3 seconds, dry mucus
membranes, heart sounds 1+2+0, vesicu lar b reath sounds, abdomen was soft, b ut tender
over the suprapubic area. There was no rigidity or guarding and bowel sounds were
p resent.
Observatio ns: Resp iratory rate 16 b reaths per minute, saturations 98% on air, b lood
p ressure 80/ 58mmHg, heart rate 122 beats per minute, temperature 38.4°C and capillary
glucose 16 mmoi/L.
Urine dip showed:
Nitrites +++
Leucocyte est erase +++
Blood +
Glucose +++
Ketones
Protein
Which medication is likely to contributi ng to t he cause o f her presentations?
Metf orm in
Tolbut amide
Dapaglifozin
Sita gliptin
sem
As
Exanetide
Dr
Metformin GD
Tolbut amide CD
Dapaglifozin GD
Sitagliptin fD
Exanetide .
(D
Dapagliflozin is a member o f the glofozin anti-diabetic drugs. The medication works by

inhibiting the sodium-glucose transport proteins (SGLT2), which reabsorbs glucose in the
proximal tubule. The drug has recently b een licensed by national institute of clin ical
excellence (NICE) for the treatment of type 2 diabetes mellitus. Dapagliflozin can be tried
if blood sugars are poorly controlled following commencement of metformin and the
patient is unable to take a sulfonylurea. Common side effect s are often secondary to the
m
se
glycosuria, wh ich include increased predisposition of urinary tract infection and
As
dehydration.
Dr
A 30-yea r-old female is started on carbimazole 20mg bd following a diagnosis of Grave's
disease. What is the best biochemical marker to assess her response to treatment?
Total T4
TSH
Free T4
ESR
m
se
As
Free T3
Dr
Total T4 CD
I TSH CD
Free T4 fD
rE Free T3
-
m
The answer the College are looking for is TSH. There is however a significant propo rtion
o f patients for whom TSH monitoring alone is insufficient. TSH may remain suppressed for
m
se
severa l weeks as co ntinued p roduct ion of thyro id stimulating immunoglobulins seen in
As
Grave's disease reduces the need for the pituitary to secrete TSH
Dr
A 23-year-old woman presents for review. She has not had a normal p eriod for around 8
mont hs now. A recent pregnancy test was negative. Blood t est s are ordered:
FSH 2.2 IU/ L {0-20 IU/ L)
Oestradiol 84 pmol/ 1 ( 100-500 pmoljl)
Thyroid stimulating hormone 3. 1 m!U/ L
Prolactin 2 ng/ml (0-10 ngjml)
Free androgen index 3( < 7)
Prolact inoma
Polycyst ic ovarian syndrome
Addison' s d isease
m
se
As
Excessive exercise
Dr
Prola ct inoma
Addison' s disease
Excessive exercise
m
se
The bloods show a hypothalam ic amenorrhoea w hich may be caused by stress o r
As
excessive exe rcise. The FSH wou ld be raised in premat ure ovarian failure.
Dr
Which of t he follow ing is least recog nised as a potential complication of acromegaly?
Colorectal cancer
Hypertension
Cardi omyopathy
Diabetes mellitus
m
se
As
Pulmonary hypertension
Dr
Colorectal cancer 6D
Hypertension CD
...._
Cardiomyopathy fD
Dia+ tes mellitus fD
Pulmonary hypertension GD
Acromegaly is associated with syst emic rather t han pulmonary hypertension.
m
se
Secondary causes o f pulmonary hypertension include COPD, congenital heart disease
As
(Eisenmenger's syndrome), recurrent pulmonary embolism, HIV and sarcoid osis.
Dr
A 55-yea r-old taxi driver with type 2 diabetes mellitus comes fo r review. When he was
diagnosed 12 months a go he was started on metformin and the d ose was titrated up. His
IFCC-HbAlc o ne year ago was 75 mmol/mol (DCCT-H bAlc 9%) and is now 69 mmo l/mo l
(8.5%). His body mass ind ex is 33 kg/m2 • What is the most ap prop riate next step in
management?
Add exenatide
Add sitagliptin
Add glipizide
Ma ke no cha nges to his medicatio n
m
se
As
Add insulin
Dr
Add exenatide GD
I Add sitagliptin ED
Add glipizide CD
Make no changes to his medication CD
Add insulin CD
~
His HbAlc is still significantly above targ et so some change to the medication is
indicated.
The NICE type 2 diabetes mellitus guidelines would generally advocate the use o f a
sulfonylurea in this situation.
However. the patient is a taxi driver and overweight. A DPP -4 inhibitor such as sitagliptin
wou ld be ideal in th is situation. The re is no risk of hypoglycaemia and they DPP-4
m
se
inhibitors are weight neutral.
As
Dr
A 75-year-old woman with a history of hypothyoidism is admitted to the Emergency
Department fo llowing an episode of chest pain. She is diagnosed as having an acute
coronary syndrome and iron-deficiency anaemia. A percut aneous co ronary intervention is
performed and a co ronary artery stent is inserted. Endoscopies of the upper and lower
gastrointestinal tract are performed and reported as normal. She is discharged on the
following drugs in addition t o her regular levothyroxine: aspirin, clopidogrel, ramipril,
lansoprazole, simvast atin and ferrous sulphate. Six weeks lat er she complains of feeling
tired all the time. Her GP arranges some routine blood t ests:
Hb 11.9 g/dl
Plat elet s 155 * 109/1
WBC 5.2 * 109/ 1
Free T4 8 . 1 pmol/1
TSH 8.2 mu/1
Prior to her recent admission the TSH has been within range for the past two years. Which
one of the following new drugs most likely explains the raised TSH ?
Simvast ati n
Clopidogrel
Ferrous sulphate
Ramipril
sem
As
Lan soprazole
Dr
Simvastatin GD
Clopidog rel CD
Ferrous sulphate CiD
Ram ipril CD
Lansoprazole GD
m
se
Iron reduces the absorption of thyroxine
As
Dr
Which one of the following may be associated with galactorrhoea?
Primary hypothyro idism
Addison's disease
Cushing's syndrome
Grave's disease
m
se
As
Bromocriptine
Dr
Primary hypothyroidism eD
Ad1 ison's disease (D
Cushing's syndrome CD
Grave's disease fD
m
se
As
Bromocriptine ED
Dr
You review a 47-year-old man one year after he was d iag nosed with pred iabetes. Last
year he had a HbAlc ta ken after bein g diagnosed as having hypertension. This was
reco rded as being 43 mmol/mol (6.1%). His most recent blood test is recorded as being
45 mmo l/mol (6.3%) d espite the patient reporting that he has changed his d iet as
instructed a nd exercis ing three times a week. His body mass index (BMI) today is 26.5
kg/m 2 . Last yea r it was 27.5kg/ m2 • What is the most appropriate cou rse of action?
Start metformi n
Start pioglitazone
Review a gain in 12 months
Start o rlitstat
m
se
As
Do a ora l glucose tole rance test
Dr
Start met formin
Start pio glitazone
Review again in 12 months
Start orlitstat
Do a ora l glucose tolerance test
NICE recommend metformin for adu lts at high risk 'whose blood glucose measure (fasting
m
se
plasma glucose or HbAlc) shows they are still progressing towards type 2 diabetes, despite
As
their participation in an intensive lifestyle-change programme'.
Dr
A 48-yea r-old lady is seen in the diabetes clinic with uncontrolled b lood sugars ranging
from 14 mmoi/L to 22 mmoi/L. She has a past med ical history of type 2 diabetes,
ischaemic heart disease, rheumatoid arthritis and recu rrent e pisodes of thrush a longside
chronic obstructive pulmonary d isease. Her body mass index is 30. Which medical co-
morbidity is the strongest contra indication to starting an SGLT2 (sodium g lucose
transport protein 2) inhibitor class of drugs?
Ischaem ic hea rt d isease
Chronic obstructive pu lmona ry d isease
Type 2 diabetes
m
se
As
Recurrent thrush
Dr
Ischaemic heart disea se
Chronic o bstructive pu lmo na ry d isease
Type 2 diabetes
Rhr umatoid a rth ritis
Recurrent thrush
Dapa gliflozin is a newer drug for the treatment o f diab etes. It is a member of the sodium -
glucose transport protein 2 (SGLT2) inhibitor class o f drugs.
SGLT2 inhibitors p re ve nt the resorption o f glucose from the proximal re nal tubule,
resulting in more g lu cose b ei ng secreted in the urine. Due to a n increased a mou nt of
glucose be ing secreted in the urine, these medications are contra -indicated in patients
with recurre nt thrush. The increased a mount of glucose in the u rine is thought to
predisp ose to bacterial growth. It s houl d also b e noted that urine di p sticks will test
pos itive for glucose.
The other medications in this class includ e: canagliflozi n & empa gliflozin
The other a nswers a re distractors with no known contraindication to SGLT2 inhibito r use
in ischaemic heart disease, chro nic o bstructive pu lmona ry disease or rheu matoid a rthritis.
SGLT2's are indicated in patients with type 2 diabetes. Note that a lthou gh trials are
o ngoing, SGLT2 inh ibitors are not curre ntly licensed as a n a djunct in patients with type 1
diab etes.
sem
As
Dr
Which one o f the following unwanted effects is most likely t o occur in patients taking
g liclazide?
Cholestasis
Photosensitivity
Syndrome of inappropriate ADH secretion
m
se
As
Weight gain
Dr
Periphe ral neuropathy
Cholestasis
n hotosensitivity
Syndrome of in appropriate AD H secretion
I Weight gain
-
......,
m
se
All of the above side-effects may be seen in patients taking su lfonylu rea s but weight gai n
As
is the most commo n.
Dr
A 54-yea r-old man is reviewed s ho rtly a fte r being d iagnosed with hypertension. as pa rt of
his wo rk-up he had a series of blood tests to screen fo r othe r risk facto rs:
Na• 142 mmol/ 1
K• 3. 9 mmol/1
Urea 6.2 mmolfl
Fasting glucose 7.7 mmolfl
Total cholesterol 7.2 mmol/1
Based on the fasting glucose resu lt you a rrange a HbAlc:
HbA1c 31 mmol/mol ( 5.0%)
Which one of the fo llowing would explain the discrepancy b etween the HbAl c and fasting
glucose leve ls?
Co nn's syndro me
Ra ised choleste ro l level
Sickle -cell a naemia

sem
As
A history o f alcohol excess

Dr
Conn's syndrome
Ra ised cholesterol level
Sickle-cell anaemia
-
~
m
se
As
A history o f alcohol excess
Dr
A 52-yea r-old woman who was d iagnosed as having p rimary atrophic hypothyroidism 12
months a go is reviewed following recent thyroid function tests (TFTs):
TSH 12.5 mU/1
Free T4 14 pmol/ 1
She is currently taking 75mcg of levothyroxine once a day. How shou ld these resu lts be
interp reted?
Poo r compliance with med ication
Her thyroxine dose needs to be increased
Evidence of recent systemic steroid therapy
She is on the correct dose
m
se
As
T4 to T3 co nversion disorder
Dr
Poor co mpliance with medication
Her thyroxine dose needs to be increased
Evidence of recent systemic steroid therapy
She is on the correct dose
T4 to T3 conversion disorder
The TSH level is high. This implies t hat over recent days/weeks her body is t hyroxin e
deficient. However, her free T4 is w ithin normal range. The most likely explanat ion is t hat
m
se
she started taking t he t hyroxine properly just before t he blood t est. This wou ld correct the
As
thyroxine level but the TSH takes longer to normalise.
Dr
A 29-yea r-old fema le who is 7 weeks into her first pregnancy is investigated for excessive
sweating and tremor. Blood tests revea l the following:
TSH < 0.05 mu/1
T4 188 nmol/ 1
Immed iate surgery
Carbimazole
Su rgery at start of third trimester
Propylthiou racil
m
se
As
Radioiodine
Dr
Immediate surgery
Carbimazole
Surgery at start of third trimester
Propylthio uraci I
Radioiodine
Acco rding to CKS:
Propylthiouracil is used in the first trimester of pregnancy in place of carbimazole, as the

latter drug may be associated with an increased risk of congenital abnormalities. At the
m
beginning of the second trimester, the woman should be switched back to carbimazole, as
se
As
propylthiouracil has been associated with a small risk of severe hepatic injury.
Dr
A 54-yea r-old -wo ma n with known ovarian cance r p resents with confusio n. She has
beco me p rogressively confused o ve r the last few days, and prior to that, she had sta rted
to beco me constipated. Her fa mily describes poor oral intake of fluid s a nd poo r u rinary
output a s well. On fu rther discussio n with the fam ily, they me ntion that she was seen in
o ncology clinic two weeks a go with results o f a bone sca n which they ha d been told was
no rma l.
On exam ination, she ap pea rs dehyd rated.
Hb 147 g/ 1
Plat elet s 32 1 * 109/1
WBC 7.8 * 109/ 1
Na• 142 mmol/ 1
K• 4 .7 mmol/1
urea 4 .6 mmol/1
Creatinine 92 IJmOI/1
Corrected calcium 3 .2 mmol/1
Parathyroid hormone Pending
What is the most like ly cause of her elevated ca lcium?
Osteo lytic hypercalcaemia
Calcitriol-mediated hyperca lcaemia
Ectopic PTH secretion
Pa rathyroid -ho rmone- related peptid e re lea se

sem
Primary hype rparathyroidis m

As
Dr
Osteolytic hypercalcaemia
Calcitriol -mediated hypercalcaemia
Ectopic PTH secretion
Parathyroid -hormone-related peptid e release
The correct answer is parathyroid -hormone-related peptide release. Whilst this is

-
~
classically described as secondary to squamous cell lung cancer, it can occur in many
malignancies.The two most co mmon causes of hypercalcaem ia are malignancy and
p rimary hyperparat hyroidism. In malignancy, roughly 80% of cases are due to
pa rathyroid-hormone-related pept ide release. The vast maj ority of remain ing cases are
due to osteolysis, and some due to calcit riol-med iated hypercalcaemia and ectopic PTH
secretion. Primary hyperparathyro idism is another common cause but is not as likely as
malignant hypercalcaemia given the know n diagnosis of ovarian cancer.
Source:
m
se
As
'Hypercalcaemia of Malignancy.' BMJ Best Practice. 14 June 2016.
Dr
Which one o f t he followin g is least associated wit h hypercalcaemia?
Sarcoidosis
Primary hyperparathyroid ism
Thiazide diuretics
m
se
As
Monoclonal gammopat hy o f uncertain significance
Dr
Sarcoidosis
Thiazide diuret/cs
I Monoclonal gammopathy of uncertain significance
One of the key differentiating features between monoclona l gammopathy of uncertain
m
se
significance (MGUS) and myeloma is the absence of complications such as immune
As
pa resis, hypercalcaemia and bone pain
Dr
A 44-year-old woman presents with a neck lu mp. She reports tiredness and fatigue and
has put on around 3kilograms of weight recently; she reports going up 3 belt notches.
Her blood results show normocytic anaemia.
On palpation of her neck, a ha rd, fixed, painless lump is felt.
Which one o f the following compl ications is associated with her condition?
Hyperthyroidis m
Retroperitoneal fib rosis
Ascites
Atrial fibrillation
m
se
Photosensitivity
As
Dr
Hyperthyroid is m
Retro p erito nea l fib rosis
Ascites
Atrial fibrillation
Photosensitivity
-
~
Ried e l's thyro iditis is associated with retroperitonea l fibrosis

Ried e l thyroi ditis (RT) is chara cterized by the replacement o f no rma l thyroid pare nchyma
with dense fibrotic tissue and by the extension of this fib rosis to a djacent structu res o f the
neck. Most patients are euthyro id, but hypothyroidism is noted in a pproximately 30% o f
cases.
Patie nt's may present with a pain less neck lump a nd symptoms o f hypothyro idis m such as
we ig ht g a in, tired ness, fatig ue a nd into lerance.
Ried e l's thyro iditis is not associated with hyperthyro idism, a scites o r photosensitivity a nd
the refo re these a nswe rs a re inco rrect.
Atrial fibrillatio n is a com plicatio n of hype rthyro id ism and patients with AF s hould have m
the ir thyroid functio n assessed. Howeve r, there is no evid ence to sug gest that Ried el's
se
As
thyro iditis is a ssociated with atria l fibrillation.

Dr
A 15-year-o ld girl is investigated for p rimary amenorrhoea, despite having developed
secondary sexual cha racte ristics at 11 years of age. On exam inatio n she has well
developed breasts with scanty pubic hair and smal l b ilateral groin swellings. What is the
most li kely diagnosis?
Turner's synd rome
Complete androgen insensitivity syndrome
m
se
As
Mullerian duct agenesis
Dr
Congenital adrenal hyperplasia CD
Polycystic ovarian syndrome fD
Turner's synd rome (D
Comp lete and rogen insensitivity syndrome ED
m
se
Mullerian duct agenesis GD
As
Dr
A 25-year-old female has type I diab et es. Her HbAlc is 58 mmoi/L. Her blood pressure is
126/ 68 mmHg. Her BMI is 28 kg/ m 2 • She is using a basal-bolus regimen whi ch she finds
easy to manage. She is not keen t o increase her total insulin dose. Which of th e follow ing
adjunct s could you consider to help improve her glyc.aemic contro l?
Add metf ormin
Swit ch to a mixed insulin regime
Add sitagliptin
Add exenatide
m
se
As
Enrol in supported weight loss programme
Dr
I Add metformin
Switch to a mixed insulin reg ime

GD
(D
I Add sitagliptin CD
Add exenatide GD
Enrol in supported weight loss programme fD
Patients with type I diabet es and a BMI > 25 should be co nsidered for met formin in
addition t o insulin
The correct answer is to add metformin. NICE recommends that ad ding metformin should
be conside red in type I diabetics with a BMI > 25, either on patient preference or t o avoid
the need to increase their insulin the rapy. The other oral diabetic medications are not
currently recommended. Weight loss is likely t o be beneficial but there is great er evidence
for benefit with the use of metformin. A mixed insulin regime might be used if a multiple
injection basal-bolus regime was not suit ed to the patient's lifestyle but is not usually
chosen for better glycaemic control.
m
se
NICE: Type I diabetes in adult s
As
https:/ /www.nice.o rq.uk/qu idance/nq 17/ chapter/1 -recom mendations
Dr
A 4-year-old boy is being investigat ed for failure to thrive and generalised weakness. His
blood pressure is normal. The fo llowing blood results are obt ained:
Na• 137 mmol/ 1
K• 3 .0 mmolfl
Urea 4 .5 mmol/1
Creatinine 6 5 IJffiOI/1
Conn's syndrome
Bartter's syndrome
Cushing's syndrome
m
se
As
Liddle's syndrome
Dr
Conn's syndrome
Bartter's syndro me
Cushing's syndrome
Liddle's syndrome
Bartter's syndrome is associated w ith normotension

Bartter's syndrome is the most likely diagnosis. Congenital adrenal hyperplasia due to 21-
hydroxylase d eficiency is associated with p recocious puberty rat her than failure to t hrive
in boys. Both Conn's and Cushing's are associated with hypertension and are not common
in th is age grou p.
m
Liddle's syndrome is a rare autosomal dominant condit ion that causes hypertension and
se
hypokalaemic alkalos is. It is thought to be caused by disordered sodium chan nels in the
As
dist al tubules leading to increased reabsorption o f sodium.
Dr
A 46-yea r-old ma n with suspected d ia betes mellitus has an oral glu cose tolerance test,
fo llowing the sta nda rd WHO p rotocol. The following resu lts are o btained:
Time ( hours) Blood gl ucose (mmol/1)
0 5. 7
2 7.6
How should these resu lts be interpreted?
Norma l
Impa ired fasting g lucose and impaired g lucose tole rance
Diabetes mellitus
Impa ired glucose to lerance
m
se
As
Impaired fasting g lucose
Dr
INorm_a_~---------------------------
Impaired fasting glucose and impaired glucose tolerance
~abetes mell itus

-
~
Impaired fasting glucose

-
~
m
se
As
Both the fasting and two-hou r glucose are within no rmal limits.
Dr
An insulin stress test is most useful in the investigation of:
Glucagonoma
lnsulinoma
Addison's disease
Hypopitu itarism
m
se
As
Diabetes mellitus
Dr
Glucagonoma tD
Insulinoma CD
Addison's disease (D
'
I Hypopituitarism ED
Diabet es mellitus fD
~
m
se
Insulin stress test s are also occasionally used t o differentiate Cushing's from pseudo-
As
Cush ing's
Dr
Which one o f t he followin g types o f ora l st eroid has t he least amount o f
mineralocortico id activity?
Fl udrocortisone
Hydrocortisone
Dexamethasone
Predniso lone
m
se
As
Cortisone
Dr
Fludrocortisone GD
Hydrocortisone CD
Dexamethasone ED
Predniso lone tiD.
Cortisone fD
This is clinically relevant as there a re some situations where it is important to combine

high glucocorticoid (anti -inflam matory) activity with minimal minera locorticoid (fluid-
m
se
retention) effects. A g ood exa mple is the use of dexamethsone for patients with raised
As
intracranial p ressure secondary to brain tumours.
Dr
A 62-year-old HGV driver is reviewed. He was diagnosed last year w ith type 2 diabetes
mellitus. Follow ing weight loss and metformin his HbAlc has decreased from 74
mmol/mol (8.9%) to 68 mmol/mol (8.4%). What is the most suitable next step in
management?
Add exenatide
Make no changes to management
Add gliclazide
Stop metformin for a period to ensure hypog lycaem ic awareness is not lost
m
se
As
Add pioglitazo ne
Dr
Add exenatide
Make no changes to management

-~
Add gl iclazide
gtop metformin for a period to ensu re hypoglycaemic awa reness is not lost
Add pioglitazone
Pioglitazone is the best option here as it would not put him at risk of hypoglycaem ia,
m
se
which obviously could be dangerous given his job. The NICE guide lines would also
As
support the use of a DPP-4 inhibitor (e.g. sitag liptin or vildagliptin) in this situation.
Dr
A 47 -year-old woman is referred to the general medical cli nic. She has gain ed 10 kg in
weight in the past 3 months but her main problem is episodic sweating. These episodes
o f sweating are associated w ith double vision and typically occur early in the morning.
Clinical examination is unremarkable. What is the most like ly diagnosis?
Bronchial carcino id
Menopause
Cushing's syndrome
m
se
As
Insulinoma
Dr
Bronchial carcino id
I Hashim! to's thyroiditis
Menopause
Cushing's syndrome
Insulinoma
m
se
As
This is a typical presentation of insulinoma
Dr
You review a 52-year-old man who is be ing investigated fo r weight gain, impotence and
hypertension. On exam ination you reco rd a blood pressure of 180/ 110 mmHg and notice
pu rple striae a round his abdomen. He also has some difficulty getting up from a chair and
you observe genera lised decreased muscle strength. Routine bloods a re o rdered. Given
the likely underlying diagnosis, what a re the urea a nd e lectrolytes most likely to show?
Hypoka laem ic metabolic acidosis
Hyperka laemic metabolic alkalosis
Hypocalcaemic metabolic acidos is
Hypoka laem ic metabolic a lka losis
m
se
As
Hyperkalaemic metabolic acid osis
Dr
Hypokalaemic metabolic acidosis
Hyperkalaemic metabolic alkalosis
Hypocalcaem ic metabolic acidos is
Hypoka laemic met abolic alkalosis
Hyperkalaemic metabolic acidosis
m
se
Cush ing's syndrome - hypokalaemic met abolic alkalosis
As
Dr
Which one of the followin g skin disorders is least associated with hypothyroid ism?
Xanthomata
Pru ritus
Pretibia l myxoedema
Eczema
m
se
As
Dry, coarse hair
Dr
Xantho mata «ED
Pru ritus CD
Pretibia l myxoedema ED
Eczema f!D
Dry, coarse ha ir CD
Fo r the p urp oses of postg rad uate exams p retibia l myxoed ema is associated with
m
se
thyrotoxicosis. There a re howeve r case re po rts o f it b een found in hypothyro id pati ents,
As
espe cially the diffuse no n-p itting va riety
Dr
You a re conducting the annua l review of a 44-yea r-o ld woma n who has type 1 d iabetes
mellitus. You want to assess fo r diabetic neuropathy affecting the feet.
What is the most appropriate screen ing test to use?
A standard ised questionnaire
Dopp ler flow stud ies of the do rsalis pedis pu lse
Nerve conductio n stud ies
Test sensation using cotton wool
m
se
Test sensation using a 10 g monofila ment
As
Dr
A standardised questionnaire
~ppler flow stud ies of the do rsalis pedis pu lse

Nerve conduction stud ies
Test sensation using cotton wool
I Test sensation using a 10 g monofilament
m
se
A 10 g monofilament should be used to assess for d iabetic neu ropathy in the feet
As
Dr
A 35-yea r-old female who has recently being diagnosed with Grave 's disease presents for
review 3 months after starting a 'block and replace' regi me with carb imazole and
thyroxine. She is concerned about developing thyroid eye disease. What is the best way
that her risk of d eveloping thyroid eye disease can be reduced?
Reduce alcohol inta ke
A diet rich in omega-3 fatty acids
Regular exercise
Stop smoking
m
se
As
Lose weight
Dr
Reduce alcoho l inta ke
A diet rich in omega-3 fatty acid s
Regula r exe rcise
Stop smoking
Lose we ig ht
m
se
Smoking is the most importa nt mo difiab le risk factor for the d evelo pment of thyro id eye
As
disease
Dr
An obese 48 -year-old man presents with leth argy and polydipsia. What is the minimum
HbAlc that wou ld be diagnostic o f type 2 diabetes mellitus?
Cannot use HbAlc for diagnosis
6.0% (42 mmol/mol)
6.3% (45 mmol/mol)
6.5% (48 mmol/mol)
m
se
As
7.0% (53 mmol/mol)
Dr
Cannot use HbAlc for diagnosis
6.0% (42 mmol/mol)

-
~
6.3% (45 mmol/mol)
6.5% (48 mmol/mol)
7.0% (53 mmol/mol)
Diabetes mellitus - HbAlc of 48 mmol/mol (6.5%) or greater is now diagnostic
m
se
(WHO 2011)
As
Dr
A 45-year-old man is investigated following referral to the endocrinology cl inic with
polydipsia. Plasma glucose and calcium are normal. A wat er deprivation test is performed
with the followi ng result s:
Starting plasma osm. 319 mOsmoljl ( 275-295 mOsmol/ 1)
Final urine osm. 142 mOsmoljl
Urine osm. post -DDAVP 885 mOsmoljl
Psychogenic polydipsia
Nephrogenic diabetes insipidus
m
se
As
Cranial diabetes insipidus
Dr
Psychogenic polydipsia GD
Nephrogenic diabetes insipidus 6'D
Primary hyperpa rathyroidism m
Pseudohypoparathyroidism D
I Cranial diabetes insipidus mt
A dramatic improvement is seen in the ability of the kidneys to co ncentrate urine
m
se
following the administration of DDAVP. This points towa rds a diagnosis of cran ial
As
diabetes insipidus
Dr
A woman presents to the emergency department with confusion. She is found to be
hypothe rmic with a low blood p ressure and bradycardic. After further exam ination and
investigation, she is found to be in a myxoedemic coma.
What is the most appropriate first-li ne treatment for this lad ies presentation?
Ad renaline and levothyroxine
Prednisolo ne and levothyroxine
Hydrocortisone and levothyroxine
Hydrocortisone and flu drocortisone
m
se
As
Ad renaline and hyd rocortisone
Dr
Adrena line and levothyroxine
Prednisolone and levothyroxine
Hydrocortisone and levothyroxine
Hydrocortisone and fludrocortisone
Adrena line and hydrocortisone
Myxoedemic coma is t reat ed with thyroxine and hydrocortisone

This question is asking about a woman p resenting w ith confusion, b radycardia,

hypot ension who has been diagnosed with a myxoedemic coma. It is asking for t he f irst
init ial treatment, thus the correct answer is hydrocortisone and levothyroxine.
Levothyroxine is used to replace t he low levels of thyroid hormone causing th e patient's

symptoms.
Hydrocort isone is given to treat adrenal insufficiency. Patients suffering f rom a

myxoedemic coma due to secondary hypothyroidism are at risk of hypopituitarism due to
m
se
the locatio n o f the lesion. Thus patients are treated as presumed adrenal insufficiency
until it has been ruled out.
As
Dr
Which one o f the fo llowing featu res is least associated with primary hyperparathyro idism?
Dep ression
Polydips ia
Sensory loss
Peptic ulceration
m
se
As
Hypertensi on
Dr
Depression CD
Polydips ia fD
Sensory loss eD
Peptic ulceration CD
m
se
As
Hypertension f.D
Dr
A 85-year-old male presents to cl inic for a review of his overactive blad der. Non-
pharmacologic treatments have so far failed to improve his symptoms. Which of the
following pharmacotherapies represents the most appropriat e initial management step?
Finasteride
Desmopressin
Ta msulosin
Mirabegron
m
se
As
Tolte rodine
Dr
Finaste ride fD
Des mo press in m.
Tamsulosii GD
Mirabegron flD
I Tolte rodine CD
NICE (Feb 2015) outlin es treatment steps for the management of overactive bladd er
symptoms in men.
If non- pharmaco logic mea sures fa il, an anticho line rg ic agent is first line. In o lder men,
to lte ro din e is p re ferred to oxybutynin as the latter has a g reater risk of causing confusion.
If antichol inergics fa il o r are contra ind icated, mira beg ron may be trialled. Its mechan ism
of a ction is via beta-adrenoreceptor-med iated re laxation o f the bladder wall.
Ta msu losin is an alpha-blocke r and indicated if t he patient if has o bstructive symptoms,

rathe r than symptoms of ove ractive bladd e r.
Finasterid e is a 5-alpha reductase inh ibito r and indicated if the patient has obstructive
symptoms and an enla rged prostate with a high risk of p rogression.
m
se
Des mop ressin is a synthetic vasopressin a nalogue that acts in the collecting duct of the
As
nep hron. It is sometimes used off- label for nocturnal urinary incontinence.
Dr
You are on the post-ta ke ward rou nd reviewing a 55-year-old lady who has been
a d mitted with her third u rinary tract infectio n in as many months. Of note she is a type II
diabetic patient and was commenced on empag liflozin by her GP fou r months ago. You
suspect recu rrent urinary tract infections secondary to he r empagliflozin, a sod ium
glucose co -transporter 2 in hibito r used in the treatment of type 2 diabetes mell itus.
Where is its main site of action?
Early dista l convoluted tubule
Collecting duct
Early proxim al convoluted tubule
Late proximal convoluted tubule
m
se
Late distal convoluted tu bule
As
Dr
Early distal convoluted tubule
Collecting duct
Early proximal convoluted tubule
Late proximal convoluted tubule
Late distal convo luted tubu le
In the norma l kidney up to 180 g rams/ day of glucose is filtered by the rena l glomerulus
and virtually all o f it is reabsorbed in the proximal convo luted tubu le. This reabsorption is
carried out by two sodi um -depend ent g lucose co-transporter (SGLT) p roteins, SG LTl,
which reabsorbs 10%, and SG LT2, which reabsorbs the remaining 90%. While SGLTl is
expressed e lsewhere in the body, SGLT2 is exp ressed solely in the kidney, making it a n
attractive target fo r novel diabetic treatments.
To date a number o f SGLT2 inhib itors have been developed. These agents have been
s hown to e nhance renal gl ucose excretion by inhibiting renal gl ucose reabsorption with
consequent improvements in HbA1C and in sulin res ista nce. Furthermo re, they have been
s hown to have protective effects in the p rogression of chro nic kidney d isease, blood
p ressu re lowering e ffects a nd red uce cardiovascula r events in high risk type II diabetic
patients. To date they are they only o ral hypoglycaemic agent to demonstrate any benefit
on macrovascu la r outcomes in type II diabetic patients.
Important sid e effects to be awa re o f with this class o f drug a re genita l tract infections
em
and euglycaemic diabetic ketoacid osis.

s
As
Dr
Which one of the following statements regarding d ipeptidyl peptidase-4 inhibitors in the
management of type 2 d iabetes mellitus is correct?
Metformin shou ld always be co-prescribed
Do not cause weight gain
Is given via a subcutaneous injection
An exa mple is exenatide
m
se
As
Patients should b e warned that hypog lycaem ia is the most common si de-effect
Dr
Metformin shou ld always be co -p rescribed «D
Do not cause weight gain GD
Is given via a subcutaneous injection CD
An exa mple is exenatide CD
Patients should be warned that hypoglycaem ia is the most common side-effect f!D
m
se
As
Hypoglycaemia is rare in patients taking dipeptidyl pe ptidase-4 inhibitors.
Dr
A 29-yea r-fe male, who is 4 months post- partum, presents with a 3 -week history of weig ht
loss, heat into le ra nce, tremor, palpitatio n a nd d ia rrhoea. Pregnancy a nd b irth we re
uncomplicated. On further questio ni ng, she admits having ta ke n off- license we ight loss
me d icatio n bou ght from the internet 1 mo nth ago. Past medica l histo ry a nd fam ily histo ry
a re insig nifica nt. She does not smoke o r drink alcoho l.
On physical examination, she has exop htha lmos, b risk re flexes and fine tremo r. Her vita l
signs were heart rate 98/ minute, b lood p ressu re 136/ 76 mmHg, tem peratu re 36.5°C. The
thyro id g land was diffusely enla rg ed .
Thyroid Stimulating Hormone (TSH) 0 .02 mU/ 1
Free thyroxine (T4) 24 pmol/1
Tot al thyroxine (T4) 150 nmol/ 1
Exo ge nous thyroxine
Graves' Disease
m
Po st-pa rtum thyroiditis
se
As
De Que rva in's thyroid itis
Dr
Exogenous thyroxine
Graves' Disease
Post-pa rtum thyroiditis
De Querva in 's thyroid itis
Graves' disease may present first or become worse during the post-natal period
This is a case of hype rthyro idism d ue to Graves' disease. Graves' disease may man ifest
itself o r worsen du ring pregna ncy and the post-natal period.
Exophthalmos is a sp ecific sign seen in Graves' disease and not in othe r hype rthyroid
conditions.
Hashimoto's thyro iditis leads to hypothyroidi sm.
In post-pa rtu m thyroiditis, the woman initia lly d evelops hyperthyroidism im mediately
after birth fo llowed by normal o r sometimes d ecreased thyro id leve ls.
m
De Que rva in 's thyroid itis can p resent with pa in and dysphagia and may lead to hig h,
se
As
normal o r low thyroid levels.

Dr
A 72-year-old woman presents with polyu ria and polydipsia. Investi gations reveal the
following:
Fasting glucose 4.5 mmoljl
Phosphate 0 .75 mmol/ 1
Parathyroid hormone 6 pmoljL (normal range = 0 .8 - 8 .5)
Myeloma
Sarcoidosis
Vita min D excess
m
se
As
Osteomalacia
Dr
Myeloma
Sarcoidos is
Primary hyperparathyro idism

-
~
Vitamin D excess
Osteomala cia
The PTH level in primary hyperparathyroidism may b e normal

Despite a raised ca lcium level the parathyroid hormone level is inappropriat ely normal.
m
se
This p oints t owards a diagn osis o f primary hyperparathyroidism and the other causes
As
(such as myeloma) wou ld lead t o a suppression o f parathyroid hormone
Dr
A 58-yea r-o ld man comes fo r review in the diabetes clinic. He was d iagnosed as havi ng
type 2 d ia betes mell itus (T2DM) a rou nd 10 yea rs ago a nd cu rrently o nly takes gliclazide
a nd atorvastatin. Three years ago he was successfully treated fo r bladd e r cancer. A recent
tria l of metfo rmin was unsuccessful d ue to g astro intestina l sid e -e ffects. He works as a n
accountant, is a non -s moker and his BMI is 31 kg/m 2 . His an nua l bloods s how the
fo llowing:
Na• 138 mmol/ 1
K• 4 . 1 mmolfl
Urea 4.3 mmolfl
HbA 1c 62 mmol/mol (7 .8%)
What is the most ap pro priate next ste p in manag ement?
Add p iog litazo ne
Add exenatide
Add acarbose
Add re paglinide
m
se
As
Add sitagliptin
Dr
Add piogl itj zone flD
Add exenatide fiD
Add acarbose CD
Add repaglinide CD
Add sitagliptin ED
Piogl itazone is contraindicated by his histo ry o f b lad der ca ncer and may contribute to his
o besity. A DPP-4 inhibitor such as s ita g liptin is the refore the b est option.
m
se
Exenatide genera lly causes weight loss a nd is therefo re useful in o bese diabetics b ut he
As
d oes not meet the NICE body mass ind ex criteria of 35 kg/ m2 .
Dr
A 64-year-old patient is prescribed pegvisomant for the treatment of acromegaly. What is
the mechanism of action of pegvisomant?
IGF-1 receptor antagonist
Growth hormone receptor antagonist
IGF-1 receptor agonist
Growth hormone receptor agonist
m
se
As
Long-acting somatostatin analogue
Dr
IGF-1 receptor antagonist f.!D
Growth hormo ne receptor antagonist ED
IGF- 1 receptor agonist CD
Growth hormone receptor agonist CD
m
se
CD
As
Long-acting somatostatin analogue
Dr
Which one of the following is most likely to be seen in a patient with multiple endocrine
neoplasia (MEN) type I?
Phaeochromocytoma
Insulinoma
Marfanoid body habitus
Medullary thyroid carcinoma
m
se
As
RET gene
Dr
Phaeochromocytoma ED
I Insulinoma ED
Marfanoid body habitus D
Medullary thyroid carcinoma flD
m
se
•
As
RET gene
Dr
You review a 70 -yea r-old who has a long past medical history and is on mult iple drugs.
He has d eveloped excessive amou nts of b reast t issue bilaterally. Which one o f the
following drugs is most likely to be responsible?
Ta moxi fen
Terbinafine
Am iodarone
Goserelin (Zola dex)
m
se
As
Lym ecycline
Dr
Ta moxifen GD
I Terb inafine CD
Amiodarone fD
I Goserelin (Zoladex) CD
Lymecycline fD
m
se
Goserelin is a gonadorelin analogue used in the treatment of advanced prostate cancer.
As
Ta moxifen may be used to treat gynaecomastia.
Dr
A Genera l Practitioner refe rs a 45-year-old female patient to the endocrinology
d epartment with hypercalcaemia and raised parathyro id hormone levels. Her b lood tests
a re high ly suggestive of primary hyperparathyro idism. Her past medical history includes
type 2 d iabetes, which is well controlled on metfo rmin alone.
Which feature woul d be the stro ngest indication for refe rral o f the patient for
consideration of pa rathyro id surgery?
Co-existing type 2 diabetes
Post meno pausal patient
Persistent hyperca lca e mia over 4 years
Vita min D d eficie ncy
m
se
As
Age of 45
Dr
Co-e~g type 2 diabetes
Post menopausal patient
Persistent hypercalcaemia over 4 years
Vitamin D d eficiency
I Age of 45
NICE g uideli nes clearly stipulate the circumsta nces under which pa rathyroidectomy
should be consid ered in primary hyperparathyroid ism. These a re listed below:
• Age und er 50 years.

• Adjusted serum calcium co ncentration that is 0.25 mmoi/L or more above the upper
end of the re fe rence range.
• Estimated glomerular filtratio n rate (eGFR) less than 60 ml/mi n/1.73 m2 a lthough
this threshold depends on other factors, such as age.
• Renal stones or presence of nephroca lci nosis on ultrasound or CT.
• Presence of osteoporosis or osteoporotic fracture.
• Symptomatic d isease
From the potential answe rs o ffered, the patient's age under 50 is the only answer that
meets the NICE criteria.
m
se
As
(Sou rce: NICE gu idelines, hyperparathyroidism - http://cks.nice.org.uk/hyperca lcaemia)

Dr
A 25-yea r-o ld Asia n woman who is 26 weeks preg nant has an o ra l glucose tole rance test
(OGIT). This was req uested due to a combination o f her ethnicity and a background of
o besity. A recent ultrasound shows that the fetus is larg e fo r d ates. The fo llowing resu lts
a re o bta ined:
Time ( h ours) Blood gl ucose (mmo l/ 1)
0 9 .2
2 14.2
What is the most ap propriate management?
Sta rt insulin
Give advice about a diabetic diet
Give advice about a diabetic diet + repeat OGIT in 4 weeks
Sta rt g liclazide
m
se
As
Sta rt metformin
Dr
Sta rt insulin
l ive advice about a diabetic diet
Give advice about a diabetic diet + repeat OGTT in 4 weeks
Sta rt gliclazide
Sta rt metformi n
m
Insu lin shou ld b e started stra ight away given the blood glucose leve ls a nd evid e nce of
se
ma crosomia. Aspirin should a lso be cons id ered a s she is at increased risk of pre-
As
eclam psia.
Dr
A 45-year-old femal e is reviewed in the medical clinic with a two month history of
lethargy. Blood test s reveal the following:
Na• 129 mmol/ 1
K• 5. 1 mmolfl
Urea 5.3 mmol/1
Total T4 66 nmolfl
Which one o f the following investigations is most likely t o reveal the diagnosis?
Serum glucose
TSH
Free T4
Overnight dexamethasone suppression t est
m
se
As
Dr
~umglucose
TSH
Free T4
I
Overn ight d exam ethasone s uppressi on test

-
""""
The sho rt synacthen test is the best test to diagnose Add ison's d isease
Hyponatrae mia and a high potassium in a patie nt with lethargy is high ly sug gestive of
Addison's disease. The thyroxine leve l is slightly low a nd she may ind eed have co-existing
hypothyro id ism but this wou ld not expla in the hig h potassium
m
se
Ma ny labs have an upper reference rang e for potassium of 5.5 mmol/1, but in the co ntext
As
of the other resu lts hypoadrena lism shou ld be suspected
Dr
A 58-yea r-old gentleman with longstanding type 2 diabetes p resents to the acute medica l
take. Blood tests are d emonstrated in the ta ble below. The b lood test results are
consistent with diabetic ketoacidos is. He has no other past medica l histo ry other than
type 2 diabetes and obes ity. He has not had e pisod es of diabetic ketoacidosis befo re and
d oes not drin k alcohol. His med ication history includ es as pirin, losa rtan, metfo rmin,
d ap agliflozin a nd glimep iride. He is allergic to pen icillin.
pH 7.26
Blood ketones 3 .6 mmoljl
Blood sugar 15 mmoi/ L
Whi ch of his medications is most likely to have contributed to d eveloping diabetic

ketoacidosis?
Metfo rmin
Dapa gliflozin
Gl imepiride
Asp irin
m
se
As
Losarta n
Dr
Metformin GD
Dapagliflozin ED
Gl imep1ride GD
Aspirin m
Losarta n .
(D
Dapagliflozin is a newer drug for the treatment of diab etes. It is a member o f the sodium -
glucose transport protein 2 (SGLT2) inhibitor class of drugs.
SGLT2 inhibitors prevent the resorption of glucose from the p roximal re nal tubule,
resulting in more glucose b eing secreted in the urine.
The other medications in this class include: canagliflozin & empa gliflozin
Importantly, whilst these med ications represent an effective class of drugs, there are
reports of patients with type 2 diab etes p resenting in diabetic ketoacidosis whilst taking
them. It essential that acute medical teams are vigilant for such p resentations as the
p revalence o f SGLT2 inhi bitor prescribin g increases.
The other possible answers (metformin I g limepiride I aspirin I losartan) a re not

associated with the develo pment of diab etic ketoacidosis. It should, of cou rse, be noted
that metformin can lead to a lactic acidosis.
em
Source: UK Government Drug Safety Bulletin (https:l/www.gov.uk/d rug-safety-

s
As
update/sglt2-inhibitors-updated -advice-on-the-ris k-of-diabetic -ketoacidosis)

Dr
A 43-yea r-old man is admitted to hos pital with pneumonia. His past medical history
includes Addison's disease for which he takes hydrocortisone (20mg in the mornings and
lOmg in the ahernoo n). What is the most appropriate actio n with respect to his steroid
dose?
Continue to take the same dose
Double hydrocortisone to 40mg mornings and 20mg ahernoon
Ha lve hydrocortisone to lOmg mornings and Smg ahernoon
Continue to take the same dose + prescribe a proton pump inhibitor
m
se
As
Continue the same morni ng dose + stop the ahernoon dose
Dr
Continue to take the same dose
I Double hydrocort isone to 40mg mornings and 20mg afternoon
Halve hydroco rtisone to lOmg mornings and Smg afternoon
Continue to take the same dose + p rescribe a proton pump inhibitor
Continue the same morning dose + stop t he afternoon dose
Patients on long -term steroids shou ld have their d oses doubled during intercurrent
m
se
illness
As
Dr
A 27 -year-old man is reviewed in a fertility clinic. Semen analysis has revealed
azoospermia. On examination at the previous appointment he was noted to be 1.83
metres tall w ith a body mass index o f 25 kg I m"2. A d egree of gynaecomastia is noted,
testicular volum e is around 10m I b ilaterally and his visual fields were normal. Which
invest igation is likely t o be diagnostic?
FISH ana lysis of DNA
Prolactin level
Karyotype
M RI pituitary
m
se
As
PCR analysis of DNA
Dr
FISH analysis o f DNA m.
Prolactin level m.
Karyotype 6D
M RI p ituitary
•
PCR analys is of DNA
•
m
se
Klinefelter's? - do a karyotype
As
Dr
A 54-year-old man with type 2 diabetes mellitus is st arted on exenatide. Wh ich one of the
following statements regarding exenatide is incorrect?
Typically result s in weight loss
May be combined with a sulfonylurea
The major adverse effect is flu -like sym ptoms
May be co mbined with metform in
m
se
As
Must be given by sub cutaneous injection
Dr
Typically results in weight loss
I
May be combined with a sulfonylurea
The major adverse effect is flu-like symP.toms

-
~
May be co mbined with metformin
Must be given by subcutaneous injection
Exenatide causes vomiti ng

m
se
As
The major adverse effect is nausea and vomiting
Dr
A 29-yea r-old woman has just found out she is pregnant for the second time. Her first
pregnancy was complicated by gestational diabetes. Fo llowing her first pregnancy she
was to ld she was no longer d iabetic. What is the most a ppropriate management?
Check HbA1c immediately
Start metform in and ask the woman to self-mon itor g lucose
Do oral g lucose tolerance test as soon as possible after booking
Do oral g lucose tolerance test at 16-18 weeks
m
se
As
Do oral g lucose tolerance test at 24-28 weeks
Dr
Check HbA1c immed iately
Sta rt metformin and ask the woma n to se lf-monitor g lucose
Do oral glucose tolerance test as soon as possible after booking
Do o ral g lucose to lerance test at 16 -18 weeks
Do o ral g lucose to lerance test at 24-28 weeks
NICE have recently u pdated the ir g uide li nes. Women who are at ris k o f g estationa l
m
se
dia betes should have a n o ral g lucose tolerance test as soon as possible after booking,
As
rathe r than wa iting to 16-18 weeks as was p reviously advo cated.
Dr
A 50 year-old wo man presents with polyuria and polydipsia. She has recently been started
on citalopram for depression, but is otherwise fit and well. She has complained of
constipation recently, but has put this down to her new medication.
Calcium 2.Bmmol/1
Phosphate 0. 7mmol/l
Parathyroid hormone S.Opmol/ 1 ( 1.2-S.Bpmol/ 1)
Renal function and full blood count are normal.
What is the most likely cause for these blood results?
Parathyroid adenoma
Myeloma
Metast atic cancer
Drug induced
m
se
As
Parathyroid hyperplasia
Dr
I Parathyroid adenoma CiD
M yeloma CD
Metast ati c cancer CD
Drug induced fiD
Parathyroid hyperplasia fiD
The PTH level in p rimary hyperparathyroi dism may b e normal

This woman has signs and symptoms of hypercalcaemia. Her parathyroid hormone should
be sup pressed in t he presence of hypercalcaemia. Given that it is normal (inappropriately),
m
se
this i ndicates the parathyroid as t he cause fo r the hypercalcaemia. The most co mmon
As
cause of hyperparathyro idism is an adenoma.
Dr
A 64 -yea r-old ma n with a history of type 2 dia betes comes to the clinic for review. His
HbAlc is e levated at 64 mmol/mol despite ta king l g of metformin BD. On examination
his blood pressure is 142/ 88 mmHg, his p ulse is 82 beats p er minute a nd reg ula r. His
body mass index is elevated at 33 kg/ m2 • A d e cisio n is made to start him o n da pag liflozin.
Which of the fo llowing wo uld yo u exp ect on starting therapy?
Hypoglycaem ia
Increased blood pressure
Increased serum urate
Increased tota l cholesterol
m
se
As
Weight ga in
Dr
Hypoglycaem ia fD
I Incr+ sed blood pressure fD
Increased seru m urate GD
r : :reased total : : festerol ED
Weight g ain 6D
SGLT-2 inhibito rs like dapagliflozin p rom ote increased glucose excretion because they
inhibit glucose reabsorption in the kidney. This co rres ponds to a calorie load o f 200-400
kcal per day. In so me patients, this resu lts in dra matic weig ht loss, although on average
this equates to 1-2% reduction in weight over 6 months. SGLT-2 inhibitors are reco gn ised
to increased to ta l cholesterol, (both HDL and LDL), although cardiovascu lar outcome
studies as yet do not suggest this translates into increased risk o f MACE events. In fact,
the EMPA-reg study with empagliflozin demonstrated a reduction in overall mortal ity.
Hypoglycaemia is not a feature o f SGLT2 inhibitor use and SGLT-2 inhibitors are
associated with increased urate excretion rather than an increase in serum uric acid.
https:/jwww .evide nee .nhs.ukjfo rmu Ia ry/ bnf/ curre nt/ 6-en doerine-system/61-d rugs- used-
m
in-diabetes/ 612-antidiabetic-drug s/6123-other-antidiabetic-drugs/dapag liflozi n
se
As
http://www.nejm.org/d oi/fuii/10.1056/N EJ Moa1504720#t =article
Dr
A 41-yea r-old woman presents with pa lpitations and heat intolera nce. On examination
her pu lse is 90/min a nd a small, diffuse go itre is noted wh ich is tender to touch. Thyroid
function tests show the following:
Free T4 24 pmol/ 1
TSH < 0 .05 mu/1
What is the most like ly diagnosis?
Grave's disease
Sick thyroid syndrome
De Querva in 's thyroiditis
m
se
As
Toxic multinodular goitre
Dr
Grave's disease fD
Sick thyroid syndrome CD
I De Que rvain 's thyroid itis GD

Hashimoto's thyroiditis fD
Toxic multino du la r goitre CD
Thyrotoxicosis with ten de r go itre = subacute (De Quervai n's) thyroiditis

Whilst Grave's disease is the most com mon cause of thyrotoxicosis it would not cause a
tend e r g o itre. In the context of thyrotoxicos is this find ing is on ly really seen in De
Q ue rva in 's thyro id itis.
Hashimoto's thyro iditis is a n autoimmu ne disorde r of the thyro id g land . It is typically
m
se
a ssociated with hypothyro idism a lthoug h the re may b e a transient thyrotoxicosis in the
As
a cute phase. The g oitre is non -tend e r in Hashimoto's.
Dr
A 24-year-old fema le with a history of type 1 diabetes mellitus presents to the Emergency
Department with vomiting and abdominal pain. Finger-prick testing estimates the blood
sugar to be 25 mmol/1. Arterial blood gases record a pH of 7.22. On examination the
patient is dehydrated and weig hs 80 kg. An intravenous line is sited and bloods are sent.
One litre of 0.9% saline is infused and an intravenous insulin pump is set-up. What rate
should insulin be initially given?
10 unit I hour
1 unit I hour
2 unit I hour
6 unit I hour
m
se
As
8 unit I hour
Dr
10 unit I hour CD
1 unit I hour f!D
~unit/hour a
6 unit I hour GD
8 unit I hour GD
m
se
The Joint British Diabetes Societies produced guidelines in 2010 recommend ing starting
As
the insulin infusion at a rate of 0.1 unit/kg/hour.
Dr
A 6-yea r- old South Suda nese boy is a dmitted p rogressive worsening o f his hearing loss.
His mother is extremely concerned with his lack of progress at school. Systems review
reveals a 2-month history o f malaise, arthralgia and constipati on. He has a past medical
history of d ea fness. On examinatio n he has dry skin and thin hair; there were no thyroid
eye signs, no ophthalmoplegia and no myxoedema. He appears to have a smooth
symmetrically enlarged goitre, which is not painful.
Thyroid function tests:
Thyroid stimulating hormone 5.7 (mu/1)
Free T4 9 pmol/1
Total T4 67 nmol/ 1
Which of the following causes of hypothyroidism is the patient suffering from?
Iod ine deficiency
Pendred synd rome
Thyroid agenesis
m
se
As
Atro phic hypothyroidism
Dr
Iodine deficiency
Pendred synd ro me
Thyroid a genesis
Atrophic hypothyroid ism
The patient is suffering from mild signs o f hypothyroi dism and progressive bilatera l
m
se
d eafness. Out of the following answe rs only Pendred syndrome p resents with signs of
As
d ea fness and hypothyroi dism.
Dr
A 45-year-old man w ith a history of depression and gastro-oesophageal reflux disease
presents due to a milky discharge from his nipples. The following blood resu lts are
o btained:
Prola ctin 700 mu/1
Which one of his medications is most likely to be resp onsible?
Omeprazole
Fluoxetine
Metoclopramide
Cimetidine
m
se
As
Am itriptyline
Dr
Omeprazole m
CD
..
Fluoxetine
Metoclopramid e
Cimetidine fD
Amitriptyline m
Causes of raised p rolactin -the p 's
• p regnancy
• p rolactinoma
• p hysiologica l
• p olycystic ovarian syndrome
• p rim ary hypothyro idi sm
• p henothiazines, metoclop ram ide, do mpe ridone
m
Selective serotonin reupta ke inhibitors such as fluoxetine have rare ly been associated with
se
hyperpro lactinaem ia but the most likely cause in this patient is metoclopram ide.
As
Cimetidine is generally associated with gynaecomastia, rather than galactorrhoea. Dr
A 27-year-old female develops eye pain and reduced visual acuity following the initiation
o f treatment for her recently diagnosed Grave's disease. Which one o f the following
treatments is likely t o have been started?
Radioiodine treatment
Thyroidectomy
Propylthiou racil
Carbimazole and thyroxine
m
se
Carbimazole
As
Dr
I Radioiodine treatment
Thyroidectomy
Propylthio uracil
~rbimazole and thyroxine

Carbimazole
m
se
Radioiodine treatment may lead to the develop ment I worsening o f thyroid eye disease in
As
up to 15% o f patients with Grave's d isease
Dr
In patients with suspected insu li noma, which o ne of the fo llowing is considered the best
investigation?
Ora l glucose tole rance test
Early morn ing C- pe ptide levels
Glucagon stimu lation test
m
se
As
Sup ervised fasting
Dr
Oral glucose tolerance test m
Insulin tolerance test m
Early morning C-pept ide levels .
ED
Glucagon stimulation test CD
I Supervised fasting CD
Insulinoma is diagnosed with supervised prolonged fasting

m
se
As
CT of th e pancreas is also useful in demonst rat ing a lesion
Dr
A 50-year-old female comp la ins that she has put on weight around her abdomen and
thig hs in the last six mo nths. She has a past med ical history of hypertension, high
cholestero l, type II diabetes and asthma. She has not changed her diet or lifestyle during
the last s ix months. Which of her medications may be contributing to her weight gain?
Atorvastatin
Tolbutamide
Exenatide
Chlortalidone
m
se
Saxagliptin
As
Dr
Atorvastatin m
Tolbutamide ED
Exenatide f!D
I
Chlortalidone GD.
Saxagliptin 6D
Su lfonylu reas often cause we ight gain

The correct answer is 2. Tolbutamide is a member of the su lfonylurea class, which are
known to often cause weight gain because they stim ulate the pancreas to release more
insu li n, therefore a llowing for the utilisatio n of mo re glucose. The glipti ns are not
associated with weight gain.
m
se
BNF
As
https:/ / bnf.nice.org.u k/ treatment -summa ry/ type-2 -dia betes. htm I
Dr
A 22-year-old female presents with recurrent painful oral ulceration. Examination reveals
signs of oral Candida ! infection. Which one of the following wou ld most suggest type 1
polyglan dular syn drome?
Hypocalcaemia
Type D diabetes mellitus
Coeliac disease
m
se
As
Hypercalcaemia
Dr
Hypocalcaemia
Rheumatoid a rth ritis
Type II d ia betes mellitus
~eliac diseyLe--~
Hypercalcaemia
Primary hypo pa rathyroidism is usually the first e nd ocrine manifestation of type 1

a utoimmu ne po lyendo crinopathy syndrome. The contrast to multiple end ocrine neoplasia
(MEN), whe re hyperpa rathyroid ism is a common findin g, shou ld be noted
m
se
The question gives a sl ightly atypi ca l history as this is the upper end of the age ra nge in
As
which patients wou ld be expected to present
Dr
Which one of the following regarding the management of thyroid problems during
pregnancy is incorrect?
Matern al free thyroxine levels should be kept in the upper third of the normal
reference range when treating thyrotoxicosis
Increased levels of thyroxine-binding globulin are seen in pregnancy
Block-and-replace is preferable in pregnancy compared to antithyro id drug

titration
Breast feeding is safe whilst on thyroxine
m
se
As
Untreated thyrotoxicosis increases the risk of premature labour
Dr
Maternal free thyroxine levels should be kept in the upper third of the normal
reference range when treating thyrotoxicosis
Increased levels of thyroxine-binding globulin are seen in pregnancy
I
Block-and-replace is preferable in pregnancy compared to antithyroid drug
titration
Breast feeding is safe whilst on thyroxine
m
se
As
Untreated thyrotoxicosis increases the risk of premature labour
Dr
A 56-yea r-old Muslim man with a history of type 2 d iabetes asks for a dvice. He is d ue to
start fasting for Ramadan soon and is unsure what he shou ld do with regards to his
diabetes medications. He currently ta kes metformin SOOmg tds. What is the most
appropriate advice?
Switch to subcutaneous biphasic insul in for the durati on of Ramadan
500 mg at the predawn meal + 1000 mg at the sunset meal
No change to the metformin d ose
1000 mg at the predawn mea l + 500 mg at the sunset meal
m
se
As
Stop metformin for the duration of Rama dan
Dr
Switch to subcutaneous biphasic in su lin for the duration of Ramadan
500 mg at the predawn meal + 1000 mg at the sunset meal
No chang e to t he met formin d ose
1000 mg at the pred awn meal + 500 mg at the sunset meal
Stop metformin for the duration of Rama dan
During Ramadan, one-third of the normal metformin dose should be taken before
sunrise and two-third s shou ld be taken after sunset
m
se
As
Please see t he Diabet es Care link for more det ails.
Dr
A 67-year-old wo man presents w ith let harg y, d epression and constipation. A set o f
screening blood t ests reveals th e follow ing:
Albumin 41 g/1
What is t he single most useful test for d etermining the cause o f her hyperca lcaemia?
ESR
Phosphate
Vita min D level
Parathyroid hormone
m
se
As
ACE level
Dr
ESR D
Phosphate fD
Vitamin D level CD
I Parathyroid hormone .
GD
ACE level D
Parat hyroid hormone levels are usefu l as malignancy and p rimary hyperparathyroidism
m
se
are t he two most common causes of hypercalcaemia. A parat hyroid hormone t hat is
As
normal or raised suggest s p rimary hyperparat hyro idism.
Dr
A 56-year-old man is reviewed in the Cardiology outpatient clinic following a myocard ial
infarction one year previously. During his admission he was found to be hypertensive and
diabetic. He com plains that he has put on Skg in weight in the past 6 months. Which o f
his medications may be contributing to his weight gain?
Metformin
Losartan
Clopidogrel
Gliclazide
m
se
Simvast atin
As
Dr
Metf ormin fD
Losartan fD
Clopidogrel fD
Gliclazide GD.
Simvastatin fD
m
se
Sulfonylureas o ften cau se weight gain
As
Dr
A 57 -year-old woman is referred to urogynaecology with symptoms of urge incontinence.
A trial o f bladder retraining is unsuccessful. It is therefore decided to use a muscarinic
antagonist.
Which one o f the following medications is an example o f a muscarinic antagonist?
Tolte rod ine
Teriparatide
Torem ifene
Finasteride
m
se
As
Ta msulosin
Dr
Tolte rod ine fiD
Teriparatide CD
f loremifene
Fina st eride
•
fD
Ta msu losin CD
Other examples of mu scarinic antagonists used in urinary incontinence incl ude

oxybutynin and solifenacin. Examples of mu scarinic antagonists used in different
conditions include iprat ropium (chronic obst ructive pulmonary disease) and p rocycl idine
(Parkinso n's disease).
m
se
As
Tamsu losin is an alpha blocker.
Dr
A 41-yea r-o ld wo man is investigated fo r hot flushes a nd night sweats. Bloods show a
s ignificantly ra ised FSH leve l a nd he r sympto ms a re attributed to the meno pause.
Fo ll owing di scussions with the patient she e lects to have ho rmone re placement
treatment. What is the most sig nifica nt risk of p rescribing a n oestrog en -o nly pre pa ration
rathe r than a com bined oestro ge n-p rog estoge n pre pa ration?
Increased risk of ve nous thro mboembo lism
Increased risk of ovaria n cancer
Increased risk of end om etria l cancer
Increased risk of breast cancer
m
se
As
Increased risk of co lo re cta l ca ncer
Dr
Increased risk of venous thromboembo lism
Increased risk of o va rian cancer
I Increased risk of endometrial cancer
Increased risk of b reast cance r
Increased risk of colorectal cancer
m
se
HRT: uno pposed oestrogen increases risk of endometrial cancer
As
Dr
A 33-year-old female is referred to endocrinology with thyrotoxicosis. Following a
discussion of management options she elects to have radioiodine therapy. Which one of
the following is the most likely adverse effect?
Hypothyroidism
Thyroid malignancy
Agranulocytosis
Oesophagitis
m
se
As
Precipitatio n o f thyroi d eye disease
Dr
I Hypothyroidism
Thyroid mal ignancy
Agranu locytosis
~~sophagi tis
Precipitatio n of thyroi d eye disease
m
se
It is well documented that radioiodine therapy ca n p recipitate thyroid eye disease but a
As
majority of patients will eventually requ ire thyroxine replacement
Dr
A 33 -year-o ld wo man is referred to t he endocrinology cl inic w ith thyrotoxicosis. Recent
blood t ests show the fo llowing:
TSH < 0 .0 5 mu/ 1
Free T4 25 pmoljl
Anti-thyroid peroxidase antibodies 115 IU/mL ( < 35 IU/ml )
A smooth, no n-tender goitre is not ed o n exami nat ion the neck. The pat ient also has
exopht halmos altho ug h there is no o phthalmo pl eg ia, no red uctio n in visual acu ity and no
eye sympto m s p resent.
What is the most ap pro priat e management?
Radioiod ine t reatment
Carb imazole
Propranolo l
Fin e need le asp irat io n b iopsy of the t hyroid g land
m
se
As
Int ravenou s corticostero id s Dr
Radio iod ine trea tment
I Carbimazole
Propra nolol
Fine needle aspiration b io psy of the thyroid g la nd
Intrave nous corticostero ids
This patient has Graves' disea se as evid enced by the thyrotoxicosis, goitre, thyro id eye
disease and anti-thyro id peroxid ase antibod ies.
Radioiod ine treatment should be avoid ed given the presence of thyroi d eye disease so
ca rbimazole is a better treatment o ptio n.
m
se
If her eye disease was severe then an o phthal mologist shou ld be consulted. Options fo r
As
seve re thyroid eye d isease include systemic steroid s a nd ra diotherapy.
Dr
A 72-year-old man is reviewed in the diab etes cl inic. He has a history of heart fa ilure and
type 2 diabetes mellitus. His current medications include furosemide 40m g od, ramipril
l Om g od and bisoprolol Smg od. Clinical examination is unremarkab le with no evidence
of peripheral oedema, a clear chest an d blood pressu re of 130/ 76 mmHg. Recent renal
and liver function test s are normal. Which one of the followi ng medications is
contrain dicated?
Sita gliptin
Pioglitazo ne
Glicl azide
Exenatide
m
se
As
Metformin
Dr
Sita gliptin D
Pioglitazone CD
Gliclazide D
Exenatide D
Metformin fD
~
Pioglitazo ne - contraindicated by: heart fa ilure
m
se
As
Thiazolidinediones are absolut ely contraindicated in heart failure
Dr
Which one of the fo llowing is most likely to be found in a patient with Hashimoto's
thyro iditis?
Ra ised ES R
Anti-TSH recepto r stimulating antibodies
Anti-thyro id pe roxid ase antibodies
Decrea sed TSH
m
se
As
Co-existing type 2 d ia betes mell itus
Dr
Raised ESR
Anti-TSH rece ptor sti mulating antibodies

-
~
r Anti-thyroid peroxidase antibodies
Decreased TSH
E o-existing type 2 diabetes mell itu s
m
se
Hashimoto's thyroiditis= hypothyroidism + goitre+ anti-TPO
As
Dr
Which o ne o f the following d rug s used in the ma na gement o f type 2 diab ete s mell itus
has the Med icines and Healthcare products Regu latory Agency wa rned is associated with
an increased risk of severe pancreatitis and re na l impairment?
Rosiglitazone
Metformin
Acarbose
Exenatide
m
se
As
Sita gliptin
Dr
I Rosiglitazone f!D
Metformin CD
Acarbose «JD
I Exenatide CD
m
se
Sitagliptin G'D
As
Dr
A 51-yea r-old wo ma n is reviewed in the dia betes cl inic. She was diag nosed with type 2
diabetes mellitus 12 mo nths a go a nd still has poor glycaemic control (63 mmoljmol). She
has recently had to stop taking g liclazide due to re peated ep isod es of hypog lycaemia a nd
is o nly ta kin g maximum d ose metfo rmin. Her BMI is 26 kg/m" 2. What is the most
appropriate next step in management?
Add eithe r pio g litazone, a DPP-4 inhibitor or a SGLT-2 inhibitor
Refer he r for a laparoscopic g astric band
Refer he r for insu lin therapy
Add eithe r a thiazolidined ione or exenatide
m
se
Add eithe r a DPP-4 inh ibitor o r e xe natide
As
Dr
Add either pioglitazo ne, a DPP-4 inhibitor or a SGLT-2 inhibitor GD
Refer her for a laparoscopic gastric band m
~fer her for insulin therapy CD
Add either a thiazolidinedione or exenatide m
m
se
As
Add either a DPP-4 inhibitor or exenatide GD
Dr
A 55-year-o ld type 1 diabetic is referred to the endocrine clinic with erratic blood sugars.
She had previously been inadequately controlled due to poor compliance with
medication, however, for the last few years has been relatively stable on a mixture of long
and short acting insu lin. Her last HBA1c was 57mmol/l. For around 3 months she has been
experiencing unpredictable hypoglycaemic episodes, alternating with very high readings,
despite being cautious with her carbohydrate counting. She reports episodes of bloating
and has vomited on a number of occasions. She has no other symptoms to report. On
review of her blood sugar diary, there is no obvious pattern to her hypoglycaem ic events
and no trigger can be identified.
Increase dose of long acting insulin
Trial of metoclopramide
Reduce dose of short acting insu lin
Continue current treatment
Trial of domperidone
m
se
As
Submit answer
Dr
Increase dose of long acting insulin CD
I Trial of metoclopramide C!D

Reduce dose of short acting insulin 6D
Continue current treatment
Trial of domperidone CD
•
Diabetic patients with gastroparesis can be treated with prokinetics such as
metoclopramide, domperidone or erythromycin
This patient has diabetic gastroparesis and as such the correct answer is a trial of a
prokinetic to improve gastric emptying. Gastroparesis in diabetics is a form of neuropathy
and occurs in patients with poorly controlled diabetes. It commonly presents as erratic
blood sugars, bloating and vomit ing often with no identifiable pattern or cause. The
evidence for antiemetics in gastroparesis is poor however some patients derive benefit
from metoclopramide, domperidone or erythromycin.
Domperidone has the best evidence base but tends not to be the first line due to its
card iac risk profile. As such NICE recommend a trial of either metoclopramide or
erythromycin with domperidone used only in exceptional circumstances.
Increasing the dose of long-acting or reducing the dose of short-acting insulin are
unlikely to benefit the patient given that t here is no clear pattern to her blood sugars.
Increasing her long acting may help stabilise her sugars however would put her at
increased risk of hypoglycaemic attacks. Reducing the dose of short-acting insu lin may
help prevent hypog lycaemic events but would increase the number of high read ings.
Whilst tweaking her insulin may be appropriate under specialist gu idance this would not
in itself treat the gastroparesis and a trial of a prokinetic would be preferable.
Continuing current treatment is incorrect as would not address her symptoms or erratic
blood sugars.
Diabetic neuropathy
Diabetes typica lly leads to sensory loss and not motor loss in peripheral neuropat hy.
Painful diabet ic neuropat hy is a common problem in clinical practice.
NICE updated it's gu idance on the management of neuropathic pa in in 2013. Diabetic

neuropat hy is now managed in the same way as other forms of neuropathic pain:
• first-line treatment: amitriptyline, d uloxetine, gabapentin or pregabalin
• if the first-line drug treatment does not work try one of t he other 3 drugs
• tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain
• topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic
neuralgia)
• pa in management cl inics may be useful in patients wit h resistant problems
Gast rointestinal autonomic neuropathy
Gastroparesis
• symptoms incl ude erratic blood g lucose control, bloating and vom iting
• management options include metoclopramide, domperidone or erythromycin
(prokinetic agents)
Chronic d iarrhoea
• often occurs at night
m
se
Gastro-oesophagea l reflux disease

As
• caused by decreased lower esophageal sphincter (LES) pressure

Dr
A 22-yea r-old man is investigated fo r we ight loss and diarrhoea. A recta l biopsy is taken
and repo rted as follows:
Deep inflammatory infiltrate from the mucosa to the muscularis propria

Numerous granulomata noted
Crohn's disease
Recta l ca rcinoma-in-situ
Tuberculosis
Laxative abuse
m
se
As
Ulcerative colitis
Dr
Crohn's disease GD
Recta l carcinoma-in -s itu m
Tuberculosis CD
~xative abuse CD
Ulcerative colitis flD
m
se
As
Inflammation in ulcerative colitis is usually limited to the mucosa and submucosa.
Dr
Which one o f the followin g is no t associated with oesophagea l ca nce r?
Acha lasia
Smoking
Gastro -oesop hageal reflux disease
Helicobacter pylori
m
se
As
Alcohol
Dr
Achalasia
Smoking
Gastro-oesophageal reflux disease
Helicobacter pylori
Alcoho l
m
se
As
He/icobacter pylori may actua lly be protective aga inst oesophageal cancer
Dr
A 34-year-old man with a backgrou nd o f polycythaemia rubra vera presented with a 2-
day history of sudden onset worsening abdominal pain. On examination of his abdomen,
there was t en derness on palpation to his right upper quadrant w ith moderate shifting
dullness and the liver edge was present 2cm below the right costa l margin.
Given the likely diagnosis, was is the most sensitive first line investigation?
Ultrasound w ith doppler flow
CT liver with tri ple phase
M RI liver w ith contrast
Contrast-enhanced CT abdomen
m
se
As
Hepatic vein venography
Dr
I Ultrasound with doppler flow
CT live r with trip le phase
r:RI~iver with contrast

Contrast-en ha nced CT a bd omen
Hepatic ve in venog rap hy
Budd-chiari syndrome - ultrasound with Doppler flow studies is very sensitive and
should be the initia l radiological investigation
This patie nt has most like ly presented here with Budd-Chiari syndrome. In this situation,
a n u ltrasou nd with d opple r flow stud ies is highly sensitive and should, the re fo re, be the
first radiological investigation. It will exhibit the absence of blood flow in the hepatic ve in
o r flow reversa l and eve n the thromb us itself.
The contrast-enhanced CT scan would be ab le to visualise the presence of patchy

e nhancement of the live r tissue and post-hepatic infe rio r vena cava (IVq may be a bsent.
The caud ate liver lob e is ofte n e nla rged and pre -h epatic d ilatatio n of the IVC is seen but
the throm bus itself can be s hown in less than 50% of patients. Sple no mega ly with ascites
wou ld a lso b e seen.
The ro le o f MRI in diagnos ing Budd- Chiari synd ro me is still up a nd coming. It is able to
d etect blood flow o r its absence within the he patic ve in o r IVC.
Hepatic vein ve nog rap hy cou ld he lp identify the thrombus a nd further d emonstrate a web
em
as a cause o f the o bstructio n. It would a lso be a ble to distinctly visualise intra hepatic
s
As
co llaterals.
Dr
A 59-year-old woman prese nts with dysphagia. There is no history of heartburn, weight
loss or change in bowel habit. During endoscopy there is some difficu lty passing through
the lower oesophageal sphincte r but no other abnormality is noted. Which one o f the
following tests is most likely to reveal the diagnosis?
Oesophageal biopsy
Oesophageal manometry
Plain chest x- ray
Endoscopy ultrasound
m
se
As
CT tho rax
Dr
Oeso phageal b iopsy
Oesophagea l mano metry
Plain chest x-ray
Endosco py ultrasound
CT tho rax
m
se
The gold standa rd test fo r acha lasia is oeso phagea l mano metry
As
Dr
A 62-yea r-old ma n is called fo r review after a positive faecal occu lt b lood test done as
pa rt o f the nationa l screen ing programme. Du ring cou nselling fo r colo noscopy he asks
what percentage of patie nts with a pos itive faeca l occult b lo od test have colorectal
ca ncer. What is the most accurate answer?
0.5 - 2%
5- 15%
20 - 30%
30 -50%
m
se
As
55- 75%
Dr
0.5- 2% GD
5- 15% aD
20 - 30% flD
30-50% CD
55- 75% CD
Colo rectal cancer screen ing - PPV of FOB = 5 - 15%

m
se
There is also a 30-45% chance of having an ad enoma with a positive faecal occult blood
As
test
Dr
A 28-year-old man undergoes an ileocaecal resectio n to treat terminal ileal Crohns
disease. Post operatively he att en ds the clinic and com plains of diarrhoea. His CRP is
within normal limits and small bowel enteroclysis shows no focal changes. Which of the
following interventions is most likely to be b eneficial?
5 ASA drugs
Azathioprine
Infliximab
m
se
As
Ora l cholestyram ine
Dr
5 ASA drugs
Azathiopri e
Infliximab
Oral cholestyramine
Malabsorption of bile salts is a common cause of diarrhoea following ileal resection. A
m
se
normal small bowel study and CRP effectively excludes active Crohns disease and
As
therefore immunomodulat or drugs are not appropriate.
Dr
A 43-yea r-old woman presents to the emergency d epartment with confusion, d istended
abdomen and jaundice. She describes a heavy cough, fever and malaise fo r three d ays
following a p eriod of heavy drinking. She is known to have cirrhosis secondary to
alcoholic live r disease. On exa mination, she is jaundiced, co nfused and ha s tense ascites,
and there are audible crackles in the right si de o f her chest. She a lso has distended veins
on her abdomen and a palpab le liver.
Blood tests:
Hb 94 gfl
MCV 104 fl
8
Platelet s 92 109/1
8
WBC 12.5 109/1
Na• 148 mmol/ 1
K• 5.1 mmolfl
Urea 6. 2 mmolfl
Bilirubin 34 IJmOI/1
ALP 245 u/1
ALT 276 u/1
yGT 32 1 u/1
Albumin 21 g/1
Prothrombin time 18 s
Which of these abnormalities is attributa ble chronic excess ive alcohol use without being
secondary to live r decom pensation?
Macrocytic anaemia
Neutrophilia
Thrombocytopen ia
Deranged dotting
sem
As
Hypoa lbuminaemia
Dr
Macrocytic anaemia GD
Neutro philia CD
Th rombocytopenia
Deranged clotting
•m
Hypoalbuminaemia .
(D
The correct answer is macrocytic anaemia. Macrocytosis is common in patients with

alcoholism, often p receding anaem ia. It can be ind ep endent of vitam in d eficiency and the
mechan is m is not complete ly unde rstood. Reduced hepatic synthetic function causes
reduced production of clotting facto rs leading to d eranged clotting, and s imilarly a failure
in production of a lbum in. Alcohol is also d irectly toxic to platelets, and associated
m
splenomegaly in porta l hypertension can cause thrombocytopenia, but reduced hepatic
se
As
function of th rom bopoietin can cause low p late lets. The neutrophilia is like ly secondary to
an acute chest infection.
Dr
A 69-year-old woman was evaluat ed following the development of a rash on her lower
limbs for the last two weeks, worsening breathlessness and weight loss. This eruption
started as a small erythematous annular patch, slowly enlarging into polycyclic patches
with a wood-grain appearance over the lateral aspects of her left thig h. The patient had a
background of atrial fibrillation on warfarin and hypothyroidism on levothyroxine. She has
45 pack year history of smoking with underlying COPD managed with regu lar inhalers and
home nebulisers. She complained of losing l Okg in weight over the last six months. Her
symptoms were not being managed using her inhalers and nebulisers.
Based on the history and clin ical findings, what is the correct diagnosis?
Erythema annulare centrifugum
Mycosis fungo ides
Erythema chronicum migrans
Erythema gyratum repens
m
se
Tinea corporis
As
Dr
Erythema annu la re centrifugum
Mycosis fung o ides
Erythema chronicum mig rans
Erythema gyrat um repen s
Tinea corporis
-
"""'
Erythema gyratum repens is a para neo plastic eruption with a 'wo od-grain' patte rn
and figurate e rythema com mon ly seen in patients with lung ca nce r
Erythema gyrat um re pe ns - associated with interna l ma lig nancies - is cha racterised by a

nu mber of concentric, erythemato us, fro m either flat to slig htly raised ba nd s with fine
white sca le in waves lo cated at the leading edge o f erythema. The ir a ppeara nce may
re present a wood -gra in pattern.lt can o fte n p recede a diag nosis of typica lly lung cancer
by a n avera ge of nine mo nths.
Erythema a nn ula re centrifugum is d efined by the p resence o f expanding, erythematous

a nnular lesions. Its cause is unknown but li kely d ue to drug s, insect bites, food &
infections.
Mycosis fungo id es is a fo rm of cutaneous T-cell lympho ma cha racterised by itchy,

erythemato us scattered patches a nd pla ques.
Erythema chronicum mig ra ns is the classical rash caused by Lyme disease fo llowing a tick
b ite. It starts off as a red macule/ pap ule deve lo ping into a n expandi ng patch of erythe ma
with a classic b ull 's eye a ppea rance.
s em
As
Tinea corp oris is a superficia l funga l ringwo rm infect ion.

Dr
A 64-year-old female with a history of COPD and hypertension presents with pain on
swallowing. Current medication includes a salbut amol and beclomethasone inhaler,
bendroflumethiazide and amlodipin e. What is the most likely cause of the presentation?
Myasthenia gravis precipitated by bendroflumethiazide
Oesophageal web
Achalasia secondary to amlodipine
Oesophageal cand idiasis
m
se
As
Oesophageal cancer
Dr
Myasthenia gravis precipitated by bendroflumethiazide
Oesophageal web
Acha la sia secondary to am lodip ine
I Oeso phageal candid ias is
Oesophageal cancer
m
se
Pain on swallowing (odynophag ia) is a typica l o f oesophageal candid ias is, a well
As
d ocumented complication of inhaled ste ro id therapy
Dr
Which of the following skin cond itions associated with malignancy are not correctly
paired?
Necrolytic migratory erythema and glucagonoma
Migratory thrombophlebitis and pancreatic cancer
Erythema gyratum repens and lymphoma
Acanthosis nigricans and gastrointestinal cancer
m
se
As
Erythroderma and lymphoma
Dr
Necrolytic migratory erythema and g lucagonoma
Mig ratory throm bophleb itis and pancreatic cancer
~hema gyratum repens and lymphoma

Acanthos is nigricans and gastrointestina l cancer
Erythroderma and lympho ma
m
se
Erythema gyratum repens is genera lly associated with solid o rgan ma lignancies such as
As
lung and breast cancer
Dr
A 59-yea r-o ld woman presented with painful dysp hagia, poor appetite and we ight loss
ove r the past nine mo nths. She is a heavy chain s moker with a 30 pack yea r history. She
a d mits to consu ming alco hol excessively. An urgent barium swa llow was a rranged a nd
shows the presence o f a suspicious ma lig nant o esop hageal stricture.
What is the b est investigation to assess for mural invasion?
T2-weighted MRI scan
Endoscopic ultrasou nd
Conventional side -viewing du od enoscopy
m
se
As
Positron-em issio n tomography (PED sca n
Dr
T2-weighted MRI scan
Endoscopic ultrasound
Convent ional side-viewing duodenoscopy
Positron -emiss ion tomography (P ET) scan
Oesophageal/Gastric Cancer - Endoscopic ultrasound (EUS) is better than CT or MRI

in assessing mural invasion
The end oscopic ultrasound aids t he visualisation of local invasion as it can disp lay all the
layers o f the wall of the oesophagus and should routinely be performed wit h CT or MRI
scans.
Overall, endoscopic ultrasound is fa r superior to CT or M RI when assessing mural

invasion.
The posit ron-emission to mography (PET) scan is increasingly being employed by

oncolog ists in detecting and following up the tumou r p rogression.
Duodenoscopes are essentially sp ecialised end oscopes that are used primarily for
endoscopic ret rograde cholangiopancreatography (ERCP). They are side -viewing (rather
s em
than forward-viewing) end oscopes t hat have an advantage in being able to view the
As
major duo denal papilla.

Dr
A 72-year-old woman is reviewed following a cou rse of oral flucloxacillin for right lower
limb cellulitis. The local protoco l suggests oral clindamycin should be used next-line.
Which one of the following side-effects of clindamycin is it most important to warn her
about?
Heartburn or indigestion
Jaundice
Sore throat, bruising or lethargy
Avoid any food or drink contain ing alcohol
m
se
As
Diarrhoea
Dr
Heartburn or indigestion
Jaundice
Pre throat, bruising or lethargy
Avoid any food or drink contain ing alcohol
Diarrhoea
m
se
Clindamycin treatment is associated with a high risk of Clostridium difficile
As
Dr
A 45-year wo man who you have treat ed for obesity comes for review. Despite ongoing
lifestyle interventions and trials of orlistat and sibutramine she has fa iled to lose a
significant amount of weight. She is cu rrently taking ramipril for hypertension but a recent
fasting glucose was normal. Fo r this patient, what is the cut-off body mass index (BMI)
that would trigger a referral for cons ideration of bariatric surgery?
BMI > 35 kg/m" 2
BMI > 40 kg/m" 2
BMI > 30 kg/m" 2
BMI > 38 kg/m" 2
m
se
As
BMI > 45 kg/m" 2
Dr
BMI > 35 kg/m"2 CD
BMI > 40 kg/m"2 eD
-
BMI > 30 kg/m"2 .
(D
BMI > 38 kg/m"2 .

(D
BMI > 45 kg/m"2 CD
Obesity- NICE ba riatric referra l cut-offs

• with risk factors (T2DM, BP etc): > 35 kg/m " 2
m
• no risk facto rs: > 40 kg/m "2
se
As
Dr
A 39-year-old man with a history of alcohol excess presents to the Emergency
Department w ith a 2 d ay history of severe epigastric pain. His amylase is found to be
1260. What is t he best marker of severity?
CRP
Amylase (on admission)
Pain scores
Lipase (o n admission)
m
se
As
Number of simi lar previous admissions
Dr
CRP
Amylase (on admission)
Pain scores
Lipase (on admission)
Number of sim ilar previous admissions

-
~
CRP is now a widely used marker of severity in acut e pancreatitis. Other methods which
m
se
have to correlate w ith prognos is include the Ranson criteria and APACHE II score (Acute
As
Physiology And Chron ic Health Evaluation)
Dr
Which one o f the following is most associat ed with the development of acute
pancreatitis?
Hyperchylomicronaemia
Amyloidosis
m
se
As
Hypotriglyceridaemia
Dr
Hyperchylomicronaemia
Amyloidosis
Hypf gammaglobulinaemia
Hypotriglyceridaemia
m
se
Hyperchylomicronaemia may be caused by hereditary lipoprotein lipase deficiency and
As
apolipoprotein CII deficiency. It predisposes to recurrent attacks of acute pancreatitis
Dr
A 36-yea r-old woman presents with flushing, diarrhoea and abdo minal d isco mfort. She
says these symptoms have come on ove r the la st few months a nd d o not ap pear to be
g ett ing b etter. You decide to run some tests. 24-hour urine 5-HIAA is e levated confirming
you r diagnosis of ca rcino id syndro me. A scan is undertaken which loca lises the neoplastic
lesion to the jejunum. Yo u start her o n octreotide to calm her symptoms whilst she awa its
surgery. What card iac abnormalities a re associated with this conditions?
Acquired ventricular septal defect
Pulmonary ste nos is a nd tricuspid in sufficiency
Aortic d issection
m
se
As
Loeffle r en docarditis
Dr
Ac:quired ventricular septal defect
Pu lmonary stenosis and t ricuspid insu fficienc~
Aortic dissection
Loeffler en docarditis
Carcinoid syndrome can affect t he right side o f the heart. The valvular effect s are
tricuspid insufficiency and pu lmonary stenosis
Important for me Less important
Carcinoid syndrome is a neuroend ocri ne tumou r. There are many locations t hat they ca n
occur in such as in t he GI tract, in t he respirato ry t ract and many other places. They can
secret e serot on in which lead s to many of t he symptoms this patient suffers. The
syndrome is associat ed with right -sided valvular patholo gy. The most com mon pat hology
is tricuspid insu fficiency and pulmonary stenosis. The best way to remember is the
acronym 'TIPS'.
HOCM is associat ed w it h inherited g ene d efect s on t he ~- myosi n heavy chain. This is not
associat ed w it h carcinoid syndrome.
Acquired VSD wou ld be associated with an MI and not ca rcinoid syndrome.
Aortic dissection is associat ed w it h hypert ension and co nnective tissue diso rder.
em
Loeffler endocarditis is endocarditis due t o eosinophil proliferat ion in the heart. It is

s
As
associat ed w it h helminthic infections and not carcinoid syndrome.

Dr
A 71-year-old man presents with two year history of intermittent p roblems with
swa llowing. His wife has a lso noticed he has halitosis and is coughing at night. He has a
past med ical history of type 2 d iabetes mellitus but states he is otherwise well. Of note his
weight is stable and he has a good appetite. Clinical exam ination is unremarkable . What is
the most li kely diagnosis?
Oesophageal cancer
Hiatus hernia
Pharyngeal pouch
Oesophageal candidiasis
m
se
As
Benign oesophageal stricture
Dr
Oesophageal cancer
Hiatus hernia
•
fD
I Pharyngea l pouch GD
Oesophageal cand id ias is CD
Benign oesophagea l stricture CD
m
se
As
Given the two yea r history a nd good health oesophag eal cancer is much less li kely
Dr
A 44-yea r-o ld man with a lcoholic live r disease is a dmitted with pyrexia . He has been
unwe ll for the past three d ays a nd has mu ltiple previo us admissions befo re with va ricea l
b leeding . Exam inatio n shows mu ltiple stigmata of chro nic live r d isease, ascites and
jaundice. Paracentesis is p erfo rmed with the fo llowing resu lts:
Neutrophils 487 cells/ul
What is the most ap pro priate treatment?
The rap eutic a bdom ina l washout
Intrave nous va ncomycin + metron id azole
Intravenous cefotaxime
Inse rt a n asciti c d ra in
m
se
As
Intrave nous ciprofloxacin
Dr
Therapeut ic abdominal washout
Intravenous vancomyci n + metronid azole
Intravenous cefotaxime
Insert an ascitic drain
Intravenous ciprof loxacin
Spontaneous bacterial periton itis - treatment: intravenous cefot axime

m
se
As
Pl ease see t he Briti sh Society of Gastroent ero logy gu id elines for more d etails.
Dr
A 29-year-old wo man who is 30 weeks pregnant is admitt ed to the Emergency
Department w ith cent ral abdominal pain. Initial b lood t ests show the follow ing:
Amylase 1,438 ujdl
What is the most likely cause of this present ation?
Gestational diabet es
HELLP syndrome
Gallstones-i nduced pancreatit is
Hypertriglyceridaemia -i nduced pancreatitis
m
se
As
Pre-eclampsia
Dr
Gestationa l diabetes
I
HELLP syndrome
Gallstones-induced pancreatitis
-
~
Hypertriglyceridae mia -i nduced pancreatitis
Pre-eclampsia
m
se
Pancreatitis occu rs in around 1 in 2,000 p regnancies. Most cases of pancreatitis in
As
pregnancy are gallstone related.
Dr
A 46-year-old, w ith an end-stage chronic kidney disease second ary to diabetes,
undertakes a renal trans plantation with no immediate complications. Two months later,
he attends t he emergency department wit h a 3-day history of a febrile syndrome and
right upper quadrant pain. Investigations showed a moderated leukopenia and mild
transam inasaemia.
Hb 119 g/ 1
Plat elet s 234 * 109/ 1
8
WBC 2.46 109/ 1
ALP 61 u/1
ALT 75 u/1
yGT 72 u/1
Albumin 38 g/ 1
What would be your first diagnostic impress ion?
Pneumocystis jirovecii infection
Varicella -zoster virus infection
Renal tuberculosis
Cytomegalovirus infection
sem
As
Hepatitis B
Dr
Pneumocystis jirovecii infectio n
•
Varicella-zoster virus
Renal tubercu losis

infectio n
•f.D
Cytomegalovirus
Hepatitis B
infection
-
GD
.
CMV infection is one of the most im portant in transp lant receptors - clinically is
characterized by fever, deranged transaminases, leukopenia and throm bocytop enia.
Diagnosed by PCR and treated with ganciclovi r
Cytomegalovirus infectio n is one of the most impo rta nt o ppo rtunist infections in
tra nsplant receptors. Usually hap pens between the first mo nth a fte r transplant and the
s ixth month. Clinically is characterized by feve r, d e ranged transam inases, leuko pen ia and
thro mbo cyto pe nia . It is diagnosed by polyme rase cha in reaction (per) and treated with
Ganciclovir.
Pneumocystis jirovecii can a lso cause an o pp ortunist infectio n, such as pneu mo nia,
pa rticu la rly a mo ng immunocom p ro mised hosts.
Varicella-zoster virus can cause prime-infectio n or re infectio n affecti ng o ne o r multiple

d e rmatomes ove r skin and mucosas, cha racte rized by a skin rash that fo rms s mall, itchy
bliste rs, which eve ntually scab ove r. It ca n also affect vita l o rgans causing, fo r insta nce,
pu lmonary va ricella.
Renal t ube rcu losis accounts fo r 15-20% of extra - pulmonary tubercu losis and ca n resu lt in
va ried and striking radiog ra p hic a ppea rances a nd ofte n p resents with pyuria in the
a bsence o f co mmon bacte ria l infectio n (o rdina ry urine cu ltures p ersistently negative).
Fi na lly, he patitis B is not an o ppo rtunist infectio n and ca n p resent with a va riety of
em
sympto ms d ep endi ng on how acute o r subacute the infection is - cli nica lly cha racterized
s
As
by hyperbilirubinaem ia, extremely elevate d tra nsam inases and genera l mala ise.
Dr
A 51-yea r-o ld woman is investigated for lethargy and p ru ritus. Her app etite is normal an d
she has not lost weight. On examination she is not clinically jaundiced and there is no
organomeg aly. Bloods tests are reported as follows:
Hb 12.8 g/dl
WBC 6 .7 * 109/ 1
Na• 140 mmol/ 1
K• 3. 9 mmoljl
Urea 6 .2 mmoljl
Creatinine 68 J,Jmol/1
Bilirubin 30 J,Jmol/1
ALP 231 u/1
ALT 38 u/1
yGT 367 u/1
Albumin 39 g/1
What furthe r test is most like ly to reveal the diagnosis?
Anti-nuclear antibod ies
Liver ultrasound
Anti-mitochond rial antibodies
Ceru loplasmin
sem
Ferritin
As
Dr
Anti-nuclear antibodies
Liver ultrasound
Anti-mitochondrial antibodies
Ceruloplasmin
Ferritin
Primary biliary cho langitis - the M rule

• IgM
• anti-Mitochondrial antibodies, M 2 subtype
• M iddle aged females
m
The demographic (middle-aged female), hist ory (lethargy, pruritus) an d liver function t ests
se
(rise in ALP and yGT) all point t o a diagnosis of primary biliary cirrhosis (PBC). Anti-
As
mitochondrial antibodies are found in 98% of patients w ith PBC.
Dr
A 39-year-old man with a history of liver cirrhosis seconda ry to alcohol excess is ad mitted
with an upper g astrointestinal haemo rrhage. He is treated with terlipressin and has an
endoscopy with variceal band ligation 6 hours following admission. Which further
intervention has been shown to reduce morta lity durin g the acute admission?
IV labetalol to induce hypotens ion for the fi rst 3 days
Low-molecula r weight hepa rin p rophylaxis
Nasogastric tube feed ing for the first 3 days
Antibiotic p rophylaxis
m
se
As
High-d ose proto n pu mp inhibitor therapy
Dr
IV labetalol to induce hypotension for the fi rst 3 days
l~ -molecular weight heparin prophylaxis
Nasogastric tube feeding for the first 3 days
I Antibiotic prophylaxis
High-dose proton pu mp inhibitor therapy

-
~
Antibiotic prophylaxis reduces mortality in cirrhotic patients with gastrointestinal
m
se
bleeding
As
Dr
A 27 -year-old man with multiple pigmented freckles on his lips and face is investigated
for iron -deficiency anaemia. A diagnosis of Peutz-Jeghers syndrome is suspected. What is
the mode of inheritance?
Autosomal recessive
Mitochondrial inherit ance
X-linked dominant
Autosomal dominant
m
se
As
X-linked recessive
Dr
Auto somal recessive fD
•
X-li nked d ominant
Autosomal dominant CD
•
X-li nked recessive m
m
se
Peutz-Jeghers syndrome- autosomal d ominant
As
Dr
A 20-yea r-old female with known Crohn's disease presents in gastroenterology cl inic for
review of her man agement. She is cu rrently being treated with o ral p rednisolone. She has
experienced 3 mild flare ups of her Crohn's d isease in the past 12 months, each occu rring
when oral steroid dose has been ta pered. You consider add ing azathioprine to her
ma nagement.
Which of the following shou ld be assessed before co mmencing azath ioprine in this
patient?
Liver function
Thio pu rine methyltransferase (TPMT) activity
Body mass index (BMI)
Renal function
m
se
As
Coagu lation
Dr
Live r function
I Thiopu rine methyltransferase (TP MT) activity
Body mass in dex (BMI)
Renal fu nction
Coagulation
TMPT activity should b e assessed b efo re offering azathioprine or mercapto puri ne

therapy in Crohn' s disease
Thiopu rine methyltransferase (TPMT) is an enzyme involved in the metabolism of

azat hiop rine and mercaptop urine. Some people have a deficiency o f TPM T due to genetic
mutations, and t hese peop le are at a great er risk o f exp erienci ng severe side effect s from
conventiona l d oses of azathioprine or merca pto puri ne. TPMT activity should therefore b e
assessed before offeri ng azathioprine or mercaptopu rine t herapy. Such medicat ions
m
se
should not be commenced if TPMT is very low or absent. If TPMT activity is below normal,
As
but not d eficient, azat hioprine or mercaptopurin e can be co mmenced at a lower dose.
Dr
Which one o f the followin g adverse effects is least associated with sulfasalazine?
Male infertility
Skin rashes
Visua l distu rbance
Diarrhoea
m
se
As
Agranulocytosis
Dr
Male infertility fD
Skin rashes CD
Visual disturbance C!D
Diarrhoea (fD
m
se
(D
As
Agranulocytosis
Dr
A 30-year-old woman is admitted to hospital with abd om inal pa in and d ia rrhoea. She has
no past medica l history other than d epression for which she takes citalopra m. She smokes
20 cigarettes/day and drinks 20 units of alcohol per week.IIeocolonoscopy shows featu res
cons istent with Crohn's disease and she is treated successfully with g lucocorticoid
therapy. Which one of the fo llowing is the most im portant interventio n to reduce the
chance of further episodes?
Infliximab
Stop drinking
Stop smoking
Mesa lazine
m
se
As
Budesonide
Dr
Infliximab m
Stop drinkin g
Stop smoking
•
6D
Mesalazine GD
m
se
•
As
Budesonide
Dr
~
A 22-year-old male w ith a history of fam ilial adenomatous polyposis (FAP) has a total
colectomy. What is the mode of inheritance of FAP?
Uniparental disomy of chromosome 12
Autosomal recessive
Uniparental disomy of chromosome 14
Autosomal dominant
m
se
As
X-lin ked recessive
Dr
Uniparental disomy of ch romosome 12 CD
Autosomal recessive (D
Uniparental disomy of ch romosome 14 m

Autosomal dominant CD
m
se
As
X-linked recessive m
Dr
A 45-year-old obese man with a history of type 2 diabet es mellitus is reviewed in cl inic.
He is well and asympt omatic. His recent annual blood tests have shown slightly abnormal
liver function test s:
ALP 104 u/1
ALT 53 u/1
yGT 58 u/1
Albumin 38 g/1
A follow -up liver ultrasound is repo rted as showing fatty changes. Other standard liver
screen bloods, including viral serology, are normal. His alcoholic i ntake is within
reco mmended limits.
What is the most appropriate next test t o perform?
Endoscopic ultrasoun d (EUS)
Enhanced liver fibrosis blood t est
Repeat liver ultrasound after ca lorific restricted diet for 1 month
Liver biopsy
m
se
As
High-sensitivity C-reactive protein

Dr
Endoscopic ultrasoun d (EUS)
Enhanced liver f ibrosis blood test

-
.....,
Repeat liver u ltrasound after ca lorific restricted diet for 1 month
I Liver biopsy
High-sensitivity (-reactive protein
In pat ients with non -alco holic fatty liver disease, enhanced liver fibrosis (ELF) testing
is recom mend ed to aid diagnos is of liver fibrosis
This is a typical patient w ho has non -alcoholic fatt y liver disease - obese and w ith type 2
diab etes mellitus.
m
se
NICE recommend that if NAFLD is found incidentally t hen an enhanced liver fibrosis (ELF)
As
blood test should be p erformed to assess for more severe liver disease.
Dr
A 62-year-old man p resents with painless jaund ice and is diagnosed with pancreatic
ca ncer undergoes pancrea ticoduodenectomy. He recovers well from surge ry. He is
referred to oncology for further management a nd is started on palliative a djuvant
chemothera py. Two months later he presents with a recurrence of painless ja und ice. Apart
from routine blood tests and serum cancer a ntigen 19-9, how s hould he be investiga ted?
Mag netic resona nce cho langiopancreatog raphy (MRCP)
Endoscopic reso nan ce cholangiopancreatography (ERCP)
US abdomen
Abdominal X- ray
m
se
As
CT scan of the chest, abdomen and pelvis
Dr
Magnetic resonance cholangiopancreatography (MRCP)
Endoscopic resonance cholangiopancreatography (ERCP)
US abdomen
Abdominal X-ray
CT scan of the chest. abdomen and pelvis
High-resolution CT scanning is the diagnostic investigation of c ho ice fo r pancrea tic

cancer
CT scan of the chest, a bdomen and p elvis is the most a pprop riate investigation. The most
li kely cause of the patient's jaundice is recurre nce of pancreatic cancer, and a CT is the
most app ropriate moda lity to assess tumou r size and also to investigate for lymphatic and
metastatic spread. None of the other investigations would reveal tumour g rowth, and an
endoscopic ap proach wou ld b e d ifficu lt post-o peratively. Abdominal X-ray and US wou ld
not b e a ble to show tumou r g rowth.
m
Sou rce:
se
As
'Pancreatic Cancer.' BMJ Best Practice.ll Dec. 2015.
Dr
Which one of the fo llowin g foodstuffs conta ins the most calories per unit we ig ht?
White b read
Butter
Pa sta
Sug ar
m
se
As
Red meat
Dr
White b read m
Butte r fD
Pasta m
Sugar CD
m
se
Red meat m
As
Dr
A 56-year-old overweight female is found t o have non -alcoholic fatty liver disease on
abdominal ultrasound following recent pyelonephritis. She is com plet ely asymptomatic
and has normal liver function t ests.
What is the recommen d investigation to monitor for advanced liver fibrosis i n this
patient?
Liver biopsy
Yearly liver function tests
Yearly albumin and coagu lation screen
Repeat ultrasou nd every 3 years
m
se
As
Enhanced liver fibrosis test every 3 years
Dr
Liver biopsy
Yearly liver function tests
p .arly albumin and coagulation screen
Repeat ultrasound every 3 years
Enhanced liver fibrosis test every 3 years
In patients with non -alco holic fatty liver disease, enhanced liver fibrosis (ELF) testing
is recommended to aid diagnos is of liver fibrosis
The correct answer is enhanced liver fibros is or ELF test. Patients who are found at
ultrasound to have asympt omatic non-a lcoholic fatty liver disease (NAFLD) should
undergo an ELF t est to check for evidence of advanced liver fibrosis and this should b e
repeated every three years. People with confirmed NAFLD and an ELF score > 10.51 are
diagn osed w ith advanced liver fibrosis.
Liver biopsy would be the correct answer if the question asked about a diagnosis of
cirrhos is, but only in patients for w hom transient elast ography is not an option.
Per NICE guidelines routi ne liver function tests are not indicated for diagnos is of
advanced liver fibrosis in patients with NAFLD, making this answer incorrect.
Whilst albumin and coagulation screen may demonstrate evidence of impaired liver
function these are not diagnostic o f advanced liver fibrosis. As such option 3 is incorrect.
Repeat ultrasou nd would not be helpful in the diagnos is of advanced liver fibrosis. In
s em
patients with confirmed cirrhosis, however, it may be useful for monitoring for
As
hepat ocellular carcinoma but this wou ld be twice yearly.

Dr
A 23-year-old nurse is reviewed in occupationa l health following a needle stick injury
from a man known to be a ca rrier o f hepatitis B. Which one of the following would appear
first during acute hepatitis B infection?
HBsAg
HBeAg
anti-HBg
anti-HBs
m
se
As
HBcAg
Dr
HBsAg GD
HBeAg fD
anti -HBg
L
anti-HBs
-
fD
m
se
As
HBcAg fD
Dr
A 78-yea r-old woman is a dmitted with a p roductive cough and pyrexia to hospital. Chest
x-ray shows a pneumonia and she is commenced on intravenous ceftriaxone. Four d ays
fo llowing a dmiss ion a stool sample is sent because o f d ia rrhoea. This confirms the
sus pected d iagnosis o f Clostridium difficile d ia rrhoea a nd a 10-day course o f o ra l
metron idazole is started . After 10 d ays he r diarrhoea is ongoing bu t she remains clin ically
stab le. What is the most app ropriate treatment?
Ora l van comycin for 14 d ays
IV va ncomyci n for 3 d ays
Ora l rifa mpici n for 7 d ays
Ora l clinda myci n for 7 days
m
se
As
Ora l metro nid azo le for a furthe r 7 days
Dr
Oral van co mycin for 14 days
IV vancomycin for 3 days
Oral rifampicin for 7 days
Oral clindamycin for 7 days
Oral metronidazole for a further 7 days
If C. diffici/e does not respond to first line metronidazole, oral vancomycin should be
used next, except in life -threatening infections
m
se
As
The Health Prot ection Agency suggests switching to oral vancomycin in this scenario.
Dr
A 27 -yea r-old wo man presents fo r review. She d escribes he rse lf as having 'IBS' and fo r the
past two years has su ffe red intermittent bouts of abdom ina l pa in, bloating and loose
stools. For the past two weeks howeve r he r symptoms have been much worse. She is now
passing around 3-4 wate ry, grey, 'frothy' stools p er d ay. Her abdominal b loating and
cramps have a lso wo rsened and she is su ffering from excessive flatu lence. Judging by th e
fitting of her clothes she a lso feels that s he has lost weight. Some b lood tests a re o rde red:
Hb 10.9 g/dl
Plat elet s 199 * 109/ 1
WBC 7.2 * 109/ 1
Ferritin 15 ng/ ml
Vitamin 6 12 225 ng/ 1
Folat e 2. 1 nmol/1
Croh n's disease
Co el iac d isease
Infective exace rbation of irritable bowel syndrome
Ulcerative co litis
m
se
As
Bacterial overg rowth syndrome

Dr
Crohn's disease
I Coeliac disease
Infective exacerbation of irritable bowel syndrome
Ulcerative colitis
-
~
Bact erial overgrowth syndrome
The main clues is t his quest ion are the anaemia and low ferritin/ folat e levels, all
charact erist ic of coel iac disease. The d escri ption of t he diarrhoea is also typical alt hough
some patient s may have more overtly 'fatty' stoo ls.
Why not irritable bowel syndrome? Common thi ng s are com mon and atyp ica l
p resentations o f co mmon co nditions are seen more t han typ ica l presentations of less
com mon condit ions. The main reason is t he bloods - a low f errit in and folat e wou ld not
d evelop wit h IBS +/ -gast roent eritis. Even ifthe woma n su ffered f rom menorrhagia t his
wou ld not explain t he low folate alt hough it may account fo r th e anaemia/low ferritin.
m
se
Coeliac disease is more com mon than Crohn's by a factor of around 100. In exams t here
As
are also usually more clues to p oint t owards a diagnosis of Crohn's (e.g. mouth ulcers etc).
Dr
A 45-yea r-old man is noted to have non -tender, s mooth hepatomega ly associated
Dupuytren's contract u re a nd pa rotid enlargement. He recently returned from a holid ay in
Thailand. What is the likely diagnosis?
Primary he patoma
Hydatid disease
Alcoholic live r d isea se
Viral hepatitis
m
se
As
Tricuspid reg u rgitation
Dr
Primary hepatoma
Hydatid disease
•
ED.
Alcoho lic liver disease CD
Vira l hepatitis fD
Tricuspid regurgitation
•
Early stage liver cirrhosis is a common cause o f hepatomegaly. The liver may shrink
in more advanced disease
Bot h Dupuytren's contracture and parotitis are associat ed w it h alcoholic liver disease.
Whilst a history o f alcohol excess wou ld normally be volunteered it should be
remembered many patient s w ill lie about their alcohol intake.
m
se
As
The recent holiday in Thailand is a distractor.
Dr
A 54-yea r-old ma n is investigated for dyspepsia. An endoscopy shows a gastric ulcer and
a CLO test done du ring the procedure demonstrates H. pylori infect ion. A course of H.
pylori erad ication thera py is g iven. Six weeks later the patients comes fo r review. What is
the most a p propriate test to confirm eradication?
Cu lture of gastric b io psy
H. pylori serology
Hydrogen breath test
Urea breath test
m
se
As
Stool cultu re
Dr
Cu lture o f gastric b io psy fD
H. pylori serology m
Hydrogen brea th test CD
I Urea breath test GD

Stool culture fD
It is importa nt to re me mb er that H. pylori sero logy re main s pos itive following e ra dication.
m
se
As
A stoo l antige n test, not cu ltu re, may b e a n a p pro p riate alternative.
Dr
An 84-year-old male p resents to the GP following a b lood test that d emonstrated a
haemoglobli n of 84 g/ l. He also remarked he had been passing some b la ck motions
recently but had no weight loss. A previous colonoscopy ha d been performed which
demonstrated no polyps o r malignancy but multiple a ngiodysplastic lesions were
documented. On exam ination, the GP identifies a mu rmu r. What valvu la r dysfu nction was
likely to cause the audible murmur?
Aortic regurg itation
Mitral stenos is
Aortic stenosis
m
se
As
Pul monary stenosis
Dr
Aortic regu rgitation «ED
I
Mitral stenosis
Aortic stenosis GD
•
Mitral regurgitation D.
Pulmonary stenosis CD
Ang iodysplasia is associated with aortic stenosis

The combination of aortic stenosis and colonic angiodys plasia resulting in a GI bleed is
indicative of Heyde's syndrome.
The condition deve lops due to a reduction in vWF as the b lood passes through a narrow
aortic valve. Treatment of the condition is that of treatin g the aortic stenosis.
m
se
As
The other valvu lar prob lems are not associated with this syndrome.
Dr
A 65 -year-old man wit h liver cirrhosis of unknown cause is reviewed in clinic. Which one
o f the following factors is most likely to indicat e a poor p rognosis?
Alanine transam in ase > 200 u/1
Caput medu sae
Ascites
Ra ised urea
m
se
As
Splenomegaly
Dr
Alanine transam inase > 200 u/1
Caput medusae
Ascites
Ra ised urea
Splenomegaly
-
"""'
Ascites is part of the Child-Pugh an d is a marker of poor prognosis. For patients with
chronic liver disease it implies a mo rtality of 15% per year and around 45% within five
years.
m
se
As
Serum creatinine, rather than urea, is part MELD criteria.
Dr
A 34-year-old male is admitted with central abdominal pain radiating through to the back
and vomiti ng. The following results are obtained:
Amylase 1, 245 ujdl
Which one of the following medications is most like ly to be responsible?
Phenytoin
Sodium valproat e
Metoclopramide
Sumatriptan
m
se
As
Pizotifen
Dr
Phe nytoin f!D.
Sodium valproate 6D
Metoclopramide CD
Su matriptan CD
Pizotifen f!D
Sodium valp roate induced pancreatitis is more common in young ad ults and tends to
m
se
occur within the first few months of treatment. Asymptomatic e levation of the a mylase
As
level is seen in up to 10% of patients
Dr
A 25-yea r-old man p resents with letharg y and increased skin pigmentation. Blood test
reveal de ran ged liver function tests a nd impaired g lucose tole ra nce. Given the likely
diagnosis of haemochromatos is, what is the most appro priate initia l investigation
strategy?
Transferrin satu ratio n + ferriti n
Haematocrit + ferritin
Live r biopsy with Peri's sta in
Serum iron + ferriti n
m
se
As
Serum iron + haematocrit
Dr
Transf errin satu ration ~ ferritin
Haematocrit + ferritin
Liver biopsy w ith Perl's st ain
Serum iron + ferritin
Serum iron + haematocrit
Screening for haemoch romatosis

• g eneral popu lation: transferrin saturation > ferritin
• fam ily members: HFE genetic testing
The British Co mmittee fo r Standards in Haemato logy (BCSH) g uidelines recommend

measuring the transferrin sat urat ion f irst as this is the most sp ecific and sensitive test fo r
m
se
iron accumulation. They also recommend that serum ferrit in is measured but t his marker
As
is not usually ab normal in t he ea rly stages o f iron accumu lation
Dr
A 59-yea r-old wo ma n is admitted to the Emergency Department with a productive coug h
and pyrexia. She is usua lly fit and we ll b ut is u nd ergoing investigation fo r dysphag ia . This
has b een present for the past 3 months a nd a ffects both food and d rink. A chest x-ray
shows an ai r-fluid leve l be hind a normal- sized hea rt. What is the most likely dia gnosis?
Massive perica rd ia! effusion
Tuberculosis
Achala sia
Pharyng eal pouch
m
se
As
Hiatus hernia
Dr
A 59-yea r-old wo ma n is admitted to the Emergency Department with a productive coug h
and pyrexia. She is usua lly fit a nd we ll b ut is u nd e rgoing investigatio n for dysphagia. This
has b een prese nt for the past 3 months a nd a ffects b oth food and drink. A chest x-ray
s hows an a ir-fluid leve l behind a normal-s ized hea rt. What is the most like ly d ia gnosis?
Massive p erica rd ia! effus ion
Tuberculosis
Achalasia
Pharyngeal pouch
-
~
Hiatus he rnia
m
se
As
A retroca rdiac a ir-fluid leve l is sometimes seen in patients with a chalasia
Dr
Which one of the following is least associated with hepatosplenomegaly?
Glandular fever
Alcoholic liver disease
Amyloi dos is
m
se
As
Dr
m
Infective endoca rditis norma lly causes an isolated splenomega ly. Theoretica lly severe
se
infective endocarditis may cause right hea rt failure and hence hepatomega ly but this
As
wou ld be unusua l
Dr
A 58-year-old male was a d mitted with a 8 month history of dysphagia, initially worse on
solids, but now encompassing liquids. This is associated with weig ht loss, vom iting and
for the last day o dynophag ia.
Barium swallow shows: Apple core stricture in the proximal third of the oesophagus.
Which of the following risk factors is only associated with increased risk o f
adenocarcinoma of the oesophagus?
Alcohol
Smo king
Acha la sia
Plummer vinson
m
se
As
Barrett's oesophagus
Dr
Alcoho l m
Smoking .
CD
Achalasia GD
Plumi er vinso n .
(D
Barrett's oesophagus CD
Th is 58-yea r-old male has p resented with prog ressive dysp hagia, initia lly wo rse on solids
a nd then later to includ e liq uid s. This in a history should immediately p rom pt thoughts
rega rding malig nancy. Barium swallow revealed a proximal apple core stricture, the
p roxima l nat u re o f which may be suggestive of squamous cell.
Risk factors fo r oesophagea l cancer:
Squamous Adenocarcinoma
Alcohol Alcoho l
Smoking Smoking
Achala sia
Plummer vinson
Barrett's oeso phagus

sem
As
Dr
A 35-year-old man who is usually fit and well presents with a 2 month history of
indigestion. His weight is stable and there is no history of dysphagia. Examination of the
abdomen is unremarkable. Of the following options, what is the most suitable initial
management?
Urea breath testing and non-urgent referral for endoscopy
H pylori eradication therapy and full-dose proton pump inhibitor for three months
Full-dose Proton pump inhibitor and immediate referral for endoscopy
Th ree month cou rse of a standard -dose proton pump inhibitor
m
se
As
One month cou rse of a full-dose proton pump inhibitor
Dr
Urea breath testing and non-urgent referral for endoscopy
H pylori eradication therapy and full-dose prot on pump inhibitor for three
months
Full-dose Proton pump inhibitor and immediate referral for endoscopy
Three month course of a standard -dose proton pump inhibitor
One month course of a full-dose proton pump inhibitor
This question highlight s the NICE guidelines for the management of dyspepsia.
There is no evidence currently to suggest whether a one month cou rse of a PPI or 'test
and treat' strat egy should be adopt ed first line. Many clinicians prefer to t est for H pylori
first as this cannot be done within 2 weeks of acid-suppression therapy, as false- negative
results may occur
m
se
As
Given the options available, only the answer is in line with cu rrent NICE guidelines
Dr
Which of the following skin conditions associat ed with malignancy are not correctly
paired?
Erythroderma and lymphoma
Necrolytic migratory erythema and gastrinoma
Acanthosis nigricans and gastrointestinal ca ncer
Sweet's syndrome and myelodyspl asia
m
se
As
Erythem a gyratum repens and lung cancer
Dr
Erythroderma and lymphoma flD
I Necrolytic migratory erythema and gastrinoma
Acanthosis nigricans and gastrointestinal cancer

CD
GD
I Sweet's syndrome and myelodysplasia
Erythema gyratum repens and lung cancer

GD
m:t
m
se
As
Necrolytic migratory erythema is associated with glucagonomas
Dr
A 54-year-old female is admitted one week following a cholecystectomy with profuse
diarrhoea. What is the most likely diagnosis?
Campylobacter
E. coli
Clostridium dif(icile
Salmonella
m
se
As
Dr
Campylobacter CD
E. coli fD
I Clostridium dif{icile CD
Salmonella CD
Staphylococcus aureus CD
m
se
Clostridium dif{icile is the most li kely cause as the patient wou ld have been given b road-
As
spectru m antibiotics at the time of the operatio n
Dr
Which of the following statements is t rue regarding the genetics of colon cancer?
Hereditary non-polyposis colorecta l ca rcinoma is a autosomal recessive condition
The adenomatous polyposis coli gene is located on ch romosome 12
Around 50% o f patients with fa milial adenomatous polyposis develop co lon cancer
Both hereditary and non-hereditary colon cancers typically present at 60-70 yrs of
age
m
se
Non-inherited colon cancer o ften involves mutation of the adenomatous polyposis
As
coli gene
Dr
Hereditary non-polyposis colorectal ca rcinoma is a autosomal recessive
condition
The adenomat ous polyposis coli gene is located on chromosome 12
Around 50% of patients with familial adenomatous polyposis develop colon

cancer
Both hereditary and non-hereditary colon cancers typically present at 60-70 yrs of m
age
m
se
Non-inherited colon cancer often involves mutation of the adenomatous
As
polyposis coli gene
Dr
A patient with upper gastro intestina l sympto ms tests pos itive fo r Helicobacter pylori
fo llowing a u rea breath test. Which one o f the fo llowing conditions is most stro ng ly
associated Helicobacter pylori infection?
Gastric ad eno ca rcinoma
Gastro -oeso phagea l reflux disease
Oeso phageal ca nce r
Duod e na l ulceratio n
m
se
As
Atrophic g astritis
Dr
Gastric adenoca rc inoma
esophageal cancer
Duodenal ulceration
Atrophic gastritis
m
se
Helicobacter pylori infection is a lso associated with both gastric adenocarcinoma and
As
atrophic gastritis but the strongest association is with duodenal ulceration.
Dr
A 67 -year-old man with ch ron ic hepatitis B presents to the emergency department. He
has been stable for the last 10 years, however, today he has noticed a yellow ing of his skin
and his w ife mentions th at he has been a little confused.
Which of the follow ing may be a cause of this man's decompensation?
High carbohydrate diet
Low protein diet
Diarrhoea
Constipation
m
se
As
High fibre diet
Dr
High carbo hydrate diet fD
Low protein diet CD
Diarrhoea f.!D
Constipatio n GD
High fib re d iet CD
Constipation can be a trig ger for liver decom pensation in cirrhotic patients
This question is asking a bout a man with a cirrhotic liver following chro nic hepatitis. In
this ca se, he is showing signs of liver decompensation (jaundice a nd confus ion). There are
ma ny causes of live r decompensation an d you should make sure to find a ny underlying
cause to ensure it is treated promptly.
From the list above co nstipation is a com mon cause of liver d ecompensation, this is d ue
to the accumulation of toxic products within the bo dy. In fact, some patients with liver
d ecompensation and hepatic ence phalopathy a re treated with enemas to reduce the
uptake of toxic p rod ucts.
m
Other common causes include infection, electrolyte imbalances, dehydration, upper GI se
As
bleed s or increased alcoho l intake.
Dr
Autoimmune hepatitis is most characte ristically associated with e levated leve ls o f which
one of the following immunoglobu lin s?
IgE
IgA
IgD
IgM
m
se
IgG
As
Dr
IgE
IgA
•
f!D
IgD
•
f.D
..
IgM
m
se
IgG
As
Dr
A nurse undergoes primary immunisation against hepat itis B. Levels of which one of the
following shou ld be checked four mont hs later to ensure an adequate response to
immunisation?
Anti-HBs
Anti-HBc
Hepatitis B vira l load
HbeAg
m
se
As
HBsAg
Dr
I Anti-HBs
Anti-HBc
fiD
.
(D
Hepatitis B viral load CD

n b eAg ED
HBsAg CD
m
se
It is preferable to achieve anti -H Bs levels above 100 m!U/ml, although levels of 10 m!U/ ml
As
or more are generally accept ed as enough to protect against infection
Dr
Which one o f the following statements is incorrect rega rding Dubin-Johnson syndrome?
Runs a benign cou rse
Due to a defect in the canillicu lar multispecific o rg anic anion transporter
Causes defective hepatic bilirubin excretion
It is an autosomal recessive di sord er
m
se
As
Resu lts in an unconjugated hyperb ilirubinaemia
Dr
Ru ns a benign cou rse CD
Due to defect in th e canillicular multispecific org anic anion transporter f!D
Causes defective hepati c bilirubin excretion GD
It is an autosomal recessive di sord er f!D
I
m
se
Results in an unconjugated hyperbilirubinaemia ED
As
Dr
Each one of the following is associated with pancreatic cancer, except:
Chronic pancreatitis
Smoking
Blood group 0
Diabetes
m
se
As
BRCA2 gene
Dr
•
Smoking
Blood group 0
•.,
Diabetes GD
m
se
As
BRCA2 gene fD
Dr
A 42-yea r-old woman is investigated for lethargy and d ia rrhoea. Investigations revea l
pos itive anti-endomys ia! antibo d ies. Each of the fo llowing food stuffs should b e avoided,
except:
Beer
Rye
Maize
Brea d
m
se
As
Pasta
Dr
Beer GD
Rye .
GD
Maize eD
Bread .
(D
m
se
.
As
Pasta (D
Dr
Which one o f t he followin g factors is most responsible for t he increased rate of colorectal
cancer in patients with ulcerative co lit is?
Shared mutation in the HNPCC g ene
Chronic inflammat ion
Increased surveillance w ith colonosco py
Increased suscept ibility to bacterial gastroenteritis
m
se
As
Prolonged immunosup p ression
Dr
Sha red mutation in the HNPCC g ene
I Chronic infla mmation
Increased su rve illa nce with colonosco py
InL ed susceptibility to bacterial gastroenteritis
Prolonged immunosu ppression
m
se
Chronic infla mmation is a n impo rta nt facto r in the deve lopment o f a number of ca ncers.
As
An exa mple is hepatocellula r carcino ma secondary to viral hepatitis.
Dr
Primary sclerosing cho langitis is most associated with:
Primary b iliary cirrhosis
Crohn's disease
Ulcerative colitis
m
se
Coeliac disease
As
Dr
Pri mary biliary cirrhosis
Crohn's disease
-
"""'
Ulcerative colitis
m
se
As
Coeliac disease
Dr
A 45-yea r-old man known to have haemochromatosis attends for blood test to assess
when he next needs venesection. Of the options given, which one o f the following bl ood
tests should be used to assess the adequacy o f venesection?
Ferritin
Serum iron
Haemoglobin
Total iron bind ing capacity
m
se
As
Haematocrit
Dr
Ferritin
Serum iron
Haemoglo bin
Total iron biT ing ca pacity
Haematocrit
-
~
m
se
The British Co mmittee for Standards in Haematology reco mmend 'transferrin saturation
As
should be kept below 50% and the serum ferritin concentration below 50 ug/ 1'
Dr
Which one o f t he followin g featu res is not seen in ca rcinoid syndrome?
Fl ushing
Diarrhoea
Bronchospasm
Hypertension
m
se
As
Pellagra
Dr
Flus hing CD
Diarrhoea CD
Bronchospasm GD
I Hypertension CID
Pellagra ED
Flush ing, diarrhoea, bronchospas m, tricuspid stenosis, pe llagra -ca rcino id with
live r mets - diagnosis: urina ry 5-HIAA
m
se
As
Hypo- not hype rtension is seen in carcino id syndrome seconda ry to serotonin re lease
Dr
A 39-yea r-old man is admitted to hospital with decompensated liver disease of unknown
aetiology. As pa rt of a liver screen the following results are obtained:
Anti-HBs Positiv e
Anti-HBc Negative
HBs antigen Negative
Anti-H Bs = Hepatitis B Surface Antibody; Anti-H Bc = Hepatitis B Core Antibody; HBs antigen = Hepatitis B
Surface Antigen
What is this man's hepatitis B status?
Chronic hepatitis B - hig hly infectious
Previous immunisation to hepatitis B
Probable hepatitis D infection
Acute hepatitis B infection
m
se
As
Chronic hepatitis B - not infectious
Dr
Chronic hepatitis B - highly inf ectious
Probable hepatitis D infection
Acut e hepatitis B infection
m
se
As
Dr
A 17-year-o ld fe ma le presents with a two-day history of rig ht iliac fossa pain, nausea and
loss of appetite. You suspect that s he has acute append icitis. Which scoring system, if
sufficiently ra ised, cou ld you use to lend su pport to your diagnos is?
Child - Pugh score
Glasgow score
Alva rado score
MELD score
m
se
As
Centor sco re
Dr
Child -Pugh score CD
Glasg ow score €D
I Alva rado sco re GD

MELD score C!D
Centor sco re CD
The Alvarado score can be used to suggest the likelihood that a patient has acute
append icitis
The correct a nswer is the Alva rado score. It consists of e ight diffe rent criteria (sympto ms,
signs and labo ratory resu lts) and divides patients into ap pend icitis un like ly, poss ible,
p ro bable and d efinite.
The Child -Pugh score assesses pro g nos is in live r cirrhosis. The Glasgow score assesses
seve rity of acute pancreatitis. The MELD score assesses the severity of end -stage liver
disease. The Cento r a ssesses the likelihood that a pharyngitis is d ue to Stre ptococcus.
m
se
MD -CALC Alva rad o score
As
https:/ jwww .m dca lc.com/a Iva ra do -sco re -a cute -append icitis
Dr
A 62-year-old man w ith a history of alcohol abuse undergoes an esopha go-
gastroduodenoscopy (OGD) following several episodes of unexplained epigastric pain.
Several varices are identified i n the low er oesophagus. It is decided that he is put on a
prophylactic medication t o reduce the risk of variceal bleeding.
Which o f the follow ing medications would be most appropriate?
Omeprazole
Warfarin
Unfraction ated heparin
Propranolol
m
se
As
Vasopressin
Dr
Omeprazole fD
~Warfarin
Unfraction ated hepa rin
-
D
I Propra no lol CD
Vasop ressin CD
A non -card ioselective B- blo cker (NSB B) is used for the pro phylaxis of oesophageal
b leeding
This q uestion re qu ires you to u ndersta nd the measures taken to reduce the risk of maj or
bleeding in patients with oeso phageal va rices.
Ome prazole - This is not the most a p propriate answer. Omeprazole is used in the
p revention and treatment of p eptic ulce rs.
Warfarin -This is not the most ap propriate answe r. Wa rfarin wo uld increase the risk o f
bleeding .
Unfractionated hepa rin - Th is is not the most ap propriate a nswe r. Unfractionated hepa rin
wou ld increase the risk of bleed ing.
Proprano lo l - This is the correct answe r. A non -ca rdioselective ~ blocker (NSBB) is used
fo r p rimary and seco nd ary p revention of b leed ing in oesophageal varices. They act by
caus ing splanch nic vasoconstriction, reducing portal blood flow.
Vasop ressin- This is not the most a ppro priate answe r. The synthetic a nalogue of this
em
med icatio n, terl ipress in, may be used to red uce acute va riceal bleeding but not as a
s
As
p ro p hylactic agent.
Dr
A 21-year-old lady is admitted to hospital from her GP with her mother due to extremely
low body mass index (BMI). Her GP notes explain that she has a history of anorexia
nervosa. Her mother explains that she hasn't been eating well for the last cou ple of
months and on examination the patient has a BMI of 14.0kg/m 2 and looks unwell. You are
aware that some patients, such as those with eating disorders, are at risk of refeeding
syndrome.
Given th is patient's hist ory, wh ich of the following electrolyte imbalances wou ld su ggest
that she is at risk of refeeding syndrome?
Hypermagnesaemia
Hypophosphataemia
Hyperkalaemia
Hyperphosphataemia
m
se
Thiamine overload
As
Dr
Hypermagnesaemia m
Hypo phos phataemia (D
Hyperka laemia m
Hyperphosphataemia fD
Th ia mine overload fD
Hypophos phataemia is a cha racteristic biochemical sig n in patie nts at risk o f

refeed ing syndrome
Option 2 - hypophosphataemia is the correct option. This is a commonly recognised

bioche mica l sign of refeeding syndrome.
In anorexia nervosa, the patient has inadequate dietary intake and may make use of othe r
methods to lose weig ht. With poor inta ke and increased clearance, these patients can
quickly become e lectro lyte deficient, therefore:
Option 1 is incorrect as refeeding syndrome is associated with hypoma gnesaem ia.
Option 3 is incorrect as refeeding syndrome is associated with hypoka laemia.
Option 4 is incorrect as refeeding syndrome is associated with hypophos phataem ia.

s em
Option 5 is incorrect as refeeding syndrome is associated with thiamine deficiency

As
Dr
I,
A 23-year-old woman is referred to the neurology clinic after developing a unilat eral hand
tremor. Over the past 12 months her family report changes in her behaviour and mood
associated with some speech problems. On examination a tremor is not ed in the right-
hand at rest. There also appears t o be paucity of movement and some bradykinesia. Dark
circular marks are also noted around the iris. The patient reports that her uncle died of
liver cirrhosis at the age of 40 yea rs. Given the likely diagnosis, what is the mode of
inheritance?
Autosomal dominant
Mitochondrial
X-li nked recessive
Autosomal recessive
m
se
As
Polygenic
Dr
Autosomal do"/inant GD
Mitochondrial m
X- li nked recessive CD
I Autosomal recessive (D
Polygen ic CD
Wilson 's disease - autosoma l recessive

m
se
As
This patient has Wilson's d isease as evide nce by the neuropsych iatric symptoms, Kayser-
Fle ischer rings a nd fam ily history of liver disease.
Dr
Which one o f the followin g is not a feature o f Peutz-Jeghers syndrome?
Intestinal obstruction
Pigmented lesions on pa lms
More than 10-fold increased risk of gast rointestinal malignancy
Osteomas
m
se
As
Iron -def iciency anaemia
Dr
Which one o f the following is not a feature o f Peutz-Jeghers syndrome?
Intestina l obstruction
r :gmented lesions on pa lms

-
~
I
More than 10-fold increased risk of gastrointestinal malignancy
Osteomas
-
~
Iron-deficiency anaemia
m
se
Osteoma s are a feature of Gardner's syndrome, a variant o f fam ilial adenomatous
As
polyposis
Dr
What percent age of cases of chronic pancreatit is in the UK are due t o alcohol excess?
35%
50%
65%
80%
m
se
As
95%
Dr
35% GD
50% GD
65% fD
I so% CD
95% f.D
m
se
The most com mon cause of chron ic pancreatit is is alcohol excess
As
Dr
A 27 -year-old female presents with alt ernatin g loose and hard stools associated with
abdominal discomfort and bloating. Which one of the following is it most importa nt to do
before making a positive diagnosis of irritable bowel syndrome?
Arra nge ultrasound abd omen
Flexible sigmoidoscopy
Ask about fa mily hist ory of ovarian cancer
Use a st andardi sed screening t ool for depression
m
se
Perform thyroid function t est s
As
Dr
Arrange ultrasound abdomen
Flexible sigmoidoscopy
~ about family hist ory of ovarian cancer

Use a st andardi sed screening tool for depression
m
se
As
Perform thyroid function tests
Dr
A 24-yea r-old ma n p resents with rectal bleed in g an d pain on defecation. This has been
present fo r the past two weeks. He has a tendency towards constipatio n and notices that
when he wipes himself fresh blood is often on the paper. Recta l examination is limited
due to pa in but no externa l ab normalities a re seen. What is the most li kely diag nosis?
Internal haemorrhoids
Anal carcinoma
Recta l polyp
Anogenital he rp es
m
se
As
Anal fissure
Dr
Interna l haemorrhoids f!D.
Anal carcinoma m
~ectal polyp fD
Anogenital herpes m
I Anal fissure GD
m
se
As
Su perficial ana l fissu res may be difficult to see on examination.
Dr
Which one o f t he followin g is least usef ul in assessing the severity of a patient with liver
cirrhosis?
ALT
Prothrom bin t ime
Bilirubin
The presence of ascites
m
se
As
The presence of encephalopathy
Dr
ALT
Protl om bin time
Bilirubin
-
~
The presence of ascites
m
se
The presence of encepha lopathy
As
Dr
A 27 -yea r-old female is referred to the medica l outpatient clinic due to a long history of
fatigue and joint pains. An autoimmune screen is d one which is positive fo r smooth
muscle antibo dies. What is the most ap prop riate next investigation?
Live r function tests
Thyroi d function tests
Creatine ki nase
Serum g lu cose
m
se
As
Electro ca rd io gram
Dr
Liver function tests GD
Thyroit nction tests f!D
Creatine kinase CD
Serum g lucose CD
Electroca rd iogram m
m
se
Smooth muscle antibodies are associated with auto immune hepatitis. Presentation is
As
usually insidious and extrahepatic cl inical featu res are common
Dr
A 43-yea r-old ma n p rese nts with d ia rrhoea and rectal bleeding fo r the past ten days . On
exam ination he has b rown p igmented lesions on his lips and palms but abdominal and
rectal exam ination is unremarka ble. What is the most li kely cause fo r this presenta tion?
Intussusception
Ang iodysplasia
Meckel's Diverticulum
Colon cancer
m
se
As
Diverticu lar abscess
Dr
Intussusception GD
Ang iodysp lasia ED
Meckel's Diverticulum GD
r Colon cancer
I tiD
Diverticular a bscess CD
This patient has Peutz-Jeghers syndrome. Intussusception would not normally cause rectal
m
se
b leeding at this age. Co lon cancer is the most common type of gastrointestinal cancer
As
that patients with Peutz-Jeghers syndrome develop.
Dr
A 36-yea r-old ma n p resents with dyspepsia. No a la rm symptoms a re present. This is his
first ep isod e a nd he has no s ignificant medical history of note. A test-and -treat strategy is
ag reed upon. What is th e most a ppro p riate investigatio n to test fo r Helicobacter pylori?
Ga stric b io psy
CLO test (rapid urease test)
Sto o l cultu re
Hydrogen brea th test
m
se
As
13C-u rea b reath test
Dr
r r astric biopsy fD
CLO test (rapid urease test) flD
Stool cultu re
Hydrogen brea th test

•
fD
I 13C-urea breath test fD
m
se
The urea breath test is highly sensitive, specific and non-invasive. There is no indication
As
for an endoscopy. Stool antigen, rather tha n cultu re, is an alternative.
Dr
You are called urgently ah er hours to review a 69 -year-old man on the ca rdiology ward
who is hypotensive, tachyca rdic and having profuse melaena. He was commenced on
dabigatran lSOmg bd by the cardiologists 48 hours earlier for non-valvular atrial
fibrillation. Following appropriat e resuscitation which of the following treatments is most
likely t o improve his bleeding?
Prothrom bin complex
Tranexamic acid
Haemodialysis
72 hour omeprazole infusion
m
se
As
Idarucizumab (Praxbind)
Dr
Prothrom b in complex
Tranexa mic acid
n aemodialysis
72 hour omeprazole infusion
I ldarucizumab (Praxbin d)
lda rucizumab is a recently developed monoclonal antibody fragment which b inds

d a bigatran with an a ffinity that is 350 times as high as with throm bin. Consequently,
ida rucizu ma b b inds free and thrombin -bound dabigatran and rapid ly neutralises its
activity. Prior to its d eve lo pment management of bleeding on d a bigatran was limited to
dia lysis or sup portive treatment with blood p roducts, which was only partially effective.
PPl infusions have on ly ever been shown to be effective in acute uppe r Gl bleeding post
endoscopy in patients with stigmata of recent haemorrhage. Cu rrently, dabigatran is the
only d irect acting o ral anticoagu lant to have a commercially ava ilab le antidote, although
o thers are in d evelo pment.
It should be noted that despite rap id reve rsa l, idarucizumab is not a 'mag ic bullet' for
patients with dabigitran induced bleeding and resuscitation remains the cornerstone of
management. Rap id reve rsal of warfari n with p rothrombin comp lex or fresh frozen plasma
has b een ava ila ble for many yea rs; howeve r, this has never been linked to improved
outcomes. It shou ld also be remembered that id arucizu mab is very expensive and is m
se
therefore like ly to be restricted to those patients with immediate and life threaten ing
As
bleed s.
Dr
A 46-yea r-old wo man with 10 year histo ry of Crohn's disease presents fo r review in the
g astroenterolo gy cl inic. She complains of persistent d iarrhoea despite b eing o n
maintenance thera py a nd having norma l inflam matory markers. A diagnosis of b ile aci d
malabso rption is be ing consid ered. What is the most appro priate test to investigate this?
Capsule endoscopy
SeHCAT test
14C-glycocholic brea th test
Ileal bio psy
m
se
As
D-xylose test
Dr
Capsule endoscopy
SeHCAT test
14C-glycocholic breath test
Ilea l biopsy
D-xylose test
m
se
SeHCAT is the investigation of choice for bile acid malabsorption
As
Dr
A 27 -yea r-old woman with chronic leh iliac fossa pain and alternating bowel habit is
diagnosed with irritab le bowel syndrome. Initia l treatment is tried with a combinati on of
antispasmodics, laxatives and anti-motility a gents. Unfortunately aher 6 months there has
been no significant improvement in her symptoms. According to rece nt NIC E guidelines,
what is the most appropriate next step?
Low-dose tricyclic antid epressant
Cog nitive b ehavioura l therapy
Refer fo r sigmoidoscopy
Trial of p robiotics
m
se
As
Selective serotonin reuptake inhibitor
Dr
I Low-dose tricyclic antidepressant
Cognitive b ehavioural therapy
Refer {or sigmoidoscopy

Trial of probiotics
Selective serotonin reupta ke inhibitor
m
se
NICE recommend considering psycho logical interventions after 12 months. Tricyclic
As
antidepressants should be used in preference to selective serotonin reuptake inhibitors
Dr
What a re the most common type of antibodies seen in pern icious anaem ia?
Vita min B12 re ceptor antibodies
Gastric pa rieta l ce ll antibo dies
Jejunal mucosa a ntibod ies
Intrinsic factor antibodies
m
se
As
Vita min B12 antibodi es
Dr
Vitamin B12 receptor antibodies CD
Gastric parietal cell antibodies ED
Jejunal mucosa antibodies fiD
Intrinsic factor antibod ies CID
m
se
As
Vitamin B12 antibodi es fiD
Dr
A 55-yea r-old ma n with a history o f gallstone disease p resents with a two-day history of
pa in in the right upper q uadrant. He feels 'li ke I have flu' and his wife reports he has had a
fever fo r the past d ay. On exa mination his te mpe rature is 38.1°C, b lood p ressure 100/60
mmHg, pu lse 102/min and he is tender in the right upper quadrant. His sclera have a
yellow-tinge. What is the most likely diagnosis?
Pancreatic cancer
Biliary colic
Ascending cholangitis
Acute cholecystitis
m
se
As
Acute viral hepatitis
Dr
Pancreati c cancer
Bi ia ry colic
Ascending cholangitis
Acute cholecystitis

-
....,
This patient has Charco t's triad (right upp er quadra nt pain, fever a nd jaundice), which is
m
se
classically linked to ascending cholang itis. The system ic upset and jaundice are Jess typica l
As
o f a cute cholecystitis.
Dr
A 44-yea r-old obese female is noted to have g a llstones du ring an a bdomi nal ultrasound,
which was re quested due to re peated urina ry tract infections. Apart from the repeated
UTis she is otherwise well. What is the most app ropriate management of the gallstones?
Ursod eoxycho lic acid
Extracorpo real Short Wave Lithotripsy
List for laparoscop ic cholecystectomy when 50 yea rs old
Observatio n
m
se
List now fo r laparoscopic cho lecystectomy
As
Dr
Ursod eoxycholic acid
Extracorpo rea l Short Wave Lithotripsy
List for lapa rosco pic cholecystectomy when 50 yea rs o ld
Observation
m
se
As
List now for laparoscopic cho lecystectomy
Dr
You are the F2 doctor starting a twilight shift on the acute medica l unit. A 50-yea r-o ld
man with known a lcoholic cirrhosis presented that morning to ambu latory ca re fo r an
elective ascitic drain. On clerking he described feeli ng g enerally unwell over the last 2
d ays with fevers and non-specific abdom inal pain. There was no histo ry of cough,
s hortness of b reath or dysu ria and no other loca lising infective symptoms. His
tem perature was 38.1°C, heart rate 130bpm but observations were o th erwise normal. He
was visibly jaundiced o n e nd -of-the- bed inspectio n. On exam ination the abdomen was
genera lly tende r, distended with sh ifting dullness and sca rs from p revious ascitic drains in
the right iliac fossa. Bowels sounds were p resent a nd normal.
ECG showed sinus tachyca rdia.
Bloods:
Hb 115 g/ 1 Na• 129 mmolfl Bilirubin 40 ~m ol/1
Plat elet s 230 * 109/ 1 K• 4 .8 mmol/1 ALP 280 u/1
WBC 17.0 * 109/ 1 Urea 8.0 mmol/ 1 ALT 65 u/1
Neuts 14.5 * 109/ 1 Creatinine 156 ~mol/1 yGT 560 u/1
Lymphs 2.0 * 109/ 1 Albumin 29 g/ 1
CRP 130 mg/ 1
Chest X- ray shows no acute abnorma lity.
The patient was adm itted and has been started on IV no rmal saline and broad-spectrum
antibiotics. Blood cultures have been sent. Du ring the evening han dover, the consultant
requests that as the even ing on-call you investigate for spontaneous bacteria l peritonitis
(SBP) and start IV cefotaxime if SBP is confirmed.
Which of the following would confirm a d iagnosis of spontaneous bacterial periton itis
(SBP)?
Blood cultures showing mixed g rowth.
Paracentesis. Glucose > 2.8 mmoi/L in ascitic fluid
Paracentesis. Neutrophi l count >250 cells/I-l l in ascitic fluid
Paracentesis. Organisms seen on Gram-stain o f ascitic flu id

em
s
Paracentesis. Neutrophi l count > 100 cells/I-l l in ascitic fluid

As
Dr
Blood cultu res showing mixed growth.
Paracentesis. Glucose >2.8 mmoi/L in ascit ic fluid
Para cent esis. Neutrophil count > 250 cells/J.J L in ascitic fluid
Paracentesis. Organisms seen on Gram-stain o f ascit ic flu id
Paracentesis. Neutrophil count > 100 cells/J.J L in ascitic fluid
In susp ected SBP- diagnos is is by paracentesis. Confirmed by neutro phil cou nt > 250
cells/ u l
Diagnosis o f spontaneous bacterial periton it is (SBP) is by paracentesis wit h a neutrophil

cou nt >250 cells/J,J L in the ascitic fluid.
1. Incorrect. Blood cu ltures are positive for the offending organism in SBP in up to l/3 of
patients and can help guide antibiotic regime. However, by the same token, b lood
cultu res will be negat ive in more tha n 2/ 3 o f cases of SBP. All patients w ith suspected SBP
should have b lood cu ltures done but they do not form part of the diagnostic criteria.
2. Incorrect. Glucose levels in the ascitic f luid do not form part of diagnostic criteria for
SBP. Neutrophils in the ascitic fluid actually consume glucose and so the concentrat ion is
oh en low ( <2.8 mmoi/L)
3. Correct. SBP is co nfirmed by a paracentesis showing a neut rophil count > 250 cell s/ J,Jl.
Based on this result a diagnosis can be made and the antibiotic of choice wou ld be IV
cefotaxime (as advised by your consu ltant).
4. Incorrect. Though Gram -stain of t he ascitic fluid will ohen show orga nisms in SBP it is
not reliable as a diagnostic test.
em
5. Incorrect. The neut rophil count is the key measure but t he threshold for diagnosis of
s
SBP is > 250 cell s/ J,J L not 100.

As
Dr
I . I __ I _ -· ... I
A 31-yea r-old woman is admitted to hos pital. As part of a liver screen the following
results are obtained:
Anti-HBs Positiv e
Anti-HBc Positiv e
HBs antigen Negative
Anti-H Bs = Hepatitis B Surface Antibody; Anti-HBc = Hepatitis B Core Antibody; HBs antigen = Hepatitis B
Surface Antigen
What is the patient's hepatitis Bstatus?
Chronic hepatitis B - highly infectious
Previous he patitis B infection, not a carrier
m
se
As
Dr
Chronic hepatitis B - highly inf ectious
Previous hepatitis B infectio n, not a carrier

-
~
m
se
As
Dr
A 65-year-old woman is referred in from her GP with d e ranged blood tests. She initially
went to see the GP due to pa in in her tongue and pa in on swa llowing . On exam ination,
she has angu la r stomatitis, a red s mooth tongue and spleno megaly.
Blood tests show:
Hb 102 g/ L
wee 10.9 10*9/ L
pit s 2 23 10*9/ L
MeV 72 fl
Kawasaki d isease
Plummer-Vinson syndrome
Vita min B12 deficiency
Behcets syndrome
m
se
As
Oesophageal malignancy Dr
Kawasaki disease f.D
I Plummer-Vinson syndrome CD
Vitamin 812 deficiency CD
Behcets syndrome CD
m
se
Oesophageal malignancy CD
As
Dr
You are reviewing a 45-year-old woman who has a history of coeliac disease in the
gastroenterology clin ic. Your consu ltant asks you to check that she is up-to-date with her
immunisations. She is otherwise fit and well and her coeliac disease is well controlled.
Why do patients w ith coeliac disease require regular immunisations?
Reduced absorption of prot eins leads to hypogammaglobulinaemia
Fun ctional hyposplenism
Reduced absorption of iron, vitam in 812 and folate impairs normal immunologica l
function
Higher incidence of T-cell dysfunction in patients with coeliac disease
m
se
Up to 15% of patients with coel iac disease have mild primary immunodeficiencies
As
Dr
Reduced absorption of proteins leads to hypogammaglobulinaemia
I Fundional hyposplenism
Reduced absorption of iron. vitamin Bl2 and folate impairs normal

immunological function
Higher incidence ofT -cell dysfundion in patients with coeliac disease
m
se
Up to 15% of patients with coeliac disease have mild primary
As
immunodeficiencies
Dr
A 29-yea r-o ld female is noted to have an elevated b ilirubin du ring a viral illn ess. Gilbert's
syndrome is suspected. Which one of the following tests may confirm the diagnosis?
Bromsu lp htha le in excretio n test
Ammonium ch lo ride acidificatio n test
Urine a nalysis
Nicoti nic acid test
m
se
As
Faecal fat excretion
Dr
Bromsulphthalein excretion test
Ammonium ch loride acidification t est
Urine analysis
Nicotinic acid test
m
se
As
Faecal fat excretion
Dr
A known alcoholic presents to the emergency department w ith severe epig astric pain
radiating to the back and a serum amylase of 1653U/L. Accord ing to either the Glasgow
o r Ranson scoring systems, w hich of the following indicate severe pancreatitis?
Hypercalcaemia
Serum amylase f ive t imes t he upper limit of normal
Ra ised serum lipase
Hypocalcaemia
m
se
As
Ra ised (-reactive p rotein
Dr
Hypercalcaemia
Serum amylase f ive times the upper limit of normal
Ra ised serum lipase
Hypoca lcaemia
Raised (- reactive p rotein
Hypoca lcaemia in pancreatitis is a marker of disea se severity

Hypocalcaemia occu rs in pancreatitis d ue to the sapon ification of fats. As lipase leaks out
o f the d a maged pancreas, it b reakd own fat into trig lycerid es and fatty acids. Fatty acid s
combine with calcium to p roduce soap. Therefo re, reduced serum calcium can be used as
a surrogate ma rke r for the leve l of enzymatic damage in pancreatitis.
Ra ised serum lipase and amylase a re useful in diagnosis but do not feature in the
Glasgow o r Ranson scores.
m
se
Ra ised white cell count rather than ( -reactive peptide feature in the Glasgow/Ranson
As
criteria.
Dr
You are a sked to see an 18-year-ol d woma n on the wa rd who has just commenced re-
feeding for anorexia nervosa under a court order. Her baseline body mass index is 17
kg/m 2 . She has developed acute shortness o f breath and muscle weakness a few hours
a fter beginning the feed .On examination her blood pressure is 100/70 mmHg, her pulse is
88 beats per minute and regular. She has b ilateral basa l crackles on auscultation of the
chest and 4/5 power weakness affecting her arms and legs. Which of the following is the
most likely cause?
Hyperkalaemia
Hypochloraemia
Hypocalcaemia
Hypomagnesaemia
m
se
As
Hypophosphataemia
Dr
Hyperka laem ia m
I Hypochloraemia CD
Hypocalcaemia «ED
Hypomagnesaem ia fD
I Hypophosp hataemia ED
Although refeeding syndrome is most li kely to be seen in patients with a body mass ind ex
of less than 16 kg/m 2, it is still the most like ly diagnosis here. Hig h ca rbohydrate feeds
can lead to a precipitous fa ll in phosphate levels because o f reactive hyperinsu li naem ia,
and this, in turn, leads to heart failure and sig nificant skeleta l muscle weakness.
m
Low levels of potassium and magnesium may a lso be seen in re -feeding syndrome, but
se
As
these do not have the same association with ma rked muscle weakness.
Dr
A 49-yea r-old woman who is known to have alcoho lic liver disease is adm itted to the
ward following a decompensation. A diag nosis o f g rade II hepatic encephalopathy is
ma de. She is co nfused a nd a screen looking for infection and other precipitants is
performed . She is started on lactulose. What other medicati on may be used to p revent
the hepatic encephalopathy if lactulose is ineffective?
Neomycin
Senna
Rifaximin
Ciprofloxacin
m
se
As
Hig h-dose vitamin C
Dr
Neomycin GD
Senna tiD
Rifaximin 6D
Ciprofloxacin f.D
High-dose vit amin C
•
m
Lactulose and rifaxim in are used for the secondary prophylaxis of hepatic
se
encephalopathy
As
Dr
A 58-year-old fema le was admitted for bowel obstruction, treated with bowel and bed
rest. She is heterozygous for factor V leiden. While in hospital she has a ca rdiac arrest but
is resuscitated after 2 cycles o f chest compressions and 1 s hock. She reports no pa in on
abdominal pa lpation. Her current med ications include pantoprazole 40mg daily,
pa racetamollg QID, morphine 3.Smg S/C PRN & perindopril Smg day.
Hb 130 g/1
Plat elet s 140 * 109/1
WBC 6 .7 * 109/ 1
Na• 135 mmol/ 1
K• 3.4 mmol/1
Creatinine 114 I,Jmol/ 1
Bilirubin 27 IJmOI/1
ALP 150 u/1
ALT 3280 u/1
AST 3400 u/1
yGT 180 u/1
APTT 33 sec
INR 1.7
USS Abdomen Unrem arkable
What is the likely cause of her abno rmal b lood tests?
Paracetamol toxicity
Alcoholic hepatitis
lschaemic hepatiti s
Budd -Chiari syndrome

sem
As
Autoimmu ne hepatitis
Dr
Paracetamol toxicity .
(D
Alcoholic hepatitis
lschaemic hepatitis
•
fiD
Budd-Ci ari syndrome flD
Autoimmune hepatitis m
Autoimmune liver disease and alcoholic liver diseases present with ASTor ALT levels
m
below 1000. A Budd-Chiari syndrome wou ld be visuali sed on the ultrasound of the
se
abdomen. And while paracetamol toxicity can present with similarly elevated liver function
As
t est s, the re needs to be a hist ory of ingestion to make it plausible in this scenario.
Dr
A 26-year-o ld man with a history o f speech a nd behavioural p ro blems p resents with
letha rgy. On examination he is noted to have jaundiced sclera. What is the most likely
diagn osis?
Wiskott-Aid rich syndrome
Haemoch romatosis
Friedreich's ataxia
Wilson's disease
m
se
As
Acute intermittent po rphyria
Dr
Haemochromatosis
Fried reich's ataxia
~son's disease
Acute intermittent porp hyria
m
se
A co mbination of liver and neurologica l disease point s towards Wilson's disease
As
Dr
A 49-yea r-old male was seen in general practice with a 2 month history of lethargy,
polyuria and polydipsia. He had recently been investigated for erectile dysfunction. The
patient is abstinent from alcohol, a non smoker an d works as an insurance broker.
Examination findi ngs showed a slender tanned man with a raised JVP. Hea rt sounds were
norma l, but his apex was at the 4th intercostal space mid axillary line. Examination of his
abdomen revealed only a 4cm liver edge with pitting oedema to the knees bilaterally.
Which of the following deficiencies is maybe associated with his disease?
HFE
ATP7B
JAK-STAT
Glucuronyl transferase
m
se
As
Alpha-1 anti-trypsi n
Dr
HFE GD
ATP7B .
(D
JAK-STAT m
Glucuronyl transferase m
Alpha-1 anti-trypsin GD
This 49 -year-old male has p resented with symptoms of diabetes mellitus, a tan, and
erectil e dysfunctio n. This including signs of heart fai lu re and liver disease on exam ination
should trigger the potential dia gnosis of haemochromatosis.
ATP7B is the dysfunctional protein associated with Wilson's d isease.
JAK-STAT is the mutation associated with primary polycythaemia ruba vera.
Glucuronyl transferase deficiency causes Gilbert's disease.
Alpha-antitrypsin deficiency is a p rotease that is associated with ea rly onset emphysema

and liver cirrhosis.
Iron a bsorption is regu lated in the duodenal crypts. HFE is a p rotein that regu lates iron
abso rption, it forms a complex at the basolateral membra ne that if bound to transferrin +
iron at the ba solatera l membrane of the duod ena l crypt cells p revents matu ration and
consequently absorption o f iron in the bowel. The most commo n fo rm of hered itary
haemochromatosis is associated with a mutatio n in th e HFE gene, leading to failure of
em
complex formation and co nstant maturatio n of duodena l crypt cells and subsequent
s
unregu lated uptake o f iron.

As
Dr
A 56-year-old Asian male is being consented for an endoscopic retrograde
cholangiopancreatography (ERCP). He is very anxious about the procedure and requests
for more information about the common complications o f ERCP. He is concerned about
peritonitis, which usually occurs secondary to a perforation of the bowel - a rare
complication of ERCP. You reassu re him that perforation of the bowel, although a very
serious complication, is uncommon. However, they are other more commo n
complications of ERCP that he should be aware of.
Which one o f the followi ng is the most common complication of ERCP?
Significant bleeding
Cholangitis
Infection
Acute pancreatitis
m
se
As
Intolerance to sedation
Dr
Acute pancreatit is is t he most co mmon com plication of ERCP
Acute pancreatitis due to irritati on of the pancreatic duct by the X-ray co ntrast material or
cannu la is the most common complication of ERCP.
m
se
Although all the other options can be regard ed as complications of ERCP, t hey are not as
As
commo n as acute pancreatitis.
Dr
A 65 -year-old man with a history o f dyspepsia is found to have a gastric MALT lymphoma
on biopsy. What t reatment shou ld be offered?
Gastrectomy
Laser ablation
None
CHOP chemotherapy
m
se
As
H. pylori eradication
Dr
Gastrectomy .
(D
None
•
CD
CHOP chemotherapy fD
I H. pylori eradication flD
m
se
Gastric MALT lymphoma - eradicate H. pylori
As
Dr
A 40-year-old man is investigated for abnormal liver function tests. It is decided t o
perform a liver bi opsy. Which one of the following is a contraindication to liver biopsy?
AlT of 2,212 iu/ 1
Aspirin therapy
Platelet count of 100 * 109/I
m
se
As
Extrahepatic biliary obstruction
Dr
A 40-year-old man is investigated fo r abnormal liver function tests. It is decided to
perform a liver biopsy. Which one o f the following is a contraindication to liver biopsy?
ALT of 2,212 iu/1

L
Aspirin therapy
9
Platelet count of 100 * 10 /I
Extrahepatic biliary obstruction
m
se
With modern t echniques such as ERCP an d MRI cholangiography the risks of liver biopsy
As
when there is extra-h epatic biliary obstruction are rarely j ustified.
Dr
A 48-year-old wo man is admitted to the ward with jaundice of unknown cause. She
noticed it in the mirro r that morning. Some of her i nvestigations are shown below:
Hb 117 g/ dl
wee 9.0 X 109/ 1
Total bi lirubin 124 umoi/ L
LDH 75 U/l ( 100-250 U/l)
Haptoglobin 45 mg/ dl (30-200 mg/dl)
ALP 324 umoi/ L
AST 26 iu/1
Exa mination of the abdomen reveals a palpable mass in the right upper quadrant and she
has yellow discoloration of the sclera and skin. There are no other positive findings. Urine
dipstick analysis shows high levels of conju gated bilirubin in the uri ne.
Biliary colic
Haemolyti c an aemia
Cholangiocarcinoma
Gilbert's syndrome m
se
As
Ascen ding cholangitis

Dr
Bilia ry colic f.D
Haemolytic anaemia m
I Cholangiocarcinoma GD
Gilbert's syndrom e GD
Ascen ding chola ngitis .
(D
Courvoisier's sign - a pa lpable gallbladder in the presence of pa inless jaundice is

unlikely to be gallstones
This woman has presented with painless jaundice with an obstructive p icture on her b lood
test resu lts. To answe r this question, you need to know Courvoisier's s ign- a palpa ble
g allblad der in the presence o f pa inless jau nd ice is unlikely to be gallstones.
Bilia ry colic- This is not the most a ppropriate answer. Although this patient has a n
obstructive pi cture on her b lood test results, b ilia ry colic is, by definition, painful. A
patient with b il ia ry colic would not present in this way.
Haemolyti c anaemia - This is not the most approp riate answer. Haemolytic anaemia ca n
present with jaundice; however, the bl ood tests results wou ld be diffe rent to this patient -
hapto globin wou ld b e reduced and LD H s ignificantly raised .
Cholangioca rcinoma -This is the correct answer. Cholangiocarcinoma is a cancer of d uctal

cells in the b iliary tree. This can be painless and obstruct the bile ducts, causing jaundice
with an obstructive picture (raised ALP, conjugated biliru bi n in the urine).
Gilbert's syndrom e -This is not the most a ppro p riate a nswer. Gi lbert's syndrome is
generally a harmless condition which presents only with a raised bili rubin. ALP would not
be raised in this conditi on.
Ascending chola ngitis -This is not the most appro pria te answe r. Ascendin g chola ngitis is
an infective condition affecting the b ile du cts. The typical triad of symptoms, known as
em
Charcot's triad, is pain in the right upper qua drant, fever and jaundice. In ad dition, the
s
As
white ce ll count would be raised .

Dr
Which one of the following may be used to monitor patients with colorectal cancer?
CA-125
Carcinoembryonic antigen
Alpha-fetoprotein
CA 19-9
m
se
As
CA 15-3
Dr
CA-125 CD
I Carcinoembryonic antigen flD

Alpha-fetoprotein CD
CA 19-f f.D
CA 15-3 D
m
se
Carci noembryonic antigen may be used to monitor fo r recurrence in patients post-
As
operatively or to assess response to treatment in patients with metastatic disease
Dr
Which one of the followin g is not associated with non-alcoholic steatohepatitis?
Hyperlipidaemia
Obes ity
Sudden weight loss or starvation
Jejuno ilea l bypass
m
se
As
Dr
Hyperlipidaemia m
Obes ity CD
Sudden weig ~t loss or starvation fJD
Jejunoilea l bypass fD
I Type 1 diabetes mellitus CiD
m
se
Obese T2DM with a bno rmal LFTs - ? non-alcoho lic fatty liver disease
As
Dr
A 75-yea r-old man was a dmitted 3 d ays ago a fte r being found at home in his own faeces
a nd urine. Prior to ad mission he was drinking a 70cl bottle of vo dka per day but had not
been eating for seve ral weeks. This morning's blood tests showed that he was deve lo ping
refeed ing syndrome.
K+ 2.3 mmoi/L
Mg2 + 0.46 mmoi/L
P0 4- 0 .51 mmoi/L
Which of the fo llowing is this man most at risk of develo ping as a consequence o f
refeed ing syndrome?
Atrial fibrillation
Ventricu la r fibrillation
Com plete hea rt block
Torsades-des-pointes
m
se
As
Left bu ndle b ra nch b lo ck
Dr
Atrial fibrillation fD
Ventricular fibrillatio n G'D
Comp lete ~eart block f.D
Torsades-des-pointes (D
Left bu nd le b ra nch b lock m
Torsades-des-pointes second a ry to hypomagnesaem ia can result as a consequence

of refeed ing synd ro me
Refeed ing syndrome is characte rised by e lectro lyte a bnormalities in cludi ng

hypomagnesaem ia a nd hypokalaem ia. Seve re hypoma gnesaemia and hypo kalae mia can
lead to the development of torsades-d es-pointes, a va riant of polymorphic ve ntricula r
tachycardia with QT pro lo ngation.
m
se
The other options are less like ly to be p recipitated by the electro lyte distu rbances
As
d escribed in the question.
Dr
A 63-year-old ma n who smokes heavily presents with dyspepsia. He is tested and found
to be positive for Helicobacter pylori infection. Desp ite eradication the rapy and a course
of lansoprazole his symptoms persist. He therefore has a gastrosco py which shows an
ulcer on the duodenal cap.
The following even ing he has an episode of haem atemesis and collapses. What is the
most li kely vessel to be responsible?
Portal vein
Short gastric a rteries
Superior mesenteric artery
Gastroduodenal a rtery
m
se
As
Left gastro-omenta l artery
Dr
Porta l ve in CD
I Sho:rt gastric a rte ries fD
Su perior mesenteric a rte ry (f.D
I Gastroduodenal artery GD
Left g astro -omenta l arte ry m
He is most li kely to have a posterio rly s ited duodenal ulcer. These can invade the
m
se
g astroduodenal artery a nd p resent with majo r bleeding. Althoug h gastric ulcers may
As
invad e vessels they d o not tend to produ ce major b leed ing of th is nature.
Dr
System ic scleros is
Thyroid disease
Sjogren's syndrome
Rheumatoid a rth ritis
System ic lupus e rythemato us
Sjogren's syndrome is common in patients with PBC

m
se
All of the a bove co nd itio ns are associated with prima ry biliary cirrhos is but Sjog ren's
As
syndrome is the most co mmon, being seen in up to 80% of patie nts
Dr
Which one the fo llowing diso rde rs is most strongly associate d with p rimary bilia ry
cirrhos is?
System ic scle rosis
Thyro id disease
Sjogren's syndrome
Rheumato id a rth ritis
m
se
As
System ic lupus e rythem atous
Dr
A 54-year-old woman presents with j aundice shortly after being discharged from hospit al.
Liver function t ests are reported as follows:
Albumin 49 g/ 1
Alanine transferase (ALT) 66 iu/1
Alkaline phosphatase (ALP) 245 IJmol/ 1
Gamma glutamyl transferase (yGT) 529 u/1
Which of the following antibiotics is she most likely t o have received?
Flucloxacillin
Gentamicin
Ciprofloxacin
Trimethoprim
m
se
As
Ceftazidime
Dr
I Fl ucloxacill in
Gentamicin
ED
.
(D
Ciprofloxacin (fD
Trimethoprim (fD
Ceftazidime m
m
se
Flucloxacillin is a well recognised cause o f cho lestasis
As
Dr
A 25-year-old woman develops deranged liver function tests following the introduction of
a new drug. Alb 40, Bilirubin 46, ALT 576, ALP 95, yGT 150. Which o f the following drugs is
the most likely cause?
Sodium valproate
Flucloxacillin
Chlorpromazine
m
se
As
Tetracycline
Dr
Ora l contraceptive pill 6D
I Sodium valproate ED
Flucloxacill in fJD
Chlorpromazine CD
Tetra cycline fD
m
se
The liver function tests suggest a hepatitis rather than cho lestasis. Sodium valproate may
As
be associated with such a pictu re
Dr
A 93 -year-old woman is seen on the acute ward round with refractory Clostridium difficile
infection. She has already received 2 weeks of oral metronidazole, oral vancomycin and
intravenous metronidazole.
Which of the following may be implemented as the next line of management?
Probiotics
IV Vancomycin
Fidaxomicin
Meropenem
m
se
As
IV Immunoglobulins (IVIg)
Dr
Probiotics
IV Vanco mycin
-
"""'
Fidaxomicin
Meropenem
-
IV Immunoglobulins (IVIg)
-
"""'
"""'
Fidaxomicin is used for Clostridium diffici/e infections that don't respond to
metronidazole/Vancomycin
Fidaxomicin is a new antibiotic that is useful for Clostridium diffici/e infections. It has a
relatively narrow spectrum and may even reduce likelihood of recurrence, compared t o
o ral vancomycin alone.
IV vancomycin has no role in Clostridium diffici/e infections. Probiotics have no valuable
m
se
evidence at present and M g has some evidence and can be used as a very last line.
As
Meropenem may, if anything, worsen the situation.
Dr
You are reviewing a 55-year-ol d man who has recently been dia gnosed with Ba rrett's
oesophag us. This wa s diagn osed ah e r the patient was referred due to difficult to contro l
symptoms. No evidence of dysplas ia was found on biopsies. In terms of risk factor
mod ification, which one of the following has been shown to be most strong ly linked to
the development of Barrett's oesophag us?
Use of NSA!Ds
Eating smoked fish
Alcohol
Smo king
m
se
As
Gastro -oesophageal reflux disease
Dr
Yo u are reviewing a 55-year-old ma n who has recently been dia gnosed with Ba rrett's
oesophagus. This was diagnosed aher the patient was referred due to difficult to co ntro l
symptoms. No evidence of dysplasia was fo und o n bio ps ies. In terms of risk factor
mod ification, whi ch o ne of the fo llowing has been shown to be most stro ngly linked to
the develop ment of Barrett's oesophagus?
Use of NSA!Ds
Ea ti ng smoked fish
~ohol
Smoking
Gastro -oesophageal reflux disease
GORD is the single strongest risk facto r for the develop ment o f Barrett's
m
se
oesophagus
As
Dr
What percentag e o f patients with Peutz-Jeghers syndrome will have died from a related
ca ncer by the a ge of 60 years?
2-3%
50%
5-7%
>95%
m
se
As
10-20%
Dr
2-3% CD
I so% CD
5-7% CD
>95% GD
m
se
10-20% CD
As
Dr
A 78-year-old man is being treat ed on the medica l ward with co-a moxi clav for a lower
respirato ry tract infection. After 3 days he st arts to exp erience loose stools. He is passing
2 - 3 offensive stools per day but is syst emically well. What is the first line choice of
therapy fo r the most likely cause of his diarrhoea?
Lopera mide
Ciprofloxacin
Vancomycin
Intravenous fluids
m
se
As
Metronidazole
Dr
Loperamide CD
Ciprofloxacin m
Vancomycin CD
Intravenou s fluids CD
Metronidazole flD
Metronidazole is the first line antibiotic for use in patients with Clostridium difficile
infection
This patient is being treated w ith broa d-sp ectrum antibiotics and has developed
diarrhoea. Clostridium difficile (C. diff) should be t op of your differential list. Oral
metronidazole is the first line therapy fo r C. diff.
Clostridium difficile infection is common in patients given broad-s pectrum antibiotics -

the most well-known antibioti cs to be associated with C. diff are cephalosp orins,
quinolones, clindamycin, co-amoxiclav an d tazocin.
Oral metronidazole is the first line antibiotic for use in C.diff. Vancomycin can be used in
patients who have not responded to metronidazole or who have severe disease. This
patient is systemi cally well and should b e tried on metronidazole first.
Clostridium difficile infection: risk w ith broad -spectrum antibiotics:

https:/ ;www.nice.o rg .uk/advice/ es m p b 1/ chapt er/ Key-p oints -from-the-eviden ce
em
Public Health England: Updated guidance on the management and treatment of

s
Clostridium difficile infection

As
https://www.gov.uk/government/uploads/ system/ uploa ds/ attachmentdata/file/ 321891/Cio:

Dr
An 82-year-old ma n is recovering from com mun ity acquired pneumo nia on the older
a dult wa rd. He has a background o f advanced vascular dementia, his function has
declined significa ntly over the past 6 months and he is unable to co pe at home. He is
making minimal progress in his recove ry, and is not eating and drinking. He is not
engaging with the speech a nd language therapy team . He has no lasting power of
a ttorney o r advance decisions. He has no close relatives o r friends besides his ca re ho me
staff.
What is the most a p propriate ma nagement plan with regard to his nutrition?
Inse rt a p ercutaneous endoscopic gastrostomy (PEG)
Inse rt a nasogastric (NG) tu be
Total parente ra l nutrition (TPN)
Continue to encourage ora l food an d flu id
m
se
As
Stop o ffering food an d flu id unless he asks fo r it
Dr
Inse rt a p ercutaneous endoscop ic gastrost omy (PEG)
Inse rt a nasog astric (NG) tu be
Total parenteral nutrition (TPN)
Continue to encourage oral food an d f lu id
Stop o ffering food an d f lu id unless he asks for it
PEG insertion is not normally recommen ded in advanced d ementia pat ient s
This difficult d ecision is clearly one that shou ld b e taken in conj unction w it h involvement
f rom the patient's family, carers and multidisciplinary t eam if possible. Some options are
more ap p rop riate t han others: refusal of food and flu id is consid ered a pre-terminal event
in dement ia pati ents. 'A rtificial nutrition and hydrat ion is rarely appropriate in advanced
d ementia' (Royal Co lleg e of Physicians o f Edinburgh, 2014). Insertion o f PEG t ubes in
d ementia patient s has show n no significant increase in short term or long term mortality,
m
se
and d oes not improve re-hos pitalisation rat es. St opp ing to offer food and flu id alto get her
As
would clea rly be inapprop riat e.
Dr
A 62-year-old woman who has recently been treated for ascendin g chola ngitis is referred
to hos pital due to persistent fever an d anorexia. An ultrasound scan reveals the p resence
o f a liver abscess. What is the most app ropriate antib iotic therapy to accom pany drainage
o f the abscess?
Vancomycin + meropenem
Co-amoxiclav + metronidazole
Amoxicilli n + ciprofloxacin + metronidazole
Clindamycin + metronidazole
m
se
As
Metronidazole + vancomycin
Dr
Vancomycin + mero penem
Amoxicillin + ci profloxacin + metro nidazole
Cl indamycin + metro nidazole
m
se
As
Metronidazole + vancomycin
Dr
A 43-year-old male attends the Emergency Department with acute abdominal pain. He
recently attended his GP for a routine check-u p and was found t o have the f ollowing lipid
profile. He does not t ake any regular medication:
Cholesterol 6 .6 mmolfl ( < 5.0)
Triglycerides 2 1.4 mmol/1 ( <2 .3)
HDL 1.4 mmol/1 ( > 1.0)
LDL 4.4 mmolfl ( <3 .0)
Cholesteroi/HDL ratio 4 .7 mmoljl ( <3 .5)
In view of this result, what blood test would you like to request as part of his initial
workup that could explain his abdominal pain?
Reticulocyte count
Amylase
Creatine kinase
Ethanol level
m
se
As
Plasma ketone level Dr
Reticulocyte count m
Amylase .
GD
Creatine kinase CD
Ethanol level CD
Plasma ketone level m
Hypertrig lyceridae mia (with levels > 10 mmo l/1) is a risk factor for acute pancreatitis
In a patient with hypertriglyce rid aemia and acute abdom inal pain, an amylase should be
checked to exclude acute pancreatitis. Alcohol and poor glycaemic co ntrol are the most
common causes for a s igni ficantly ra ised trig lyceride (TG) level.
Hypertriglycerid aemia may be prima ry (famil ia l) or secondary. Secondary causes inclu de :

• high alcohol intake
• type 2 d iabetes mellitus
• renal disea se
• drugs (cyclosporin, oestrogens, corticosteroids)
• bulim ia nervosa
• p regnancy
Management of hypertrig lyceridae mia:
For peop le with a TG co ncentration > 20 mmol/1 that is not a result of excess alcohol o r
poor glycaemic control, refer for urgent specialist review (i.e at a regional li pid clin ic).
For peop le with a triglyceride concentration b etween 10 and 20 mmoi/L:

• Repeat the triglyceride measurement with a fasting test (fo llowing a meal, the
chylomicron leve l rises in the seru m which will lea d to a rise in triglycerid e levels)
• Review for potential secondary causes of hype rlipidaemia
• Address lifestyle fa ctors: encourage weig ht loss, hea lthy d iet an d exercise
• Commence high-potency statins (atorvastatin, rosuvastatin) if unable to address the
triglyce ride level through lifestyle measures. Monitor liver function tests and
creatine kinase in these patients
• Fibrates can also b e used (for exa mple fenofib rate). These lower triglycerides
through increasing the activity of lipoprotein lipase
• Omega-3-acid ethyl esters and nicotinic acid are other p harmacological options
For peop le with a triglyceride concentration b etween 4.5 and 9.9 mmoi/L, optimize the
management of other CVD risk fa ctors present.
em
Reference: NICE, October 2015 http://cks.nice.org.uk/ lipid -modification -cvd -

s
As
p revention#'scenario :1
Dr
A 39-year-old man is investigated for fatigue and arthralgia. The joint pain is worse
around his metacarpophalangeal joints and knees. On review o f systems he is noted to
have polyuria and polydipsia.
An x-ray of his knees reveals chondrocalcinos is.
What is the mode of inheritance o f the likely underlying diagnosis?
Autosomal recessive
X-linked dominant
Autosomal dominant
m
se
As
X-l inked recessive
Dr
I Autosomal recessive
X-lin ked dominant
Mitochondria l inheritance
Autosomal dom inant
X-lin ked recessive
Haemochromatosis is autosomal recessive

This patient has typical sympto ms of haemochromato sis:

• lethargy
m
se
• arthra lgia, with evidence of chrondrocalcinosis
As
• diabetes mellitus (polyuria and polydi psia)
Dr
Which one o f the following antibiotics is most likely to cause pseudomembranous co litis?
Cefuroxime
Cefalexin
Cipro floxacin
Co -amoxiclav
m
se
As
Piperacillin -tazobactam
Dr
Cefuroxime
Cefalexin
Ciprofloxacin
Co-amoxiclav
Piperacillin-tazobactam
Cephalosporins, not just cl indamycin, are strongly linked t o Clostridium difficile

This is a difficult question as both co-amoxiclav and ciprofloxacin are known to cause
Clostridium dif{icile. Studies looking at the relative risk (RR) of developing Clostridium
dif{ici/e following antib iot ic t herapy give the following results (please see the link):
• clindamycin: RR = 31.8
• cephalosporins: RR = 14.9
• ciprofloxacin: RR = 5.0
m
se
Cefalexin is a first generation cephalosporin and less associated w ith Clostridium dif{ici/e
As
than newer agents such as ceftriaxone Dr
A 35-yea r-old forme r intravenous d rug use r is reviewed in the live r cl inic. He has recently
been diag nosed with hepatitis C after bei ng found to have abno rmal live r function tests. It
is d ecided as pa rt of his wo rk-up that he should be assessed for liver cirrhosis. What is the
most app ro priate test to p erform?
MRI liver
Live r biopsy
Urina ry fibrob last quantification
Endosco pic ultrasoun d
m
se
As
Transient elastography
Dr
MRI liver
Liver biopsy
Urinary fibroblast quantification
Endosc1 pic ultrasound

-
........
Transient elastography
Transient elastography is now the investigation of choice to detect liver cirrhosis

m
se
As
NICE recommend that all patients with hepatitis Care assessed for liver ci rrhosis.
Dr
Which one o f the following is not associat ed with villous atrophy on j ejunal biopsy?
Tropical sprue
Coeliac disease
m
se
As
Whipple's disease
Dr
Tropical sprue
Coeliac disease
-
"""
p .milial Mediterranean Fever
Whipple's disease
Causes of villous atrophy (other than coeliacs): tropical sprue, Whipple's, lymphoma,
m
se
hypog ammaglobulinaemia
As
Dr
A 54-yea r-o ld female presents with fatig ue a nd xerostom ia. Bloods tests reveal the
following:
Hb 13.9 g/dl
WBC 6 . 1 *109/1
Plat elet s 246 * 109/1
ALP 292 u/1
ALT 47 u/1
Primary b iliary cirrhos is
Autoimmune hepatitis
m
se
Primary Sjogren's synd rome As
Dr
Infectious mononucleos is
Primary biliary cirrhos is

-
~
Primary Sjogren's syndrome

-
~
Primary biliary cirrhosis - the M rule

• Ig M
• anti-Mitochondrial antibodies, M2 subtype
• Middle aged females
The dry mouth is this patient is due to sicca syndrome, which occu rs in 70% of cases of
m
se
primary biliary ci rrhosis. The raised alkaline phosphatase point towards a diag nosis
As
primary biliary ci rrhosis rather than primary Sjogren's syndrome.
Dr
A 26-yea r-o ld woman who is known to have type 1 diabetes mell itus presents with a
three-month history of diarrhoea, fatigue and weight loss. She has tried excluding gluten
from her diet for the past 4 weeks and feels much bette r. She requests to be tested so
that a diagnosis o f coeliac d isease is confirmed. What is the most app ropriate next step?
Check her HbAlc
No need for further investigation as the cl inical response is diagnostic
Check anti-endomysia! antibodies
Arra nge a jejunal bio psy
m
se
As
Ask her to reintroduce gluten for the next 6 weeks before fu rther testing
Dr
Check he r HbAl c
-
No need for further investigation as the cl inical response is d iagnostic
Check a nti- endomys ia! a ntibodies
Arra ng e a jejuna l biop sy
Ask her to reintroduce gluten for the next 6 weeks befo re further testing
Sero lo gical tests and jejuna l bio psy may be negative if the patient is fo llowing a g luten-
m
se
free d iet. The patient shou ld eat some g luten in more than o ne mea l eve ry d ay fo r at least
As
6 weeks befo re further testing .
Dr
A 31-yea r-old wo ma n prese nts with symptoms co nsiste nt with coeliac disease. Which o ne
o f the following tests s hould be used first-line when screening patients fo r co el iac
disease?
Anti-casein anti bodies
Tissue transgluta minase antibod ies
Anti-gliadin anti bodies
Xylose a bso rpti on test
m
se
As
Anti-end omysea l antibodies
Dr
Anti-casein anti bodies
Tissue transgluta minase antibod ies
Anti-gliadin anti bodies

-
~
Xylose a bsorpti on test
Anti-e nd omysea l a ntibod ies
Coeliac d isease - tissue transglutam inase antibodies a re the first-line test

m
se
Tissue transg luta minase antibod ies a re recommended as the first-line serologica l test
As
a ccording to NICE.
Dr
A 67-yea r-old man with a 10-year history o f gastro -oeso phageal reflux disease is
investigated fo r dysphagia. An endoscopy shows an obstructive lesion hig hly susp icious
o f oesophageal cancer. What is the biopsy most likely to show?
Normal squamous epithelium
Adenocarcinoma
Leiomyoma
m
se
As
Metap lastic columnar epithelium
Dr
Squamous cell carcinom a
Normal squamous epithelium
Adenocarcinoma
Leiomyoma
Metaplastic columnar epithelium
Oesophageal adenocarcinoma is associated w ith GORD or Barrett's

m
se
Metaplastic columnar epithelium wou ld b e seen with Barrett's b ut t his is not consistent
As
with the obstructive lesion seen on endoscopy.
Dr
A 28-year-old woman is diag nosed with irritable bowel syndrome (IBS). She occasionally
experiences spasms of pain in the left iliac fossa and has periods of both constipation and
loose stools. You are considering drug thera py to provide her with symptomatic relief
from the symptoms.
Which one of the following does NICE recommend that we avoid in patients with IBS?
Mebeverine
Ispaghu la
Methylcellulose
Sterculia
m
se
As
Lactulose
Dr
Mebeverine GD
Ispaghula GD
Methylcellulose CD
Sterculia CD
Lactulose CD
m
se
NICE recommend avoiding lactulose in the manage ment of IBS
As
Dr
A 59-yea r-o ld fema le with a history o f hypothyro idism presents with fatigue . Blood tests
reveal the fo llowing:
Hb 9.4 g/dl
MCV 121 fl
Pit 156 * 109/1
WBC 4 .3 * 109/ 1
What is the most appropriate investigation to pe rfo rm next?
Antral biopsy
Bo ne marrow biopsy
Lactate dehydrogenase
Intrinsi c factor antibod ies
m
se
As
Barium enema
Dr
Antral biopsy
h e marrow biopsy
Lactate d e hydrog e nase
~rinsic factor antibodies

Barium enema
m
se
Macrocytic a naemia in a patient with a history o f hypothyro id ism points towards a
As
diagn osis of pernicious a naemia
Dr
A 46-yea r-old man is being investigated for indigestion. Jejuna l biopsy shows deposition
of macrophages containing PAS-pos itive granules. What is the most li kely diagnosis?
Bacterial overg rowth
Coeliac d isease
Tropical sprue
Whipp le's disease
m
se
As
Small bowel lym phoma
Dr
Bacteria l ove rgrowth m
Coeliac disease CD
Tropical sprue f!D
I Whipple's disease fD
Sma ll bowel lymphoma CD
m
Whipp le's disease: jejuna l b iopsy shows d eposition of macro p hages containing
se
Period ic acid-Schiff (PAS) granules
As
Dr
A 31-yea r-old ma n returns fo r review. He was diag nosed with a n a nal fissu re a round 7
weeks ag o a nd has tried d ietary mod ificatio n, laxatives a nd topica l a naesthetic with little
benefit. What is the most a ppro priate next step?
Oral bisacodyl
Oral ca lcium channel b locker
To pica l steroid
Buccal g lyceryl trinitrate prio r to defecation
m
se
As
To pical glyceryl trinitrate
Dr
Oral bisacodyl
Oral calcium channel blocker
I Topi cal steroid
Buccal glyceryl trinitrate prior t o defecation
Topical glyceryl trinitrate

-
~
m
se
Anal fissure - topical glyceryl trinitrate
As
Dr
Each one of the fo llowing is a risk facto r for gastric cancer, except:
Smo king
Blood group 0
Nitrates in diet
Pernicious anae mia
m
se
As
H. pylori infection
Dr
Smoking CD
I Blood group 0
Nitrates in diet
fZ!D
.
(D
Pernicious anaemia CD
m
se
H. pylori infection f!D
As
Dr
Which one o f the following medications is least associated with dyspepsia?
Pred nisolone
Aminophylline
Ateno lol
m
se
As
Amlod ipine
Dr
Isosorbide mononitrate tED
Prednisolone fD
Aminophylline GD
Atenolol GD
m
se
As
Am lodipine fiD
Dr
A 46-year-old male com plains of aching in his hands and feet fo r several months. He also
repo rts diarrhoea, colicky abdominal pain, night sweats and weight loss o f 6kg over the
last two mont hs. On examination, his abdomen is soft and non-tender but his face
appears hyperpigmented and he has bilateral cervical and inguinal lymphadenopathy.
What is the most likely cause?
Ulcerative colitis
Peritoneal tubercu losis
Tropheryma whipplei
Wilson's disease
m
se
As
Giardiasis
Dr
Ulcerative co litis m
Peritoneal tubercu losis fD
I Tropheryma whipplei
Wilson's disease
ED
(D
Gia rd iasis CD
The combination of GI ma la bsorptio n and syste mic features in a middle -a ged man point
to a diagnosis o f Whipple's disease.
Exp la natio n for othe r o ptions:

• 1. Ulce rative colitis would be mo re li ke ly to present with d ia rrhoea with blood a nd
mucus. Also, lymp hadenopathy a nd hyperpigmentatio n are not com mon
extra intestina l features of UC.
• 2. Peritoneal TB is possib le with the history o f a bdomi na l pa in and
lympha de no pathy, but the re a re no pointers in the history to sug gest TB and there
wou ld usua lly be some ascites present.
• 4 . Wilson's d isease may b e asym ptomatic or may present with signs of live r disease
m
o r neu ro lo gica l s ig ns.
se
As
• 5. Gia rdiasis may cause chro nic GI upset b ut is not associated with
lympha de no pathy, a rthra lgi a o r skin changes.
Dr
Which one o f t he following foodstuff contain s the most energy per u nit weight?
Past a
Cheese
Butter
Peanut s
m
se
As
Whit e rice
Dr
Pasta fD
Cheese fiD
Butter CD
Peanuts GD
White rice fD
m
se
As
Butter is a type of fat and therefore contains the most e nergy.
Dr
A 23-yea r-old female with a history of diarrhoea and weight loss has a colonoscopy to
investigate her symptoms. A biopsy is taken and reported as follows:
Pigment laden macrophages
Intestina l melanoma
Haemoch ro matosis
Ulcerative colitis
Laxative abuse
m
se
As
Colorectal cancer
Dr
Intestinal mela noma CD
Haemochromatosis fiD.
Ulcerative colitis fD
r
Laxative abuse GD
Colo rectal cancer m
m
se
Diarrhoea - biospy shows pig ment lade n macro phages = laxative abuse
As
Dr
Which of the following is not a recognised complication of coeliac disease?
Hypersp lenism
Osteoporos is
Lact ose intolerance
Oesop hageal cancer
m
se
As
Subfertility
Dr
I Hypersp lenism 6D
Osteoporosis m
Lactose intolerance CD
Oesophageal cancer tiD
Subfertility CD
m
se
As
Hypo -, not hypersplenism is seen in coeliac disease
Dr
Which one o f the followi ng is least associated with the development of colorectal cancer
in patients with ulcerative colitis?
Unrem itting disease
Disease d u ration > 10 yea rs
Onset befo re 15 yea rs old
Poo r co mpliance to treatment
m
se
As
Disease confin ed to the rectum
Dr
Unrem itting d isease
I Disease duration > 10 yea rs
Onset befo re 15 yea rs o ld

-
.....,
Poor co mpliance to treatment
m
I
se
As
Disease confined to the rectu m
Dr
A 35-year-old man is investigated fo r letharg y, arthralgia and deranged liver function
t ests. He is eventua lly diagnosed as having hereditary hemochromatosis. His w ife has a
genetic test which shows she is not a ca rrier of the disease. What is the chance his child
will develop haemochromatosis?
0%
25%
50% if f emale, 0% if male
50% if male, 0% if female
m
se
As
50%
Dr
25%
50% if female, 0% if male
I 50% if male, 0% if fema le
50%
-
~
Haemochro matosis is autosomal recessive

Haemoch romatosis is an aut oso mal recessive condition. If one o f the parent s has
haemochromatosis (i.e. is homozygous) and t he other is not a carrier/affected then all t he
m
se
children will inherit one copy of t he g ene from t he affected parent and hence will be
As
carriers.
Dr
You wish to screen a pat ient for hepat itis B infection. Which one o f the following is the
most su itable test to perform?
HBcAg
HBsAg
Hepat itis B vira l load
anti -H Bs
m
se
HBeAg
As
Dr
HBcAg .
(D
I HBsAg CD
Hepatitis B vira l load CD
Ianti-~Bs CD
HBeAg CD
m
se
A positive anti-HBs would imply immunity through either previous immunisation or
As
disease. A positive HBsAg implies either acute or chronic hepatitis B.
Dr
A 31-yea r-old man with a known history of alcoholic liver disease is reviewed following a
suspected oesop ha geal variceal haemorrhage. He has been resuscitated and intrave nous
te rlip ressin has been g iven . His blood pressure is now 104/ 60 mmH g and his pu lse is
84/min. What is the most a ppropriate inte rvention?
Transjugular Intrahepatic Porto systemic Shu nt
Su rgical referral
Endoscop ic variceal ba nd ligati on
Sengstaken-Biakemore tube
m
se
As
Endoscop ic sclerothera py
Dr
Transjugular Intrahepatic Portosystemic Shu nt
Surgical referral
Endoscopic variceal band ligation
Sengstaken-Biakemore tube
-
~
m
se
As
Endoscop ic sclerothera py
Dr
Which one of the fo llowin g statements rega rd ing hepatitis Band p reg nancy is co rrect?
Without interve ntio n the vertical transm ission rate is aroun d 3%
Only a t risk g roups shou ld be screened fo r hepatitis B d u ring preg nancy
Aro und 30% o f mothers with hepatitis B d eve lop pre -eclam psia
It is s afe fo r a mother with hepatitis B to b reastfeed her newborn
m
se
All p regna nt women with hepatitis B should take o ra l ribavirin in the last trimester
As
o f pregnancy
Dr
Without intervention the vertical transmissi on rate is around 3%
Only at risk groups should be screened for hepatitis Bduring pregna ncy
Around 30% of mothers with hepatitis Bdevelop pre-eclampsia
I It is safe for a mother with hepatitis B to breastfeed her newborn
All pregnant women with hepatitis B should take oral ribavirin in the last
trimester of pregnancy
m
se
Without intervention the vertical transmission rate is around 20%, which increases to 90%
As
if the woman is positive for HBeAg.
Dr
A 54-year-o ld fema le presents with a 3 mo nth h istory o f dysphagia affecting both food
and liquids from the start, along with occasional symptoms o f heartburn. What is the
most li kely underlying d iagnosis?
Pharyngea l pouch
Gastric ad enoca rcinoma
Benign stricture
Oesophageal cancer
m
se
As
Acha lasia
Dr
Pharyngeal pouch
Gastric ad e no ca rcinoma
Benig n stricture
Oeso~~hageal ca ncer
-
~
Acha lasia
Dysphagia affecting both solid s and liqu ids from the start - think acha lasia
m
se
This is a classic histo ry o f acha lasia with dysphag ia affecting b oth solids and liqu id s from
As
the start.
Dr
You are reviewi ng a 38-year-old man that you saw last week w ith an anal fissure ca used
by constipation and straining. He has no syst emic sympto ms and is ot herwise well. He has
been using the lidocaine oi nt ment (which you p rescrib ed last week) before every stoo l but
he is st ill trou bled by severe rectal pain when he has his bowels open. He is st ill passin g
bright red blood with every st ool. The pain conti nues to burn fo r 30 minut es after each
st ool. His st ools are now soft as he is t aki ng regular lactulose and has modified his diet.
The next opt ion for this man is:
Ref er rout inely t o a co lo rect al su rgeon
Ref er urgently to a co lorecta l surgeon
Prescri be topical GTN ointment for 6-8 w eeks and review if still not hea led
Prescri be topical diltiazem 2%
m
se
As
Prescri be hydrocortiso ne ointment for 7 d ays
Dr
I Refer routinely t o a colo rect al su rgeon
Refer urgently to a colorecta l su rgeon
I Prescrib e to pical GTN ointment for 6-8 w eeks and review if still not hea led
Prescri be to pical diltiazem 2%
Prescri be hydrocortisone ointment for 7 days

-
"""'
Topical GTN is t he f irst line t reat ment for a ch ron ic anal fissu re
This patient has an anal f issu re which has not settled for one week and the use o f
lidocaine ointment. The next st ep is to consider p rescribing rectal glyceryl trinitrate (GTN)
0.4% oint ment (provided t here are no contraindications) to relieve pain and aid healing.
Advise t he person to use it twice a day for 6-8 weeks. Therefore, th e correct answer is
opt ion 3.
He does not need a referral to t he colorectal su rgeons at this point as he has no

symptoms of a serious underlying pathology. If the GTN does not work ah er 6-8 weeks
you cou ld consider referring him to the su rgeons. Therefore, options 1 and 2 are w rong.
Topical diltiazem is occasiona lly prescribed following specialist advice. Therefore, option 4
I S wrong .
em
Hydrocortisone o int ment is not a recommended t reatment for an anal fissu re. Therefore,
s
As
opt ion 5 is wrong .

Dr
A 54-year-old man d evelops central abdominal pain a few hours after having an
Endoscopic Retrograde Cholangiopancreatography (ERCP) p erformed. Investigations
reveal the following:
Amylase 545 u/dl
Erect chest x-ray Normal heart and lungs. No free ai r noted
Repeat ERCP + analgesia
Reassure normal + ana lgesia
Intravenous ciprofloxacin + ana lgesia
Surgical opinion + analgesia
m
se
As
Intravenous fluids + analgesia
Dr
I Rel eat ERC P + analgesia
Reassure normal + analgesia
Intravenous ciprofloxacin + analgesia
Surgical opinion + analgesia
( Intravenous fluids + analgesia
This patient has developed acute pancreatitis following ERCP and should be treated with
m
intravenous fluids and ana lgesia.
se
As
Quinolo nes have not been shown to be beneficial in acute pa ncreatitis.
Dr
A 54-yea r-old man with a long history o f heartburn has an endoscopy to investigate his
symptoms. A biopsy is taken from an abno rmal a rea of mucosa in the lower oesophagus
and repo rted as follows:
Non-dysplastic columnar -lined oesophagus
What is the most su itab le management?
Reass ure and discha rge
Fundo plication
Laser a blation
Ivor- Lewis oesophagectomy
m
se
As
Hig h-d ose p roton pump inhibito r and follow-up
Dr
Reassu re and discha rge
Fundo plicatio n
R e r ablation
Ivo r- Lewis oesophagectomy
I High-dose proton pump inhibitor and follow-u p
The 2005 British Society of Gastroente ro logy guide lines state that high-dose proton
m
se
pu mp inhibitor thera py is first-line treatment in such patients. The re is yet insufficient
As
evid ence to support the use of end oscopic ab lation.
Dr
A 44-year-old man is diagnosed w it h a right -sided colon cancer. He has a strong family
history of co lo recta l and ovarian cancer. Genetic tests confirm a diagnosis of hereditary
non-polyposis co lorecta l cancer (HNPCC) due to a defect in the MSH2 gene. What is t he
f unction of this gene?
Signal t ransduction
Apoptosis regulation
Epidermal growth factor receptor
DNA mism atch repa ir
m
se
As
Regulatory GTPase
Dr
Signal transduction
Apoptosis regulation
Epidermal,growth factor receptor
DNA mismatch repair
m
se
As
Regulatory GTPase
Dr
A 54-yea r-old man who is known to have gastric cancer is reviewed in clinic. He asks you
about a rash he has deve loped. Which of the fo llowing skin disorders is most associated
with gastric cancer?
Erythema gyratum repens
Necro lytic migratory erythema
Sweet's syndrome
Acquired ichthyosis
m
se
As
Acanthosis n ig rica ns
Dr
Erythema gyratum repens CD
Necrolytic migratory erythema tiD
Sweet's syndrome m
Ac< uired ichthyosis CD
m
se
As
Acanthosis nigricans GD
Dr
A 50-year-old alcoholic w ho drinks 20 units o f alcohol per d ay co mes to the Emergency
d epartment com plaining of chronic epigastric pain and diarrhoea. He is unable t o
maintain his weight and co mp lains that he is wasting away. On examination his blood
p ressure is 125/ 85 mmH g, p ulse is 75 beats p er minute and regular. Cardiovascu lar and
respiratory systems are unremarkab le. His abdomen is soft, there is mild ep igastric
t end erness. His body mass index is 20 kg/m 2 •
Investigations:
Hb 101 g/ 1
8
Plat elet s 95 109/ 1
WBC 7.2 * 109/ 1
Na• 139 mm ol/ 1
K• 3 .7 mmol/1
urea 6 . 1 mmol/1
Albumin 24 mmol/ 1
You susp ect ch ron ic pancreatitis, which o f t he following tests would b e most usef ul in
confirming t he diagnosis?
Faecal calp rotectin
Faecal elastase
Faecal fat esti mation
SeHCAT test
s em
As
Small bowel follow through

Dr
Faecal calprotectin
Faecal e lastase
-
~
Faecal fat estimation
SeHCAT test
Small bowel follow through
Faecal e lastase is a useful test o f exocrine function in chronic pancreatits

Elastase 1 is a protease synthes ised by pa ncreatic acina r cells and secreted into the
duodenum. It is not deg raded during transit and is concentrated in the faeces.
Measu rement of stool Elastase 1 allows the diag nosis or exclusion o f pancreatic exocrine
insufficiency. A level less than 100 IJg/g of stool ind icates severe pancreatic insufficiency,
levels of 100-200 IJg/g indicate mild to moderate pancreatic insufficiency.
Faecal ca lp rotectin is used as a measure o f bowel mucosa l inflammation, and can be

helpfu l in the dia gnos is of inflammatory bowel disease. Faecal fat estimation can indi cate
malabsorption and be useful in the diag nosis o f small bowel disease, although it is less
specific versus elastase measurement, and more difficult to collect. SeHCAT testing is
m
used for ru ling out bile acid diarrhoea, and small bowel follow throu gh is only useful for
se
demonstrating abnormal anatomy.
As
Dr
A 37-year-old woman who has a BMI of 44 kg/m"2 undergoes a Roux-en-Y gastric
bypass. Of which vitam in/ minera l is she most likely to requ ire supplementation?
Vitamin C
Iron
Folic acid
Zinc
m
se
As
Vitamin B6
Dr
Vitamin C CD
Iron CID
Folic acid flD
Zinc m.
Vitamin 86 fD
m
The duodenum is the primary site of absorption fo r both iron and calcium. All gastric
se
bypass operations bypass the duodenum. Nearly all menstruating wom en will therefore
As
require iron supplement ation.
Dr
A 29-yea r-old man is reviewed. Four weeks ago he presented with a one month history of
bloody d ia rrhoea. He was previously fit and well prior to this e p isode. When in itially
reviewed he was pass ing on average four loose stoo ls a d ay with some visible blood. He
was haemodynamically stable with no fever and bloods showed the following:
Hb 15.2 g/dl
Plat elet s 298 * 109/1
WBC 8 .6 * 109/ 1
CRP 15 mg/1
Colonoscopy showed extensive infla mmatory changes consistent with u lcerative colitis.
He was started on o ral mesalazine and a review appointment was made fo r today.
Unfortunate ly there has been no sig nificant change in his symptoms. He is still passing
around four b loody stools a day although he rema ins systemically well. What is the most
appropriate cou rse of action?
Add oral pred nisolone
Stop oral mesalazine and start oral prednisolone
Rectal corticosteroids
Add oral methotrexate

m
se
As
Add oral azathioprine

Dr
Add oral prednisolone
Stop o ral mesalazine a nd start o ral prednisolo ne
Recta l corticosteroids
Add o ral methotrexate
Add oral azath io prine

-
.....,
This p atient with mild/ moderate ulcerative co litis has not resp onded to the a p propriate
m
se
first-line the ra py o f o ral am inosa licylates. He shou ld there fo re be offered o ra l
As
predn isolone to help induce remissio n.
Dr
Which one of the followi ng featu res is least associated with ulcerative colitis?
Inflammat ory cell infiltrate in the lamina propria
Pseudopolyps
Non-caseating granulomas
Depletion of goblet cells
m
se
As
Inflammation confined t o the mucosa and submucosa
Dr
Inflammatory cell infiltrate in the lamina propria
Pseudopolyps
Depletion of goblet cells
m
se
As
Inflammation confined to the mucosa and submucosa
Dr
A 22-year-old male blood donor is not ed to have the following blood resu lts:
Bilirubin 4 1 IJmo i/L
ALP 8 4 U/ l
ALT 23 U/ l
Albumin 4 1 g/ l
Dipstick urinalysis No bilirubinuria
He has recently complained o f coryzal symptoms and a non -productive cough. What is
the most likely diagnosis?
Gilbert's syndrome
Rot or syndrome
m
se
As
Dr
Gilbert's syndrome
Roto r syndrome
Hepatitis C infectio n
An isolated rise in bilirubin in response to physiological stress is typical o f Gilbert's

syndrome
An isolat ed hyperbilirubinaemia in a 22 -year-old male is likely to be secondary to Gilbert's

syndrome. The normal dipstix urinalysis exclu des Dubin-Johnson and Roto r syndrome as
m
se
these both produce a conjugat ed bilirubinaemia. Viral infections are common triggers for
As
a rise in the bilirubi n in patient s with Gilbert's
Dr
Which of the following anti-retroviral drugs is most characteristically associated w ith
pancreatitis?
Zidovudine
Didanosine
Indinavir
Ritonavir
m
se
As
Nevi rapine
Dr
Zidovudine a
Didanosine ED
Indinavir flD
Ritonavir CD
Nevira pine m.
m
se
Ritonavir may cause acute pa ncreatitis but this is not as common as with didanosine
As
therapy
Dr
A 48-yea r-old male with known live r cirrhosis p resents to the emergency depa rtment with
ma la ise and a bdom inal tend e rness. On exam ination he has obvious jaundice and tend e r
hepato meg a ly. He mentions that he drinks heavily - a round 35 units of a lcoho l per week.
His blood resu lts are as fo llows:
Hb 135 g/ 1
Plat elet s 140 * 109/ 1
Neutrophils 23 s 109/ 1
ALP 120 u/1
ALT 342 u/1
Albumin 34 g/ 1
Yo u susp ect a diagnosis of a lco holic he patitis.
Which is the most app ro priate treatment fo r acute seve re a lcoholic he patitis, as
d etermined by the Maddrey d iscriminant funct ion?
No trea tment req uired
IV antibiotics
Liver tra nsp lant
Prednisolone
em
s
As
Chlo rdiazepoxid e
Dr
No treatme nt requ ired tED
IV a ntib iotics GD
Liver transplant flD
Predniso lone ED
Chlo rdiazepoxid e GD
Corticoste roids are used in the management of severe alcoholic hepatitis

Corticostero ids a re the recom me nde d treatment fo r severe a lcoho lic he patitis
(d ete rmined by a Maddrey discriminant function value >32). The STOPAH tria l (Ste ro ids o r
Pentoxifyll in e fo r Alco holic Hepatitis) d etermined that treatme nt with stero id s reduced
mortality by 39% at 28 days. The typical regime n is pred nisolo ne 40mg/ day fo r 28 d ays.
IV a ntib iotics may be used if the re is concurrent infection. Howeve r, as the basis of
a lco ho lic hepatitis is non- infectious, antibiotics will not treat the hepatitis itself.
Liver transp la nt is a conte ntious issue in a lcoholic hepatitis as a lmost a ll patients with
m
a lco ho lic hepatitis a re active alcoho l d rin ke rs at the time of p resentatio n.
se
As
Chlo rdiazepoxid e is used in the treatme nt of alcohol withdrawal.
Dr
A 25 -year-o ld female cu rrently under investigation for secondary amenorrhoea p resents
with jaundiced sclera. On examination spider naevi are p resent a long with tender
hepatomega ly. Blood tests show:
Hb 11.6 gfdl
Pit 145 * 109/J
wee 6.4 • 10911
Albumin 33 g/1
Bilirubin 78 J.Jmol/1
ALT 245 iu/1
Haemoch romatosis
Wi lson's disease
m
se
As
Primary sclerosing cho langitis
Dr
Haemochro matosis
Willson's disease
r Autoimmune hepatitis
I
Primary sclerosing cholangitis
m
se
The combination of deranged LFTs combined with secondary ameno rrhoea in a young
As
female strongly suggest autoimmune hepatitis
Dr
A 75-year-old man who lives alone is admitted to hospital w ith community-acqu ired
pneumonia (CAP) an d acute kidney injury (AKI) secondary to dehydration. He is treated
with IV fluids and antibiotics for his pneumonia and his cond ition improved.
Unfortunate ly, his discharge is delayed due to issues restarting his care package. He
completes his course of antibiotics for his CAP but develops severe non-bloody diarrhoea
and abdominal pain. He spikes a temperature o f 38.1°C, is tachycardic (HR 125bpm) and
hypotensive, requiring IV fluids. Bloods show a w hite cell count (WCC) o f 15.5 (10 9/I).
There are no signs of peritonism. Abdominal imaging shows a very dilated colon and
thumb-printing sign. A stool sample is positive for C.diff toxin.
Which of the following is the best drug regime for the treatment of his diarrhoea?
Lopera mide
Oral metronidazole
IV vancomycin and oral metronidazole
Oral vancomycin and IV metronidazole
m
se
As
IV vancomycin
Dr
Loperamide
Oral metronidazole
IV vanco ycin and oral metronidazole
Oral vancomycin and IV metronidazole
IV vancomycin
-
~
In life-th reatening Clostridium difficile infectio n treatment is with ORAL vancomycin

and IV metronidazole
This gentleman has developed Clostridium difficile (C.diff} infection secondary to his
recent antibiotic treatment for a community-acquired pneumonia (CAP). Don't baulk at
the background to this scenario, just identify the pertinent facts; diarrhoea in the context
of recent antibiotic treatment and positive C.diff toxin in the stool. Unfortunat ely,
scenarios like this are encountered more and more often in clinical practice.
He has life-threatening C.diff infection (as indicat ed by features such as his hypotension
and radiological evidence of toxic megacolon).
Drug treatment for life-threat ening C.diff infection is with oral vancomycin + N
metronidazole.
1. Incorrect- Loperamide can be used in uncomplicat ed cases of diarrhoea t o reduce stool

frequency but would be completely inappropriate in the context of a severe/life-
threatening C.diff infection
2. Incorrect- oral metronidazole would be a suitable cho ice for a first episode of mild to
moderate C.diff infection
3. Incorrect- Generally as the proliferation of bacteria in C.diff infection is within the bowel
drug treatment s are actually more effective when administ ered orally. With more severe
infection oral vancomycin given instead of oral metronidazole. In life-th reatening
infection oral vancomycin is given with IV metronidazole.
4. Correct- in life -threatening C.diff infection as in th is scenario, treatment is with a

combination of oral vancomycin and IV metronidazole
s em
5. Incorrect- IV vancomycin is not a recommended treatment for C.diff infection of any

As
severity
Dr
Which one o f t he following is most suggestive o f Wilso n's di sease?
Reduced hepatic copper concent rat ion
Reduced 24hr urinary copper excretion
Increased skin pigmentat ion
Reduced serum caeruloplasm in
m
se
As
Increased serum cop per
Dr
Reduced hepatic copper concentration CD
Reduced 24hr urinary copper excretion GD
Increased skin pigmentation CD
Reduced se rum caeruloplasmin (D
Increased seru m copper GD
m
se
Wi lson's disease - seru m caerulo plas min is decreased
As
Dr
A 55-yea r-old woman with a history of a lco holic live r d isease is reviewed in clinic. She has
a dvanced c irrhosis and has started to accumulate ascites. An ascitic tap was recently
pe rfo rmed and showed a prote in concentration of 12 g/ L but no e vid ence of any
o rga msms.
What is the most a pp ropriate management concerning the risk o f spontaneous bacteria l
pe ritonitis?
No antibiotic pro p hylaxis is in dicated
Oral pen icilli n
Oral ciprofloxacin
Oral a zithromycin
m
se
Oral d oxycycline
As
Dr
No antibiotic prophylaxis is indicated
Oral penicillin
Oral ciprofloxacin
Oral azith romycin
Oral doxycycline
Patients with ascites (an d prot ein concentration < = 15 g/L) should b e given oral
m
ciprofloxacin or norfloxacin as prophylaxis against spontaneous bact erial peritonitis
se
Important for me Less · m ::~c rtC~nt
As
Dr
Which one of the following statements regarding hepatocellular ca rcinoma is correct?
Diabetes mellitus is a risk factor
Screening has not been shown to be effective
Bevacizumab may be used fo r advanced cases
The incidence is significantly higher in women
m
se
As
Alcohol excess is the most com mon underlying cause worldwide
Dr
I Diabetes melli tus is a risk factor
Screening has not been shown to be effective
Bevacizumab may be used for advanced cases
The incidence is significantly higher in women
m
se
As
Alcohol excess is the most common underlying cause worldwide
Dr
A 70-year-old man who is known to have atrial fibrillation presents with abdominal pain
and recta l bleeding. A diagnosis of ischaemic colitis is suspected. Which part of the colon
is most likely to be affect ed?
Hepatic flexure
Descending colon
Splenic flexure
Ascen ding colon
m
se
As
Rectum
Dr
Hepatic flexure fD
-
Descending colon (ED
Splenic f lexure CD
Ascending colon CD
m
se
As
Rectum CD
Dr
A 50-year-o ld lady is readmitted 3 days after a lapa roscopic cho lecystectomy fo r
symptomatic gallstones. She compla ins o f freq uent and uncontrollable dia rrhoea .
Abdomina l examination e ludes no features other than a lapa roscopic sca r.
Her o pe ration a nd initia l recovery were unrema rkable .
In view of the history, what treatment is she likely to need?
Co -Amoxiclav
Pancreatin
Lansoprazo le
Cholestyramine
m
se
As
Azathioprine
Dr
Co-Amoxiclav CD
Pancreatin CD
Lansoprazole CD
Cholestyramine fD
Azathioprine m
Post-cholecystectomy synd rome is a recognised complication of cholecystectom ies.
Typica lly symptoms of dyspepsia, vom itin g, pa in, flatulence and d ia rrhoea occur in up to
40% patients post su rgery.
The pathology b ehind the syndrome isn't complete ly clea r, however there is some
association with remnant stones and biliary injury. Pa in is ohen due to sp hincter o f Oddi
dysfunction and the d evelopment of surg ical adhesions.
Management is oh en d ifficu lt, but ohen invo lves a low-fat diet and the introd uction of
b ile acid sequestrants, such as Cholestyram ine, to b ind the excess b ile acid s and th us
p reventing lower gastrointestinal s igns. Proton -p ump inhibitors like Lansoprazole d o play
m
se
a role, if the patient is complaining of dys peptic li ke sympto ms. Antibiotics and pancreatic
As
enzyme replacements play no part in management. Dr
A 45-year-old man is admitt ed to t he Emergency Department wit h severe abdominal
pain. He smo kes 20 cigarettes a day and drinks approximat ely 50 u nits of alcohol per
week. He also complains o f sud den d et erioration in vision. Fundosco py reveals shows
multiple micro infa rcts (cott on wool spots). Which invest igation would b est confirm the
most likely diagnosis?
Gastroscopy
Serum glucose
Amylase
Biliary USS
m
se
As
ECG
Dr
--
Gastroscopy CD
Serum glucose CD
I Amylase CD
Biliary USS flD
ECG flD
m
The cotton wool spots seen on fundoscopy represents Purtscher retinopathy. This
se
condition may be seen following head t rauma and in cond it ions such as acute
As
pancreatitis, fat embolisation, amniotic f luid embolisation, and vasculitic diseases
Dr
The action of which one of the following brush border enzymes results in the formation of
glucose and galacto se?
Dipeptidase
A-dextrina se
Maltase
Lactase
m
se
As
Sucrase
Dr
Dipeptidase f.D
A-dextrinase CD
fD
.,
Maltase
r :tase
Sucrase «D
Brus h border e nzymes:

• maltase: glucose + glucose
• sucrase: glucose + fructose
m
• lactase: glucose + galactose
se
As
Dr
A 25-year-old man with a history of Crohn 's d isease is reviewed in cl inic. Over the past
week he has developed painfu l perianal ulcers. On examination numerous shallow ulcers
can be seen w ith a small number of skin tags. What is t he most appro priate f irst- line
treatment?
Topical mesalazine
Oral metronidazole
Barrier creams + laxatives
Oral prednisolone
m
se
As
Oral mesalazine
Dr
Topical mesalazine eD
I Oral metron idazole
Barrier creams + laxatives

CI\D
.
(D
Oral p rednisolone CD
Oral mesalazine
•
m
se
As
Please see t he Brit ish Society of Gastroent erology guidelines for more details.
Dr
Where do the maj ority of VI Po mas arise from?
Small intestine
Pituita ry
Pancreas
Antrum of stomach
m
se
As
Pylorus of stomach
Dr
Small intestine e:D
Pituita ry
Pancreas
•
CiD
Antrum of stomach GD
m
se
Pylorus of stomach fD
As
Dr
A 37-yea r-old lady is b rought into the emergency department after being assaulted with
a bottle. She reports being struck on the abdomen multiple times and reports pa in across
her entire a bdomen. On cl inical examination there is bruising across the abdomen
howeve r no d istension, no guarding and no active sites of b leed ing.
Her initia l observations as handed over from the pa ra medics a re listed be low:
30 mins ago 15 mins ago Now
Heart rat e 110/min 104/min 100/min
Blood pressure 125/ SOmmHg 109/ 7SmmHg 97/ 79mmHg
Respirat ory rate 18/min 14/min 14/min
Temperature 37 .20( 37 .30( 37 .30(
She has been p rescribed intravenous fluids and co mmenced on oxygen at a rate of
l SL/min via a non -rebreathe mask.
What is the single most a pp ro priate initial investiga tion(s) to assess for the presence of
free flu id in the a bdomen and chest?
CT a bdomen a nd CT chest
MRI a bdomen and MRI chest
MRI a bdomen a nd CT chest
Diag nostic pe ritoneal lavage

sem
As
FAST scan
Dr
CT abdomen and CT chest fD
MRI abdomen and MRI chest m
MRI abdomen and CT chest m
Diagnostic peritoneal lavage m
I FAST scan GD
FAST scans ca n be used to assess the presence of fluid in the abdomen and thorax
While CT ima ging is useful in the assessment o f free fluid in the a bdomen and chest o f
tra uma patie nts, the most app ro priate initial investigation to conduct is a focused
assessment with sonogra phy fo r trauma (FAST) scan. In the hand s of a skilled practitioner,
this can d etect free fluid surrounding the kid neys, the sp leen, th e liver, bladd e r and
perica rd ium. It is also possible to visua lise all fou r cha mbers o f the heart a nd to assess the
hepatic vascu lat u re. An extended focused assessment with sonography fo r trauma
(eFAST) can be conducted, which a lso assesses fo r pneu motho rax. The sensitivity o f a
FAST d etecting a pneu motho rax is 40%, howeve r is consid ered mo re sensitive tha n a
su pine chest ra diogra ph at d etecting pneumotho races.
FAST sca ns have re placed dia gnostic p erito neal lavages as the investigation of cho ice fo r
sus pected haemoperitoneu m. MRI imag ing is less com mo nly used in patients presenting em
with traumatic injuries.
s
As
I •• I •• • Discuss Imp rove

Dr
J
A 64-year-old patient is referred to dermatology outpat ients due to a rash. A diagnosis
necrolytic migratory erythema is mad e. What is the most likely underlying diagnosis?
Gastrinoma
Lung cancer
Glucagonoma
Pancreatic cancer
m
se
As
Lym phoma
Dr
Gastrinoma «D
Lung cancer m
I Glucagonoma ED
Pancreatic cancer GD
m
se
fD
As
Lymphoma
Dr
Which one o f the following is least a ssociated with Crohn's disease?
Fistu lae
Kantor's string sign
'Cobblestone' pattern of mucosa
Crypt abscesses
m
se
Involvement of all layers of bowel wall
As
Dr
Fistulae
Kantor's string sign
'Cobblestone' pattern of mucosa

-
~
Crypt abscesses
-
~
Involvement of all laye rs of bowel wall

-
~
m
se
Crypt abscesses are sometimes seen in Crohn's disease but they are more commonly
As
associated with ulcerative colitis
Dr
A patient presents with gastrointestinal symptoms. Which one of the following featu res in
the history would be least consistent with making a diagnosis of irritable bowel
syndrome?
Urgency to open bowels
Symptoms made worse by eating
62-yea r-old female
Passage of mucous with stool
m
se
As
Bladder symptoms
Dr
Urgency to open bowels CD
Symptoms made worse by eating .
(D
I 62-year-old female CiD

Passage of mucous with stool tiD
Bladder symptoms ED.
m
se
As
Onset after 60 yea rs of age is considered a red flag in the new NICE guidelines.
Dr
An 80-yea r-o ld female is referred to the endocrino logy clinic by he r GP with new onset
dia betes. She has a backgrou nd of hyperte nsion, mild osteoa rthritis of the knees and
myelodysplasia. She has been d ependent on twice- monthly blood tra nsfusions for the
past five yea rs.
On exam ination she has a tan co mplexion wh ich she attributes to being a keen g ardener.
The re is no pa lpa ble o rganomeg aly.
Hb 95 gf l
Plat elet s 222* 109/ 1
WBC 5 .7~ 109/ 1
Cush ing's disease
Hered ita ry haemochromatosis
Bo ne marrow fa ilure
Secondary hae mochromatosis
m
se
Addiso n's disease
As
Dr
Cush ing's disease
Heredit ary haemochromatosis
Bone marrow failure
Secondary haemochromatosis
Addison's disease
Although hereditary (aut osoma l recessive) haemochromatosis is fairly co mmon in

Western Europe, this patient's age makes a genetic diagnosis less likely. Her fortnight ly
transfusions are cont ributing t o an iatrogenic iron overload. Clues point ing t o
m
haemochromatosis are the new onset diabetes and classic 'bronzing' of t he skin. Althoug h
se
osteoarthritis is extremely co mmon among elderly popu lation, j oint disease can also be a
As
manifest ation of haemochromatosis.
Dr
A 44-yea r-o ld man is diagnosed w ith a d uodenal ulcer. CLO testing perfo rmed during the
g astroscopy is pos it ive fo r Helicobacter pylori. What is t he most appro p riate management
t o erad icat e Helicobacter pylori?
Lansoprazole + cl ind amycin + metronidazole
Lansoprazo le + amoxicillin + clindamycin
Lansoprazole + amoxicillin + clarithromycin
Omeprazole + amoxicillin + clindamycin
m
se
As
Omeprazole + pen ici llin + m etron idazole
Dr
Lansoprazole + cl ind amycin + metronidazole
Lansoprazo le + amoxicillin + clindamycin
I Lansoprazo le + amoxicillin + clarithromycin
Omeprazole + amoxicillin + clindamycin
Omeprazole + pen icillin + metron idazole

-
~
H. pylori eradication:
• PPI + amoxicillin + clarithromycin, or
• PPI + metronidazole + cla rith romycin
m
se
The BNF recommends a reg imen cont aining amoxicil lin and clarithromycin as f irst -lin e
As
thera py
Dr
A 67 -year-old man with a history of oesophageal cancer is reviewed on the ward . He has
been treated previously with an oesophagectomy and has recently had a cou rse o f
chemotherapy.Unfortunately he has been feeling increasingly unwell recently and has not
eaten anything for the 7 days due to dysphagia. An nasogastric tube is passed and it is
decided to start entera l feeding . What is the most appropriate cou rse o f action to avoid
refeeding syndrome?
Provide 50% of norma l energy and protein requirements for the first 2 days
Start a sa line infusion with 20 mmol of potassium for the first 8 hours
Provide 75% of norma l energy and protein requirements for the first 2 days
Give furose mide 40mg IV at the mid-point o f the first feed
m
se
As
Give hydrocortisone 200mg IV at the mid -point of the first feed
Dr
Provide 50% of normal energy and protein requirements for the first 2 days
Start a saline infusion with 20 mmol of potassium for the first 8 hours
Provide 75% of normal energy and prot ein requirements for the first 2 days
Give furosemide 40mg IV at the mid-point of the first feed
Give hydrocortisone 200mg IV at the mid-point of the first feed
m
Give 50% of normal energy intake in starved patients (> 5 days) to avoid refeeding
se
As
syndrome
Dr
A 28-year-old wo man who is 32 weeks pregnant presents w it h itch.
On examination her abdomen is non tender w ith t he uterus an appropriate size for her
gestation. There is no visible rash, although she is mildly j aundiced. Her heart rate is
74/min, blood pressure 129/ 62mmHg, resp iratory rat e 20/ min, o xygen saturations are
98% in air, t emperature 36.8°C.
A set o f blood resu lt s revea l:
Hb 110 g/ 1 Na• 139 mm ol/ 1 Bilirubin 54 IJmOI/1
Plat elet s 243 109/ 1 K• 4 . 1 mmol/1 ALP 353 u/1
WBC 8 .2 109/ 1 Urea 4 .6 mmol/1 ALT 84 u/1
Neuts 5.7 109/ 1 Creatinine 74 iJmOI/1 yGT 207 u/1
Lymphs 1.8 * 109/ 1 Albumin 34 g/1
Int rahepatic cholestasis o f pregnancy
HELLP syndrome
Pre-eclampsia
Acute fatty liver o f pregnancy m

se
As
Biliary co lic
Dr
Intrahepatic cholestasis of pregnancy
li! ELLP syndrome

-
~
Pre-eclampsia
Acute fatty liver of pregnancy
Biliary colic
The answer here is intrahepatic cholestasis of preg na ncy.
This is a common cause of itch in the third trimester of pregna ncy. It will give a cholestatic
picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT.
Patients may also be jaundiced with right upper quadrant pain and steatorrhoea.
Ursodeoxycholic acid is a common treatment.
The cholestatic LFTs could indicate biliary colic, however the absence of abdominal pain
he re makes it very un likely.
Acute fatty liver of pregnancy also occu rs in the third term of pregnancy but a hepatic
picture would be expected on LFTs, with a rise in ALT/AST greate r than that of ALP, a
raised white cell count and potential clotting abnormalities. This condition is rare and
pati ents are likely to be unwell with nausea, vomiting, jaundice and possible
encephalopathy.
In HE LLP synd rome you would see a haemolytic anaemia, th e mild anaemia seen here
does not correlate with th is and also low platelets not seen here.
em
This lady is not hypertensive and does not have any other features of pre -eclampsia so
s
As
this is un likely. In late pre -eclampsia a hepatic derangement of LFTs mig ht be seen.
Dr
A 47 -yea r-o ld man with a histo ry o f alco ho l live r disease is adm itted to the
g astroentero lo gy ward. He has d eve lo ped tense ascites a ga in and a pla n is made to site
a n ascitic dra in. His renal functio n after 2 d ays is as fo llows:
Na• 131 mmol/ 1
K• 3.8 mmolfl
Urea 12.2 mmol/ 1
Which of the fo llowing pathophys io log ical changes is most li kely to be respons ible fo r the
d eclinin g rena l function?
Spla nchnic vasoconstriction
Spla nchnic va so dilatio n
Am monia- induced nephropathy
Intra hepatic portosystem ic shu nting of blood
m
se
As
Renal a rte ry vasodilatio n
Dr
Splanchnic vasoconstrictio n
I Spla nchnic vasodilation
Ammonia-induced nephropathy
Intrahepatic portosystemic shunting of blood
Renal artery vasodilation
m
se
Hepatorenal syndrome is primarily caused by splanchnic vasodilatio n
As
Dr
A 73-yea r-old man comes to the gastroentero logy clinic fo r review. He has moderate
aortic ste nosis but is cu rrently not keen to p rogress to va lve rep lacement. He presents
with persistent iron d eficiency anaemia fo r which no cause has been fou nd in spite of o ne
up per GI e ndoscopy a nd two colo noscopies. What is the next most app rop riate step?
CT abdomen
Capsule endoscopy
Intra-operative enteroscopy
Labelled white cell scan
m
se
As
Repeat upper GI en doscopy
Dr
CT a bdo men
Capsule endoscopy
Intra-operative ente roscopy
Labe lled white ce ll scan
Repeat upper GI en doscopy

-
"""
There is a suspicion here that the patient may have Heyde's syndrome, with aortic
stenosis and a ngiodys plasia resu lting in ch ron ic gastro intestinal blood loss. The repeated
negative upper and lower GI endoscop ies sugg est that small bowe l a ng io dysplasia may
be the cause, in an area which is difficult to image via conve ntional end oscopy. In this
s ituation capsu le e ndoscopy has a higher yie ld and would be the a pp ro p riate next step.
The patho phys io logy o f angi odysplasia in this situation isn't known, a lthou gh it may be
d ue to changes in p ressure withi n the mesente ric venous plexus, a s the cond ition ofte n
resolves once the va lve is treated.
CT abdomen d oesn't have su itab le resolutio n to identify a reas of ang iodysp las ia, a nd a
re peat uppe r GI e nd oscopy is un li kely to identify a cause of bleeding give n the first
investigation was neg ative. La bell ed white cell sca nning is most useful in cases of ma rked
blood loss, and intra -o p erative ente roscopy is usually conside red if repeat endoscop ies
m
se
a nd ca psu le testing are neg ative. Intra-operative enteroscopy a lso ca rries greater risk until
As
the valve is repaired .
Dr
A 78-yea r-old woman presents with persistent diarrhoea. Her symptoms started around
three months ago and she is now passing frequent 'mucous' like stoo ls. There is no visible
blood in the stool and her weight is stable. Bloods show the following:
Hb 11.6 g/dl
Platelets 222 * 109/J
WBC 7.8 * 109/ 1
Na• 144 mmol/ 1
K• 3 .1 mmol/1
urea 8 . 2 mmol/1
Creatinine 10l1Jmol/ l
Diverticu lar disease
Ang iodysplasia
Tubular a denoma
Colon cancer
m
se
Vi llous adenoma
As
Dr
Diverticu lar disease fD
Ang io dysplasia
Tubular adenoma CD
-
Colon cancer (fD
I Villous adenoma CD
m
se
Diarrhoea + hypokalaemia - villous adenoma
As
Dr
Which one of the following investigations is considered the gold standard fo r the
diagnosis of gastro-oesophageal reflux disease?
Endoscopy
24hr oesophageal pH monitoring
Oesophageal manometry
Barium swallow
m
se
As
CT tho rax
Dr
Endoscopy
24hr oesophag eal pH monitoring
Oesophagej l manometry
Barium swa llow
CT tho rax
m
se
24hr oesophageal pH monitoring is gold standa rd investigation in GORD
As
Dr
A 67-year-old man is investigated for dyspepsia. A gastroscopy reveals a suspicious lesion
which is biopsied. Which one of th e following findings on biopsy wou ld be most
consistent with a diagnosis of gastric adenoca rcinoma?
Columnar metaplasia
Histiocytic infiltration
Paneth cell metaplasia
Giant cell granulomas
m
se
As
Signet ring cells
Dr
Columnar metaplasia flD
Histiocytic infiltration .
(D
Paneth cell metaplasia CD

Gia nt cell granulomas m
Signet ring cells ED
m
se
Gastric adenoca rcinoma - signet ring cells
As
Dr
A 30-yea r-old wo man presents with abdomina l pain that is associated with a lternati ng
dia rrhoea and constipation. Which one of the fo ll owing symptoms is least consistent with
a dia g nos is of irritable bowel synd rome?
Feeling of incomplete stool evacu ation
Waki ng at nig ht due to the pain
Abdo mina l bl oating
Faecal urge ncy
m
se
As
Pa ssag e o f mucous with sto ol
Dr
Feeling of incomplete stool evacuation .
CD
I Waking at night due to the pain CD

Abdomina l bloating CD
Fae, al urgency fD
Passage of mucous with stool GD
m
se
Pain which wakes a patient at night is not a feature that would be expected in irritable
As
bowel syndrome.
Dr
A 50-year-old man who is known to have obesity and hypertension comes for review. His
cu rrent BMI is 38 kg/ m " 2 and blood pressure t oday is 154/ 92 mmHg despit e ramipril and
bendroflumethiazide. Lifestyle and a trial of orlist at have failed t o reduce his weight.
Which one of the following is the most suitable int ervention?
Biliopancreatic diversion with duodenal switch
Laparoscopic-a djust able gastric banding
Trial of sibutramine
Referral for counselling to discuss his excessive eating
m
se
As
Sleeve gastrecto my
Dr
Biliopancreatic diversion with duodena l switch
I Laparosco pic-adjustable gastric banding
Trial of sibutram ine
Referra l for counsell ing to discuss his excessive eating
Sleeve gastrectomy
A tria l o f s ibutramine would not be app ropriate given his poorly controlled hypertension.
m
se
La parosco pic-adjusta ble gastric banding is the intervention of cho ice in patients with a
As
BMI < 40 kg/m"2.
Dr
A 58-yea r-old ma le was ad mitted for bowel obstructio n 2 weeks ago, treated with b owe l
rest, a nd after seve ra l d ays commenced o n intravenous tota l pa rental nutrition. Murphy's
sign neg ative, an d no abdomina l pa in is present. His cu rrent medications inclu de
panto prazole 40mg daily, pa racetamol l g QID, mo rp hine 3.Smg subcutaneous PRN &
perindop ril Smg day.
Hb 130 g/ 1
Plat elet s 140 * 109/ 1
WBC 6 . 7 * 109/ 1
Na• 135 mmol/ 1
K• 3.4 mmol/1
Urea 8 . 5 mmol/1
ALP 150 u/1
ALT 328 u/1
AST 340 u/1
yGT 180 u/1
Albumin 30 g/1
I NR 1.2
USS abdomen is unre markable. What is the like ly cause o f his abnormal blood tests?
Pa racetamol toxicity
Choledocholithiasis
Ischaem ic hepatitis
Budd -Chia ri syndro me

sem
As
TP N-re lated LFT deran gement

Dr
Paracetamol toxicity
Choledocho lithiasis
Ischaemic he patitis
Budd-Chia ri syndrome
TP N-related LFT deran gement
The key here is the presence ofTPN, rise of ALT/ AST less than 1000 (unlikely ischaemic or
pa raceta mo l) and no abdomina l pai n (In Budd -Chiari you would expect some abdo mina l
pain, and findings on ultrasound). For ischaemic hepatitis the stem would have given
info rmation about cardiac arrest. If it was pa raceta mol ingestion, the ste m wou ld have
m
se
indicated as such. Both pa raceta mol and ischaem ic he patitis will often have transaminases
As
in the thousands .
Dr
A 72-year-o ld female is adm itted with diarrhoea to the acute med ical unit. A
s igmoidoscopy is perfo rmed wh ich shows multip le white p laques adhered to the
gastro intestina l mucosa. What is the most likely d iagnos is?
Crohn's disease
Ulcerative col itis
Ischaem ic colitis
Pseudomembranous colitis
m
se
As
Colorectal cancer
Dr
--
Crohn's disease CD
Ulcerative colitis CD
Ischaemic colitis (D
'
I Pseudomembranous co litis GD
m
se
m
As
Colorectal cancer
Dr
A 43-yea r-old man is reviewed in the gastroenterology clinic. He has had troublesome
dyspepsia fo r the past s ix months which has not settled with proton pu mp inhib itor
the ra py. Du ring the review of systems he also re po rts passing 6-7 wate ry stools per d ay.
An OGD 3 weeks a go showed g astric e rosions and ulcers. Which one of the following
investigations is most likely to be diagnostic?
Serum amylase
Urea breath test fo r Helicobacter pylori
Fasting g astrin
14C-xylose breath test
m
se
As
CT abdomen
Dr
Serum amylase
Urea breath test for Helicobacter pylori
Fasting gastrin
14C-xylose breath test
CT abdomen
m
se
CT abdomen has a sens it ivity of only 50% for p rimary tumou rs in Zo llinger-EIIison
As
syndrome (ZES). Normal levels o f fasting g astrin in untreated ZES are extremely rare
Dr
Which one o f t he followin g is most associat ed with oesophageal cancer?
Coeliac disease
Hypothyroidism
Crohn's disease
Addison's disease
m
se
As
Ulcerat ive colitis
Dr
I Coel iac d isease
Hypothyro idism
CJD
.
(D
Cro hn's d isease ED

I Adcllson's disease fD
m
se
Ulcerative colitis (D
As
Dr
What is t he most com mon cause of hepat ocellular carcinoma in the United Kingdom?
Haemochro matosis
Hepatitis B
Alcoho l excess
Aflatoxin
m
se
As
Hepatitis C
Dr
Haemochromatosis
Hepatitis B
•
6D
r :coho l excess 6D
I
Aflatoxin
Hepatitis C
•
GD
Hepatocellu lar carcino ma

• hepatit is B most com mon cause worldwide
m
• hepatit is C most co mmon cause in Euro pe
se
As
Dr
A 35-yea r-old woman is admitted to the Emergency Department followin g a deliberate
overdose of 50 paracetamo l tab lets around 10 hours ago. On adm iss ion she complai ns o f
abdominal pain and lethargy. Her prothrom bin time is elevated and arterial blood gases
show that she is develop ing a metabo lic acidosis. An urgent transfer to the tertia ry liver
transplant unit is arranged. What is the main pathological process seen in the hepatocytes
of such patients with ful minant hepatitis?
Apoptosis
Fibrosis
Ischaemia
Senescence
m
se
As
Necros is
Dr
Apoptosis GD
Fibr0 sis m
Ischaem ia CD
Senescence m
Necrosis CD
In patients such as this one necrosis affects the entire acinus (pa nacinar necrosis) resulting
m
in live r failure . This is in contrast to the a poptos is seen in patients with mi ld cases of viral
se
As
hepatitis, resu lting in the possibility of regeneratio n and recovery of hepatocellular
function.
Dr
A 24-yea r-old man is b rought to the eme rgency department by a mbulance with p rofound
haematemesis. He was discha rged three months ago fo llowing a sma ll e pisod e of
haematemesis where he was found to have a posterior g astric ulcer and was treated
endoscopica lly initia lly a long with Helicobacter pylori e radication therapy. He had a fo llow
up gastroscopy four weeks later which showed some active oozing from the ulce r
a lthou gh it ap pea red to be hea ling. Fu rthe r e ndosco pic treatment was perfo rmed at the
time. He reports that since then he has had two ep isodes of dark stoo ls but they resolved
on thei r own.
On exam ination he has a pulse rate o f 143 bpm, a blood p ressu re o f 98/ 61 mmHg and a
ca pillary refill time of 4 seconds centrally. He has no past medical history and he only
ta kes lansop razole 30 mg d a ily regula rly.
Given the history, which of the followi ng treatments is most ap propriate to manage this
man's bleeding ulcer?
Laparotomy a nd su rgica l exploratio n
Repeat e ndosco pic treatment
Intrave nous proton-pum p inh ibito r therapy
Insertion of a Sengstake n-Bia ke mo re tube
m
se
As
Intrave nous terlipressin
Dr
Laparotomy and surgical exp loration
Repeat endoscopic treatment
Intrave nous proton-pum p inhib itor the rapy
Inse rtion of a Sengstaken -Bia kemore tube
Intrave nous terlipressin
Su rgery is indicated in patients with ongoing acute bleed ing despite repeated
endoscopic the ra py
A repeat end oscopy g iven two previous trea tments is u nlikely to be effective a nd it wo uld
be more a ppro priate to proceed to su rgica l exploration a nd repair of the ulcer at
la pa rotomy. The pos ition of the ulcer sug gests invo lvement of one of the large vessels
supp lying the fo reg ut, eithe r the right o r left gastric arteries o r the gastroduodenal a rte ry,
and the refo re a n urg ent su rgica l procedure is more likely to be successful in arresti ng the
b leeding.
While he will li kely re ce ive intravenous proto n-p um p inhibitors a nyway, these alone a re
unli kely to be of a ny help g iven the seve rity of the bleeding.
m
se
Te rlip ressin a nd use o f a Sengstaken-Biakemore tube a re both treatme nts fo r
As
oesophag eal va rices and wou ld be of no benefit in treating this ma n's ulce r.
Dr
A 52-yea r-o ld woman is diagn osed with non-a lco holic steato hepatitis following a liver
biopsy. What is th e s ingle most importa nt ste p to help p revent the pro gressio n o f he r
disease?
Stop smoking
Sta rt statin therapy
Ea t more omeg a-3 fatty a cids
Sta rt sulfonylurea the rapy
m
se
As
Weight loss
Dr
Stop smoking CD
Start statin therapy .
(D
Eat more omega-3 fatty acid s m

Sta rt sulfonylurea therapy m
I Weight loss fD
m
se
Weight loss is the best first line management for NAFLD
As
Dr
A 30-year-old ma n enquires about screening for haemochromatosis as his b rother was
diagn osed with the condition 2 years a go. The patient is currently well with no featu res
suggestive of haemochromatosis. What is the most ap propriate investigation?
Seru m total iron- binding capacity
HFE gene analysis
Seru m transferrin saturation
Seru m ferritin
m
se
As
Seru m iron
Dr
Serum to tal iron- binding capacity
H FE g ene analysis
Serum transferrin saturation
Serum ferritin
Serum iron
Screening for haemochro matosis

• g eneral population: transferrin saturation > ferritin
• family members: HFE genetic testing
Serum transferrin sat uration is cu rrently the p referred investigatio n for popu lation
screening. However, t he patient has a sibling with haemochromatosis and therefore HFE
m
se
gene analysis is th e most suita bl e investigation. In clinical p ractice this wou ld be
As
combin ed with iron studies as well
Dr
A 26-year-old man is investigated for diarrhoea and weig ht loss. A bowel biopsy shows
findings co nsistent with Crohn's disease. Which one of the fo llowing factors is like ly to be
the most important aetio logica l factor?
A diet with an increased ratio of omega-3 to omega-6 polyunsaturated fatty acids
Smo king
A diet low in vitamin B6
High levels of su lfate-reducing bacteria in the gut
m
se
As
Genetic pred isposition
Dr
A diet with an increased ratio of omega-3 to omega-6 polyunsaturated fatty acidsfD
Smoking
~ diet low in vitam in B6

High levels of su lfate-reducing bacteria in the gut
I Genetic predisposition
Cro hn's disease is known to have a strong genetic component - sib lings are 30 tim es
-
~
more like ly to d eve lop Crohn's than the genera l po pulation.
m
se
Remember, smokin g is bad for Crohn's in the sense it makes fla res on more likely (in
As
contrast to ulce rative colitis) but it is not thought to be a cause o f Cro hn's di sease.
Dr
A 25-year-o ld man presents with b loody diarrhoea associated with systemic upset. Blood
tests show the fo llowing:
Hb 13.4 gfdl
Plat elet s 467 * 109/ 1
WBC 8 .2 * 109/ 1
CRP 89 mg/1
A diagnosis o f u lcerative colitis is suspected . Which pa rt of the bowel is most likely to be

a ffected?
Sigmoid colon
Rectum
Ascending colon
Descend ing colon
m
se
As
Terminal ileum
Dr
Sigmoid colon CD
Rectum CD
Ascending colon m
Descending colon fD
Terminal ileum tiD
m
se
Ulcerative colitis - t he rectum is the most com mon site affect ed
As
Dr
A 76-year-old woman with a history of atrial fibrillation presents with abdominal pain and
bloody diarrhoea. On examination her te mperature is 37.8°C, pulse 102 1 min and
respiratory rat e 30 I min. Her abdomen is tender w ith generalised guarding. Blood test s
reveal the follow ing:
Hb 10.9 g/dl
MCV 76 fl
Pit 348 * 109/ J
WBC 23.4 8
109/ J
Na• 141 mmol/ 1
K• 5.0 mmol/1
urea 8 .0 mmol/1
Diverticulitis
Campylobacter infection
Ruptured abdominal aortic aneurysm

sem
As
Ulcerative colitis
Dr
Diverticu litis
Ca'lpylobacter infection
Ruptured abdominal aortic aneu rysm
Ulcerative colitis
m
se
The low bicarbonate points to a metabolic acidosis - highly suggestive of mesenteric
As
ischaemia.
Dr
A 43-yea r-old man presents to the emergency d epartment with severe right upp er
quadrant abdom inal pa in. It develo ped to maximum intensity over the cou rse of a day.
On exam ination it is noted that he also has gross ascites an d a 3cm live r ed ge is noted.
He is not jaundiced. Bloods a re as follows:
Hb 195 g/ 1
Platelet s 60* 109/ 1
WBC 9 * 109/ 1
What is the most likely underlying pathology?
Schisto so miasis
Hepatitis A
Pancreatic cancer
Essentia l throm bocythaemia (ET)
m
se
As
Polycythaem ia rubra vera (PRV)
Dr
Schistosomiasis GD
Hepatitis A tiD
Pae reati c cancer a
Essential thro mbocythaemia (ED GD
I Polycythae mia rubra vera (PRV) GD
Budd -C hia ri syndro me is most like ly due to a thrombo philia

This is a classical presentation of Budd-Chiari syndrome - a triad of abdomina l pain,

he patomeg a ly and ascites. It is occlusion o f the hepatic ve in s that drain the live r that
causes a pa in ful distension o f the liver capsu le and backflow portal hypertension - which
will lea d to the ascites.
Schistoso miasis can cause he patic fibrosis and portal hypertension. Howeve r, there is no
history to suggest this (it is end em ic in sub-Saha ra n Africa). He patitis A can cause acute
liver fa il ure, but jaundice wo uld be expected and ascites would be unusua l.
Pancreatic cancer can very rare ly cause a secon da ry Budd -Chia ri syndro me by
comp ression of the he patic ve ins.
Howeve r, primary Bud d-Chiari is the most common cause - and thrombophilias a re the
most common trigger. In this case ET is excluded by the low platelets (wh ich is a lso a
hall ma rk o f the porta l hypertension) and the high Hb is suggestive of PRV. JAK2 testing in
this case would b e diagnostic.
em
Othe r imp ortant causes are Antiphospholi pid synd ro me, p regnancy a nd Paroxysmal
s
As
nocturnal haemo glo bi nuria .

Dr
Which one o f the following is most strongly associated w ith coel iac disease?
HLAAS
HLA-DQ2
HLA-DR2
HLA-DR4
m
se
As
HLA-827
Dr
HLAAS €D
I HLA-DQ2 CiD
HLA-DR2 GD
----<
HLA-DR4 CD.
m
se
HLA-827 GD
As
Dr
A 66-year-old comes for review. He had a prosthetic aortic va lve replacement five yea rs
ago for which he is warfarinised. Over the past three months he has been complaining of
fatigue and a full blood count was requested:
Hb 10.3 g/dl
MCV 68 fl
Pit 356 * 109/1
WBC 5.2 * 109/ 1
Blood film Hypochromia
INR 3.0
An upper GI endoscopy was reported as normal. What is the most appropriate next
investigation?
Transthoracic echocardiogra m
Colonoscopy
Th ree sets of blood cultures
Transoesophageal echocardiogram
m
se
As
Reticu locyte count
Dr
Transthoracic echocardiogram
Colonoscopy
Tt : sets of blood cu ltures
Transoesophageal echocardiogram
Reticu locyte count

-
""""
m
se
Any patient of th is a ge with an unexplained microcytic anaemia sho uld have a lower
As
gastro intesti na l tract investigation to exclude colorectal cancer
Dr
A 32-yea r-old woma n presents with a 2-month histo ry of secon da ry ameno rrhoea. This is
a ssociated with a no rexia, nausea and fatigue. She has a past med ical history o f pe rnicious
anaemia and type 1 dia betes mellitus.
On examination: no p eriphe ral stig mata o f liver disea se, JVP 2cm, mild scleral icte rus,
tend e rness in the rig ht hypochondrium with no rigidity or g ua rdin g an d a 2cm live r ed ge.
Blood s:
Hb 12.2 gfdl
wee 19.2 g/dl
Platelet s 344 g/ dl
Na+ 139 mmol/ 1
K+ 4.3 mmol/1
Urea 4 .7 mmolfl
CRP 48 mg/1
Bilirubin 78 iJffiOI/1
ALT 368 iu/1
ALP 190 iu/1
Albumin 34 u/1
Anti-LKM Antibodies positi ve
Which immunog lobuli n type wo uld you expect the patient to have high tit res of?
IgA
Ig D
Ig M
IgG
s em
Ig E
As
Dr
IgA f!D
rlgD
Ig M
•
flD
~ ED
IgE
•
Autoimmune hepatitis is commonly associated with young to middle aged females. The
condition is linked with other autoi mmu ne conditions including: coeliac disease,
pernicious anaemia, thyroiditis and type 1 diabetes mel litus.
The pathophysiology of the disease is a T-cell med iated progressive necro-inflam matory
process resulting in fibrosis and cirrhosis. The disease is characterised by an IgG
hypergam mag lobulinaemia.
Disease Associated raised immunoglobulin subtype
Alcoholic liver disease IgA
Primary biliary cirrhosis IgM
Autoimmune hepatitis IgG

sem
As
Dr
A 40-year-old female patient co mes to see you in cl inic with a recent diagnosis of
hereditary non -polyposis colorecta l cancer (HNPCC). Other t han co lorect al cancer, o f
which of these malignancies is she most at risk?
Vaginal cancer
Breast cancer
CervicaI cancer
Endometrial ca ncer
m
se
As
Ovarian cancer
Dr
Vaginal cancer fD
Breast cancer
C rvicaI cancer
•m
Endometrial cancer ED
Ovarian cancer EJD
In female patients, endometrial cancer is the most common extra-colonic manifestat ion of
HNPCC. The exact risk depends on H NPCC genotype (60% lifetime risk in MLHl, 20% in
MSH2). In fact, some studies show that women wit h the M LHl genotype are more at risk
o f endometrial cancer t han co lo recta l cancer.
Rates of ova rian cancer are also increased in HNPCC but not to the same extent (1 -20%
depending on genotype).
There is no co nf irmed link between b reast cancer and HNPCC, however this has been
suggested. There is no link between H NPCC and vag inal or cervical cancer.
m
There is no co nsensus about t he va lue of endometrial screen ing fo r women for HNPCC,
se
and current guidelines suggest that this takes place only within the context of a clin ical
tria I. As
Dr
Which o f t he follow ing drug s is least likely to cause cholestasis?
Anabolic steroids
Erythromycin
Prochlorperazine
Halothane
m
se
As
Flucloxacillin
Dr
Anabolic steroids CD
Erythromycin flD
Prochlorperazine CD
Halothane GD
m
se
Flucloxacillin flD
As
Dr
A 67 -yea r-o ld ma n p resents with sho rtness -o f- breath. He ha s a past history o f aortic
stenosis but is otherwise well. On examination he has a systolic murmur and a clear chest.
Routine b loods a re as fo llows:
Hb 8 .7 g/ dl
MCV 71 fl
Pit 277 * 109/1
WBC 6 .4 * 109/ 1
Which one o f the followin g investigations is most li kely to explain his anaemia?
Colonoscopy
Renal biopsy
Duod ena l biopsy
Gastroscopy
m
se
As
Echocardiogram
Dr
Colonoscopy fiD
Renal biopsy m
Dj odenal biopsy m
Gastroscopy f!D
Echoca rdiogram m
m
se
This patient most likely has angiodysplasia which has a known association with aortic
As
stenosis.
Dr
You are reviewing a 59-year-old male in the g astroent erolo gy out-pat ient clinic follow ing
a a recent su rveillance ultrasound scan for hepatocellular carcin oma (HCq. This
d emonstrat ed three new liver lesions w hich were not p resent on his scan from six months
p reviously. A t riple phase CT performed following his ultrasound scan conf irmed t hree
lesions measuring 6cm, 4.5 em and 1.9 em that all show arterial enhancement with ven ous
washout. Evidence of vascu lar and lymphatic invasion is also ident ified.
His medica l history is notable for Child -Pugh C cirrhosis seco ndary to a comb ination of
haemochromatosis and previous heavy alcohol use. This has been complicated by one
ep isod e o f variceal bleeding 18 months previously and recurrent episodes of
encephalopathy. The latter has been successfully managed medically since the
introduction of rifaxim in at his last clin ic review.
With respect to the likely diagnosis of HCC, what is the most approp riate management?
Best sup portive care
Sorafenib
Radio Frequency Ablation (RFA)
Resect ion of the affect ed lobe
m
se
Transarterial chemo embolization (TACE) As
Dr
I Best sup portive care
Sorafenib
-
~
Radio Frequency Ablati on (RFA)
Resection o f the affe cted lobe
Transarte rial chemoembolizatio n (TACE)
Hepatocellular carcino ma (HCC) shou ld be managed according to the Ba rcelona

Class ification fo r Live r Cance r Treatment System.
Patients with Ch ild-Pugh A cirrhosis without s igns of porta l hypertension who have single
lesions <2cm in size shou ld b e treated with surgical resection.
For those patients with Ch ild-Pugh A and B cirrhosis a nd 2-3 tu mours < = 3 em o r 1
t u mour < =5 em without vascular invasion o r extra hepatic sp rea d should be cons idered
fo r liver tra nsplantation. As a brid ge to liver tra nsplantation these p atients can b e treated
with TACE or RFA.
For those patients who have Child -Pu gh A orB cirrhosis , good performance status, an d
evidence of vascular, lymp hatic or extrahepatic spread the multiple tyros ine kinase
inhibitor, Sora fenib, has been shown to pro long su rvival.
Those with Child-Pug h C cirrhosis have end -stage live r disease and a re poor cand id ates
fo r therapy as they lack any hepatic functional reserve to tole rate either resection, TACE o r
RFA. These patients are best treated symptomatically. Ea rly involvement of community
em
a nd/ o r hospita l pa lliative ca re teams should be considered . Best suppo rtive care is
s
therefo re the correct option he re .

As
Dr
Which one of the following drugs used in the management of diabetes mellitu s is most
likely to cause cholestasis?
Metformin
Gliclazide
Aca rbose
Pioglitazone
m
se
As
Insulin
Dr
Metformin GD
Gliclazide CD
Acarbose tiD
Pioglitazone f.I!D
Insulin D
m
se
Sulphonylureas may cause cholestasis
As
Dr
A 47 -yea r-old female patient attends her GP w ith a one week history of nausea, upper
abdominal discomfort and acid reflux. Four weeks earlier she had complet ed a
Helicobacter pylori (H. pylon) eradication therapy, consisting of omeprazole, amoxicillin
and clarithromycin. What is the most appropriate next step in the management of th is
patient?
Re-test for H. pylori using a carbon-13 urea breath test
Refer the patient for an upper GJ endoscopy
Re-test for H. pylori using a stool antigen test
Commence second-line treatment for H. pylori with omeprazole, amoxicil lin and
doxycycline
m
se
Commence second-line treatment for H. pylori with omeprazole, amoxicil lin and
As
metronidazole
Dr
Re-test for H. pylori using a carbo n-13 urea breath test
Refer the patient for an upper Gl endosco py
Re-test for H. pylori using a sto ol a ntigen test
l com mence second -line H. with omep razole, amoxicillin an d

I treatment for pylori doxycycl ine
Commence second -line H. with omeprazole, amoxicillin a nd

treatment for pylori metronidazole
The presentation of th is patie nt sugg ests an inad eq uate respo nse with her initia l H. py lori
era dicatio n regime. Expe rt o pinio n recommends re -testing for H. pylori befo re seco nd -
lin e treatment is conside red to confirm e rad icatio n as there a re serious si de effects
a ssociated with a ntibiotics, e.g. Clostridium difficile infection, and antibiotic resistance is
increasing.
According to the British Infectio n Association! , the ca rbo n-13 urea breath test is the most
a ccu rate method of re -testing fo r H. pylori. This should be perfo rmed 4 weeks a fter the
eradicatio n the rapy s ince antibiotics a nd proton pump inhibito rs (PPis) ca n sup press the
bacte ria causing a fa lse negative result.
A PPI, amoxicillin a nd clarithromycin o r a PPI, a moxicillin a nd metro nidazole is typica lly

used first-li ne in H. pylori e radication. Seco nd-line treatment will use a PPI, a moxicillin a nd
either cla rithromycin or metronidazole whichever was not used fo r first -li ne treatme nt.
In patie nts who have a n inadeq uate res ponse to second -li ne treatment, patients shou ld
be re fe rred fo r upper GI endoscopy.
em
1.
s
As
https://www.gov.uk/government/uploads/ system/ uploa ds/ attachmentda ta/file/ 346305/He l

Dr
A 34-year-old fema le with a history of alcoholic liver disease is admitted with frank
haematemesis. She was discha rged three months ago following treatment for bleed ing
oesophageal varices. Following resuscitation, what is the most app ropriate treatment
whilst awaiting endoscopy?
Oct reotide
Omeprazole
Proprano lol
Tranexamic acid
m
se
As
Terlip ressin
Dr
Octreotide Cl!D
Omeprazole m
Propranolol CD
Tranexamic acid
Terlipressin GD
•
m
se
As
Terlipressin is the only licensed vasoactive agent for va riceal haemorrhage in the UK
Dr
The most common type of inherited colorectal cancer:
Familial adenomatous polyposis
Li-Fraumeni syndrome
Hereditary non-polyposis colorectal carcinoma
Fanconi syndrome
m
se
As
Dr
Familial adenomatous polyposis fD
Li -Fraumeni syndrome fD
Hereditary non-polyposis colorectal carcinoma GD
Fanconi syndrome fD
m
se
m
As
Dr
A 57-yea r-old gentleman p resents to the emergency department compla in ing of nausea,
vomiting and a bdom in al pain. His urine and serum test results show elevated ketone
levels and his serum g lucose level is 3mmol/l. An ABG is performed and shows the
following results:
pH 7.24
Pa0 2 14.7 kPa
PaC0 2 3. 5 kPa
HC03 13 m Eq/l
Which one o f the followin g is most likely to be responsib le fo r these findings?
Hype ros molar hyperglyce mic state
Diabetic ketoacid osis
Alcoholic ketoacidosis
Diabetic hypoglycemic episod e
m
se
As
Gastroente ritis
Dr
Hyperos molar hyperglycemic state
Alcoho lic ketoacidosis
Diabetic hypoglycemic episode
Gastroenteritis
-
~
Metabolic ketoacidosis with norma l or low glucose: think alco hol

Th is gentlema n is suffering a metabolic ketoacidosis with pa rtial respiratory

compensation. Diabetic or alcoho lic ketoacidosis cou ld cause this, howeve r, a serum
glucose of 3mmoi/L makes d iabetic ketoacidosis unl ikely to be the cause. Hence this
patient is li kely to be suffering from alcoholic ketoacidosis.
A hyperosmolar hyperg lycem ic state wou ld present with raised serum glucose and normal
ketone leve ls.
A diabetic hypoglycemic episode wou ld not usually p resent with a ra ised ketone level o r
metabo lic acidosis.
m
se
Gastroenteritis may present with electrolyte d istu rba nces and in some cases a metabolic
As
acidosis, however, se rum ketone leve ls would not usually be e levated.

Dr
A 35-yea r-old woman is referred to hospital. As pa rt of a liver screen the fo llowing results
a re o btained :
Anti-HBs Negative
Anti-HBc Positive
HBs antigen Positive
IgM anti-HBc Negative
Anti-HBs = Hepatitis B Surface Antibody; Anti-H Bc = Hepatitis B Core Antibody: HBs antigen = Hepatitis B
Surface Antigen
What is the patient's hepatitis B statu s?
Proba ble hepatitis D infection
Previous immu nisation to hepatitis B
Chro nic hepatitis B
m
se
As
Previous he patitis B infection, not a carrier
Dr
Proba ble hepatitis 0 infection
Chronic hepatitis B
Previous hepatitis B infection, not a carrier
m
se
As
The negative IgM anti-HBc points to a chronic rather than acute infection.
Dr
A 45-year-old man p resents t o his GP. He has had a series of b lood t ests as part of a
p rivate medical screening test t hat have d emonstrated abnormal liver f unctions t ests. He
is f it and well, asymptomatic and drinks around 40 u nits of alcohol per week.
ALP 100 u/1
ALT 67 u/1
yGT 110 u/1
Albumin 40 gjl
Other bloods, including FBC, U&Es and fasting glucose were normal. You arran ge a liver
screen, results of which include:
Hepatitis B Negative
Hepatitis C Negative
Serum ferritin 550 microg/L ( 25-300 micr og/L)
Immunoglobulins Normal
Ultrasound liver Fatty changes
Transferrin saturation 4 1% ( <50%)
What is the most underlying likely cause o f t he elevated ferrit in?
Primary polycythaemia
Hereditary haemochromatosis
Excessive exercise
Alcohol excess
em
0
s
Carbon monoxide poisoni ng

As
Dr
Primary polycythaemia
Hereditary haemochromatosis
Excessive exercise
Alcoho l excess
Carbon monoxide poiso ning
m
se
The normal t ransferrin saturation effectively excl udes iron overload as a cause of the
As
raised ferritin. It is t herefore likely t hat th is is caused by his alcohol excess.
Dr
Which of the following cond itions is least associated with He/icobacter pylori?
Gastric carcinoma
B cell lympho ma of MALT tissue
Atrophic gastritis
m
se
As
Peptic u leer d isease
Dr
Gastric carcinoma CD
B cell lymphoma of MALT tissue «<D
Gastro-oesophageal reflux disease ED
Atro phic gastritis CD
m
se
Peptic ulcer d isease CD
As
Dr
Which one o f the following cond itions is most associated with angiodysplasia?
Aortic stenosis
m
se
As
Dr
Aortic regu rg itation
Ventricular septal d efect
Aortic stenosis

-
~
-
~
Ang iodysplasia is associated with aortic stenosis

The association between angiodysplasia and aortic stenosis is thought to be caused by

von Willebrand facto r (vWF) being proteolysed in the turbulent blood flow a rou nd the
aortic valve.
m
se
vWF is most active in vascular beds with high shear stress, such as angiodysplasia, and
As
deficiency of vWF increases the bleed ing risk from such lesions.
Dr
You are asked to review a 24-yea r-o ld man who has been admitted with a n exacerbatio n
o f Croh n's disease. Despite p red nisolone and mesalazine therapy for the past 3 weeks he
is still passing 6-7 watery stools per day. He has lost a consid erab le amount of weight
during this period. On exa mination he is apyrexial, haemodynamically stab le and his
abdomen is soft and non -tender. What is the most appropriate next step?
Metronidazole
Infliximab
Methotrexate
Azathioprine
m
se
As
Su rgery
Dr
Metronidazole CD
Infliximab CD
Methotrexate CfD
I Azathioprine ED
m
se
As
Surgery fD
Dr
~
A 45-yea r-old man with a histo ry o f alcoho l excess is diagnosed as having g ra de 3
oesophagea l va rices during an outpatient endoscopy. Of the following o ptions, what is
the most ap propriate management to p revent va ricea l bleeding?
Propra nolo l
Endo sco pic scle rothe rapy
Terlipressin
m
se
As
Lansoprazole
Dr
Propranolol
Endoscopic sclerotherapy
Terlip ressin
Lansoprazole
A non -cardioselective B-bloc ker (NSBB) is used for the prophylaxis of oesophageal
b leeding
m
se
As
Endoscopic sclerotherapy now has little role in t he p rophylaxis o f varicea l haemorrhage.
Dr
A 56-yea r-old man p resents with a 48 hour history of nausea, vomiting and abdomina l
tenderness. His partner accompanies him and reports an in crease in confusion. His past
med ical history includes alco hol dependence an d depress ion. On exam ination you notice
a liver flap and abdominal distention, wh ich tests positive for sh ifting dullness. He has an
AMTS score o f 6/10. Observations a re as follows: heart rate 92/ min, blood p ressu re
142/85mmHg, respiratory rate 14/min, Sp02 96%, te mperature 37.8°C.
Paracentesis is performed, which revea ls an ascitic neutrophil count of 314x106/L.
What is the most li kely o rga nism that will be found on ascitic fluid culture in this patient?
E. coli
Candida species
m
se
As
Staphylococcus epidermis
Dr
Staphylococcus aureus CD
I E. coli CD
Streptococcus pyogenes GD
l l andida species
Staphylococcus epidermis
•
tiD
Spontaneous bacterial periton itis: most common o rgan is m found on ascitic fluid
cu ltu re is E. coli
The patient in this que stion has sponta neous ba cte rial peritonitis (SBP). SB P p rese nts with
non -s pecific symptoms includ ing nausea and vom iting, abdo mina l tenderness, fever and
m
se
g eneral mala ise. Patients may a lso d evelo p hepatic encep ha lopathy. The most com mon
As
organism causing SB P is E. coli.
Dr
Which of the following drugs is least likely to cause cholestasis?
Gliclazide
Amiodarone
Chlorpromazine
m
se
As
Co-amoxiclav
Dr
Gliclazide
I Amiodarone
Chlorpromazine
m
se
Co-amoxiclav
As
Dr
A 64-yea r-old woman complains of having 'excessive wind'. She is normally fit and well
but for the past three months she has felt bloated and has been passing wind frequently.
She also com plains of vague upper abdomi nal pain and chronic diarrhoea. A hydrogen
breath test confirms a diagnosis of small bowel bacterial overgrowth syndrome. What is
the treatment of choice?
Tetracycline
Rifaximin
Cefaclor
Nitrofuratoin
m
se
Ciprofloxacin
As
Dr
Tetra cycline GD
I Rifaxim in CD
Cefaclo r
r ::trofurato in
•
CD
Ciprofloxacin f!D.
m
se
As
Tetra cyclines a re no longer com mo nly used due to wid esp read bacteria l resista nce.
Dr
A 49-year-old female is referred to the gastroenterology outpatient cl inic with a 3 month
hist ory of epigastric pain and diarrhoea. Her GP initially prescribed Jansoprazole 30mg od
but this didn't alleviate her symptoms. The only past medical history of note is
hyperparathyroidism.
Endoscopy revealed multiple duodenal ulcerations. What is the likely diagnosis?
Multiple endocrine neoplasia type II a
Coeliac disease
Multiple endocrine neoplasia type I
Autoimmune polyendocrinopathy syndrome
m
se
As
Croh n's disease
Dr
Multiple endocrine neoplasia type II a
Coeliac disease
Multiple endocrine neoplasia type I
Autoimmune polyendocrinopathy syndrome
Crohn's disease
Zo llinger-Ellison syndrome: epigastric pain an d diarrhoea

Zollinger-Ellison syndrome typically presents with multiple gastroduodenal ulcers causing

abdominal pain and diarrhoea. High -dose proton pump inhibitors are needed to control
the sympt oms. Around a third of patient s may have multiple endocrine neoplasia type I
(MEN -I), explaining the hyperparathyroidism in this patient.
MEN-I
• pa rathyroid (95%): hyperparathyroidism due to pa rathyroid hyperplasia
• pituitary (70%)
m
se
• pancreas (50%, e.g. Insulinoma, gastrinoma)
• also: adrenal and thyroid As
Dr
A 43-yea r-old man with type 2 diabetes mel litus presents with letha rgy. His current
med ications include metformin and gliclazide, although the gl iclazid e may soon be
stopped due to his obesity. A number of blood tests are o rdered which reveal the
following:
HbA1c 66 mmol/mol
Ferritin 204 ng/ml
ALP 162 u/1
ALT 120 u/1
AST 109 u/1
On discussing these results he states that he does not drink alcohol. What is the most
likely cause of these abnormal results?
Metfo rmin-induced steatohepatitis
Haemochromatosis
Acute hepatitis secondary to gliclazide
Crypto genic cirrhosis

m
se
Non -alco holic fatty liver d isease

As
Dr
M etform in -induced st eat o hepatitis CD
Haemochromatosis GD
Acute hepatitis secondary t o gliclazid e fJD
Cryptogenic cirrhosis fD
I Non-alcoholic fatty liver disease

I eD
Obese T2DM w ith abnormal LFTs - ? non-alcoho lic fatty liver disease
By far th e most likely diagnosis in an obese type 2 diabetic is non -alcoholic fatty liver
disease. This patient w ill require a liver screen, ultrasound and liver biopsy to co nfirm t he
diagn osis.
m
se
A normal ferrit in makes a diagnosis o f haemochromatos is unlikely, although it shou ld
As
always be cons idered in patients with both abnormal LFTs and diabetes.
Dr
A 59-yea r-old male with a histo ry of type 2 d iabetes me llitus treated with metformin
lgram bd and mod ified re lease gliclazide 60mg od, and hypertens ion treated with
olmesartan 40m g o d and am lo dipine Smg o d, p resents with a 2-yea r history of watery,
non-bloody dia rrhoea and p re-d efecatory abdo minal pain. He denies recent trave ls, sick
contacts, dietary chang es, other med ications o r additional system ic sym ptoms. He ha d
been on his cu rrent medications fo r 5 yea rs and the only recent change is a reduction in
his gliclazid e d ose from 120mg as his d iabetic contro l improved fo llowing un intentio nal
weight loss of l Skg . An abdominal/pelvis CT pe rformed in the emergency d epartment
revealed an oed ematous proxima l small bowel but nil else of note. On exam ination he has
p rofound muscle wasting. Results of his investigations are shown in the table below:
138 22
Hb 106 g/ 1 Na• Bilirubin Immunoglobulins Normal
mmol/1 ~mol/1
189 * K• 3.8
Plat elet s ALP 220 u/1 HLA DQ2/ DQ8 Negative
109/ 1 mmol/1
9 .0 * 7.7
WBC
109/ 1
Urea
mmol/1
ALT 33 u/1 c. diff toxins A/B Negative
7.0 *
Neuts Creatinine 87 IJmOI/1 yGT 55 u/1 Stool cul ture Negative
109/ 1
1.5 *
Lymphs CRP 2.3 mg/1 Albumin 23 g/1 Anti -TTG AB Negative
109/ 1
0.1 * Vitamin 20 Anti -endomysia!

Eosin TSH 1.0 miU/ L Negative
109/ D ng/ml AB
He proceeds to upper Gl end oscopy and biopsies on an unrestricted gluten conta ining
diet reveal sub-tota l villous atrophy. What is the most likely d iagnos is?
Crohn's disease
Collagenous sp rue
Whipp le 's disease
Drug (olmesarta n) induced enteropathy

s em
Small bowel lym phoma

As
Dr
Croh n's disease CD
Collagenous s prue flD
Whipp le's disease eD
I Drug (olmesartan) induced enteropathy ED

Small b owel lym phoma f!D
Althou gh coeliac disease is the most com mon cause of villous atro p hy, patients with
villous atro phy and negative coeliac serologies a re encounte red, posin g a diagnostic and
the rap eutic dile mma. Possible aetio logies associated with villous atro phy a nd negative
coeliac sero log ies in clude com mon variable immunodeficiency, auto immu ne ente ro pathy,
sma ll intestina l bacte ria l ove rg rowth, infection, intestinal lymphoma, colla ge nous sp rue,
c ro h n's disease, and tro p ical sp rue. Whe n coeliac sero log ies are neg ative o n a g lute n-
conta ining diet, a lternative aetio logies fo r villous atro p hy s hou ld be co ns id ere d befo re a
diag nosis of seronegative coeliac disease, to p reve nt a n unnecessary life lo ng gluten free
diet. This is pa rticularly true whe n the patient is neg ative fo r HLA DQ2/ DQ8. HLA
DQ2/ DQ8 is stro ng ly associated with coeliac disease and a negative HLA-DQ2/ DQ8
g e notype has a strong negative predictive va lue (<1% likelihood of coeliac disease b eing
p resent; a lthough please note that the conve rse of this is not true, as HLADQ2/ DQ8 has a
high preva le nce in the g e nera l po pulation). In this scena rio, a ltho ug h sero negative coeliac
disease is a potentia lly valid a nswe r, the patie nt is on o lmesa rtan, an ang iotensin ll
rece pto r blocker, which has a we ll esta bli shed association with seve re sp rue -li ke
ente ro pathy with d uod ena l vill ous atro p hy. Impo rtantly, the ente ro pathy associated with
o lmesartan can d eve lo p months to yea rs a fte r the medication is started . As such, the
o lmesartan s hou ld be discontinued a nd the patient fo ll owe d up to see if there is
resolutio n of his sympto ms. Othe r medications which have been associated with villo us
sem
atro phy include mycophe no late mofetil and azathio prine.

As
Dr
I•
A 19-year-old man is referred to the general medical cl inic. For the past six months his
family have noted increasi ng b ehavioural and speech problems. He himself has noticed
that he is more clumsy than normal and reports excessive salivation. His ol der brother
died of liver disease. Given the likely underlying condition w hat is the most appropriat e
therapy?
Vitamin 86 supplements
Venesection
Ribavirin + interferon alpha
Pul sed methylprednisolone
m
se
As
Penici llamine
Dr
Vita min 86 su pplements
Venesection
Ribavirin + interferon alpha
Pu~sed methylp rednisolone
Penicillamine
Treatment for Wilson's disease is cu rrently penici llamine
m
se
As
This man is likely t o have Wilson's disease.
Dr
A 23-year-old man is investigated for chronic diarrhoea associated with raised
inflam matory markers. A bowel biopsy is taken. Wh ich one of the following findings is
most suggestive of ulcerative colitis?
Multiple granu lomas
Goblet cell depletion
Inflam mation affecting the serosa
Cobblestone appearance
m
se
As
Skip lesions
Dr
Multiple granulomas
Goblet cell depletion
Inflammation affecting the serosa
Cobblestone app earance
Skip lesions
m
se
Ulcerative colitis - depletion of goblet cells
As
Dr
A 34-yea r-old woman with a histo ry o f alcohol excess is adm itted with abdo minal swelling
to the Acute Medical Unit. A diag nosis of ascites secondary to live r cirrhosis is made and
pa racentes is is performed. The serum creatinine on ad mission is 95 IJmo l/1. Ten days after
a d mission u rine output decreases significa ntly a nd blood tests reveal:
Na• 129 mmol/ 1
K• 3.7 mmolfl
Urea 14.2 mmol/ 1
Creatinine 22 1 ~mol/1
Album in is given to correct suspected hypovolaemia. What is the most appropriate

fu rther manag ement?
Octreotid e
Propranolol
Terlipressin
Acetylcysteine
m
se
As
Dopam in e Dr
Octreotide CD
Propranolo l G'D
I Terlip ressin 6D
Acetylcysteine
Dopam ine
•m.
m
se
As
This patient has d eveloped hepatorenal synd rome
Dr
A 23-yea r-old who is 10 weeks pregnant is reviewed by the mi dwife at the booking visit.
This is her first pregnancy and she is well apart from some sickness which is worse in the
morning and a generalised pruritus. Bloods tests including the full blood count, hepatitis
B, C and HIV se rology are normal. A slight yellow tinge of her sclera is noticed and liver
function tests are ordered:
Bilirubin 42 1Jmol/l
ALP 90 U/l
ALT 25 U/l
Albumin 34 g/ l
Gilbert's syndrom e
Gallstones
Acute fatty liver
Intra hepatic cholestasis of pregnancy
m
se
As
Primary biliary cirrhosis Dr
Gilbert's syndrome
Gallstones
Acute fatty liver
Intrahepatic cholestasis of pregnancy
An isolated rise in bilirubin in response to physiological stress is typical o f Gilbert's

syndrome
Morning sickness and pruritus are common in pregnant women. Intrah epatic cholestasis
o f pregnancy would not occur in the first trimester.
The ALP may be elevated during pregnancy but is not typically significantly elevated until
m
the thi rd trimester. Bilirubin usually falls in pregnancy.
se
As
The most likely diagnosis is, therefore, Gilbert's syndrome.
Dr
A 31-yea r-old woman who initially presented with abdominal pain and constipation is
diagnosed with irritab le bowe l syndrome. Which one of the fo ll owing b its of dieta ry
advice is it least suitab le to give?
Avoid missing meals
Restrict tea and coffee to 3 cu ps per d ay
Increase the inta ke of fibre such a s b ran and wholemeal b rea d
Reduce inta ke o f a lcohol
m
se
As
Drin k a t least 8 cups o f fluid per d ay
Dr
Avoid missing meals
Restrict tea and coffee t o 3 cu ps per d ay
Increase the intake of fib re such as b ran and wholemeal brea d
Reduce intake o f alcohol
Drink at least 8 cups o f f luid per d ay
m
se
Insoluble sou rces of fibre such as bra n and wholemea l shoul d be avoi ded in I BS
As
Dr
A 35-year-old lady presents to the emergency department with right upper quadrant
pain. She has also noticed that her skin seems slightly yellower over the last week or so
and you notice a yellow ti nge to her sclera. On further questioning, she complains of
it ch ing of her arms. Her only past medica l hist ory of note includes ulcerative colitis fo r
which she t akes mesalazine.
Given her presentation, what is the best i nvestigation to diagnose the most likely
underlying condition?
ANCA antibody testi ng
ERCP (endoscopic retrograde cholangiopancreatography)
Serum transam inase levels
Liver ultrasound
m
se
As
Liver biopsy
Dr
ANCA antibody testing
ERCP (endoscopic retrograde cholangiopancreatography)
SeruQl transam inase levels
Liver ultrasou nd
-
~
Liver biopsy
ERCP is the investigation of choice in prima ry sclerosing cholangitis

This qu estion is asking about a 35-year-old woman presenting with jaundice, right upper
quadrant pain and pruritus on a background of ulcerative colitis. This is the typical pattern
of primary sclerosing chola ngitis. The best diagnostic investigation for prima ry sclerosing
cholangitis is ERC P.
ANCA antibody testi ng may be helpful as ANCA antibodies may be positive in these
patients, however, it wou ld not be diagnostic as it can be positive in many conditions
includ ing granu lomatosis with polyangiitis or Churg-Strauss syndrome.
Serum transam inase levels will help point towards a diagnosis of primary sclerosing
cholangitis, however, will not be diagnostic. They are a very general marker for liver
damage and in primary sclerosing cholangitis they can either be normal or raised.
A liver ultrasound will likely be the first investigation used in this woman's case to look for
any other likely causes of her jaundice and pain, such as gallstones. In primary sclerosing
cholangitis, you may see bile du ct di latation, however, this would not diagnostic.
s em
A liver biopsy can be used to help in the staging of primary sclerosing cholangitis
As
however it is not used in its diagnosis.

Dr
Which one of the followin g genetic conditions is t he most p revalent in a Caucasian
population?
Wilson's disease
Sickle cell anaemia
Cystic f ibros is
Alpha-1 ant itrypsin
m
se
As
Haemochromatosis
Dr
Wi lson's disease GD
Sickle cell anaemia fD
Cystic fibrosis ED
Alpha-1 antitrypsin f!D
Haemochromatosis ED
Haemochromatosis is more common than cystic f ibrosis

Haemochromatosis is an autosomal recessive disorder w ith a carrier rate o f 1 in 10 and is
m
p resent in about 1 in 200-400 p eople. Cystic fibrosis (CF) has a carrier rate o f 1 in 25 and
se
As
is present in about 1 in 2,500 births. CF is often quoted as being the most common lethal
inherited condit ion in Caucasians
Dr
A 30-yea r-o ld woman is investigate d for chronic d ia rrhoea, bloating and tired ness. A
diag nosis of coeliac d isease is susp ected. Which o ne of th e fo llowing facto rs would
increase the likelihood o f a fa lse negative sero logy test?
Hyposplenism
Being on a g luten free diet for o ne week prior to the test
A course o f predniso lo ne one week p rior to the test
The presence o f d ermatitis herpetifo rmis
m
se
As
Select ive IgA d eficie ncy
Dr
Hyposplenism
Being on a gluten free diet fo r one week prio r to the test
A cou rse of p rednisolone one week p rior to the test
The presence of d ermatitis herpetiform is
Selective IgA deficiency
Selective IgA deficiency is mo re commo n in patients with coel iac d isease. For th is reason
IgA levels shou ld be checked when serological tests are ordered. If the patient has
selective IgA d eficiency tissue transglutam inase IgG can be measured .
m
se
Patients normally need to be fo llowing a gluten-free diet fo r at least 6 months b efore the
As
sero logy beco mes negatives.
Dr
Which one of the following is least likely to cause ma labso rption?
System ic sclerosis
Cystic fibrosis
Whipple's disease
m
se
As
Haemoch romatosis
Dr
Systemic scleros is G'D
Cystic fibrosis fD
~
Primary biliary cirrhosis CD
Wt ipp le 's disease m
m
se
CD
As
Haemochromatosis
Dr
A 34-yea r-old HIV positive man is referred to gastroenterology due to jaundiced sclera.
Liver function tests are as follows:
Albumin 34 g/ 1
ALP 540 iu/1
Bilirubin 6 7 IJmol/1
ALT 45 iu/1
Hepatic abscess
Fun gal o bstruction o f the bile duct
Duodena l adenoma
Pri mary biliary cirrhosis
m
se
As
Sclerosing cholang itis
Dr
I He1atic a bscess
Fun gal obstruction o f the bile duct
Duodena l aden oma
~erosing cholangitis
m
se
The LFTs clea rly show a cho lestatic pictu re . Given the background of HIV the most li kely
As
cause is scle rosing cho la ngitis
Dr
A 36-yea r-old ma le is seen in hepatology outpatients with a re peat hepatitis screen. He
d escribes a 1-week history o f anorexia, fatigue and jaundice. On examination there was
no perip he ral sti gmata of chro nic live r disease, JVP 3cm, mild scle ral icterus, a bdo men
was soft, non-tender, with 2cm regu lar liver edge.
Key:
HBs Ag Hepatitis B surface antigen
HBe Ag Hepatitis B E antigen
HB DNA Hepatitis B DNA titre
Anti-HBs Anti Hepatitis B surface antibody
Anti-HBc IgM Anti Hepatitis B core antibody
Anti-HD IgM Anti Hepatitis D IgM antibody
Blood s: 6 months ago
HBs Ag positi ve
HBe Ag positive
HB DNA positi ve
Anti HBs negative
Anti HBc IgM positi ve
Anti HD IgM negative
Blood s: Today
HBs Ag positive
HBe Ag positi ve
HB DNA positive
Anti HBs negative
Anti HBc IgM positive
Anti HD IgM positi ve
What termino logy best describes the patients hepatitis resu lts?
Hepatitis B positive a nd a superinfection with hepatitis D
Hepatitis B positive a nd a co- infection with hepatitis D
Hepatitis B vaccinatio n and a n active hepatitis D infection
Cleared hepatitis B infection and an active hepatitis D infection

sem
Chronic hepatitis B only

As
Dr
I Hepatitis B positive and a superinfection with hepatitis D ED
Hepatitis B positive and a co-infection with hepatitis D ED
~patitis B vaccination and an active hepatitis D infection (D
Cleared hepatitis B infectio n and an active hepatitis D infectio n (D
m
se
Chronic hepatitis Bonly (D
As
Dr
A patient is recove ring in the gastroentero logy ward a fter an u pper gastrointestinal
va riceal b leed. He has ascites and jaundice as a result of a ch ron ic hepatitis C infection.
His routine b lood tests come back s howing impa ired rena l funct ion. The results a re shown
be low. They were norma l 3 days ago when he was adm itted. Urina lysis shows no p rotein
o r b lood.
Na• 140 mmol/ 1
K• 3.8 mmol/1
Urea 11.2 mmol/ 1
Given this man's presentation, what is the most likely diagnosis?
Renal calculi
Foca l segmental glomerulone phritis
Type-1 he patorenal syndrome
Type -2 hepatorenal syndrome
m
se
As
Minimal change glomerulonep hritis Dr
Renal calculi
Foca l segmental glome rulonephritis
I Type-1 hepatorenal syndrome
Type -2 hepatorenal syndrome
( }inimal change g lomeru lonep hritis

-
~
Speed of onset can help to differentiate the type of hepatorenal syndrome

This question is asking about a patient cu rrently adm itted to hospital following an upper
GI b leed. The patient is su ffering from chronic liver fa ilure and then goes onto develop
renal fa ilure. This is the typica l history of hepatore nal syndrome.
Hepatorenal synd ro me is split into type 1 and 2. Type 1 is a rapid onset hepato rena l
syndrome (less than two weeks). This typically occu rs following an acute event such as an
upper GI bleed. Type 2 is a more gradual d ecl ine in rena l function a nd is g enera lly
associated with refractory ascites. Therefo re as his blood tests were norma l 3 days ago
this is type 1.
Renal calculi would p resent with loin to groin pai n as well as blood in the uri ne.
m
In focal seg mental glomerulonephritis o r minima l change glomerulonephritis, you would
se
As
expect to see protein o r blood in the urine and their absence helps to rule these out.
Dr
A 38-yea r-o ld fe male with a long history of a lcoho l excess p resents with abdo minal pain,
weight loss and bu lky stoo ls. What is the most su itable investig ation to confirm the
diagn osis?
Endoscopic ultrasoun d
Endoscopic retrogra de cholangiopancreatography
Ultrasound abdomen
CT abdomen
m
se
As
Endoscopy with 02 b iopsy
Dr
Endoscop ic ultrasound
Endoscopic retrograde cholangio pancreatog raphy
Ultrasound abd omen
I CT abdomen
Endoscopy with 02 b iopsy
CT pancreas is the preferred d iagnostic test for chronic pancreatitis - looking for
pancreatic calcification
m
se
This patient has chronic pancreatitis. CT is the most sensitive method to detect the
As
characte ristic pancreatic calcification which is associated with the condition
Dr
A 30-year-old woman presents with a three-month history of indigestion. There is no
history of weight loss, anorexia, dyspha gia, vom iting or change in bowel ha bit and
abdom inal examination is unremarkable. Which one of the fo llowing may decrease the
accu racy of a 13C-urea breath test?
Use of Gaviscon around 10 days ago
Use of ranitidine stopping 4 weeks ago
Course of amoxicil li n stopp ing 3 weeks ago
Use of lansoprazole stopping 6 weeks ago
m
se
As
Current use o f the combined oral contraceptive pill
Dr
I
l Use o f Gaviscon around 10 days ago
Use of ranitid ine stopping 4 weeks ago
I Course of amoxicillin stopping 3 weeks ago
Use of lansoprazole stopping 6 weeks ago
Current use of the combined oral contraceptive pill
Urea breath test - no antibiotics in past 4 weeks, no ant isecret ory drugs (e.g. PPI) in
m
se
past 2 weeks
As
Dr
A 52-yea r-old man p resented to the emergency department with nausea and vomiting
that started 2 hours ago. The vom iting contains some food content but there is no blood.
He a lso compla ins of abdom ina l pa in but is unable to point to a specific location fo r the
pa in on his abdomen. On examination, he has a heart rate of 88 beats per minute, a
respirato ry rate of 18 breaths per minute and b lood p ressu re of 143/ 90 mmHg. The
emergency physician notices that he has very red palms and his abdomen shows ascites.
The blood results are as shown below.
Hb 130 g/ 1
AST 82 u/1
ALT 38 u/1
Upon further questioning, the man reveals that he used to engage in binge d rinking and
he currently consumes more than 60 units of alcohol every week s ince he got d ivo rced 15
years ago and recently lost his job. Upo n liver biopsy, which of the following pathological
features is likely to be observed?
Excess col lagen and extracellu la r matrix d eposition in peripo rta l and pericentral
zones leading to the formatio n of regenerative nodules
Macroves icular fatty change with g iant mitochondria, spotty necrosis and fibrosis
Triglyceride accumulation with the prolife ration o f myofibroblasts
Mo nonuclea r infiltration o f live r lobu les with hepatocytes necrosis and Kupffer cells
hyperplasia
em
Dense lymphoid infiltrates of hepati c portal tracts with ch ron ic inflammation and
s
hepatocytes necros is
As
Dr
I Excess collagen and extracellular matrix d eposition in peripo rtal and pericentral
zones leading to the fo rmatio n of regenerative nodules
Macroves icular fatty cha nge with g iant mitocho ndria, spotty necrosis and
fibrosis
Triglyceride accumulation with the pro life ration of myofibroblasts
Mononuclear infiltration o f liver lo bu les with hepatocytes necrosis and Kupffer

cells hyperplasia
Dense lymphoid infiltrates o f hepatic po rta l tracts with chronic inflammation and «D
hepatocytes necros is
This man presented with the signs and symptoms of liver cirrhosis. His history of heavy
alcohol intake, nausea, and vomiting along with examination find ings of ascites and
palmar erythema are consistent with such a diagn osis. He also had elevated liver enzymes.
1: This pathologica l featu re is typical of liver cirrhosis. Excessive a lco hol consumption
damages hepatocytes through the formation o f reactive oxygen species. Ku pffer cells
activation occu rs and excessive p rofibrotic cytokines are produced lead ing to excessive
fibrous tissue formatio n.
2: This pathology is re lated to alco hol consumption. However, it d oes not indicate that
cirrhosis has taken p lace. It characterizes alcohol steatohepatitis and it may reverse with if
the person stops consuming alcohol.
3: This in dicates non-a lcoholic fatty live r d isease. It is a common condition in individuals
with insulin resistance, dyslip idemia and a fatty diet.
4: This pathology is common to livers infected with the viral hepatitis viruses. Hepatitis
virus A and E leads to acute hepatitis, while B and C lead to chronic hepatitis. Hepatitis
virus D only affects liver if there is current or past infectio n with hepatitis B virus.
5: This pathology is characteristic o f primary biliary cirrhos is. It is liver condition seen
mostly in females and affects s mall to medium-sized bile du cts . About 90% of patient with
em
this condition have anti-mitochond rial antibodies.

s
As
Dr
A baby is born to a mother who is known t o have chronic hepatitis B. The mothers latest
results are as follows:
HBsAg Positiv e
HBeAg Positiv e
What is the most appropriate strategy for reducing the vertica l transmission rate?
Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
Give the newborn hepatitis B vaccine
Give the newborn hepatitis B immunoglobulin
Give the mother intravenous zidovudine during labour
m
se
Give the mother hepatitis B immunoglobulin shortly before birth + the newborn
As
hepatitis B vaccine
Dr
Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
Give the newborn hepatitis B vaccine
Give the newborn hepatitis B immunoglobulin
Give the mother intravenous zidovudine during labour

-
......,
Give the mother hepatitis B immunoglobu lin shortly before birth + the newborn f!D
hepatitis B vaccine
HBeAg is a marker of infectivity. The Green Book guidelines advise giving both the
vaccine and immunoglobulin in this situation. If the patient had antibod ies again st HBe
m
se
(anti-H Be), rather than the H Be antigen as in this scenario, then only the vaccine wou ld
As
need to be given. Please see the link for more details.
Dr
A 20 yea r-o ld female presents with a rash o n the extensor aspect of her arms. It is
inte nsely itchy. She gives a history o f fatigue and diarrhoea fo r the last few mo nths, but
has been unable to boo k an ap pointment until now. He r past med ica l histo ry includes
recurre nt chest, urine and ea r infectio ns thro ugh out childhood req uiring mu ltiple courses
o f antibiotics. She still occasionally su ffe rs with infectio ns. On exam ination the re is a
bliste ring rash a round both elbows. You suspect d ermatitis herpetifo rm is and coeliac
disease, a nd send off a coeliac disease blood test. She is started o n a g lute n free diet and
improves. In the meantime her blood test comes back negative.
What is the likely explanation for the negative test resu lt?
She has g luten intolera nce and ecze ma that has respo nded to dietary measures
She has selective IgA deficien cy
Her history is too short for the test to be po sitive
She has Cro hn 's disease
m
se
As
She has low im muno glob ulins due to recent infection
Dr
She has g luten intolera nce and eczema that has responded to dietary measures CD
She has selective IgA deficiency GD
He~ history is too sho rt for the test to be positive 8

She has Crohn's disease D
She has low immunoglobul ins due to recent infection «D
The histo ry of recu rrent infections is sugg estive o f a n immunodeficie ncy. The rest of the
histo ry is high ly sug gestive of coelia c disease with dermatitis he rp etifo rm is. Testing fo r
coeliac disease usua lly invo lves IgA tissue transglutam inase (TIG) antibod ies. If howeve r,
li ke in this case, a patient is IgA d eficie nt, they will test neg ative for coeliac d isease. An
alternative test fo r coelia c's wo uld be IgG TIG a ntibod ies.
m
se
Anothe r possibility in this case wo uld be that she was o n a g luten free d iet, however this
As
is not g ive n a s a n o ptio n.
Dr
A 41-yea r-old alco holic is admitted with a suspected va riceal haemorrhage. Terlip ressin is
given. What is the ma in mechan ism of a ction of terlip ress in?
Portal system vasodilation
Antifib rinolytic
Constriction of hepatic venules
Endotheli n-1 antagonist
m
se
As
Constriction of the sp lanchnic vessels
Dr
Portal system vasodilation
Antifibrinolytic
I Col striction of hepatic venules
Endotheli n-1 antagonist
Constriction of the splanchnic vessels
m
se
Terlip ressin -method of action =constriction o f the sp lanchnic vessels
As
Dr
Which one of the following patient s is most likely to require screening for hepatocellular
ca rcinoma?
A 45-year-old man with liver cirrhos is secondary t o hepatitis C
A 33-year-old man with HIV. He is ta king antiretroviral therapy
A 22-year-old man with alpha-1 antitrypsin deficiency. He has no evidence o f

cu rrent liver disease
A 52-year-old woman with alcohol-related liver cirrhos is who is still drinking
m
se
A 75-year-old man who drinks 100 units I week. He has no current signs of liver
As
disease
Dr
A 45-yea r-old ma n with liver cirrhosis secondary to hepatitis C
A 33-year-old ma n with HIV. He is taking antiretroviral therapy
I
J:b2-year-old ma n with a lpha-1 antitrypsin deficiency. He has no evid ence of
cu( ent liver disease
A 52-yea r-old woman with alcohol-related liver cirrhosis who is still drinking
A 75-year-old ma n who drinks 100 units I week. He has no cu rrent s igns of liver
disease
m
se
Patients with liver cirrhosis secondary to hepatitis C have a 3-5% annual incidence of
As
hepatocellular carcinoma.
Dr
A 45-yea r-old man p resents with diarrhoea, abdominal cramps and Skg weight loss over 6
months. He has a past medical history of Hashimoto's thyro iditis and gallstones. He has
an endoscopy and biopsies taken which show villous atrophy in the intestinal mucosa.
Which of the following human leukocyte antigen (HLA) genes is most strong ly associated
with this disease?
HLA-DQ2
HLA-827
HLA-DQ4
HLA-DR4
m
se
As
HLA-C13
Dr
HLA -DQ2 GD
HLA-827 Cl!D
HLA-DQ4 CD
HLA-DR4 CD
HLA-C13
•
Coeliac disease has a strong association with HLA-DQ2 (present in 95% of patients)
The correct answer is 2. This man is presenting with coeliac disease, as evidenced by his
symptom s and b iopsy finding s. HLA-DQ2 is found in up to 95% of patients with coeliac
disease.
The hum an leukocyte antigen (H LA) gene fam ily produces HLA p roteins in two classes
which are found o n the surface o f cells and disp lay antigens to cells of the immune
system. They are involved in a numb er of inflammatory and autoimmune conditions.
m
se
NICE: Coel iac disease
https:/ jwww.nice.o rg .uk/gu id ance/ng20
As
Dr
A 35-year-old man with a strong fa mily history of colo rectal cancer is noted to have
hundreds o f polyps during a colonoscopy.
Which one o f the following genes is most likely to have a mutation?
p53
APC
MSH2
MLHl
m
se
As
e-Ras
Dr
p53 flD
APC GD
MSH2 CD
MLHl CD
e-Ras CD
Familial adenomat ous polyposis is due to a mut ation in a tumour supp ressor gene
ca lled adenomatous po lyposis co li g ene (APC)
m
Having hundreds o f colon ic polyps is very suggestive of fa milial adenomatous polyposis,
se
a condition caused by a mutation in a tu mour suppressor gene ca lled adenomatous
As
polyposis coli gene (APC).
Dr
A 55-yea r-old man is b rought into the e mergency department by the paramedics. He
collapsed on the street suffering from a myocardial infarction and subsequently
resuscitated following a cardiac arrest. Follow u p b lood tests a re sent and the results
s how impaired liver function. He regularly has liver function tests as he is on a statin, and
a t his appointment last week they had been normal. There is nothing to note on
examination and he is cu rrently not complaining o f any pain.
ALT 1400 u/1
Given this man 's presentation, what is the most likely cause of his impaired liver function
tests?
Hepatitis B
Chronic alco hol abuse
Ischaemic hepatitis
Budd -Chiari syndrome
m
se
As
Wilson 's disease
Dr
I! ..epat1t1s B m
Chronic a lcohol abuse m
I lsc haemic hepatitis GD.
Budd-Chiari syndrome m
Wilson's d isease m
Live r fa ilure following cardia c arrest think ischaemic hepatitis

This qu estion is asking about a 55-year-old man presenting following a cardiac arrest and
then having impaired liver function tests. This is a typical picture of ischemic hepatitis.
Hepatitis and chronic alcohol abuse wo uld not cause such an acute rise in this man liver
function tests, and would most likely have b een picked up by the GP.
Budd -Chia ri syndrom e characteristically presents with right upper quadrant pain
associated with refractor ascites. And so this does not match his clinical picture.
Wi lson's disease typical ly presents in teenagers or peop le in the ir twenties with
m
se
neurological sym ptoms followed by liver fa ilu re. This do es not match this patients As
p resentation.
Dr
Which one of the fo llowin g features o f haemochromatosis may b e revers ib le with
treatment?
Card iomyo pathy
Hypogona dotrop hic hypog o nadism
Diabetes me llit us
Arthropathy
m
se
As
Live r cirrhosis
Dr
I Cardi omyopathy
Hypogonadotrophic hypogonadism
ED
m.
Diabetes mellitus ('fD
Arthropathy G'D
Liver cirrhosis m.
m
In haemoch romatosis, cardio myo pathy and s kin pi gme nta tion a re reversible with
se
treatment
As
Dr
A 27 -yea r-old woman is investigated for bloody dia rrhoea. This started a round six weeks
ago. She is currently passing 3-4 loose motions a day which no rmally contain a small
amount of b lood. Other than feeling lethargic she remains system ical ly we ll with no fever
o r si gnificant abdomina l pain. A colonoscopy is performed which shows inflammatory
changes in the ascen ding colon consistent with ulcerative colitis. Bloods show the
following:
Hb 14.2 g/dl
WBC 8.1 * 109/1
CRP 22 mg/1
What is the most appropriate first-line medication to induce rem ission?
Rectal aminosalicylate
Ora l am in osalicylate
Ora l predn isolone
Intravenous corticosteroids
m
se
Rectal corticosteroids As
Dr
Rectal aminosalicylate
Oral am in osalicylate
Ora l predn isolone
Recta l corticosteroids
This patient has symptoms consistent with mild/moderate u lcerative co litis. As she has
disease outside the reach o f enemas she shou ld be g iven an ora l a minosalicylate first-line.
NICE state the following:
To induce remission in adults with a mild to moderate first presentation or inflammatory

exacerbation of /eft-sided or extensive ulcerative colitis:
• offer a high induction dose of an oral aminosa/icylate
m
se
• consider adding a topical aminosalicylate or oral bec/ometasone dipropionate, taking
As
into account the person's preferences.
Dr
A 62-year-old wo man with a history of scleroderma is reviewed. For the past few months
she has suffered with recurrent bouts of diarrhoea. During these b outs her st ools are pale,
bulky and offensive. She drinks 14 units of alcohol/week. Bloods show the following:
Hb 10.8 g/dl
Plat elet s 23 1 * 109/ 1
WBC 5.4 * 109/ 1
Ferritin 14 ng/ml
Vitamin B12 170 ng/ 1
Folat e 2.2 nmol/1
Na• 142 mmol/ 1
K• 3.4 mmolfl
Urea 4.5 mmol/1
ALP 88 u/1
ALT 21 u/1
yGT 55 u/1
Albumin 36 gfl
Which one of the following complications is most likely to have occurred?
Whipple's disease
Colonic hypomotility
Malabsorption syndrome
sem
As
Ileal stenosis
Dr
Whipp le's disease CD
~Ionic hypomotility CD
Chronic pancreatitis QD
I Malabsorption syndrome GD
Ileal stenosis CD
m
Malabsorption syndrome is a very com mon complication of scleroderma (systemic
se
sclerosis). The blood s show evidence of impaired absorpt ion o f some vitamins (Bl2,
As
folate}, nutrients (iron) and prot ein (low albumin).
Dr
Crohn's disease is associated with ea ch one o f the followin g findings, except:
Non -caseating granu lomas
Rose-thorn ulcers
Cobblestone pattern
m
se
As
Fistu las
Dr
Rose-thorn ulcers
-
~
Co~blestone pattern
m
se
As
Fistulas
Dr
Acco rding to recent NICE gui delines, which one of the following may have a role in the
management of irritable bowel syndrome?
Reflexology
Acupunctu re
Aloe vera
Homeopathy
m
se
As
Hypnotherapy
Dr
Reflexology GD
Acu puncture fD
I Aloe v!ra CD
Homeopathy CD
m
I
se
Hypnotherapy CD
As
I
Dr
Which one o f the following types o f bariatric su rgery is most likely t o cause significa nt
malabsorption?
Laparoscopic-a djust able gastric banding
Roux-en-Y gastric bypass surgery
Sleeve gastrecto my
m
se
As
Intragastric balloon
Dr
Laparoscopic-a djustable gastric bandi ng
Roux-en-Y gastric bypass surgery
Sleeve gastrecto my
Intragastric balloon
m
se
Biliopa ncreatic d iversion with duodena l switch is a primarily malabsorptive p roced ure and
As
reserved fo r patients who are very obese.
Dr
You are asked to review a 78-year-old woman with a non-healing leg ulcer by the ward
nurse. You not ice she is very thi n. W hat is t he most appropriat e t ool to screen for
malnutrition?
GPMS
MN -10
MUST
GP- MN
m
se
As
Waterlow score
Dr
GPMS fD
MN -10 CD
I MUST
GP- MN
aD
.
(D
Wate rlow score 6D
The Waterlow score is used to estimate the risk of a patient d eveloping a p ressure sore.
m
se
Whil st this includes an assessment of ma lnutrition a s one of it's components the
As
Wate rlow score is not d esigned to screen for malnutrition.
Dr
A 57-yea r-old man who has ha d multiple emergency depa rtment ad missions fo r alcohol
related injuries and admissions und er the general medical team fo r a lcohol withdrawa l,
p resents acutely unwell after a twelve d ay drinking b inge. He is icteric, co nfused and has
hepatomegaly. There are stigmata of chronic live r disease. Admission blood work shows a
thrombo cytopaenia, transam initis with hyperb ilirubinem ia and a seve re coagulopathy. A
diagnosis of severe acute alcoholic hepatitis is made. With resp ect to the coagulopathy
associated with live r disease, which clotting facto r is characteristically in creased?
Fa ctor Vlll
Fa ctor II
Fa ctor IX
Fa ctor VII
m
se
As
Fa ctor Xll
Dr
I Factor VIII C!D
Factor II tiD
Factor IX (fD
~
Factor VII «D
m
se
As
Factor Xll CD
Dr
Which one of the following is least associated with hepatocellular carcinoma?
Hepatitis C
Aflatoxin
Wilson's disease
m
se
As
Haemoch romatosis
Dr
Hepatitis C fD
Primary biliary cirrhosis t:D
Aflatoxin f!D
r Wilson's disease e:D
m
se
Haemoch ro matosis GD
As
Dr
A 45-yea r-old ma n with on-g o ing co nstipation presents to his phys icia n hoping to g et
some laxatives. He has been eating and drinking we ll, and apart from constipation, does
not have a ny significa nt medi cal history. He d oes not drink alco ho l but smokes
o ccasionally whe n o ut with frie nds.
The physicia n wa nts to prescribe a laxative to help reso lve the patient's co nstipation,
howeve r, laxatives like any other medication have adverse effects that should b e
considered befo re prescribing .
Which o ne o f the following laxatives is shown to have to carcinog enic potential?
Lactulose
Husk
Sen na
Co-danthramer
m
se
As
Bisa codyl
Dr
Lactulose CD
Husk m.
Senna CD
Co-danthramer 63
Bisacodyl (fD
Co-d anth ra me r is genotoxic and s hould o nly be prescribed to pa lliative patie nts
d ue to its ca rcinog en ic potential
Co -danthramer has been shown be carcinogenic and therefore is not be p rescribed

normally. The only exception is in the case of pa ll iative patients where it can be
p rescribed, especially if constipation is not im p roved by the other laxatives.
The use o f co-danth ramer and co-danthrusate is limited to constipation in te rmi nally ill
patients because o f potentia l ca rcinogen icity (based on an imal studies) and evidence of
genotoxicity. (BN F)
The rest of the laxatives are not known to be ca rcinogen ic. A thorough history will help
dictate which laxative wou ld be the best option for this patient.
In a ll patients with constipation, an increase in dietary fibre, adequate fluid intake and
exercise is advised. Diet shou ld be ba la nced and contain whole grains, fruits and
vegetables. Fibre intake shou ld be increased gradually (to minimise flatulence and
bloating). The effects of a hig h-fibre diet may be seen in a few days although it can take
as long as 4 weeks. Adequate fluid intake is im portant (particularly with a high -fib re diet
em
or fibre su pplements), but can be difficult for some people (for example, the frail or
s
elderly). Fruits high in fibre and sorbitol, and fru it juices high in sorbitol can help p revent
As
and treat constipation.

Dr
A 22-year-old woman who is 34 weeks into her first pregnan cy p resent s to t he emergen cy
d epartment w ith severe ep ig astric pain and p rof use vomit ing. Her concerned partner tells
you that she has no other significant past medical h istory and t hat she has attended all of
her p regnancy checks. These have all been normal. On examination she is t ender in the
ep ig astrium. Her reflexes are mildly brisk and she does not have any clonus. Her blood
pressure is 124/55 mmH g. You note that she is confused and p oint of care glucose
monitoring reads 'low' . Her laborat ory results return showin g the following:
Hb 110 g/ 1 Na• 132 mmol/ 1 Bilirubin 94 IJmOI/1
Plat elet s 123 * 109/ 1 K• 4 .9 mmol/1 ALP 173 u/1
WBC 11 8
10 9/ 1 Urea 8.5 mmol/1 ALT 676 u/1
Neuts 9 .0 * 109/ 1 Creat inine 98 IJmOI/1 AST 590 u/1
Lymphs 2.0 * 109/ 1 CRP 15 mg/1 Albumin 29 g/ 1
I NR 2.2 Urine PCR 5 Glucose 1.8 mmoljl
A blood film shows no evidence of haemolysis.
Acute hepatit is A
Pre-eclampsia
HELLP Syndrome
Acute fatty liver o f pregnancy

sem
As
Cholesta sis o f pregnancy

Dr
Acute hepatitis A
Pre-eclampsia
-
"""'
HELLP Syndrome
Acute fatty liver of pregnancy

-
Cholestasis of pregnancy
Acute fatty liver of pregnancy (AFLP) is a rare, potentially fatal co mplication that occu rs in
the third trimester or early postpa rtum period. Although the exact pathogenesis is
unknown, this disease has been linked to an abnormal ity in foetal fatty acid metabo lism.
Early diag nosis of AFLP sometimes can be difficult because it sha res featu res with other
commo n conditions such as pre-eclampsia, viral hepatitis and cholestasis of pregna ncy.
However, a careful history and physical exami nation, in co njunctio n with compatible
m
laboratory and imaging results, are ohen sufficient to make the diag nosis, and liver biopsy
se
is rarely indi cated. Supportive care and delivery of the baby are essential to optimal
As
maternal-foetal outcomes and are the mainstay of treatment for AFLP.
Dr
A 55-year-old female with a history of colorectal node pos itive cancer, ma naged with
resection and chemotherapy. She is fou nd to have a single 2cm liver lesion a few years
later. What is the most appropriate next step in her management?
Radiofrequency ablation
Transarterial chemoembolization
Radiotherapy
Metastatic lesion resection
m
se
As
Chemotherapy
Dr
Radiofrequency ablation GD
Transarte rial chemoembolizatio n GD
Radiotherapy .
(D
I Metastatic lesion resection CID

Chemotherapy GD
Colorectal carcino ma is o ne of the o nly onco logical diseases where the presence of a
metastatic deposit can be treated with cu rative intent. A so litary live r lesion shou ld be
su rgically resected . In fact, the purpose of followi ng patients with CEA is to identify
patients with solitary metastatic lesions amena ble to su rgical resection.
Transarterial chemoembolization & Rad io frequency ab lation a re used as palliative

p rocedures when the lesions are too numerous o r la rge to resect.
AJCCC Sta g ing of Co lo recta l Can ce r
Primary Tu mo r (T)
TX Primary tumor cannot be assessed
TO No evidence of primary tumor
Tis Carcinoma in situ : intraepithelial or invasion of lamina propria
Tl Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues
T4a Tumor penetrates to the surface of the visceral peritoneum
T4b Tumor directly invades or is adherent to other organs or structures
Regiona l Lymp h Nodes (N)

NX Regional lymph nodes cannot be assessed
NO No regional lymph node metastasis
N1 Metastasis in 1-3 regional lymph nodes
N1a Metastasis in one regional lymph node
N1b Metastasis in 2-3 regional lymph nodes
Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or peri rectal

N1c
tissues without regional nodal metastasis
N2 Metastasis in 4 or more regional lymph nodes
N2a Metastasis in 4-6 regional lymph nodes
N2b Metastasis in 7 or more regional lymph nodes
Distant Metastasis (M)

MO No distant metastasis
M1 Distant metastasis
M1a Metastasis confined to one organ or site (for example, liver, lung, ovary, nonregional node)
em
M1b Metastases in more than one organ/site or the peritoneum

s
As
Dr
A 65 -year-o ld man known to have a carcino id tumou r o f the append ix is fou nd to have
hepatic metastases. If the patient develops carcin oid syndro me, wh ich one of the
following symptoms is most li kely to occur first?
Facial flushing
Headache
Vom iting
Diarrhoea
m
se
As
Palpitations
Dr
Dr
As
se
m
A 36-year-old man is reviewed in clinic. He has recently been started on mesalazine
400mg tds for ulcerative co litis. Which one of the fo llowing a dverse effects is least likely
to be attributable to mesalazine?
Interstitial nephritis
Headaches
Acute pancreatitis
Agranulocytosis
m
se
As
Inferti lity
Dr
Interstitial nephritis fD
Headaches CD
Acute pancreatitis flD.
Ag ra nulocytosis fD
Infertility CD
Sulphasalazine can cause oligospermia and infertility in men

m
se
As
Oligospermia is seen in patients ta king sulphasalazine due to the sulphapyridine moiety,
which is not present in mesalazine
Dr
A 54-year-old female is diagnosed with primary biliary cirrhosis. What is her increased risk
o f developing hepatocellular cancer, compared to a standard population?
50% increased risk
3-fold increased risk
m
se
As
Dr
50% increased risk .
(D
I 3-fold increased risk

I
f.D
5-fold increased risk fD
10-fold increased risk .
ED
m
se
ED.
As
20 -fold increased risk
Dr
Which one of the followin g enzymes is mainly responsible for breaking st arch down into
sugars?
Amylase
Sucrase
Alpha-g lucosidase
Maltase
m
se
As
Lactase
Dr
Amylase ED
Sucrase QD
Alpha-glucosi dase fD
Maltase CD
Lactase CD
m
se
Amylase: breaks starch down to suga rs
As
Dr
What is the lifetime risk of developing co lo rectal cancer in the United Kingdom?
1%
2%
5%
10%
m
se
As
15%
Dr
I 1%
L flD
2% GD
I 5% CD
10% fD
15% flD
m
se
Colorectal cancer is t he th ird most common cancer in the UK, with ap proximately 30,000
As
new cases in England and Wales p er year
Dr
A 65-year-old man with a history of ischaemic heart disease and hypertension presents to
the emergency department wit h abdominal pain accompanied by some rectal bleeding.
He has had associated diarrhoea. This has happened several t imes before, and tends to be
most ly after eating a large meal. He had put off seeing a Doctor but his wife had insisted
on him coming to hospita l on this occasion.
On examination, the patient is wel l and the pain has subsided. A chest x-ray does not
show any free air under the diaphragm and abdominal x-ray does not show any
obstruction. He is discharged with colonoscopy booked as an outpatient.
Given the likely diagnosis, which part of the colon is most likely to be affected?
Caecum
Ascending colon
Hepatic flexure
Splenic flexure
Rectum
m
se
As
Submit answer
Dr
Caecum GD
Ascending colon GD
Hepatic flexu re GD
I Splen ic flexure
Rectum
CD
6D
The splenic flexure is the most likely area to be affected by ischaemic colitis
Impo rta nt fo r me less important
Given t he history of ischaem ic heart disease and hypert ension an ischaemic cause of the
pa in is likely. Add to this t he pain gets worse after eati ng, when the bowel requires more
blood flow for its increased energy demands for digestion and ischaemic colitis would be
the diagnosis to invest igate first.
This is an anatomy question testing knowledge of 'watershed' areas (areas where arterial
blood supplies change from one major vessel to the next). These areas are most
vu lnerable to reduced blood supply as t hey are the most dista l parts of the distribution
from t heir supplying arteries. The splenic fl exure marks the point where the majority of
blood supplied changes from the superior mesenteric art ery (SMA) to the inferior
mesenteric artery (IMA).
The SMA supplies the caecum, ascend ing colon, and hepatic flexure.
The rect um itself gets an excellent supply of blood from collaterals due to branches from
the interna l iliac art ery.
The recto-sigmoid j unction also forms a watershed area but this is less often examined
and was not a choice here.
Next question )
Ischaemia to the lower gastrointestinal tract
Ischaemia to the lower gastrointesti nal t ract can result in a variety of clinica l condit ions.
Whilst t here is no standard classifica tion it can be useful to separate cases into 3 main
cond itions
• acute mesenteric ischaem ia
• chronic mesenteric ischaemia
• ischaemic colitis
MMent eric ischaemia lschaemic colitis
Typically small bowel Large bowel
Due to embol sm lschaem1a to lower Gl Mulnfaaorial

tr8Cl
Sudden onset, severe TranSiefll less severe
symptoms Abdominal pain
symptoms. Bloody
diarrhOea
Urgent surgery
'Thumbprinting'
HIQh mortallly
·-
Venn diagram showing types of bowel ischaemia
Common features in bowel ischaemia
Common pred isposing facto rs

0 0
• 1ncreasmg age
• atrial fibrillation - part icularly for mesenteric ischaemia
• other causes of emboli: endocard itis, malignancy
• card iovascular disease risk facto rs: smoking, hypertension, d iabetes
• cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
Common features
• abdomina l pain - in acute mesenteric ischaem ia this is often of sudden onset, severe
and out-of-keeping with physica l exam fi nd ings
• rectal bleeding
• diarrhoea
• fever
• bloods typically show an elevated white blood cell count associated with a lactic
acidosis
Diagnosis
• CT is the investigation of choice
Acu te mesenteric ischaemia
Acute mesenteric ischaemia is typically caused by an embolism result ing in occl usion of
an artery which supplies the small bowel, for example t he superior mesenteric artery.
Classically patients have a history of atrial fibrillation.
The abdominal pa in is typica lly severe, of sudden onset and out-of-keeping with physical
exam findings.
Management
• urgent surgery is usually required
• poor prognosis, especially if su rgery delayed
Chronic mesenteric ischaemia
Chronic mesenteric ischaemia is a relatively ra re clinical diagnosis due to it's non-specifi c

featu res and may be thought of as 'intestinal angina '. Colickly, intermittent abdominal
pa 1n occu rs.
lschaemiac colitis
lschaemic colitis describes an acute but t ransient compromise in the blood flow to the
large bowel. This may lead to infl ammation, ulceration and haemorrhage. It is more likely
to occur in 'watershed ' areas such as the splenic flexure that are located at the borders of
the territory supplied by the superior and inferior mesent eric art eries.
Investigations
• 't humbprint ing' may be seen on abdominal x-ray due to mucosal
oedema/haemorrhage
Management
m
- usually supportive
se
As
-surgery may be required in a minority of cases if conservative measures fail. Indications

would include generalised peritonitis, perforation or ongoing haemorrhage
Dr
A 68-year-o ld man presents to the emergency depart ment with sudden onset abdom inal
pa in. He describes the pa in as cramping/ 6/10 in severi ty and all over his abdomen. He has
a past medical history of hypertension and type 2 diabetes mellitus. He is an ex smoker
with a 40 pack year history.
Which part of t he colon is most likely to be affected in t his patient?
Ascending colon
Hepatic flexure
Transverse colon
Splenic fl exure
Sigmoid colon
m
se
As
Submit answer
Dr
Which part of t he colon is most likely to be affected in t his patient?
Ascending colon fD
Hepatic flexu re C1\D
Transverse colon CD
I Splenic flexure CD
Sigmoid colon fD
The splenic flexure is the most commonly affected site in ischaemic colitis
The cramping, genera lised abdominal pains, in conjunction with a history of smoking and
hypertension, point to a diagnosis of ischaemic colitis.
The splenic flexure is a watershed area, at the border of the regions supplied by d ifferent
arteries. This makes the area vulnerable t o compromised blood supply.
The rectosigmoid junction is another watershed area, but is less commonly affected than
the splen ic flexure.
The other regions of the large bowel are less likely to be affected by ischaemic colitis.
Next question )
lschaemic colitis
lschaemic colitis describes an acute but t ransient compromise in the blood flow to the
large bowel. This may lead to inflammation, ulceration and haemorrhage. It is more likely
to occur in 'watershed ' areas such as the splenic flexure that are locat ed at the borders of
the territory supplied by the superior and inferior mesenteric arteries.
em
Investigations
s
As
• 'thu mbprinting' may be seen on abdominal x-ray due to mucosal

oedema/haemorrhage
Dr
A 65-year-o ld woman was found to be posit ive for H. pylori, and was commenced on
triple therapy erad ication. Her GP wants to test if the eradication therapy has worked, as
the woman is still experiencing symptoms.
Which of the following is the most appropriate for post-eradication therapy testing?
CLO test
Gastric biopsy
Serum antibody
Stool antigen
Urea breath test
m
se
As
Submit answer
Dr
CLO test GB
Gastric biopsy fD
CD.
..
Serum antibody
Stool antigen
Urea breath test CD
Urea breath test is the only test recommended for H. pylori post-eradication
therapy
According to NICE, the on ly recommended test for H. pylori post-eradication therapy, is

urea breath test. The others are either too invasive, remain positive, or are not sensitive
and specific enough.
[ .. Ia• tt Discuss Improve ]
Helicobacter pylori: tests
Urea breath test

• patients consume a drink containing carbon isotope 13 (13C) enriched urea
• urea is broken down by H. pylori urease
• after 30 mins patient exhale into a glass tube
• mass spectrometry analysis calcu lates the amount of 13C C02
• should not be performed within 4 weeks of treatment with an antibacterial or within
2 weeks of an antisecretory drug (e.g. a proton pump inhibitor)
• sensitivity 95-98%, specificity 97-98%
• may be used to check for H. pylori eradication
Rapid urease test (e.g. CLO test)

• biopsy sample is mixed with urea and pH indicator
• colour change if H pylori urease activity
Serum antibody
• remains positive after eradication
• sensitivity 85%, specificity 80%
Culture of gastric biopsy

• provide information on antibiotic sensitivity
Gastric biopsy
• histological evaluation alone, no cu lture
m
se
Stool antigen test

As

Dr
A 54 year old female is admitted with a severe pneumonia following a holiday in Turkey.
Bloods reveal both hyponatraemia and deranged liver function test s. A chest x-ray shows
patchy alveolar infiltrates with consolidation in the right lower lobe. Which one of the
fo llowing investigations is most likely to confirm the probable diagnosis?
Sputum culture
Urinary antigen
Blood cultures
Bone marrow aspirate
m
se
As
Lumbar puncture
Dr
Sputum culture .
(D
Uri nary antigen GD.

Blood cultures a
Bone marrow aspirate
Lumbar puncture
•m
m
se
legionella pneumophilia is best diagnosed by the urinary antigen test
As
Dr
A 28-year-old man who has recently returned from Nigeria presents with a painful ulcer
on his genitals. On examination, you note a l cm x lcm ulcerated lesion with a ragged
border. You also note tender lymphadenopathy in the groin.
What is the most likely causative organism?
Herpes simplex virus
Chlamydia trachomatis
Treponema pallidum
Haemophilus ducreyi
m
se
Klebsiella granulomatis
As
Dr
Herpes simplex virus GD
Chlamydia trachomatis tiD
Treponema ppllidum f.D
Haemophilus ducreyi CD
Klebsiella granulomatis GD
Chancro id causes painfu l genital ulcers

The pa infu l genital ulcer with a ragged borde r associated with tender inguinal
lympha denopathy points to chancroid . Chancro id is caused by Haemophilus ducreyi.
Herpes simplex virus a lso causes painful genital ulcers, but they a re generally smaller and
multip le and primary attacks are often associated with fever.
The other o rga nis ms a re causes of painless genital ulcers: C. trachomatis causes
m
se
lymphogranuloma vene reu m; T. pallidum causes syphil is; K. granulomatis causes
As
granuloma inguinale.
Dr
A 28-yea r-old lady is reviewed in a follow-u p appointment at the sexua l health clinic.
Twelve months ago she was diagnosed with syphil is and was given intramuscular
benzathi ne penicillin. Blood tests were taken a week p rior to the follow-u p appointment
and the sero logy results a re shown below:
TPHA positive
VORL negative
What is the most likely explanation for the sero logy results shown above?
She has been re-infected and has developed syph ilis
She is HIV positive
She is p regnant
She has been successfully treated for syphilis
m
se
As
She has been subopti ma lly treated for syphil is
Dr
She has been re-infected and has devel oped syphilis
She is HIV positive
I
She is p regnant
She has been successfully treated for syphilis

-
~
She has been suboptimally treated for syphilis
Foll ow ing treatment for syphilis: TPHA remains positive, VDRL becomes neg ative
VDRL becomes neg ative following treatment of syphilis. TPHA remains posit ive despite
successful treatment of syphilis.
Her serology is co nsist ent with previous syphilis inf ection, for example aher su ccessf ul
treatment. Therefore 4 is the correct answer.
Options 1 and 5 sugg est active infection w ith syphilis, in which case the VDRL would be
posit ive.
m
se
Options 2 and 3 are causes of a false -positive VDRL test, w hich wou ld not explain the
negative VDRL b ut positive TPHA in the question. As
Dr
A 65-year-old diabetic male patient p resent s with back pain and dysuria. MRI Pelvis shows
evidence of prostat itis. He has a p rolonged course of antib iotics to t reat his p rostatitis,
however, at a follow -u p visit he has been shown to be co lonised with M RSA (met hicill in-
resistant Staphylococcus aureus)
Which o f the follow ing antibiotics is most likely to have contributed t o this?
Cipro floxacin
Trimethoprim
Gentam ici n
Tobramyci n
m
se
As
Nitrofurantoin
Dr
Ciprofloxacin mt
Tri methopri m (fD
Gentamicin CD
Tobramycin GD
Nitrofurantoin f!D
Ciprofloxacin promot es acquisition of MRSA

Although ciprofloxacin is not a beta-lact am antibiotic, its use is strongly linked t o the
acquisition o f MRSA as with all quinolone antibiotics.
m
se
As
The other choices are unlikely to lead t o M RSA infection or colonisation.
Dr
A young black African ma le recently moved from Zimbabwe presents with a skin lesion on
his hand. On examination you note an ulceration with a black centre (eschar) with
su rrounding oedema, he says it is not painfu l.
What is an important microbe to consider?
Mycobacterium ulcerans
Bacillus anthracis
Chikungunya virus
m
se
As
Mycobacterium /eprae
Dr
Mycobacterium ulcerans
Bacillus anthracis
Chikun gunya virus
Mycobacterium leprae
-
"""'
Painless b lack eschar- anthrax

Classical description o f a cutaneous manifestation o f anthrax, caused by Bacillus anthracis.

Zimbabwe had the largest known outbreak of more t han 10,000 cases in t he lat e 80's
(Central Af rica n Journal of Medicine, 1996)
Mycobacterium ulcerans usually p resent s as a painless nodule and progresses to an ulcer

wit hout an eschar.
Strongyloides stercora/is is an helmint h w hich is cont ract ed t hrou gh contact w it h soil

conta ining the larvae and most commonly in t he t ropics and su btrop ics. Usually
asymptomat ic and raised eosinophils maybe t he only indicat ion.
Chiku ngunya virus is contracted through infect ed mosquit os. Common ly present wit h
myalgia, arthralgia and fevers.
s em
Mycobacterium leprae causes leprosy characterised by dama ges t o perip heral nerves, skin
As
and muscle.
Dr
A 30-yea r-old man presents to the genito-u rinary med icine cl inic. He has been handed a
s lip from an ex-g irlfriend stating she has tested positive for Chlamydia. He last sle pt with
he r 2 months ago. He has no symptoms of note, in pa rticu la r no dysu ria o r discha rge.
Rea ssure sympto ms wo uld have presented by now
Offe r a ntibiotic the rapy
Offe r Chlamydia testing a nd a ntibiotic trea tment immediately without wa iting for
the resul ts
Offe r Chlamydia testing a nd a ntibiotic trea tment if pos itive
m
se
As
Notify public health
Dr
I Reassure symptoms would have presented by now
Offer antibiotic the rapy
. t esting and antibiotic treatm,ent immediately without waitin g for -

ere hiam:rd ta h ~
t e results
Offer Chlamydia testin g and antibiotic treatment if positive
Notify public healt h
m
se
As
Treatment is given on the basis of exposure to infect ion rather than p roven infection
Dr
A 52-year-old man with a history of alcohol dependence is admitted w ith fever and
feeling generally unwell. An admission chest x-ray shows co nsolidation in the right upper
lobe with early cavitation. What is the most likely causative organism?
Legionel/a pneumophilia
m
se
As
Mycoplasma pneumoniae
Dr
m
se
Pneumon ia in an alcoholic - Klebsiella
As
Dr
A 35-yea r-old ma le patient p resents to the emergency depa rtment with fever and
hypotension. He had returned 2 d ays previously from a business trip from India, which
lasted 3 weeks. The p atient had not sou ght any p re-travel a dvice a nd had not taken any
malaria pro p hylaxis.
The patient was pa le and looked lethargic. His temperature was 38.5°(, oxygen
saturations were 92% o n air, b lood pressure was 80/ 60 mmHg a nd heart rate was
135/ min at initia l presentation.
A malaria rap id d iagnostic kit had revealed a pro bable falcipa rum malaria.
Which o f the following options is most app ropriate?
Oral quinine
IV qui nine
IV a rtesu nate
Doxycycline
m
se
As
Clind amycin
Dr
Oral quinine fD
IV quinine «D
F rtesunate GD
Doxycycline m
Clindamycin CD
Quinine is no longer recommended as a first -line treatment for com plicated/ seve re
fa lciparu m ma la ria
Whilst a ll the above o ptions are potential antimalarial treatments, according to the UK
malaria treatment guidelines 20 16 (Journal of Infection) IV artesunate is the first line
treatment where available for complicated o r severe mala ria.
The patient is shocked and this therefore suggests complicated malaria.
m
se
Severa l tria ls have demonstrated benefit o f IV a rtesunate over IV quinine for complicated
As
falciparu m ma la ria .
Dr
A 24-yea r-old ma n with no past med ical history is diag nosed with syphilis and the
treatment is administered.
An hour later he starts to develop a rash and you a re called to review him.
His hea rt rate is 120 beats per minute an d his blood p ressu re is 96/ 62 mmH g. On
auscultation o f his chest, you notice a wheeze throughout.
What is the most a pp ropriate initial manage ment?
Give o ral chlorphenami ne
Give an intravenous fluid bolus
Reassu re and discha rge
Give intramuscular adrenaline
m
se
As
Mo nitor his o bse rvations every 30 minutes
Dr
Give oral chlorphenamine
Give an intravenous fluid bolus
Reassure and discharge
Give intramuscu lar adrenaline
Monitor his observations every 30 minutes
The Jarisch-Herxheimer reaction, unlike an anaphylactic reaction, w ill not present

with hypotension and w heeze
The scenario is describin g an anaphylactic reaction followin g the treatment for syphilis,
p robably due to an unknown penicillin allergy. He, therefore, requires treatment with
intramuscular adrena line in the f irst instance. The other options are therefore incorrect .
It is important to dist inguish an aphylacti c reactions from the Jarisch-Herxheimer reaction,
m
se
which can result in fever, tachycardia and rash following syphilis treatment. A Jarisch-
As
Herxheimer reaction would not cause a w heeze and is unlikely to cause hypotension.
Dr
A 28-year-old man who has recently emi grated fro m Nigeria present s with a p enile ulcer.
It initially st arted as a papule w hich later progressed to become a painful ulcer with an
undermined ragged edge. Examination o f the t estes w as unremarkable but tender
inguinal lymphadenopathy was noted. What is the most likely diagnosis?
Chancroid
Lym phogranuloma venereum
Syphilis
Herpes simplex infection
m
se
As
Gran uloma inguinale
Dr
Chancro id
Lymphogranuloma venereum
I Syphilis
Granuloma inguinale
Genita l ulcers
• painfu l: herpes much more common than chancroid
• painless: syphilis more common than lymphogranuloma venereum
A diagnosis of chancro id is more likely than lymphogranuloma venereum as the ulcer is

painful. Whilst herpes simplex is obviously more common the description of the ulcer is
m
se
very characteristic of chancroid. Painful inguinal lymphadenopathy is present in around
As
50% of patients.
Dr
A 29-yea r-old HIV positive man is adm itted with right-sided hemipleg ia. For the past fou r
d ays he has been complaining o f headache and flu-like symptoms. CT scan shows
multiple ring enhancing lesions. A diagnosis o f ce rebral toxop las mosis is suspected. What
is the most su itable management?
Artemether and lumefantrine
Co -tri moxazole
Su pportive treatment
Pyrim etha mi ne and sulphadiazine
m
se
As
Metronidazole and gentam icin
Dr
A 29-yea r-old HIV positive man is admitted with right-sided hemiplegia. For the past fou r
d ays he has been com plaining of headache and flu-like symptoms. CT scan shows
multip le ring enhancing lesions. A diagnosis of cereb ra l toxop las mos is is suspected . What
is the most suitab le management?
Arte mether and lumefantrin e

-
Co-tri moxazole
-
"""'
~
Su ppo rtive treatme nt
Pyrim ethamine and sulphadiazine

-
"""'
m
se
As
Metro nidazole a nd g e ntam icin
Dr
A 35-yea r-old male patient p resents to the emergency depa rtment with fever. He ha d
returned 2 days previously from Ind ia on a b usiness trip which lasted 3 weeks. The patient
had not sought any pre-travel advice and had not taken a ny malaria p rop hylaxis.
A malaria rap id diagnostic kit had revealed non-falciparum parasites.

The patient received initia l treatment fo r P. vivax malaria a nd was subsequently
discharged .
Which of the following is the most important next step in management?
G6PD deficiency testing prior to a dm inistration of primaquine
Lifelo ng quinine for malaria prophylaxi s
Mefloquine fo r 6 weeks
No further treatment necessa ry
m
se
As
Regula r blood films to look for persistent pa rasitaem ia
Dr
I G6PD deficiency testing prior to administration of primaquine
Lifelong quinine for malaria prophylaxis
Mefloquine for 6 weeks
No fu rth er treatment necessary
Regu lar blood films to look for persistent parasitaem ia
Hypnozoite eradication is important to prevent relapsed P. vivax and P. ovate

malaria
It is important to note that hypnozoites may persist in the liver with non-falciparum
malaria, even after treatment. This cou ld lead to relapsed malaria months or even years
later.
Primaquine is an important drug which can be used for eradication of hypnozoites.
m
se
Primaquine should not be given to people with glucose-6- phosphate dehydrogenase
As
(G6PD) deficiency due to the risk of haemolysis.
Dr
A 25-yea r-old fema le primary school teacher presents to the emergency d epartment with
a rash and fever. She states that there have been a number of cases of slap cheek
(pa rvovirus 819) infection at the school.
Of the cho ices g iven, what is the most important consideration?
Skin swab
Arterial blood gas
Pregna ncy test
Stool culture
m
se
As
Sputu m culture
Dr
Skin swab CD
Arte rial blood gas (D
Pregna ncy test CD

Stool culture (D
Sputum cul ture .

(D
Parvovirus is a common cause of feta l hydrops during p regnancy and can be

treated with fetal transfus io n
'Erythema infectiosu m', 'fifth d isease' and 'slap chee k' a re the same condition which are all
possible manifestations of parvovirus B19 infection. It is associated with fetal
abnormalities and common ly causes a cha racteristic rash in ch ildren and in ad ults in can
additionally cause arthra lgia.
Infection in a p regnant woman can lead to feta l hydrops and spontaneous misca rriage,
pa rticularly in the fi rst trimester. Th is can be managed with the use of fetal blood
transfusion.
m
In patients with s ick-cell d isease, aplastic crisis may be p recipitated by parvovirus.
se
As
Immunocomprom ised individuals are also at risk.
Dr
A 73-yea r-o ld man p resents with worsening cellulitis. The nurse takes his observatio ns
which are the following a respiratory rate of 28/min, heart rate 110/min, blood pressure
100/70 mmHg and a temperature o f 39.5°C. Blood cu ltures are taken and later reported
as growing a gra m positive, catalase and coagulase pos itive cocci.
Which is the most likely organism?
Clostridium difficile
m
se
As
Dr
Clostridium diffici/e
Staphylococcus aureus is a g ram +ve bacterium, cata lase +ve, coagulase +ve
organism
Answers 1, 2, 3, 5 a re a ll gram positive cocci, 4 is a rod and so incorrect. Streptococcus

viridans and Streptococcus pyogenes are both catalase negative. Staphylococcus
epidermidis is catalase positive but coagulase negative.
m
se
As
This therefo re leaves Staphylococcus aureus as the answer.
Dr
A 64-yea r-old man is a d mitted to the e me rgency d epa rtment as his wife is concerned that
he is beco ming co nfused fo ll owing a recent bad chest infectio n. She reports that he has
not improved a fter a course of amoxicilli n.
On exam ination, his resp iratory rate is 30/min, blood pressu re 88/60 mmHg, heart rate
120/ min. Crackles are noted on the right si de o f his chest.
What is the most a p propriate flu id therapy to give?
20 ml/kg stat
30 ml/kg stat
SOOml stat
20 ml/kg over 1 hou r
m
se
As
10 ml/kg over 1 hou r
Dr
20 ml/kg stat C!D
30 ml/kg stat CD
SOOml stat ED
20 ml/kg over 1 hou r GD
10 ml/kg over 1 hour C!D
This patient has a number o f features o f red flag sepsis, including the confusio n, low
b lood pressure and raised resp iratory rate. The sepsis 6 should be started.
In the NICE guidelines on sepsis the following recommendations a re made with regards
to flu id resuscitation:
If patients over 16 years need intravenous fluid resuscitation, use crystalloids that contain
m
sodium in the range 130-154 mmoVlitre with a bolus of 500 ml over less than 15 minutes.
se
As
Dr
A 25-year-old male patient is admitted to the emergency department following an assault
in prison. On examination, the patient has suffered a bite which has broken the skin.
Hepatitis B surface antibody is shown to be more than 100 m!U/ml and he admits to
previous vaccination against hepatitis B.
Which of the following is the most appropriate next step in management?
Hepatitis B immunoglobulin
Antiretrovirals for post-exposure prophylaxis for HIV
Antibiotics and tet anus booster
Hepatitis B vaccination
m
se
As
Hepatitis C vaccinatio n
Dr
Hepatitis B immunoglobulin
Antiretrovirals for post-exposure prophylaxis for HIV
r Antibiotics and tetanus booster
Hepatitis B vaccination
Hepatitis C vaccination
Post-exposure prophylaxis for HIV is not recom mended following human bites
The hepatitis B surface antibody levels suggest adequate immunity and therefore negates
the need for further hepatitis B vaccination or hepatitis B immunoglobulin.
Post-exposure prophylaxis for HIV is not recommended following human bit es. Estimated
risk of HIV tra nsmission from a bite from a know n HIV-positive individual not on anti-
retroviral treatment is < 1 in 10,000. (BASHH guidelines, UK guideline for the use of HIV
Post-Exposure Prophylaxis Following Sexual Exp osure, 2015)
m
se
As
There is no current hepatitis C vaccination.
Dr
A 22-year-old female presents with an offensive vag inal discharge. History and
examination findings are consistent w ith a diagnosis o f bacterial vaginosis. What is the
most appropriat e initial management?
Oral azithromycin
Oral metronidazole
Clotrimazole pessary
m
se
As
Advice regarding hygiene and cotton underwear
Dr
Oral azithromycin (fD
Topical hydrocortisone CD
Oral metronidazole CD
Clotrimazole pessary fD
Advice rega rding hyg iene and cotton underwea r GD
m
se
Bacterial vaginosis: oral metroni dazole
As
Dr
An 18-year-old male student presents to the emergency d epa rtment with fever, headache
and photopho bia. On examination, he is pyrexial a t 39°C and has observable neck
stiffness. There is no evidence of rash and other than a recent ear infection, there is no
other relevant past medical history.
Which of the following is the most app ropriate intravenous treatment option?
Benzylpenicillin
Ceftriaxone
Ceftriaxone and dexamethasone
Cefalexin
m
se
As
Amoxicil li n
Dr
Benzylpenicillin
Cehriaxone
Cehriaxone and d examethasone

-
Cefalexin
Amoxicillin
Dexamethasone improves outcomes in the treatment of bact erial meningit is

The clinica l p icture is of possible bacterial meningiti s. In th is context cehriaxone is clearly

the correct antibiot ic cho ice. It is important to note t he use of dexamet hasone w hen
treating potential meningit is. Dexamet hasone has been shown to improve outcomes with
particular relevance to pneumococca l meningiti s. It has shown in particular to prevent
long -term hearing loss.
Until t he cause o f t he meningit is is known then dexamethasone shou ld be init iated. The
recent ear infect ion is a risk fact or fo r pneumococcal meningitis.
m
se
See Brit ish Infect ion Associat ion guidelines on management o f meningitis for fu rther
information. As
Dr
A 28-year-old man from Zimbabwe presents to the emergency department with a 2 week
history of fever, cough, headache, vomiting and neck stiffness. He is known to be HIV
positive and is on treatment. His most recent CD4 count was 450 cells/mm'
On examination he has no focal neurologica l signs but appears drowsy and confused. You
suspect meningitis and perform and lumbar puncture
The resu lts show:
Opening pressure 25mm H20
Appearance cloudy
White cells 200 cells/mm'
Cells 90% lymphocytes
CSF protein 3 g/L
CSF glucose 1.1 mmolfl
Blood glucose 6.8 mm/L
Meningococcal meningitis
TB meningitis
Cryptococcal meningitis
Partially treated bact erial meningitis

s em
Herpes simplex meningitis

As
Dr
I TB meningitis
IPa~tially treated bacterial meningitis

-
~
Herpes simplex meningitis
The lymphocytic CSF with high protein and low glucose in this case could be due to both
cryptococcal and TB meningitis, however the insidious onset of symptoms, very high
protein and low glucose compa red to the plasma glucose (<l/3 of plasma) points more
towards TB meningitis. Also this man has a relatively high CD4 count and only a mildly
m
ra ised opening pressure which makes cryptococcal meningitis more unlikely. TB and HIV
se
co-infection are common, especially in sub-Saharan Africa and should always be
As
considered.
Dr
Which one o f the following is the most common cause of visceral larva migrans?
St rongyloides st ercoralis
Visceral leishmaniasis
Toxocara can is
m
se
Giardiasis
As
Dr
Dr
As
se
m
A 31-year-old woman presents t o the Emergency Department co mplaining of a headache.
She has had 'flu' like sym ptoms for the past three days with the headache developing
gradually yesterday. The headache is described as being 'all over' and is worse on looking
at bright light or when bending her neck. On examination her temperature is 38.2°, pulse
96 I min and blood pressure 116/78 mmHg. There is neck stiffness present but no focal
neurological signs. On close inspection you notice a number o f petechiae on her torso.
She has been cannulat ed and bloods (including cultures) have been taken. What is the
most appropriate next step?
IV cefotaxime
Arrange a CT head
Perform a lumbar puncture
IV dexamethasone
m
se
As
Intra muscular benzypenicill in
Dr
IV cefotaxime
Arrange a CT head
j
Perform a lumba r puncture
IV dexamethasone
Intramuscular benzypenicillin
This patient has meningococca l meningitis. They need appropriate intravenous antibiotics
immediately. With the advent of modern PCR diagnostic techniques there is no
m
se
justification for delaying potentially lifesaving treatment by performing a lumba r punctu re
As
in patients with suspected meningococcal meningitis.
Dr
A 24 -yea r-old woman who is 18 weeks pregnant presents to the Emergency Department.
Earlier on in the morning she came into contact with a child who has chickenpox. She is
unsure if she had the cond ition herself as a child. What is the most appropriate action?
Advise her to p resent with in 24 hours o f the rash d eveloping for consid eration of IV
aciclovir
Reassure her that there is no risk of feta l complications at this point in pregnancy
Give varicella imm unoglobulin
Check varicella antibodies
m
se
As
Prescri be o ral aciclovir
Dr
Advise her to p resent with in 24 hou rs o f the rash developing for consideration of C3
IV aci clovir
Reassure her that there is no risk of fetal complicati ons at this point in pregnancy D
Give varicella imm unoglobu lin
~eck varicella antibodies

Prescri be o ral aciclovir
Chicken pox exposure in p regnancy - first step is to check antibodies

m
se
If there is any doubt about the moth er previously having chickenpox maternal blood
As
should be checked fo r varicella antibodies
Dr
A 35-year-old man is reviewed in clinic having been diag nosed with HIV two years ago
and is stable on anti-retroviral thera py. He has a new regular partner and is concerned
about transmitting the disease to him. What factor is most likely to increase the risk of
transmission?
Circumcis ion
Low CD4 count
Co -i nfection with gen ital warts
Diabetes
m
se
As
Mucosal ulceration
Dr
Circumcision
Low CD4 count
Co -infect ion with g en ital warts
Diab et es
Mucosal u lceration
The correct answer is mucosal ulcerat ion. Ulcerat ion limits barrier p rot ection to HIV
inf ect ion. A low CD4 cou nt is not associated w it h increased transmission rate, b ut an
increased HIV viral load. Genito -urinary infection ca n increase transmission rat es but
g enit al warts has not been shown t o d o so. Diabetes wou ld increase t he rat es o f bacterial
and f ungal inf ect ions but not viral ones. Circumcision is p rot ect ive to HIV t ransm ission.
Source:
m
se
'UK Guideline for the Use of HIV Post- Exposure Prophylaxis Following Sexual Exposu re
As
(PEPSE) 2015.' BASHH. N.p., 2015.
Dr
An 18-year-old man is bitten by a frantic dog whilst taking a gap yea r in Ecuador. He is
worried about rabies and phones for advice. He was not immunised against prior to
travell ing to Ecuador. What is the most appro priate advice after thorough cleansing o f the
wound?
Give human rabies immunoglobulin + full cou rse o f vaccination
Give human rabies immunoglobulin + ora l penicillin for the next 2 w eeks
Advise low risk but take oral co-amoxiclav for the dog bite
Give human rabies immunoglobulin
m
se
As
Give full course of vaccination
Dr
Give human rabies immunoglobulin + full course of vaccination
Give human rabies immunoglobulin + oral penicillin for the next 2 weeks
Advise low risk but ta ke o ral co-amoxiclav for the dog bite
Give human ra bies immunoglobulin

-
~
Give full course of vaccination

-
~
m
se
Ra bies - following possible exposure give immunglobulin + vaccination
As
Dr
A 64-yea r-old woman presents to the Eme rgency Department with a coug h, fever,
diarrhoea and myalg ia. The cough is non- productive a nd a nd has been getting gradually
worse s ince she returned from holid ay in Spain one week ago. Her husband is co ncerned
because over the past 24 hou rs she has become more drowsy and febrile. He initially
thought she ha d the 'flu but her symptoms have got p rogressively worse. She is normally
fit and well but drinks around 20 un its of alcohol per week.
On exam ination pu lse is 76/ min, b lood p ressure 104/ 62 mmHg, oxygen satu rations are
94% on room a ir and temperature is 38.4°C. Bilateral coa rse crackles a re hea rd in the
chest.
Initia l blood tests show the fo llowing:
Hb 13.6 g/dl
Plat elet s 3 11 * 109/ 1
8
WBC 14 .2 109/ 1
Na• 131 mmol/ 1
K• 4.3 mmolfl
Urea 9.2 mmol/1
ALP 31 u/1
ALT 64 u/1
A chest x-ray shows patchy consolidation in the left lower zone with an associated pleural
effusion.
What is the most li kely causative o rgan is m?
Legionel/a pneumophila
s em
As
Dr
-
~
LegioneUa pneumophila
KlebsieUa pneumoniae
Stereotypical features of LegioneUa include flu-like symptoms and a dry cough,

relative bradycardia and confusion. Blood tests may show hyponatraemia
Important for me l ess impcrtc.nt
rhere are a number of features here w hich strongly suggest Legionella:

• recent foreign t ravel
• flu -like symptoms
m
se
• hyponatraem ia
As
• pleural effusion
Dr
Which one o f t he following is t rue regarding linezolid?
Active ag ainst bot h MRSA and VRE (Vancomycin- Resist ant Enterococcus)
Bact ericida l in action
No activity against GISA (Glycopept ide Int ermediate Staphylococcus aureus)
Adverse effects include raised p latelet cou nt
m
se
As
Dr
Active against both MRSA and VRE (Vancomycin-Resistant Enterococcus) fD3
''da I(1n actron
Bactenc1 . -
~
No activity against GISA (Glyco peptide Intermediate Staphylococcus aureus ) (D
Adverse effects include raised platelet count 0
m
se
tD
As
Dr
A 34-year-old man presents w ith a widespread maculopapular rash and mouth ulcers.
Two months ago he presented t o the local GUM clinic after developing a painless penile
ulcer. At the time he was noted to have inguinal lymphadenopathy. Which one of the
following organisms is most likely t o be responsible?
Lym phogranuloma venereu m
Herpes simplex virus type 2
Mycoplasma genitalium
Haemophilus ducreyi
m
se
As
Treponema pallidum
Dr
Lymphogranu loma venereum QD
Herpes simplex virus type 2 tlD

Mycoplasma genitalium CD
Haemophilus ducreyi .
(D
I Treponema pallidum CD
m
I
se
As
This patient has sympto ms of secondary syphilis.
Dr
A 28-year-old nurse on you r ward receives a needle stick injury ah er taki ng blood from a
known HIV positive patient. You give her first aid treatment and send bloods for an initial
HN t est. She asks you about post exp osure prophylaxis.
What wou ld you advise?
Teno fovir, rep eat HIV t est in 12 weeks
Combination antiretrovirals (Tenofovir, emtricitabine and lopinavir/ritonavir) repeat

HN t est in 4 weeks
Nevi rapine, repeat HN t est in 4 weeks
Combination antiretrovirals (Tenofovir, emtricitabine and lopinavr/rito navir), rep eat

HN t est in 12 week
m
se
As
Teno fovir, rep eat HIV t est in 4 weeks
Dr
Tenofovir, repeat HIV t est in 12 weeks
Combination antiretrovirals (Tenofovir, emtricitabine and lopinavir/ritonavir)

repeat HIV test in 4 weeks
Nevi ra pine, repeat HN test in 4 weeks
Combination antiretrovirals (Tenofovir, emtricitabine and lopinavr/ritonavir),

repeat HIV test in 12 week
Tenofovir, repeat HIV t est in 4 weeks
Combination antiretrovirals should be given rather than si ngle therapy as it is more

effective and it helps prevent development of resistan ce. Nevirapine ca n be used in post
exposure prophylaxis in new born babies born to HJV positive mothers.
Repeat t esting for HIV antibody/antigen should be done at 12 w eeks as this is how long it
can t ake to develop antibodies.
m
se
Source: British HIV association - UK guideline for the use of post-exposure prophylaxis for
As
HN following sexual exposure (2011)
Dr
A 31-yea r-old man who is known to be HIV positive presents with dyspnoea and a dry
cough. He is currently homeless and has not been attending his outpatient appointments
or taking antiretroviral medication.
Cli nical exam ination reveals a res piratory rate of 24 I min. Chest auscultation is
unrema rkable with only scattered crackles. His oxygen saturation is 96% on room air but
this falls rapidly after walking the length of the ward. Given the li kely diag nosis, what is
the most appropriate first-line treatment?
Fluconazole
Co-trimoxazole
Erythromycin
Ganciclovir
m
se
Sulfadiazine and pyri metham ine
As
Dr
Fluconazole fD
Co-trimoxazole CD
Erythromycin fD
Ganciclovir CD
m
se
Sulfadiazine and pyri methamine GD
As
Dr
A 25-year-old woman has recently moved to the Un ited Kingdom from sub-Saharan
Africa to attend Univers ity. She comes fro m an area where there is a high prevalence of
tuberculosis (TB). The patient is not pregnant a nd is currently asymptomatic. She thinks
she may have had a BCG vaccination in the past but is not sure. She has no other medical
histo ry and is a non -s moker. A chest x-ray is normal. She has a Mantoux test which is
positive and subsequently an interferon-gamma release assay which is a lso positive.
What is the best management option for this patient?
Isoniazid and pyridoxine for 6 months
No treatment indi cated at present
Rifa mpicin and ison iazid with pyridoxine for 6 months
Arra nge a b ronchoscopy and lavage
m
se
As
Rifa mpicin, ison iazid, pyrazinamide and ethambutol for 6 months
Dr
I Isoniazid and pyridoxine for 6 months
No treatment indicated at present

-
~
Rifampicin and isoniazid with pyridoxine for 6 months
( 1ange a bronchoscopy and lavage
Rifampicin, isoniazid, pyrazinamide and ethambutol for 6 months
The 2016 NICE guidelines on Tuberculosis (TB) advice that if a Mantoux test is positive
(>Smm) then the patient should be screened for active TB.If there is no evidence of active
TB and an interferon-gamma release assay is positive then you should consider treatment
for latent TB. The two options are:
• 3 months of isoniazid with pyridoxine and rifa mpicin
• 6 months of isoniazid with pyridoxine
The other drug combinations are incorrect and not recommended by NICE. We have been
m
se
given the diagn osis of latent TB with the Mantoux test and interferon -gamma release
As
assay and therefore a bronchoscopy and lavage are not required.
Dr
You are counsell ing a 26-year-old man who has recently had a posit ive HIV test. His most
recent CD4 count is 650 ce lls/ mmA 3. Which one o f t he following vaccinat ions is
contraindicated?
Oral poliomyelitis
Yellow fever
Pneumococcus
Parent eral poliomyelit is
m
se
As
Measles, Mumps, Rubella
Dr
I Oral poliomyelitis
Yell ow fever .,
f!D
Pneumococcus fD
Parentera l poliomyelit is GD
m
se
Measles, Mumps, Rubella GD
As
Dr
A patient wit h HJV is reviewed. Which one o f t he following is an example o f a nucleoside
analogue reverse transcript ase inhibitors?
Zidovudine
Indinavir
Ritonavir
Ribavirin
m
se
As
Efavirenz
Dr
I Zidovudine
Indinavir
CD
.
(D
Ritonavir GD
I Ribavirin .
(D
Efavirenz GD
HN drugs, ru le of thumb:
• NRT!s end in 'ine'
• Pis: en d in 'vir'
• NNRT!s: nevirapine, efavirenz
m
se
As
Zidovudine (AZT) was one of the first HIV drugs and remains important today.
Dr
A 20-year-old st udent p resent s co mplaining of multip le painfu l ulcers on the shaft of his
penis. He tell s you he has had a new sexual partner recent ly but she has not reported any
sympto ms. He feels generally unwell and ha d t end er enlarged inguinal lymph nodes
b ilaterally. He denies u rethral discharge or dysu ria.
Behcets syndrome
Herp es simplex
Syphilis
Lym p ho granuloma venereum
m
se
As
Donovan osis
Dr
Behcets syndrome CD
I Herp es simplex CD
.
Syphilis CD
Lym p ho granuloma venereum ED
Donovan osi s CD
~
Syphilis, Lym p hogranulom a venereum (LGV) and d onovanosis (granulom a inguinal) all
m
se
cause painless g enital ulcers. Behcets may cause painf ul genital ulcers but herp es simplex
As
is more likely given the recent chang e in sexual partner and the lack o f other sympt oms.
Dr
A 29-yea r-old ma n with HIV is adm itted with shortness of breath. He has recently
em igrated from South Africa and has only just started taking a nti-retroviral medicatio n.
Auscu ltatio n of his chest is unremarka b le although chest x-ray shows bilateral pulmona ry
interstitia l shadowing. What is the investigation of choice?
Bronchoalveolar lavage
CT tho rax
Transbronchial bio psy
Sputum culture
m
se
As
Blood culture
Dr
I Bronchoalveolar lavage CD
CT thorax «D
IT~ansbronchia l biopsy CD
Sputum culture GD
Blood culture CD
m
se
This man li kely has Pneumocystis carinii pneu monia. Definitive diagnosis is by bronchial
As
alveolar lavage with silver staining
Dr
A 25-year-old woman is admitted to a local hospita l w hilst travelling in north India. She is
26 weeks p regnant with her first child and t he pregnancy has been uneventful to d ate. For
the past 3-4 days she has been feeling g enerally unwell with fever, lethargy and vom it ing.
She takes no regular medication other t han malaria prop hylaxis (chloroqu ine).
On examinat ion her pu lse is 96/ min, blood p ressure 102/ 66 mmHg. Jaundiced sclera,
along w ith some b ruising on her arms is not ed. Her partner stat es that she also seems
conf used.
Blood s show t he following:
Bilirubin 102 ~mol/1
ALP 256 u/1
ALT 1024 u/1
yGT 563 u/1
Albumin 35 g/1
INR 2.4
What is the most likely cause of her det erioration?
Hepatitis A
Hepatitis B
Hepatitis E
Malaria
sem
Amoebiasis
As
Dr
Hepatitis A &3
Hepatitis B CD
Hepatitis E CD
Malaria CD
Amoebiasis .
(D
Severe hepatitis in a pregnant woman - think hepatitis E

This lady has developed fulminant hepatitis, or acute liver failure. Th is is uncommon with
the hepatitis viruses but pregna nt women are at particular risk from hepatitis E infection.
m
se
As women approach their third trimester (slightly later than the scena rio here) the
As
mortality rate approaches 20%.
Dr
A 17-year-o ld gi rl presents with a sore th roat. On exam ination she has inflam ed tonsils
covered in white patches. Te nder cervica l lymphadenopathy a nd a low g rade pyrexia a re
also present. Which one of the following organisms is most li kely to be responsible?
Streptococcus agalactiae
m
se
As
Dr
Streptococcus viridans GD
Streptococcus agalactiae m
Streptococcus pneumoniae (D
Staph{ tococcus aureus CD
m
se
Streptococcus pyogenes 6D
As
Dr
A previously well 68-year-old woman is reviewed on the acute medical ward. She has
recently been commenced on methotrexate for newly diagnosed rheumatoid arthritis.
During you r review, she comp lains of dysuria and urinary frequency. She is oth erwise
systemically well, with no fever or loin t en derness.
Urinalysis results show:
Leucocytes +++
Nitrites Positive
Blood Trace
Which antibiotics should be used to treat this patient's urinary tract infection?
Amoxicillin + Gentamicin
Trimethoprim
Ciprofloxacin
Co -tri moxazole
m
se
As
Nitrofurantoin
Dr
Amoxicilli n + Gentamicin
Trimethoprim
-
~
Ciprofloxacin
Co-trimoxazole
I Nitrofurantoin
Trimethoprim and Co-trimoxazo le should be avoided in patients on Methotrexate

Both trimethoprim and methotrexate work by inhibiting the enzyme dihydrofolate

reductase. When given alongside one another, patients can develop life-threatening
myelosup pression due to the cumulative effect of the folic aci d antagonism that occu rs.
Since co-trimoxazole is a com bination of trimethoprim and sulfamethoxazole, this effect

occurs with the co-prescription of co-trimoxazole and methotrexate also.
Amoxicillin and gentamicin is usual ly given in the treatment of pyelonephritis/urosepsis,
m
se
and would be inappropriate in this patient. Ciprofloxacin is also mo re commonly used in
As
complicated urinary tract infections and would not com monly be first line. Dr
A health ca re ass istant susta ins a need lestick inju ry wh ilst taking b lood from a patient who
is known to be HIV positive. Following thorough washing of the wound what is the most
HIV test of health care wo rker in 3 months to determine treatment
Immed iate p24 HIV test of health ca re worker to d etermine treatment
Ora l a nti retroviral therapy for 4 weeks
Ora l a nti retroviral therapy for 3 months
m
se
As
Intravenous zidovudine
Dr
HIV t est of health care worker in 3 months to determine treatment
Immedij te p24 HIV test of health care worker to d etermine treatment
Oral antiretroviral therapy for 4 weeks
Oral antiretroviral therapy for 3 months

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~
Intravenous zidovudine
Post-exposure prophylaxis for HIV: oral antiretroviral therapy for 4 weeks
m
se
As
Dr
A 75-year-old woman is admitted with confusion to the Emergency Depa rtment. Her
urine d ipstick is positive for nitrites and leucocytes and a diagnosis o f urinary tract
infection is suspected . She is the refore prescribed a 7 day cou rse of trimethoprim. Bloods
taken in the Emergency Department are as follows:
Na• 141 mmol/ 1
K• 3.7 mmolfl
Urea 4.3 mmol/1
CRP 21 mg/1
Five d ays late r on the ward her bloods a re re peated:
Na• 140 mmol/ 1
K• 3.9 mmol/1
Urea 5.3 mmolfl
CRP 6 mg/1
What is the most like ly explanation for the change in renal functio n?
Impaired renal function secondary to acute pyelonephritis
Crysta l-induced nep hropathy secondary to trimethoprim
Trimethoprim competitively in hibiting the tu bular secretion of creatinine
Interstitial nephritis secondary to tri methoprim

sem
As
Spu rious result d ue to plasma-bound trimethoprim be ing confused with creatinine

Dr
Impa ired renal fu nction secondary to acute pyelonephritis
Crystal- induced nep hropathy secondary to trimethop rim
~methoprim competitively inhibiting the tubular secretion of creatinine

Interstitial nephritis secondary to tri methoprim
Spurious resu lt due to plasma-bound trimethoprim being confused with

creatin ine
m
se
As
The fall in CRP is not co nsistent with the deve lopment of acute pye lonephritis.
Dr
A 33-year-old man is admitt ed due to profuse diarrhoea. He has a history of HIV infection
and Cryptosporidium diarrhoea is suspect ed. What investigation is most likely to confirm
the diagnosis?
Blood cultures
Sigmoidoscopy with biopsy
Abdominal x- ray
Acid-fast st aining of st ool sample
m
se
As
Cryptosporidium PCR of stool sample
Dr
m
se
Cryptosporidium cysts turn red following acid-fast staining. Molecular methods are
As
currently used mainly as a research tool
Dr
A 53-year-old woman is diagnosed with left leg cellulitis. A swab is taken and oral
flucloxacillin is started. The following result is obtained:
Skin swab : Group A Streptococcus
How should the antibiotic therapy be changed?
No change
Add topical fusidic acid
Add clindamycin
Switch to phenoxymethylpenicilli n
m
se
As
Add eryth romycin
Dr
No change
Add topical fusidic acid
Add clindamycin
I Switch to phenoxymethylpe~i c illin

Add erythromycin
Penici llin is the antibiotic of choice for group A streptococcal infections. The BNF suggests
stopping flucloxacillin if streptococcal infection is co nfirmed in patients with cellulitis, due
m
se
to the high sensitivity. This should be balanced however with the variable absorpti on of
As
phenoxymethylpenici llin.
Dr
A 30-year-old man returns from a cheese a nd wine tasting ho liday in Portuga l. On
questioning, he tells you about all the unpasteurised cheese he tried. He comes to the GP
complain ing of feeling very unwell. On q uestioning, he reports having fluctuating
temperatures, he has pa in in his jo ints and muscles that is transient and has noticed a
peculia r 'wet hay' smell when he sweats, which is a lot. What is the most likely causative
organism?
Yersinia pestis
Brucella melitensis
Wuchereria bancrofti
Bartonella henselae
m
se
Plasmodium falciparum
As
Dr
Yersinia pestis
I Brucella melitensis
Wuchereria bancrofti
Bartonella henselae
Plasmodium falciparum
This patient is presenting with symptoms typical of Brucellos is; Fluctuating temperatures,
transient arthralgia and myalg ia, hyperh idrosis with a 'wet hay' smell. The clue in the
history is his exposu re to unpasteurised cheese.
Brucella melitensis is the bacteria found in contam inated unpasteurised milk that causes
brucellosis.
Bartonella henselae, the causative agent o f cat scratch d isease, wou ld present with a
history of exposure to cat scratches.
Yersinia pestis, the causative agent of bubonic plague, would p resent with a history of
exposure to flea b ites in a plague endemic a rea. The patient would a lso p resent with a
fixed rathe r than fluctuating temperature.
Plasmodium falciparum, the causative agent of ma la ria, would s imilarly p resent with
fluct uating temperatu res and excessive sweating, though the history wou ld show
exposure to mosquito b ite in a ma la ria endemic area
s em
As
Dr
A 17 -yea r-o ld fe ma le presents fo r review. Fou r days a go she presente d to he r d octo r with
a seve re sore throat, letharg y and head ache. Her d octo r prescribed a cou rse o f a moxicill in
to treat an up per respiratory tract infection. Two d ays ago she d eve lo ped a wid esp read,
p ruritic macu lo papu la r rash. Her o riginal symptoms have a lso not improved . What is the
most li ke ly diag nosis?
Kawasaki disease
Penicillin a llergy
HIV seroconve rsio n
m
se
Beta -lacta mase pro d ucing streptococcal sore thro at
As
Dr
Infect ious mononucleosis
Kawasaki disease
Penici llin a llergy
HN seroconversion
Beta - Iactamase producing strepto coccal sore throat
URTI symptoms + a moxicillin - rash ?glandular fever

m
se
A rash d evelops in around 99% of patients who take amoxicillin whilst they have
As
infectious mononucleo sis. Her treatment should be su pportive as d etailed below.
Dr
A 28-yea r-old female returns from a country that is known to have Zika virus transmission.
She p resents with feve r, headache and mya lg ia fo llowing a mosqu ito b ite. She exp resses
the wish to have children in the nea r future.
In view o f the possibility of Zika virus, how long should s he wait before attempting
conceptio n?
2 months
4 months
6 months
8 months
m
se
10 months
As
Dr
2 months C!D
4 months CD
p months GD
8 months CD
10 months CD
The answe r a ccording to the World Hea lth Orga nisation is to use barrie r method s fo r 6
m
se
mo nths a fte r return ing fro m a categ ory 1 o r 2 a rea
As
(http:/jwww .who .int/cs rId isea se/ zika/ info rmatio n -fo r-trave lers/ en/}.
Dr
A 39-year-old female who has recently emigrated from su b -Saharan Africa is screened for
tuberculosis. She reports being fit and well w ith no past medical history and has never
had a BCG vaccination. Her chest x-ray is normal so she has a Mantoux test which is
positive. An interferon gamma t est is also performed w hich is positive. A HN t est is
request ed w hich is negative. What treatment would you recomm end?
3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid

(with pyridoxine)
Rifampicin, isoniazid, pyrazinamide and ethambutol for 6 months
Observe
Rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months then step dow n
to rifampicin and isoniazid for 4 months
m
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As
3 months of pyrazi namide and isoniazid OR 6 months of pyrazinamide
Dr
3 months of iso niazid (with pyridoxine) and rifa mpicin OR 6 months of isoniazid
(with pyridoxine)
Rifa + icin, isoniazid, pyrazinamide and ethambutol for 6 months
Observe
-
~
Rifa mpicin, isoniazid, pyrazinamide and ethambutol for 2 months then step
down to rifa mpicin and isoniazid for 4 months
3 months of pyrazi nam ide and isoniazid OR 6 months of pyrazinamide
m
se
As
This patient has latent tuberculosis
Dr
A 34-year-old male returns from india and upon arriving home is diagnosed with
pneumonia that is resistant t o multiple antibiotics, in particu lar to imipenem. What is the
likely virulence factor which caused the pneumonia?
D-alanyi -D-Iactate variation leading to loss of affinity
New Delhi metallo-bet a-lactamase 1
Presence of MexAB-OprM efflux pumps
Alteration to the penicill in binding protein 2
m
se
As
Reduced permeability & ribosomal modification
Dr
D-alanyi -D-Iactate variation leading to loss of affinity
I New Delhi metallo-beta-lactamase 1
Presence of MexAB-OprM efflux pumps
Alteration to the penicillin binding prot ein 2
Reduced permeability & ribosomal modification
New Delhi metallo-bet a-lactamase 1 is the mutation that leads to carbapenem resistance.
Typica lly found in Klebsiella pneumoniae, Escherichia Coli (E. Coli), Ent erobacter cloacae
and others. First line of management is the old antibiotic colistin and second line may be
tigecycline.
D-alanyi -D-Iactate variation leading to loss of affinity to antibiotics is the mechanism of

VRE (vancomycin resist ant ent erococci). Vancomyci n binds to D-ala-D-ala.
The presence of MexAB-OprM efflux pumps is one of the mechanisms by which

pseudomonas aeruginosa is resistant t o -lact ams, chloramphenicol, fluoroquinolones,
macrolides, novobiocin, sulfonamides, t etracycline, and trimethoprim .
Alteration to the penicillin binding prot ein 2 is the mechanism behind methicillin-resistant
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se
staphylococcus au reus. Mutations in the MEC gene which codes the penicillin binding As
proteins give staphylococcus au reus its resistance.
Dr
A 20-yea r-old stu dent p resents to the Emergency Depa rtment three weeks after being
scratched by their pet kitten on the ir left arm. The re is a crusted papule at the site of the
scratch and painful left axillary lympha denopathy. Wh ich is the most likely causative
o rganism?
Bartonella
Coxie lla
Brucella
Myco plasma
m
se
As
Ye rsinia
Dr
Bartonella GD
Coxie lla flD
Brucella C!D
Mycoplasma CD
Yersinia fD
The correct answer is Ba rtonella, the causative agent of cat scratch disease.
Coxie lla burnetii is a gram -negative rod and the causative agent of Q fever, a zoonos is.
The history usually includ es exposu re to fa rm an imals. The clinical presentation is va ried
and acute infection may resu lt in flu- like symptoms, pneu monia, hepatitis and a
potentially fata l endoca rd itis.
Brucella spp. a re gram-negative rods and the causative agent of b rucellosis, a zoonosis.
The history usually includ es exposu re to animal fluids (e.g . unpasteurised milk).
Yersinia s pp. a re gra m-negative rods and the causative agents of yersiniosis, a dia rrhoeal
illn ess, and plague (Y. pestis).
m
Mycoplasma spp. are g ram-indeterm inate bacteria, the genus includes over 100 species.
They most commonly cause pneumon ia (M. pneu moniae) and gen ital tract infections (M. se
As
genitalium).
Dr
A 37-yea r-old imm igrant from Bolivia is adm itted to the Emergency Department fo llowing
a collapse. He is known to have a history of Chagas' disease. Which one of the following
complications of Chagas' d isease accounts for the majority of mortality in affected
patients?
Large bowel perforation secondary to megacolon
Myocarditis
Perineph ric abscess
Meningoencephalitis
m
se
Pulmonary haemo rrha ge
As
Dr
Large bowel perforation secondary to megacolon
I Myocardit is
Perinephric abscess
Meningoencephalitis
Pulmonary haemorrha ge
m
se
As
Cardiac involvement is t he leading cause of deat h in patients w it h Chagas' disease
Dr
A 42-yea r-o ld d entist is reviewe d in the med ica l clinic com pla ining of pe rsistent letharg y.
Routine b loods s how a bnormal liver function tests so a he patitis screen is sent. Th e results
a re shown be low:
Anti-HAV IgG negative
HBsAg negative
Anti-HBs positi ve
Anti-HBc negative
Anti-HCV positi ve
What d o these results most likely d emonstrate?
Hepatitis B infection
Previous vaccination to he patitis B a nd C
Hepatitis C infection with previous hepatitis B va ccination
m
se
Hepatitis Ba nd C infection
As
Dr
Hepatitis B infection
Hepatitis C infectio n
I
Previous vaccination to hepatitis B and C
Hepatitis C infectio n with previous hepatitis Bvaccinatiol

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~
Hepatitis Band C infection
Given the deranged liver function tests these results most likely ind icate previous hepatitis
B vaccination with active hepatitis C infection. However, around 15% of patients exposed
to the hepatitis C virus clear the infection. It woul d therefore be necessary to perform a
HCV PCR to see if the virus is still present
m
se
As
There is cu rrently no vaccination fo r hepatitis C
Dr
Which one of the following conditions is not associated w ith prior Epstein-Barr virus
infection?
Hodgkin's lymphoma
Adu lt T-cell leukaemia
Burkitt's lymphoma
Nasopharyngeal carcinoma
m
se
As
Hairy leukoplakia
Dr
Hodgkin's lymphoma
Adult T-cell leukaemia
Burkitt's lymphoma
Nasopharyngeal carcinoma
Hairy leukoplakia
EBV: associated malignancies:

• Burkitt's lymphoma
• Hod gkin's lymphoma
• nasopharyngeal carcinoma
m
se
As
Adu lt T-cell leukaemia is associat ed w ith HTLV-1 infect ion
Dr
A 78-year-old wo man is admitted to t he general medica l wa rd with lobar pneumonia and
is com menced on Co-amoxiclav. A few days later, she reports having some loose stool
and abdominal pain. Microb iology repo rts co me back positive for Clostridium diffici/e.
Which classification o f bacteria do Clostridium species b elong to?
Gram pos it ive cocci
Gram negative cocci
Gram pos it ive baci lli
Gram negative bacilli
m
se
As
Int racellular bact eria
Dr
Gram positive cocci m
Gram negative cocci m
Gram positive bacilli CD
Gram negative bacilli 6D
Intracell ular bacteria CD
Clostridium - Gram-positive rod

Clostridium species are classified as gram positive bacilli.
Other gra m positive bacilli include:

• Actinomyces sp.
• Bacillus anthracis
• Corynebacterium diphtheriae
m
se
• Listeria monocytogenes
As
Dr
A 44-year-old man who is known to have HIV is ad mitted to the Emergency Department
following a se izure. He has been taking a ntiretroviral therapy for the past two years. ACT
scan (without contrast) shows a so litary lesion in the basa l ganglia. What is the most
effective method to help differentiate between lym phoma and toxoplas mosis?
MR spectroscopy
CT with co ntrast
Thallium SPECT
Peripheral b lood film
m
se
Lumba r punct ure
As
Dr
MR spectroscopy CD
CT with contrast 6D
I Tha llium SPECT
Peripheral blood film

aD
.
(D
Lumbar puncture .
(D
Differentiating between t oxoplasmosis an d lym phoma is an important asp ect of

managing neurocomplications relating t o HIV. Given the more limit ed availablity o f SPECT
compared to CT many patients are treated empirically on the basis of scoring systems, for
example there is a 90% likelihood o f toxoplasmosis if all of the following criteria are met:
• t oxopla smosis IgG in the se rum
• CD4 < 100 an d not receiving prophylaxis for toxoplasmosis
m
se
• multiple ring enhancing lesions on CT or MRI
As
Dr
A 17-year-old g irl presents to the emergency department compla inin g of a widespread
erythematous rash. She has recently been commenced on amoxicill in fo r an upper
respiratory tract infection by her general p ractitioner. Which of the fo llowing is the most
appropriate test to p rovide a d iagnosis?
Blood culture
Heterophile antibody test
Mast cell tryptase
Lym ph node biopsy
m
se
Blood film
As
Dr
Blood cu lture
Heterophile antibody test
Mast cell tryptase
Lymph node b io psy
Blood film
-
"""'
Heterophi le antibod ies - infectious mononucleos is
Important for me Less imoortc.nt
Infectious mononucleosis is an important differe ntial to consid e r in patie nts presenting

with no n-specific uppe r resp irato ry tract symptoms, esp ecially in the a bove demogra phic.
In patients with infectious mononu cleosis, emp irica l treatme nt with a moxicillin oh en leads
to a morb illiform rash. A hete rophile antibo dy test (Pau l-Bun nell) has high specificity and
moderate sensitivity fo r infectious mo nonucleosis.
With the clinica l story pointing towa rds infectious mono nucleos is a nd with nothing in the
story suggesti ng that the patie nt is septi c, blood culture woul d not be ap propriate . Mast
cell tryptase is a useful test when investigati ng an e pisode of ana phylaxis. Aga in the
clinical sto ry does not fit with this and moreove r, the mast cell tryptase test would not
p rovid e a ny usefu l info rmation in the imme d iate setting . Whilst a lymph node bi opsy can
p rovid e further evidence of infectious mononucleosis, g iven its invasive nat u re and the
rather typica l story, it wou ld not be the most ap propriate test.
em
A blood film may show evid ence o f atypica l lympho cytes, b ut wou ld not provid e a
s
As
d efin itive diagnos is, especially as that finding is not pathogno mo nic.
Dr
Which one o f t he followin g vaccines uses a protein that att aches to t he polysaccharide
outer coat to make t he pat hogen more immunogenic?
Rabies
Yellow fever
Oral polio
Measles
m
se
As
Meningococcus
Dr
Ra bies (fD
Yellow fever CD
-
Oral polio CD
Measle{ tiD
m
se
Meningococcus CD
As
Dr
A 27 -year-old bisexual man presents to you r GUM cl inic w ith a 7 -day history o f rectal
discharge, pain on passing stools and tenesmus. On examination, he has t ender inguinal
lymphadenopat hy and p roctoscopy reveals red mucosa with yellow discharg e and some
shallow ulcers.
Which one o f the following org anisms is most likely t o be causat ive?
Enterococcus coli
Treponema pallidum
Haemophilus ducreyi
Neisseria gonorrhoea
m
se
As
Dr
Er erococcus coli CD
Treponema pallidum CD
Haemophilus ducreyi tiD.

Neisseria gonorrhoea fiD
I Chlamydia trachomatis ClD
If a sexua lly active patient p resents with genita l c hla mydia and bowel symptoms,
LGV proctocolitis shou ld be considered
The presence o f ulcers and s ignificant rectal sympto ms in a sexua lly active man ra ises the
question of lymphogra nuloma venereu m, which is caused by a type o f Chlamydia
m
se
trachomatis. Recta l infection with gonorrhoea could cause simila r symptoms but would
As
not be expected to cause ulcers.
Dr
A 34-year-old man is diagnosed as being HIV positive. He was born and brought up in
the United Kingdom and is cu rrently fit and well with no past medica l history. At what
point should anti-retroviral therapy be started?
At the time of diagnosis
CD4 < 200 * 106/ l
CD4 < 250 * 106/ l
CD4 < 300 * 106;1
m
se
As
CD4 < 350 * 106/ l
Dr
I At the time of diagnosis
6
fD
CD4 < 200 * 10 /I CD
6
CD4 < 250 * 10 /I CD
llD4 < 300 * 10

6
/I m
CD4 < 350 * 10 6
/I .
CD
m
Ant i-retroviral t herapy for HIV is now started at the t ime of diagnosis, rat her than
se
waiti ng for the CD4 count t o drop to a particular level
As
Dr
A 24-yea r-old woman presents due to an itchy vu lva an d pain during sex. She a lso
mentions a g reen, offensive va ginal d ischarge for the past 2 weeks. What is the most
like ly diagnosis?
Candida
Bacterial vag inos is
Gonorrhoea
Trichomonas vagina/is
m
se
As
Chlamydia
Dr
Bacterial vaginos is
Gonorrhoea
m
se
Chlamydia
As
Dr
A 34-year-old postman attends the Emergency Department following a dog bite to his
right hand. What is the most appropriate antibiotic therapy?
Metronidazole + amoxicillin
Erythromycin
Co -amoxiclav
Metronidazole
m
se
Flucloxacill in + penicillin
As
Dr
Metronidazole + amoxicillin CD
Eryth romycin
•.,
I Co-amoxiclav
Metronidazole m.
Fl ucloxacillin + penicillin GD
Animal bite - co-amoxiclav

m
se
A combination of doxycyclin e and met ronidazole is recommended in the BNF if the
As
patient is penicillin allergic
Dr
A 30-year-old man has returned fro m South America aher one w eek. He has d eveloped a
mild fever, muscle pain, headache and conjunctivit is. He has been taking his anti-ma larial
t ablets. What is the most likely diagnos is?
Dengue
Chikun gunya
Malaria
Influenza
m
se
As
Zika
Dr
Dengue CD
Chikun gunya fD
r : :a ria (D
Influenza m.
Zika tD
Zika, Chikungunya and Dengue can produce similar symptoms. Zika is prevalent in South
Ame rica. It tends to cause mild fever whereas d engue and chikungu nya tend to cause
abrupt onset of high fever. Chikungunya a nd dengue wou ld cause more jo int pa in and
conjunctivitis is less co mmon with these conditions. He has been taking his antimalarials
m
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making mala ria less likely. Influenza cou ld be a consideration but because of the recent
As
trave l history zika should be considered first.
Dr
A 30-year-old HIV positive man attends your travel clinic asking for you r advice on
holiday vaccinations. His is taking anti-retroviral therapy and his most recent CD4 count is
200 cells/ mm'. He is otherwise well and has no other medical conditions.
Which of the following vaccines are contrain dicated in this man?
Rabies
Meningitis ACWY
Japanese encephalitis
Tuberculosis (BCG)
m
se
Hepatitis B
As
Dr
Live attenuated vaccines such as BCG are co ntraindicat ed in all HIV posit ive pati ents.
Other live attenuated vaccin es w hich shou ld not be given in immunocomprom ised
patients are:
• Yellow fever
• Oral polio
• Intranasal inf luenza
• Varicella
• Measles, mumps and rubella (MMR)
m
se
As
Source: uptodate
Dr
A 37 -year-old sewer worker present s to the Emergency Department w ith flu -li ke
sympt oms and pyrexia for the past 3 days. Since this morning he has started to develop a
headache and signs of meningism are found on examination. Blood tests show:
Sodium 145 mmol/ 1
Urea 10.3 mmol/1
What is the antibiotic treatment of choice?
Co-trimoxazole
Ciprofloxacin
Metronidazole
Benzylpenicillin
m
se
As
Erythromycin
Dr
Co-trt oxazole CD
Ciprofloxacin CD
Metronidazole CD
Benzylpenicillin ED
Erythromycin f!D
Leptospirosis - give penicillin or doxycycline

m
se
This patient has leptospirosis. The treatment of choice is benzylpenicillin. A lumbar
As
puncture should ideally be done first to confirm meningeal involvement.
Dr
A 23-year-old solider w ho returned f rom a tour of Afghanistan 2 months ago presents
with a large painless ulcer on the back of his hand. He reports that it started as a small
papule and gradually enlarged. On examination he has a 3cm ulcer w ith a central
depression and a ra ised indurated border. He is otherwise well in himself and has no
other medical problems.
Cut aneous leish maniasis
Sarcoidosis
Primary syphilis
m
se
As
Buruli ulcer
Dr
I Cutaneous leish man iasis CD
Sarcoidosis
Primary syphilis
•
GD
Pyoderma gangrenosum fD
Buruli ulcer (D
Given the travel history to Afghanistan and the painless single lesion the most likely
explanation is cutaneous leishmaniasis. Primary syphilis may present with a single painless
lesion but the large size and location on the back of the hand is unusual. Pyoderma
gangrenosum you wou ld expect to be painful and present more acutely. A buru li ulcer is
an ulcer caused by mycobacterium ulcerans and can present li ke this but is ra re, usually
found in children and has not been reported in the Middle East.
Source: WHO fact sheets on leishmaniasis

Cutaneous leishmaniasis is transm itted by sandflies and usually presents as an
erythematous patch or papule which gradually enlarges and beco mes an ulcer with a
raised indurated border. In 'dry' forms the lesion is crusted with a raised edge. It is usually
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painless unless a secondary bacterial infection is present. Afghanistan has particularly hig h
As
levels of cutaneous leishmaniasis.
Dr
A 17-yea r-old ma le presents with a severe sore throat, fever and lethargy. On exam ination
he is noted to have cervical lymphadenopathy. He has now been unwell for 6 d ays. A
b lood test is taken the next day:
Male: ( 135-180)
Hb 15.5 g/L
Female: (11 5- 160)
Platelet s 300 * 109/ L (1 50- 400)
W BC 9 * 109/L (4.0 - 11.0)
Neuts 3 * 109/L (2.0 - 7.0)
Lymphs 5.5 * 109/L (1.0 - 3.5)
Mono 0.5 * 109/L (0.2 - 0 .8)
Eosin 0.1 * 109/L (0.0 - 0 .4)
Heterophil antibody test POSITIVE
What is the most appropriate next step in management?
Ultrasound of spleen
Amoxicil li n
Observation
Oseltamivir
m
se
Zanamivir
As
Dr
Ultrasound of spleen tiD.
Amoxicillin fl!D
Observation ED.
Oseltamivir fl!D
Zanamivir m
Infectious mononucleosis is generally a self-limiting condition
This patient has infectious mononucleosis. No active treatment is required although
m
se
patients should be counselled regarding the need t o avoid contact sports for 8 weeks
As
given the risk of splenic rupture.
Dr
A 25-yea r-old intravenous drug user with chronic hepatitis C becomes pregna nt.
Approximately what is the chance of the virus bei ng tra nsmitted to her child?
<10%
10-20%
20-30%
30 -40%
m
se
As
40-50%
Dr
<10% CiD
10-20% QD
20-30% fiD
30 -40% .
(D
m
se
.
(D
As
40 -50%
Dr
A 19-year-old man prese nts with an annular rash, pyrexia and polyarthralgia to the
Emergency Department. He has just returned from the New Forest and remembers being
bitten by a tick. Given the likely diag nosis, what is the most appropriate antibiotic
therapy?
Ciprofloxacin
Amoxicil li n
Metronidazole
Doxycycline
m
se
As
Ceftriaxone
Dr
Ciprofloxacin m
Amoxicil lin fD
Metronidazole m
Doxycycline fZD.
Ceftriaxone m
First line treatment fo r early Lyme disease is a 14-21 day course of oral doxycycl ine
m
se
As
As he only ha s features of early disease, doxycycline is sufficient.
Dr
A 31-year-old woman presents a s she has noted an offensive, fishy va ginal d ischarge. She
d escribes a grey, watery discharge. What is the most likely diagnosis?
Candida
Chlamydia
Bacterial vag inosis
m
se
As
Phys iologica l d ischarge
Dr
Trichomonas vagina/is fD
Candida m
Chlamydia m
I Bacterial vag inos is CD
m
se
•
As
Physiological discha rge
Dr
A 12-year-old boy who had a splenectomy following a road t raffic accident is reviewed in
clinic. He had his fu ll immunisation course as a child and was g iven a repeat
pneumococcal vacci nation 5 days following su rgery. What is t he most appropriate
ongoing management?
Booster dose o f Hib and MenC vaccine + lifelong penicillin V
Booster dose o f Hib and MenC vaccine + penicill in V fo r 2 years
Lifelong penicillin V
Booster dose o f Hib and MenC vaccine + annua l inf luenza vaccination + pen icillin
V fo r 2 years
m
Booster dose o f Hib and MenC vaccine + annua l influenza vaccination + lifelong
se
As
pen icillin V
Dr
Booster do se of Hib and M enC vaccine + lifelong penicillin V
Booster dose of Hib and M enC vaccine + p enicill in V for 2 years
Lifelong pen icill in V

I
Booster dose of Hib and M enC vaccine + annual inf luenza vaccinati on +
penicil lin V for 2 years
Booster dose of Hib and MenC vaccine + annual influenza vaccinati on + lifelong ED
penicillin V
Debate still exist s regardin g how long a patient shoul d take penicil lin p ro phylaxis fo r. The
majority of d oct ors advocate lifelong peni cill in. Consensus guidelines agree however that
m
se
In this case p ro phylaxis should be conti nued until t he patient is at least 16 yea rs old, so of
As
the available o ptions E is t he correct answer
Dr
A 31-year-old female with no past medica l history of note is admitted to hospital w ith
dyspnoea and fever. She has recently returned from holiday in Turkey. A cli nical diagnosis
o f pneumonia is made. On examination she is noted to have an ulcerated lesion on her
upper lip consistent with rea ctivation of herpes simplex. Which organ ism is most
associated w ith this examination finding?
Pneumocystis carinii
m
se
As
Dr
I Streptococcus pneumoniae
Pneumocystis carinii
Streptococcus pneumoniae is associated with cold sores

m
se
Streptococcus pneumoniae commonly causes reactivatio n of the herpes s imp lex virus
As
resu lting in 'cold sores'
Dr
A 29-year-old man presents w ith a nine day history of watery diarrhoea that developed
one week after return ing from India. He had t ravelled around northern India for two
months. On examination he is apyrexial and his abdomen is soft and non-tender. What is
the most likely causative organism?
Amoebiasis
Giardiasis
Campylobacter
Shigella
m
se
As
Salmonella
Dr
Amoebiasis GD
Giardiasis CD
Campylo~acter f!D
Shigella fD
Salmonella CD
-
m
se
As
The incubation period and prolonged, non-bloody diarrhoea point towards giardiasis
Dr
A 7-year-old boy is admitted to hosp ital after presenting w it h fever, hea dache an d neck
st iffness. A diagnosis o f pneumococcal meningitis is made. There are no other reports of
meningit is in the local area over the past 4 weeks.
How should t he close contacts of th is boy b e mana ged?
No action is needed
Pneumococcal vaccine boost er
Ora l amoxicillin
Ora l amoxicillin + pneumococcal vaccine booster
m
se
As
Ora l ciprofloxacin
Dr
No action is needed
Pneumococcal vaccine booster
Orj' amoxicillin
-
"""'
Oral amoxicillin + pneumococca l vaccine booster
Oral ciprof loxacin
Carriage of pneumococcus is extremely common and no antibiotic p ro phylaxis is
m
se
genera lly required in this sit uation. There are however exceptions to t his if a 'cluster' o f
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cases develop - please t he H PA link for more details.
Dr
A 43-year-old man from Sierra Leone present s with a flu-like illness. On examination he
has very large posterior cervical lymph nodes. A diagnosis of African trypanosomiasis is
confirmed on blood smear. What is the most appropriate treatment?
Atovaquone-proguanil
Sodium stibogluconate
Benznidazole
Metronidazole
m
se
As
Pentam idine
Dr
Atovaquone-proguan il fD
Sodium stibogluconate .
(D
Benznidazole fD
Metronidazole m
m
Pentamidine ED
se
As
Dr
A 26-year-old man ret u rns to the genito-u rinary medicine clin ic. He is a known
intravenous drug user. Five days ago he was seen with a u ret hral discharge. A swab ta ken
in the cli nic showed a Gram-negative diplococcus and treatment w ith IM ceftriaxone was
given. Unfortunat ely his symptoms have not resolved. What is the most like ly
explanation?
Gonorrhoea -resistant t o ceftriaxone
Co -exist ent Candida infection
HIV inf ecti on
Co -exist ent syphilis infection
m
se
As
Co -exist ent Chlamydia inf ecti on
Dr
Gonorrhoea-resistant t o ceftriaxone
I co -r,st ent Candida infection
HN inf ection
Co-exist ent syphilis infection
Co -existent Chlamydia infection

-
~
m
se
As
Co-exist ent infection with Chlamydia is extremely common in patient s with g onorrhoea.
Dr
Which one o f t he followin g viruses is associated w ith nasopharyngeal carcinoma?
Adenovirus
Rhinovirus
Herp es simplex virus
Epstein- Barr virus
m
se
Pico rnavirus
As
Dr
Adenovirus m
Rhinovirus m
Herp es simplex virus (D
Epstein-Barr virus .
('JD
Pico rnavirus CD
EBV: associated malignancies:

• Burkitt's lymphoma
• Hod gkin's lymphoma
m
• nasopharyngeal carcinoma
se
As
Dr
You review a 14-year-old boy who has recently emigrated from Russia. He was involved in
a car accident two years ago and underwent an emergency splenectomy.
Following the accident, he takes penici llin Von a daily basis. He is unsure o f his
vaccinati on history.
Which organism is he particularly susceptible to?
HIV
m
se
As
Mycobacterium tuberculosis
Dr
HN
Haemophitus influenzae
m
se
Penici llin V wou ld p rotect him a gai nst Streptococcus pneumoniae but not Haemophitus
As
influenzae due to the production of beta-lactamases by the organism.
Dr
A 44-year-old man who is known t o be HJV pos itive presents w ith shortness-of-breath.
Which one of the followin g featu res is most characteristic of Pneumocystis carinii
p neumonia?
Usually occu rs when the CD4 count is 200-300/ mm'
Absence o f fev er
Pro ductive cough
Oxygen saturations usually improve after short period of exertion
m
se
As
Normal chest auscultation
Dr
Usually occurs when the CD4 count is 200-300/ mm'
I Absence o f fever
Productive cough
Oxygen saturations usually improve after short period of exertion

-
~
m
I
se
As
Normal chest auscultation
Dr
A 31-yea r-old woman with a three year history of ulcerative col itis is sta rted on
azathiop rine to help prevent re lapses. Which one of the following vaccines must be
avo ided whilst she is on this treatment?
Ye llow fever
Rabies
Pertussis
Diphthe ria
m
se
As
Tetanus
Dr
Yellow fever (D
Rabies t:ID
Pertussis .
(D
Diphtheria CD
Tetanus m
Live attenuated vaccines

• BCG
• MMR
• oral polio
• yellow fever
• oral typhoid
m
se
Live vaccines shou ld not be g iven to patients who a re immunosuppressed, such as those
As
ta king azathio prine.
Dr
A 28-year-o ld medical student presents to the infectious diseases ward with fevers,
letha rgy and a productive coug h that has been o ngo ing fo r two weeks. He has recently
returned to the UK following an e lective period spent vo lunteering in refugee camps
ove rseas. He has no significa nt past medica l history. Prior to his travel, th e patie nt
received a ll appropriate vaccinations and received the BCG vaccin e prio r to starting his
studies 4 years ago.
White Cell Count 13 x10A9/ I
C-reactive Protein 240 mg/ L
Na• 137 mmoi/ L
Chest X- ray Left upper zone consolidation
Sputum appearances Mucopurulent with streaks of blood
Sputum cultures Awaited
What is the most li kely causative o rga nism for the patient's pneumonia?
m
se
Legionel/a pneumophi/a
As
Dr
Staphylococcus aureus (tD
Mycoplasma pneumoniae (tD
I Mycobacterium tuberculosis CID

Klebsiella pneumoniae GD
Legionella p_neumophi/a GD
The BCG vaccine is unreliable in protecting aga inst pu lmonary tubercu losis
Although the BCG is routinely given to people at high ris k of exposure through
occupation, it's strengths lie in preventing extra pulmonary manifestations of tuberculosis,
rather than the more common, pulmonary form. This patient has spent a prolonged
period of time working in refugee camps, which te nd to be overcrowded, creating an
environment in which TB can spread rapidly a mongst inhabitants.
Pneumonia caused Staphylococcus aureus often is preceded by a vira l ill ness such as
influenza.
Mycoplasma pneumoniae frequently causes mild cases of pneumonia, otherwise referred

to 'Walking pneumonia'. Systemic symptoms are less common, and it usually presents
with a non -productive cough.
Klebsiella pneumoniae often causes cavitating lu ng lesions and is most common ly

associated with pneumonia in patients with a history of alcohol excess.
Legionella pneumophi/a is often accompan ied by more generalised symptoms, such as

em
diarrhoea and myalgia. It is also associated with hyponatraemia, however the mechanism
s
through which this occurs is unclear.

As
Dr
You are speaki ng to the partner o f a 28-year-old man who ha s recently been admitted
with pyrexia and neck stiffness. The results of init ial investig ations are shown below:
Serum glucose 5.0 mmoljl
Lumbar puncture:
Appearance Cloudy
Glucose 1. 2 mmoljl
Protein 1.8 g/1
White cells 450 I mm• ( 85% polymorphs)
Microscopy Gram-negative diplococci
No other results concerning the serotype of the organism are available.
The partner is 27-years-old and has no past medical history of note o th er than depression
for which she ta kes fluoxetine. She has had a full course of immunisations including a
cou rse of MenC vaccines whilst at university 8 years ago. What is th e most appropriate
next step to reduce her chance o f d eveloping meningitis?
No f urther action is required
MenC boost er d ose
Oral ciprof loxacin + MenC booster dose
Oral ciprof loxacin

sem
As
Oral rifa mpicin

Dr
No further acti on is required
MenC booster d ose
Ora l ciprofloxacin + Me nC booster dose

-
~
F l ciprofloxacin
Ora l rifa mpicin
Tough q uestion. Clearly the patient has men ingitis which the CSF microscopy confirms as
being due to meningococcal disease.
Firstly there is the cho ice between ciprofloxacin an d rifam picin. Ri fam picin has b eing
historica lly used for this p urp ose but the most recent guid ance fro m the Health
Protection Agency and the Greenbook su ppo rts the use o f ciprofloxacin.
Second ly the re is the question as to whethe r a booste r d ose o f vaccine is need ed . The
gu idelines regard in g this are worded vaguely b ut imply that most close contacts should
receive a b ooster dose/ complete cou rse o f vaccine d e pending on the serotype of the
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se
o rgan ism. As this is not known, on ly o ral chemo pro phylaxis s hould be g ive n fo r now, with
As
the vaccine given once this is ascertained. Please see the HPA li nk fo r mo re d etails.
Dr
A 35-yea r-old man who has recently immig rated from Zimbabwe to the UK presents to
the e me rgency d epartment with fever, mya lg ia and headaches. He is suspected to have
ma la ria.
Which test is most li kely to allow for accurate sp eciatio n of the ma la ria l pathogen?
Thick blood film
Thin bloo d film
Qu antita tive buffy coat ana lysis
Bloo d cultures
m
se
As
Point o f care ma la ria test
Dr
Th ick b lood film
~n blood film
Quantita tive buffy coat analysis
-
~
Bloo d cu ltures
Point o f care mala ria test
Th ick b lood films check fo r paras ite bu rden, thin films allow for speciation
1) Parasite burden is evaluated from thick b lood fil ms, while thin fil ms allow for
s peciation.
2) Thin peripheral b lood films allow for better visualisation o f the pa rasites and therefore
speciation
3) Quantitative buffy coat analysis is performed by centrifug ing the blood sa mple, and
examining the interfa ce between the buffy coat (laye r of p latelets and white cells) a nd the
red cells fo r parasites. This test is mo re sensitive than thick smears at diagnosis of
pa rasitaemia, however is n't as good as thin smea rs for speciation.
4) Blood cultures a llow fo r bacterial g rowth and speciation however have no role in the
diagnosis of pa rasitic diseases
5) These allow fo r rapid diagnosis and d iagnosis- led treatment in resource limited a reas,
em
rather than b lind treatment which may promote the development of resistance. They a re
s
As
not able to di fferentiate between the various species of non -falcipa rum ma la ria .
Dr
Which one o f the fo llowin g is least associated with ra bies?
Hydro phob ia
O pisthoto nus
Pyrexia
Head ache
m
se
As
Hypersalivation
Dr
Hydrophobia CD
I Opisthotonus CD
Pyrexia GD
Headache GD
Hypersalivation fD
Op isthotonus is associated more with tetanus. It describes a state of a hyperexte nsion and
m
se
spasticity in which a patient's neck and spinal column enter into a n a rching position. It is
As
an extrapyram idal effect an d is caused by spasm o f the axia l muscles
Dr
A 19-year-old man presents with a compound fracture of his leg following a fall from
scaffolding. Examination reveals soiling of the wound with mud. He is sure he has had five
previous tetanus vaccinations. What is the most appropriat e cou rse of action to prevent
the development of t etanus?
Clean wou nd + intramuscular human tetanus immunoglobulin
Clean wou nd + tetanus vaccine
Clean wou nd + tetanus vaccine + intramuscular human tetanus immunoglobulin
Clean wou nd + tetanus vaccine + benzylpenicill in
m
se
As
Clean wou nd
Dr
Clean wound + intramuscular human tetanus immunoglobulin
Clean wound + tetanus vaccine

--
~
Clean wou nd+ tetanus vaccine+ intramuscular human tetanus immunoglobulinf!D
Clean wou nd + tetanus vaccine + benzylpenicillin
Clean wound
A soiled, com pound fractu re is rega rded as high-risk for tetanus and intramuscular human
m
se
tetanus immunoglobulin should be given. There is a role for antibiotics given the soiled
As
wound although benzylpenicillin would not be the drug of choice.
Dr
A 25-year-old woman has recently moved to the United Kingdom from sub-Saharan
Africa to attend University. She comes from an area where there is a high preva lence of
tuberculosis (TB). The patient is not preg nant and is currently asymptomatic. She thinks
she may have had a BCG vaccination in the past but is not sure. She has no other medical
history and is a non-smoker.
Which test should initially be used to screen this lady for TB?
Mantoux test
Interferon gamma blood test
Early morn ing urine sa mple
Chest x-ray
m
se
As
Send three spu tum samples
Dr
Mantoux test
Interferon gamma blood test
~Earl y morning urine sa mple

Chest x- ray
Send three s putum samples
The patient is asymptomatic so we can say she does not have active TB. However, she
may have latent TB. TB is not easily caught and requires p rolonged close conta ct. The
recent NICE guidelines state that the in itia l screening test is the Mantoux test. The
inte rp reta tion has also chang ed in the recent guid e lines. A d iameter o f 5 mm is
considered positive reg a rdless of BCG history.
Changes o n the chest x-ray cannot a lways di ffere ntiate between a ctive and latent TB.
Interferon gamma b lood test is recommended if the Ma ntoux test is positive.
m
An early morn ing urine sa mple is no lo nger recommended.
se
As
The patient is currently asymptomatic a nd therefore we cannot co llect sputum. Dr
A 63-yea r-old man who migrated from India 7 months ago is referred to the acute
med ical unit with a history of headache and pyrexia. A lumba r puncture suggests a
diagnosis of meningeal tube rculosis. What treatment should he be started on?
Rifa mpicin, isoniazid, pyrazinamide and ethambutol
Rifa mpicin and streptomycin
Rifa mpicin, isoniazid, pyrazinamide, ethambutol and strepto mycin
Rifa mpicin and iso niazid with prednisolone
m
se
As
Rifa mpici n, isoniazid, pyrazinamide and ethambutol with prednisolone
Dr
Rifa mpicin, isoniazid, pyrazinamide and ethambutol
Rifampicin and streptomycin
Rifampici n, isoniazid, pyrazinamide, ethambutol and streptomycin
Rifampicin and isoniazid with prednisolone
Rifa mpicin, isoniazid, pyrazinamide and ethambutol with prednisolone
m
se
The use o f steroids in patients with tuberculous meningitis is supported by a Cochrane
As
review in 2008
Dr
A 67 -yea r-old man is referred to the respirato ry clinic. He has a past history o f
tuberculosis as a ch ild but is otherwise no rmally fit an d well. Over the past two months he
has had a cough, lost one stone in weight and had four episodes of haemo ptysis. A chest
x- ray shows a solid mass occupying the right upper zone. Investigation results include the
following:
Aspergillus preci pitin antibody Positive
Lu ng abscess
Invasive aspergillosis
Aspe rgi lloma
Reactivation of primary tuberculosis
m
se
As
Allergic b ronchopu lmonary aspergillosis
Dr
Lu ng abscess
Invasive aspergillosis
Asperg illoma
Reactivation of p rimary tuberculosis
m
se
Allergic b ronchop ulmonary aspergillosis
As
Dr
A 31-year-old man is admitted to hospital with a 4 day history of fever and dyspnoea. He
is known to be HIV positive but poorly compliant with his antiretrovira l therapy (ART).
Bloods taken during a clinic visit two weeks ago show the follow ing:
CD4 180 cells/IJI
On examination today his pulse is 102/ min, oxygen saturations 97% on room air w ith a
temperature of 38.1°C. He has coa rse crackles on the right side of his chest. A chest x-ray
shows co nsolidation of the right mid zone.
What is the most likely causative organ ism?
Pneumocystis jirovecii
m
se
As
Dr
Whil st Pneumocystis jirovecii is o f cou rse associated with HIV, patients who a re
immunocomprom ised are more likely to deve lop infections due to the common
pathogens which affect im munocompetent individua ls. Streptococcus pneumoniae is
therefore the most likely cause of commun ity-acquired pneumonia in this patient.
m
se
Remember a lso that Pneumocystis jirovecii tends to present in a different way, with very
As
few chest signs and b ilatera l interstitial pulmo na ry infiltrates on chest x-ray.
Dr
You review a 45-year-old woma n who has been admitted feeling generally unwell. Fo ur
months ago she ha d a renal transplant and has since been taking a combination of
ciclos porin and myco phenolate for im mu nosuppression. For the past three days she has
had fever, dyspnoea and a dry cough. A chest x-ray s hows bilateral interstitial infiltrates.
Graft-versus host d isease
Cytomegalovirus pneumonitis
Cell mediated acute transp lant rejection
Mycophenolate p neumonitis
m
se
As
Cryptococcus neoforman s pneumonia
Dr
Graft-versus host disease
Cytomegalovirus pneumonitis
Cell mediat ed acute t ransp lant rej ection
Mycophenolate p neumonit is
Cryptococcus neoformans pneumonia
Renal tra nsp lant + in fection ?CMV

Over 50% of rena l transplant pat ients have a significant infection w ithin the f irst 12
months o f having a renal transplant.
At the t ime of transplant the CMV-serological status of t he d ono r and recipient are noted.
The highest risk is seen in CMV -seronegative recip ients who receive a kidney from a
CMV-seropositive donor. These pat ient s are usually given antiviral prophylaxis.
m
se
Cytomegalovirus tend to be seen after fou r weeks as before th is t ime the immune system
As
has not been fully affect ed by the immunosuppressants.
Dr
A 64-yea r-old gentleman with chronic obstructive pulmonary disease p resents to the GP
with increas ing dyspnoea. He is febrile and gives a histo ry of a co ugh productive of green
s putum over the last few days. You diagn ose a n infective e xacerbation of his und erlying
lu ng disease. After sending a sputum sam ple you make the decision to start oral ste roids
and appropriate anti bio tics. On reviewing the resu lts of the s putum sample the lab has
reported a n initia l culture o f a Gram-negative cocci. What is the most likely organis m?
Moraxel/a catarrhalis
m
se
As
Dr
Moraxel/a catarrhalis - Gram-negative cocci

Of all the available organisms only Neisseria and Moraxella are Gram -negative cocci.
Neisseria meningitidis is not a common respiratory pathogen and therefore the likely
organism in this case is Moraxel/a.
Moraxel/a catarrhalis is a Gram-negative coccus that is a common cause of respiratory
m
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infections in patients with underlying lung disease. It also commonly causes sinusitis and
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middle ear infections.
Dr
A 55-year-old business man presents with a 15 day history o f watery, non-bloody
diarrhoea associated with anorexia and abdominal bloating. His sym ptoms st arted 4 days
after returning fro m a trip t o Pakist an. On examination he is apyrexial w ith dry mucous
membranes but normal skin turgor. Given the likely organism, what is the most
appropriat e treatment?
Hydroxychloroquine
Aciclovir
Benzylpenicillin
Ciprofloxacin
m
se
As
Metronidazole
Dr
Hydroxychloroquine m
Aciclovir CD
Benzylpenicillin
•
ED
..
Ciprofloxacin
Metronidazole
Althou gh Escherichia coli is the most common cause of travellers' diarrhoea, in this
m
se
particu lar case the length of illness and nature of symptoms (bloating, wat ery diarrhoea)
As
points to a diagn osis of Giardiasis.
Dr
A 20-year-old woman was adm itted overnight with suspected meningitis. You a re asked
to review the initial microscopy results fro m the lum ba r punctu re. The lab tells you the
cultu re is g rowing gra m negative diplococci.
What is the most likely organism?
Listeria monocytogenes
Escherichia coli
m
se
As
Dr
I Listeria monocytogenes
Escherichia coli
Neisseria meningitis and Streptococcus pneumoniae would be most common in this age
group but it is N.meningitis that is a g ram negative d iplococci.
• S. pneumoniae is a gram positive diplococci/chain
m
• E. coli is a g ram negative bacilli
se
• H. influenzae is a gram negative coccobacilli
As
• L. monocytogenes is a gram positive rod
Dr
An 18-yea r-old ma le is admitted with feve r, headache and neck stiffness. He receives IV
ceftriaxone. A lumbar pu ncture and cu ltu re of his cereb rospinal fluid revea l that the
pathogenic organism is Neisseria meningitides. What is the app earance of this bacterium
on gram staining?
Gram-positive cocci
Gram-negative cocci
Gram-positive rod
Gram-negative rod
m
se
As
Poorly staining o rgan ism
Dr
Gram-positive cocci
Gram-negative cocci
Gra L sitive rod
Gram-negative rod
-
.....,
Poo rly sta ining organism
Neisseria gonorrhoeae - Gra m-neg ative cocc i

Neisseria species are gram-negative cocci. The bacteria cluster together in pairs to form
diplococci. Other important gram-negative cocci include Moraxella catarrhalis and
Haemophilus influenza.
m
se
Interpretation of gra m stains fo r the non -micro biologist
As
Barenfanger and Drake. l aboratory medicine. 2001, number 7, vol 32
Dr
An 82-year-old gentleman ad mitted with back pa in to a medica l wa rd for a ma gnetic
resonance imaging of his spine has a background of prostate cancer under surveillance
and a long-term catheter inserted a few weeks ago by urology. A midstream specimen of
urine was positive for extended spectrum beta-lacta mases (ESBL) (> 100.000 colonies). He
claims he has no dysuria and urine in catheter bag looks clear and there a re no signs of
hematuria. He is a lso afebrile and hemodynamically stable.
Hb 111 g/ 1
Platelet s 236 * 109/ 1
WBC 6 .8 * 109/ 1
Na• 143 mmol/ 1
K• 5. 1 mmol/1
Urea 6 .2 mmol/1
CRP 7.8 mg/1
What wou ld be the next step to manage his bacteriu ria?
This bacteriuria s hould not be treated. Ensure good hydration and monitor any
urinary symptoms or pyrexia
Com mence nitrofurantoin 100 mg four times a d ay for 3 d ays
Com mence one stat d ose o f gentam icin intravenously and if no response contact
microb iology
Check sensitivities first and commence antibiotics regardless of clinic

em
s
As
Remove catheter imm ediately and contact urology

Dr
I This bacteriuria should not be treated . Ensu re good hydration and monitor any
urinary symptoms or pyrexia
Commence nitrofurantoin 100 mg four tim es a d ay for 3 d ays
r m:nce one stat d ose of gentamicin intravenously and if no response contact •

rob1o logy
l_
Check sensitivities first and co mm ence antib iotics regardless of clinic
Remove catheter imm ed iately and contact urology
Asymptomatic bacteriuria should not be treated except in pregnancy, ch ildren

younger than 5 years or im munosuppressed patients due to the risk of
complications
This is a case of a e lderly patient with a long-term catheter. Bacte riuria is likely to be
conta mination and does not require a ny treatment if patient asymptomatic to prevent
increase in antimicrobial resistance. Asymptomatic bacteriuria s hould not be treated
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se
except in preg nancy, children younger than 5 years o r immunosuppressed patients d ue to
As
the risk of comp lications.
Dr
A 34-yea r-old female with a ba ckground o f HIV p resent with prog ressive weakness in he r
lowe r limbs. She also states that she is finding it difficult to walk up the stairs and is
beco ming g eneral ly clumsy. She is known to b e non complia nt with her anti-retroviral
thera py. She had no other systemic symptoms such as we ig ht loss and no other past
med ical histo ry. On exa mination, one notes power is normal in both upper a nd lowe r
limbs. However, one notes b ilateral dysmetria in the upper limbs and lowe r limbs. She had
an MRI which showed some white matter lesions b ilaterally in the parietal lobes. What is
Cere bral vasculitis
Cere bral metastas is
Multip le sclerosis
Progressive mu ltifoca l leukoencephalopathy
m
se
As
Toxopla smosis
Dr
Cerebral vasculitis
Cerebral metast asis
Multip le sclerosis
Progressive multifocal leukoencephalopathy
Toxo plasmosis
HN, neuro symptoms, w idespread demyelin ation - prog ressive mult ifoca l
leukoencephalopathy
Multiple sclerosis and prog ressive multifocalleukoencep halopathy lead to white matter
lesions on MRI. However, with her backgrou nd of HIV and being non-compliant w ith her
medication, she is at risk of neuro-complications f rom b eing immuno com prom ised.
Therefore progressive multifocal leukoencephalopathy is the more likely diagnosis.
Cerebral metast asis typi cally p resents as ring enhancing lesions on the MRI and one
would exp ect for there to be some other systemic symptoms t o su ggest malignancy from
an unknow n p rimary.
Cerebral vasculit is is a possible diagnosis, however one wou ld expect other symptoms
such as a vasculit is rash. One wou ld also expect a past medical history other than HIV
which cou ld lead t o vasculitis, such as a systemic disease like rheumatoid arthritis o r
Behcet's disease. MRI normally shows mult iple bilat eral infarctions, affecting different
vascu lar t erritories, in various st ages of hea ling,
Toxo plasmosis is a diagnosis to consider in a pat ient with HN non -co mpliant with her
medication and p resent ing with neurological symptoms. However, one woul d expect rin g
em
enhancing lesions on M Rl. One wou ld not expect white matte r lesions bilaterally in
s
As
t oxoplasmosis.
Dr
A 23-year-old man has a Mantoux t est prior to receiving the BCG vaccine. He develops a
12 mm indurated lesion on his forearm. Wh ich one of the following cytokines is most
involved in this resp onse?
Interleu kin -8
Interferon-y
Interferon- ~
Interferon-a
m
se
As
Interleukin-10
Dr
Interleukin-8 GD
r :erferon-y ED
Interferon- ~ .
(D
Interferon-a GD
Interleukin-10 GD
Tuberculin skin tests a re an exa mple of type IV (delayed) hype rsens itivity reactio ns. These
m
se
are la rge ly mediated by interfe ron -y secreted by Thl ce lls which in tu rn stimu lates
As
ma crophag e a ctivity.
Dr
Following a recent holiday to South America, a 19-year-old woman returned home an d
within a month developed a swelling around the right cheek with increased fatigue and
diarrhoea. Diagnostic th ick and th in blood films identified the pa rasite Trypanosoma cruzi.
Which medication can be used to treat her condition during the acute phase of the
disease?
Riluzole
Benznidazole
Praziquantel
Miltefosine
m
se
As
Chloroquine
Dr
I
Riluzole
Benznid azole
•
CD
Praziquantel fiD
Miltefosine
Chloroquine
•
f.D
Benznid azole is used in the acute phase of Cha gas' disease to manag e the illness
Azoles such as b enznidazole are antifungal medications which target the p450
cytochrome enzyme syst em t o inhibit the growth of a wide range of organisms.
Riluzole - used to manage mot or neurone disease
Praziquantel - used in patients with schistosomiasis
Miltefosine - Used in patient s with Leish maniasis
m
se
As
Chloroqu ine- Used in the treatment of Malaria
Dr
A 23-year-old woman comes for review. She has had recu rrent genital warts for t he past 4
years which have failed to respo nd to topical podophyllum. On one occas ion she had
cryotherapy but will not have it again due to local discomfort. On examination she ha s a
large number of fleshy genital warts around her introitus. What is the most appropriate
next step in t reatment?
Topical glutaraldehyde
Oral podophyllum
Topical imiquimod
Oral aciclovir
m
se
As
Topical salicylic acid
Dr
Topical glutaraldehyde m
Oral podophyllum f!D
~pical imiquimod CD
Oral aciclovir f!D
m
se
Topical salicylic acid CD
As
Dr
A 41-year-old female presents with 3 day history o f a dry cough and shortness of breath.
This was preceded by flu -like symptoms. On examination there is a symmetrical,
erythematous rash with 'target' lesions over the whole body. What is the likely organism
causing the symptoms?
Pseudomonas
Chlamydia pneumoniae
m
se
As
Dr
Pseudomonas
•
.
C!D
I Mycoplasma pneumoniae GD
Chlamydia pneumoniae m
Legionel/a pneumophilia CD
Mycoplasma is associat ed with erythema mult iforme
m
se
As
Pneumococcus may also cause erythema mult iforme
Dr
Which one o f the following statements best describes the preventio n and treatment of
hepatitis C?
No vaccine is ava ilable and treatment is only successful in a round 10-15% o f

patients
No vaccine and no treatment is ava ilable
A vaccine is ava ilable and treatment is successful in around 50% of patients
A vaccine is ava ilable but no treatment has been shown to be effective
m
se
No vaccine is ava ilable but treatment is successful in the majo rity of patients
As
Dr
No vaccine is ava ilable and treatment is only successful in around 10-15% o f
patients
No vaccine and no treatment is ava ilable
A vaccine is ava ilable and treatment is successful in around 50% of patients
A vaccine is ava ilable but no treatment has been shown to be effective
m
se
No vaccine is ava ilable but treatment is successful in the majo rity of patients
As
Dr
A 19-year-old man presents asking for advice. His girlfriend has recently been diagnosed
with meningococca l meningitis. He is worried he may have 'caught it'. What is the
recommended antibiotic prophylaxis for close contact s such as th is man?
Ora l co-amoxicl av
Ora l phen oxymethylpenici llin
Ora l rifa mpicin
Ora l erythromycin
m
se
Intramuscular cefotaxime
As
Dr
Oral co-amoxiclav
-
Oral phenoxymethylpenicillin
Oral rifa mpicin
Oral erythromycin
Intramuscula r cefotaxime
The BNF recommends a twice a day d ose of rifam p icin for two days, based on the patients
m
se
weight. Please note that if ciprofloxacin is given as a choice this should be picked due to
As
recent changes in HPA guidelines - see be low.
Dr
A 30-year-old man has just returned to the UK after visiting Kenya. He did not take any
anti-mala rials du ring his visit and received multiple mosquito b ites. He is pyrexial but
stable at p resent. Ma la ria is confirmed with a rapid antigen test. You a re wa iting for the
rest of his test results. Which of the following fin dings wou ld suggest that he should be
treated as having severe malaria?
Temperature > 38°C after pa racetamol
Plasmodium vivax species on blood film
CRP > 300 mg/ L
Blood suga r 18 mmoi/L
m
se
As
Parasitae mia of 6%
Dr
Tem perature > 38°C after paracetamol
Plas1 odium vivax species on bl ood film
CRP > 300 mg/ L

-
~
Blood sugar 18 mmoi/L
Parasitae mia of 6%
-
~
Paras itaemia > 2% is a feature of severe malaria

A parasite level of > 2% is diagnostic of severe malaria on UK guid elines. Other crit eria
include cli nical finding s (impaired consciousness, res piratory distress, multiple
convulsions, shock, j aundice) and laboratory f indings (hypoglycaemia, acidosis, raised
lactate, acute kidney injury an d severe anaemia). The other options are not included in the
criteria. The majority of severe forms of malaria are due t o Plasmodium falciparum but
other species can also cause serious complications.
Patients wit h severe malaria should be treated w it h IV ant i-malarials and HDU or JCU
should be considered.
m
se
UK malaria treatment guid elines 2016 As
http:/ ;www.j o u rna lof i nfection.com/article/ SO 163-44 53 (16)0004 7 -5/ abst ract
Dr
A 23 -year-old man develops watery diarrhoea 5 days after arriving in Mexico. Which one
o f the following is the most likely responsible orga nism?
Salmonella
Shigella
Campylobacter
Escherichia coli
m
se
Bacillus cereus
As
Dr
Salmonella CD
Shigella .
(D
Campylobacter CD
Escherichia coli ED
Bacillus cereus .
(D
m
E. coli is t he most common cause of t ravellers' diarrhoea
se
As
Dr
An 18-year-old male w ho has recently undergone chemotherapy fo r leukaemia presents
with fever, cough, haemoptysis and shortness of breath not responsive to antibiotics. He
underwent a chest CT which revealed a 'halo' sign suggestive o f invasive aspergillosis.
What immune response component is the first line of action against aspergillosis?
Cytokines
Neutrophils
Eosinophils
Basophils
m
se
As
Macro phages
Dr
Macro phag es a re the first lin e immu ne response, they he lp to recruit neutro p hils which
a re a lso crucia l co mponents in fig hting aspe rg illosis. This knowled ge is re leva nt as it
a ll ows us to und erstand that patie nts with d eficiencies in macro phages and neutro phils
a re pro ne to aspe rgillosis. In healthy individ ua ls when asp erg illosis s po res a re inhaled,
mucociliary clearance is initiate d a nd spo res a re phagocytosed, clea ring the infection.
A ra ised level o f eosino phils a re fou nd in a lle rg ic bronchopulmona ry asp ergillosis but
the ir ro le is late r in the p rocess after d ep osition o f the im mune complexes. Cyto kines a re
impo rtant in cell sig na lli ng b ut d o not directly fight the di sease process, they are re leased
by macro phages, lympho cytes, mast cells and o the r immune components. Basop hils a re
invo lved in response to a lle rgic d iseases like asthma and ana phylaxis but a re not the first
li ne in aspe rg illosis.
Invasive Aspergillosis
Seen in the immu nocompro mised host to include patients with a chro nic gra nulo mato us
disease, pa tie nts und ergo ing chemothera py a nd patie nts receivi ng a bo ne marrow
tra nsplant.
Presentation - Pulmonary sympto ms a re most commo n, presenting with a cou gh, feve r,
haemo ptysis (which ca n b e severe), dysp noea and pleu ritic c hest pa in b ut may be
atyp ical. The re is haematogenous sp rea d to other o rga ns, most commo nly bo ne resulti ng
in osteomye litis.
Investigatio ns - can be ha rd to dia g nose. Chest X-ray may show conso lidation, nodules,
infiltrates, o r cavitating les io ns. Chest CT may s how the 'halo' sig n (howeve r aspe rgillosis
in patients with chro nic g ra nulo matous disease typically d oes not pro duce this s ign).
Cu ltures can be obta ined fro m s putum, bro ncho -a lveola r lavage, lung tissue via trans -
tho racic percutaneous bio psy. In a dd itio n, the re is an assay to d etect Ga lacto manna n
which a co mponent as perg illosis cell wall.
Treatment - is with a ntifungals. The first li ne is voriconazole
ref: Centres fo r disease contro l we bsite -

https:/ /www .cd e.g ov/ fu nga1/d iseases/ a spe rg iIlos is/ treatment.htm I
a nd
king J, Henriet Sa nd Wa rris A. Asperg illosis in Chro nic Gra nulo mato us Disease. Jou rna l o f
em
fungi. May 2016.

s
As
Dr
What is the mechanism of action of the antiviral agent amantadine?
Inhibits DNA polymerase
Protease inhibitor
Nu cleoside analogue reverse transcriptase inhibitor
Inhibits uncoating of virus in the cell
m
se
Interferes with the capping of vira l mRNA
As
Dr
Protease inhibitor
Nucleoside analogue reverse tra nscri ptase inhibitor
Interferes with the capping of viral mRNA

-
""""
Amantadine - inhibit s uncoating (M 2 protein) of virus in cell. Also releases
m
se
dopamine from nerve endings
As
Dr
Which one o f the following organisms causes lymphogranuloma venereum?
Haemophilus ducreyi
Chlamydia
m
se
As
Treponema pallidum
Dr
Haemophilus ducreyi GD
Klebsiella granulomatis CD
H rpes simplex virus m
Chlamydia ED
Treponema pallidum CD
Lymphogranuloma venereum - Chlamydia trachomatis
m
se
As
Dr
A 19-year-old man p resents with a two -day history of a diffuse headache and sore t hroat.
He is pyrexial at 37.8°C and is reluctant to have a fundoscopy due to photophobia. A
lumbar puncture is performed:
Lu mbar puncture reveals:
Appearance Clear
Glucose 4.1 mmoljl
Protein 0 .3 g/ 1
lymphocytes 2 tmm >

White cells
polymorphs 0 /mm •
Guillain - Barre syndrome
Viral menin gitis
Bacterial meningitis
m
se
Cerebral malaria
As
Dr
NormaI CS F result
r : \uillain-Barre syndrome
Viral meningitis
Bacterial meningitis
Cerebral malaria
Norma I CS F result
m
se
There results are consistent with normal CSF - an alternative diagnosis should be
As
considered
Dr
You are working in the Emergency Department and you see a 22-year-old man with an
itchy erythematous rash across his back, shou lders and backs of his arms. The rash
appeared yesterday after he started taking an antibiotic, having been unwell fo r 10 days
with general malaise and a so re t hroat. Which antibiotic is most like ly to be t he cause?
Flucloxacillin
Phenoxymethylpenicillin
Amoxicillin
Ciprofloxacin
m
se
As
Co -amoxiclav
Dr
Flucloxacill in
Phenoxymethylpenicillin
Amoxicillin
Cip;o floxacin
Co-amoxiclav
URTI symptoms + amoxicillin - rash ?glandular fever

The correct answer is 3. The patient is like ly to have underlying infectious mononucleosis
due to Ebstein -Barr virus. Amoxicillin is known to commonly produce a w idespread
erythematous rash in patients with infectious mononucleosis. For this reason, it should
not b e prescribed to pati ents with sore throats. Phenoxymethylpenicillin (or penici llin V) is
the first line cho ice for bacterial tonsillitis instead. The patient's rash cou ld also be an
urticarial rash due to an allergy to an antibiotic, but there is nothing to guide you as to
which antibiotic he is most likely to b e allergic to.
m
se
BNF:
As
https:// bnf.nice.org.u k/ drug/amoxici IIin.htm I Dr
What is the most appropriat e antibiotic to use in cholera?
Erythromycin
Metronidazole
Doxycycline
Penici llin V
m
se
As
Trimethoprim
Dr
Erythromycin CD
Metronidazole CD
I Doxycycline CID
Penicillin V CD
m
se
Trimethoprim CD
As
Dr
A 33 -year-old is invest igated for lethargy. The fu ll blood cou nt is reported as follows:
Hb 10.1 gfdl
Pit 156 * 109/ 1
WBC 3 .7 * 109/ 1
His daughter was unwell one week p reviously w ith a pyrexial illness associated with a red
rash on her cheeks. What is the most likely cause?
Measles
Coxsackie a16
Group A haemolyt ic streptococci
Parvovirus B19
m
se
As
HHV-6 (Human Herpesvirus-6)
Dr
Measles (fD
I Coxj ackie a16 fD

Group A haemolytic streptococci tiD
I Parvovirus B19 CD
m
se
As
HHV-6 (Human Herpesvirus -6) fD
Dr
A 19-yea r-old man p resents with a 12-hour history of a headache and fever. On
exami nation, you e licit neck stiffness, photophobia and a positive Kernig 's sign. He scores
15 on the Glasgow Coma Scale (GCS) a nd there has been no change in behaviou r and
the re is no evidence of ra ised intracran ia l pressure. He is ha emodynam ica lly stable and
there is no rash.
Blood cultures are ta ken and a lumbar puncture is performed. You decide to treat
empirically fo r bacterial mening itis and p rescribe intravenous cefotaxime every 6 hours.
Which of the following is most appropriate in ad d ition to intravenous cefotaxime?
Give intravenous aciclovir
Give intravenous dexameth asone with the first antib iotic dose and continue every 6
hou rs
Give intravenous d examethasone with the first antibiotic d ose only
Await the cerebrospinal fluid results and p rescribe intravenous dexa methasone
only if Streptococcus pneumoniae is isolated
m
se
As
Give intravenous amoxici ll in
Dr
Give int ravenous aciclovir
-
~
I Give int ravenous d exameth asone with the f irst antibiotic d ose and continue
every 6 hours
Give intravenous dexamethasone with the f irst antib iot ic dose only
-
~
Await t he cereb rospinal fluid resu lts and p rescribe Streptococcus is GD

intravenous d examethasone only if pneumomae isolated
Give int ravenous amoxicillin
Corticoste ro ids (d examethasone) shou ld be given as an adjunct t o p revent

neuro logica l sequelae
1: Aciclovir shou ld be given if herpes simplex encephalitis is suspected, based on reduced

consciousness or chang e in behaviou r or cognit ion. These feat ures are not present and so
aciclovir is not indicat ed.
2: This is the correct answer. Intravenous dexamet hasone should be given p rior to or with
the first dose of antibiotic to reduce t he risk o f neurolog ical sequelae by reducing
cerebrospinal inflammation. If pneumococcal meningitis is suspected or confirmed from
clinical feat ures, cerebrospinal f luid parameters or cultu re results, then dexamethasone
should be continued for 4 days. It shou ld be stopped if another causative organism is
st rong ly suspected o r confirmed.
3: Dexamethasone shou ld be continued until investigation resu lts suggest an alternative

o rganism to Streptococcus pneumoniae .
4: Dexamethasone shou ld be given w ith t he f irst dose o f antibiotic to reduce t he risk of

neurological sequelae.
s em
5: Amoxicillin is recommended in additio n to cefotaxime in the empirica l treat ment o f

As
pat ients <3 months old or >50 yea rs old.

Dr
Which of the follow ing types of viral meningit is may be charact eristically associat ed with a
low cerebrospinal fluid glucose level?
Mumps
Cytomeg alovirus
Mea sles
HN
m
se
As
Echovirus
Dr
I Mu mps ED
Cytomegalovirus fD
[ :easles flD
HIV (D
Echovi rus CD
Mumps meningitis is associated with a low CSF g lucose

m
se
As
Mumps menin gitis is associated with a low glucose in up to a third o f patients
Dr
A 24-yea r-old gentleman p resents with a worsening headache to the emergency
departm ent. He emigrated from Sudan two weeks ago. He has ha d a cough for six weeks.
His GP did a tubercu lin skin test which was found to be negative and ha s not responded
to oral antibiotics. He has no medical history and takes no regular med ications. Blood
tests demonstrate positive HIV serology but cryptococcal antigen is negative and other
tests are no rmal. Toxo plasmosis sero logy is negative. CT demonstrates a s ingle 3cm lesi on
and meningeal enhancement but no other abnormalities. What is the most likely
organism that is res ponsible for his headache?
Toxoplasma gondii
Cytomegalovirus
m
se
As
JC virus
Dr
Toxoplasma gondii f!D
I Cryptococcus neoformans f!D

Cytomegalovirus f!D
~cobacterium tubercu losis ED
JC virus 6D
The correct answer is Mycobacterium tuberculosis. This young patient has a headache in
the context of untreated HIV and therefore likely has a low CD4 count making him
vu lnerable t o HIV neurological complications. He also has a chronic cough with a
significant history of t ime in Sudan, making him at high risk of TB. Meningeal
enhancement on the CT also increases the suspicion of TB. In immunosuppression, the
tuberculin skin test is unreliable and therefore does not exclude TB. Cryptococca l infection
is unlikely w ith a negative antigen test. Toxoplasmosis is possible but t he lack of
confusion and drowsiness and the lack of any neurolog ical deficit makes it less likely,
especially w hen considering the negat ive serology. The absence of fever and confusion
makes CMV encephalitis unlikely. Progress ive multifoca l leukoencephalopathy shows
widespread demyelination.
m
se
Source:
As
Leonard, John M. 'Central Nervous Syste m Tubercu losis.' UpToDate. N.p., 04 Jan. 2017.
Dr
A 25-year-old student with an anaphylactic allergy to egg protein is plann ing to travel in
South East Asia. Wh ich of the following vaccinations is contrai ndicated in egg allergy?
Yellow fever vaccine
Typhoid vaccine
Inactivated polio vaccine
Japanese encephalitis vaccine
m
se
As
Rabies vaccine
Dr
Yellow fever vaccine
Typhoid vaccine
Inactivated polio vaccine
Japanese encephalitis vaccine
Rabies vaccine
Eg g p rotein is present in cli nically sig nifica nt quantities in the yellow feve r vaccine.
-
~
Eg g embryos a re also used in the p roduction of the MMR and some rabies vaccines. The
egg protein content is not clinically significant, however, as it is in the range of picog rams
to nanograms per dose.
Eg g p rotein is present in potentially significant amou nts in ki lled injected and live
attenuated influenza vaccines. It is not present in recombina nt influenza vaccine.
m
se
As
Anaphylaxis to egg protein is a lso a contra indication to the use of propofol.
Dr
A 30-year-old man comes for review. He returned from a holiday in Egypt yesterday. For
the past two days he has been passing frequent bloody diarrhoea associated with crampy
abdominal pain. Abdominal examination demonstrates diffuse lower abdominal
t enderness but there is no guarding or rigidity. His t emperature is 37.5°C. What is the
most likely causative organism?
Giardiasis
Enterotoxigenic Escherichia coli
Salmonella
m
se
As
Shigella
Dr
Giardiasis
Enterotoxigenic Escherichia coli
p.ap~occus aureus
Salmonella
Shigella
Enterotoxigen ic Escherichia coli infections do not usually cause bloody diarrhoea. A
m
se
differentia l d iagnosis would be amoebic dysentery, ente rohemorrhag ic Escherichia coli
As
and possibly Campylobacter.
Dr
A prison GP is b itten by a patient who is known to have hepatitis B. The GP has a
documented fu ll history of hepatitis B vaccination and was known to be a responder.
What is the most appropriate action to reduce the chance of contracting hepatitis B?
Admit fo r intravenous interferon
Give hepatitis B imm une globul in
Give hepatitis B imm une globul in + hepatitis B vaccine booster
Give hepatitis B vaccine booster
m
se
As
Give oral ribavirin for 4 weeks
Dr
Admit for intravenous interferon
Give hepatitis B immune globulin
Give hepatitis B immune globulin + hepatitis B vaccine boost er
Give hepatitis B vaccine booster
m
se
As
Dr
A 45-year-old man is diagnosed as having primary syph ilis. Six hours after receiving his
first injection of benzylpenicillin he complain s o f feeling generally unwell. On examination
he appears flushed. His blood pressure is 94/62 mmH g, pulse 96/ min and t emperature
37.9°. These symptoms settle after around fou r hours. Wh ich one of the following is most
likely to explain this finding.
Arunan -Leadbetter reaction
Jarisch-Herxheimer reaction
Concurrent infectious mononucleosis infection
Allergic reaction to benzylpenicillin
m
se
As
Undiagnosed tertiary syphilis
Dr
Arunan-Leadbetter reaction
Jarisch-Herxheimer reaction
Concurrent infectious mononucleosis infection

-
~
r
Allergic reaction to benzylpenicillin
- ......,
m
se
As
Undiagnosed tertiary syphilis
Dr
A 43-yea r-old woman who is a recent immigrant from Mozambique is referred to the
d ermatology o utpatient clinic. She has d eveloped a number of hypopig mented, ova l
shaped les ions on her b ody which a re associated with red uced sensation. These are
mainly located on the extensor surfaces of her limbs. She has no p ast medical history of
note othe r than suffering from ma la ria as a ch ild . What is the most like ly d iagnosis?
HIV
Chagas disease
Pityriasis ve rsicolo r
Tub erculosis
m
se
As
Leprosy
Dr
~~ CD
Chagas disease .
(D
Pityriasis versicolo r CD
Tuberculosis D
m
se
Leprosy GD
As
Dr
A 63-yea r-old man presents to the acute receiving ward with a two -week history of a
cough, fever, night sweats, weight loss and diarrhoea. He has tender hepatomegaly on
exami nation. His past medical history includes HIV and his recent CD4 cou nt is less than
50. A blood culture reveals mycobacterium avium com plex. What is the treatment for this
condition?
Rifa mpicin + Ethambutol
Pentamidi ne
Rifa mpicin + Isoniazid + Pyrazi nam ide
Rifa mpicin + Ethambutol + Clarithromycin
m
se
Rifa mpicin + Isoniazid + Pyrazi nam ide + Ethambutol
As
Dr
Rifa mpicin + Ethambuto l
Pentamidine
Rifa mpicin + Isoniazid + Pyrazinamide
Rifa mpicin + Ethambutol + Clarithromycin
Rifa mpicin +Isoniazid + Pyrazinamide+ Ethambutol
A minimum of two drugs shou ld be given: clarithromycin plus ethambut ol. In severe
disease, rifabutin can be added. This is recommended due to fewer side-effects than
rifa mpicin however rifampici n is still w idely used as the third drug in severe disease due to
it s chea per cost. Azithromyci n can be also substituted for clarithromyci n in severe disease.
ref: oxford handbook of tropical medicine.
Mycobacterium avium complex and mycobacterium tubercul osis ca n present similarly,

however mycobacterium avium complex can result in marked hepatomegaly, whereas
mycobacterium tu berculosis usually results in focal lesions in the liver. ref: Radin DR.
Intraabdominal Mycobacterium tuberculosis vs Mycobacterium avium - intracellulare
m
se
infecti ons in patients with AIDS: distinction based on CT findings. AJR Am J Roentgenol.
As
1991 Mar;156(3):487 -91.
Dr
A 23-yea r-old male presents with a pu rulent urethra l discha rge. A sample of the discharge
is shown to be a Gram negative d iplococcus. What is the most app ropriate antimicro b ial
thera py?
Oral ciprofloxacin for 7 days
Oral pen icilli n V for 7 d ays
Oral d oxycycline for 7 days
Oral a zithromycin stat d ose
m
se
As
Intra muscula r ceftriaxo ne stat d ose + oral azith ro mycin sta t d ose
Dr
Oral ciprofloxacin for 7 days
Oral penicillin V for 7 days
Oral doxycycline for 7 days
Oral azithromycin stat dose
Intra muscular ceftriaxone stat dose + oral azithro mycjn stat dose
Intramuscular ceftriaxone + o ral azithromycin is the treatment of choice fo r

Gonorrhoea
Ciprofloxacin should only be used if the organism is known to be sensitive due to
m
se
increasing resistance. Penicillin, previously first-l ine treatment, is rarely used now due t o
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widespread resistance.
Dr
A 52-yea r-old ma le is admitted to hospita l with a temperature of 38.2 C and a 3 days
history of a productive cough. He has been generally unwell for the past 10 days with flu-
like symptoms. On examination blood pressu re is 96/60 mmHg and the heart rate is 102 I
min. Chest x-ray shows bilatera l lower zone consolidation. What is the most likely
causative organ ism?
Klebsiella
m
se
As
Dr
-
...wr
Klebsiella
Preceding inf luenza predisposes to Staphylococcus aureus p neumonia
m
se
As
Dr
A 33-yea r-old wo ma n who was d iag nosed as having HIV-1 two years a go is reviewed in
clinic. She is fit a nd well cu rrently a nd has no sympto ms of note. The o nly medicatio n she
takes is the occasiona l pa racetamol for tension heada ches. Her latest blo od tests a re as
follows:
CD4 325 * 106/1
What is the most a p propriate a ction with reg a rd with to a nti-retroviral the ra py?
Wait until th e CD4 count is below 200 * 106; 1
Wait until th e CD4 count is above 350 * 106;1
Sta rt a ntiretroviral therapy now
m
se
As
Dr
Wait until the CD4 count is below 200 * 10 6
/I m
r Wait until the CD4 count is above 350 * 10 6
/I m
/I m
Sta rt antiretroviral therapy now CD
m
se
/I m
As
Dr
A 31-yea r-old woman who is 26 weeks pregnant presents with a rash . The rash is located
j ust u nder her axilla a nd has been gettin g progressive ly la rge r sin ce it first a pp eared five
d ays. She a lso reports feeling 'flu-like' and having some joint pains. She has recently
returned from a weekend away in Hampshire. Her pregna ncy is uncomplicated to date
a nd the re is no o th er significa nt med ical history o f note. On exam ination a la rge
erythematous rash is noted as above. In the middle a central p unctum is seen. Given the
like ly diagnosis, what is the most ap pro priate treatment?
Topica l miconazo le
Oral d oxycycline
Oral amoxicill in
Oral fluconazole
m
se
As
Oral e rythromyci n
Dr
Topical miconazole tiD
Oral d oxycycline f!D
I Oral amoxicillin ED
Oral f luconazole fD
Oral erythromycin fD
Amoxicillin is an alte rnative to treat early Lyme disease if doxycycline is

cont raindicated such as in pregnancy
m
se
This lady has Lyme disease. Doxycycline is therefore contraindicated and amoxicillin
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should be given instead. A fungal rash would not cause t he syst emic sympt oms.
Dr
The most appropriate treatment for cutaneous larva migrans is:
Thiabendazole
Sulfadoxi ne
Pyrimethamine
Met ronidazole
m
se
As
Dapsone
Dr
Th iabendazo le ED
Sulfadoxine
Pyrim ethamine .
crD
•
Metronidazole .
(D
m
se
Dapsone GD
As
Dr
A 27 -year-old pregnant woman is found to have Chlamydia. She reports being allergic to
penicillin. What is the most appropriate treatment?
No antibiotic therapy is indicated
Cefixime
Erythromycin
Doxycycline
m
se
Ciprofloxacin
As
Dr
No antibiotic therapy is indicated
Ceft me
Erythromycin
Doxycycline
Ciprofloxacin
Azithromycin, erythromycin or amoxicillin may be used to treat Chlamydia in

pregnancy
NICE Clinica l Knowledge Summaries recommends azithromycin, erythromycin or

amoxicillin for pregnant women who have Chlamydia.
The effica cy of amoxicillin, often assumed t o be ineffect ive against Chlamydia, was
m
se
supported in a recent Cochrane review. A test of cure should be carried out following
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treatment.
Dr
A man presents with seve re vom iting. He repo rts not being able to keep flu id s down for
the past 12 hours. You suspect a dia gnos is of gastroe nteritis and o n discussing possible
causes he mentio ns reheating curry with rice the nig ht b efo re. What is the most likely
causative o rgan is m?
Escherichia coli
Campylobacter
Salmonella
Shigella
m
se
Bacillus cereus
As
Dr
Escherichia coli m
I Campylobacter m
Salmonella CD
Shigella D
Bacillus cereus GD.
Bacillus cereus characteristically occurs after eating rice that has been re heated
m
se
As
Bacillus cereus infect ion most commonly results from reheated rice.
Dr
Which one of the following best describes th e action of aciclovir?
Interferes with the capping of viral mRNA
Inhibits RNA polymerase
m
se
As
Prot ease inhibitor
Dr
Inhi, its uncoating of virus in the cell
Interferes with the capping of vira l mRNA

I
Protease inhibitor
Aciclovi r - guanosine analog, phosphorylated by thym idine kinase which in turn
m
se
inhibits the viral DNA polymerase
As
Dr
A patient wit h a severe head ache, nausea and vomiting co mes t o the emergency
d epartment. Exa mination reveals neck st iffness and a positive Kernig's sign. A lumbar
puncture is perfo rmed and the CSF is purulent. She is urg ent ly start ed on ceftriaxone.
Which class o f antibiotics d oes ceftriaxone belong to?
Macrolides
Tetracyclines
Am inog lycosides
Beta- lact ams
m
se
As
Lincosamid es
Dr
Macrolid es m
I Tetracyclines CD
.
Aminoglycosides CD
Beta-lacta ms GD
Lincosam ides m
Cephalosporins are a type of beta-lactam
Ceftriaxone is a cephalospo rin, which is a subset o f beta -lacta ms. Beta-lactams also
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se
include penicillins and carbapenems. Cephalosporins are incredibly potent antibiotics and
As
are usually rese rved for ve ry severe conditions (e.g. mening itis, as in this scena rio).
Dr
A 43-year-old sheep farmer presents wit h a lesion on his right hand. It init ially started as a
sma ll, raised, red papule but has now become larger. On examination a 2cm, f lat -t opped
haemorrhagic lesion is seen. What is t he most likely diagnos is?
Orf
Stap hylococcal furuncle
Hand, foot and mout h disease
Paronychia
m
se
As
Ant hrax
Dr
I Orf
Staphylococcal furuncle
CD.
.
CD
Hand, foot and mouth disease CD
Paronychia m
m
se
Anthrax mt
As
Dr
A 39-year-old ma n with HIV is admitted due to shortness of b reath. Chest x-ray shows
bilateral pulmona ry infiltrates and Pneumocystis carinii pneumo nia is suspected. What
type of sta ining shou ld be applied to the b ron choalveolar lavage to demonstrate the
organism?
Rubeanic acid
Silver stain
Pea rl's stain
Rose Bengal
m
se
As
Congo red
Dr
Ru beanic acid CD
I Silver sta in
Pearl's stain
CD
tED
Rose Bengal CD
m
se
Congo red GD
As
Dr
A tearful 35-year-old pregnant lady repo rts that her husband has recently told her he has
chlamydia. She is cu rrently at 36 weeks gestation and is requesting treatment for
chlamydia. What (if anything) should you give her?
Azithromycin 1 g single dose
Reassure her that if her results come back negative then she does not need
treatment
Doxycycline lOOmg BD for 7 days
Ceftriaxone 500 mg intramuscular (IM) injection
m
se
As
Gentamicin 3mg/kg
Dr
Azithromycin 1 g single dose
Reassu re her that if her results come back negative then she does not need
treatm ent
Doxycycline l OOmg BD for 7 days
Ceftriaxone 500 mg intramuscular (IM) injection
Gentam icin 3mg/kg
Azithromycin, erythromycin or amoxicil lin may be used to treat Chlamydia in

pregnancy
All chlamydia contacts are offered treatment. Prompt treatment in this patient is essential
m
as she is due to give birth soon and if the chlamydia is untreated she risks passing it on to
se
he r baby.
As
Dr
Which one of the fo llowing statements regard ing hepatitis B is correct?
Ribavirin is the trea tment of choice fo r chronic hepatitis B
All patient immunised aga inst he patitis B require an anti- HBs check to a ssess their
respo nse to the vacci ne
10-15% of adults fa il to respond o r respon d poorly to 3 d oses of the vaccine
The va ccine is of the live-attenuated type
m
se
As
An a nti -HBs level of 20 m!U/ml indicates a n adequate respo nse to the va cci ne
Dr
Ribavirin is the trea tment of choice for chronic hepatitis B
All patient immu nised aga inst hepatitis B require an anti-HBs che ck to assess
-
"""
their res ponse to the va ccine
10-15% of adu lts fail to respond o r respon d poorly to 3 doses o f the vaccine
The va ccine is o f the live -attenuated type
An a nti-HBs level o f 20 m!U/ml indicates a n adequate response to the va cci ne

-
"""
m
se
Only those at risk of occupatio nal exp osure (i.e. Hea lth ca re workers) and patients with
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chronic kidney disease require an anti-H Bs check.
Dr
A 35-year-old male presents w ith a facial droo p. On neurological examination, a lower
motor neuron facial nerve lesion is localised. He d escribes a rash over his fo rearm 3 weeks
ago w hich sett led. What is the most like diagnosis?
Lyme disease
Stroke
M otor neuron disease
Multip le sclerosis
m
se
As
Ramsay Hunt syndrome
Dr
Lyme disease
Stroke
Moto r neuron disease
r Multiple sclerosis
This patient has a lower mot or facial nerve lesion. One must next consider all t he causes
o f a facial nerve palsy. Cons ideri ng t he history o f a rash (erythema migrans), Lym e disease
is the most likely answer. The sym ptoms o f Lyme disease most often occurs 3 d ays to 1
mont h after the initial t ick bit e. A stroke and multiple sclerosis affects the central nervous
system and p resent with a upper mot or neuron lesion as opposed t o a lower mot or
neuron lesion. Mot or neuron disease doesn't normally affect the facial nerve and never
p resents w ith a rash. Ramsay Hunt syndrome typically present s with a triad of ipsilat eral
m
se
facial paralysis (lower motor neuron facial pa lsy), ear pain, and a vesicular rash on t he face
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or in the ear. The rash d oesn't appea r on t he forearm.
Dr
A 72-year-old woman who is known to have type 2 diabet es mellitus and heart fa ilure is
reviewed. One week ago she was treated with oral flucloxacillin and penicillin V for a right
lower limb cellulitis. Unfortunately there has been no response to treatment. What is the
most appropriate next line antibiotic?
Co -amoxiclav
Erythromyci n
Clindamycin
Vancomycin
m
se
As
Gentamici n
Dr
ICo-amox~clav flD
Erythromycin m.
I Clindamycin CD
Vancomycin QD
m
se
m.
As
Gentamicin
Dr
A 30-year-old woman presents with a white, ma lodorous vaginal d ischarge. There is no
associated itch or dyspareunia. A d iagnosis o f bacteria l vaginosis is suspected.
Overg rowth of which one of the following o rganisms is most likely to cause this
presentation?
Lactobacilli
Trichomonas
Candida
Mycoplasma hominis
m
se
As
Gardnerel/a
Dr
Lactobacilli GD
Trichomonas GD
R ida fD
Mycoplasma hominis m
Gardnerel/a ED
m
se
Bacterial vaginosis - overgrowth of predominat ely Gardnerel/a vagina/is
As
Dr
A 38-year-old man presents to the genitourinary cl inic w ith multiple, painless genital
ulcers. A diagnosis of granuloma inguinale is made. What is the causative organism?
Chlamydia
Treponema pallidum
m
se
As
Haemophilus ducreyi
Dr
Klebsiella granulomatis tD
Chlamydia CD
Herp es simplex virus fD
Treponema pallidum GD
Haemophilus ducreyi QD
m
se
Gran uloma inguinale - Klebsiella granulomatis
As
Dr
A 25-year-old man returns from a gap-year in Central and South America and presents
with a 2 month history o f an ulcerat ing lesion on his lower lip. Exam ination of his nasal
and oral mucosae revea ls widespread involvement. What is th e likely cause?
Leishmania brasiliensis
Leishmania mexicana
Trypanosoma cruzi
m
se
As
Leishmania donovani
Dr
Leishmania brasiliensis
Leishmania mexicana
Trypanosoma cruzi
Leishmania donovani
Mucocutaneous ulceration follow ing travel? - Leishmania brasiliensis

m
se
Th is patient most like ly has leishmaniasis. The pattern of a p rimary skin lesion with
As
mucosal involvement is characteristic of Leishmania brasiliensis
Dr
Which of the following antibiotics is predominately bactericidal?
Trimethoprim
Erythromycin
Ciprofloxacin
Chloramphenicol
m
se
As
Minocycline
Dr
Trimethoprim GD
Erythromycin f!D
Ciprofloxacin CJD
Chloramphenicol 6'D
m
•
se
Minocycline
As
Dr
A 25-yea r-old man w ith a history of epilepsy p resents f o r advice regarding malarial
pro p hylaxis. Next month he plans to travel t o Vietnam. His trip will take him to some of
the costal tou rist destinations but he also p lans to travel inland. W hat is the most
appropriat e medication to p revent him d eveloping malaria?
Qui nine
Atovaquone + proguanil
M ef lo qu ine
Primaquine
m
se
As
Pyrim ethamine + sulfadoxine
Dr
Quinine f!D
I Atovaquone + proguanil ED.

Mefloquine 6D
Primaquine 6D
Pyrimethamine + sulfad oxine CD
In certain parts of South-East Asia there is widespread chloroquine resistance.

Chemoprophylaxis using atovaquone + proguanil (Malarone), mefloquine (Lariam) or
m
se
doxycycline is therefore recommended. Mefloquine shou ld b e avoided in this patient due
As
t o his hist ory of epilepsy.
Dr
A 38-yea r-old man who has recently em igrated from eastern Europe presents to
Emergency Department one hou r after sustain ing a 4 em laceration to the dorsu m of his
left hand. He wo rks as a builder and sustained the laceration after cutting into a
ca rdboa rd box using a Stanley knife.
On exam ining the wound there is no sign of a forei gn body o r neu rovascu la r deficit. He is
referred to Plastics for apposition of the wou nd.
You ask him about his tetanus vaccination status. He has 'no idea' but can remem ber
getting some vaccinations as a child.
What is the most appropriate action with respect to tetanus?
Requires human tetanus imm unoglobu lin + tetanus vaccine + complete vaccine
cou rse at a later date
Requires tetanus vaccine + co mplete vaccine course at a late r date
Requires human tetanus imm unoglobu lin
No action required
m
se
As
Requires tetanus vaccine + ora l penicil li n V p rophylaxis for one week
Dr
Requires human tetanus immunoglo bulin + tetanus vaccine + complete vaccine CD
cou rse at a later date
Requires tetanus vaccine + co mplete vaccine course at a later date
Requires human tetanus immunoglobulin

-~
No action required
Requires tetanus vaccine + oral penicillin V p rophylaxis fo r one week
This wound is not high risk for tetanus. The Green book would however recommend that
we vaccinate against tetanus in this situation. His immunisat ion status is unknown and it is
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se
therefore prudent to reduce his risk of develop ing tetanus in future by ensuring he has a
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com plete course of teta nus vaccinat ion.
Dr
A 29-yea r-old Russian man who has recently a rrived into the country presents with feve r
a nd feeling generally unwe ll. His temperatu re is 38.2°( and pulse 96/ min. On exam inatio n
a grey coating is seen su rro undin g the tons ils a nd there is extensive cervica l
lympha denopathy. What is the most li kely diagnosis?
Dengue fever
Typho id
Pa ratyp ho id
Actinomycos is
m
se
As
Diphthe ria
Dr
Dengue f ever m
ITyp~oid fD
Paratyphoid
~
m
Actinomycos is fD
m
se
I
As
Diphthe ria fD
Dr
A 62-year-old patient with type 2 diabetes mellitus presents with a 'rash' on his left shin.
This has grow n in size over the past two days and is now a painful, hot, erythematous area
on his anterior left shin spreading around to the back o f the leg. He is syst emica lly well
and a decision is made to give oral treatm ent. He has a past history of penicillin allergy.
What is the most appropriat e antibiotic to give?
Ciprofloxacin
Cefaclor
Flucloxacill in
Vancomycin
m
se
As
Clarithromyci n
Dr
Ciprofloxacin «D
Cefaclor f.D
Flucloxacillin GD
I_
Vancomycin «D
m
se
Clarithromycin ED
As
Dr
A 43-year-old Asian man presents with headache and neck stiffness. CT brain is normal
and a lumbar punctu re is performed with the following results
Lumba r puncture reveals:
Opening pressure 15 cmCSF
Appearance Cloudy
Glucose 3 .3 mmolfl
Protein 0 . 7 g/ 1
White cells 100 I mm• ( 70% lymphocytes)
Bacterial mening itis
Viral meningitis
Tu berculous meningitis
m
Norma l CSF resu lt
se
As
Dr
Viral meningitis
Tuberculous meningitis
Normal CSF result

-
~
Cryptococcal mening itis
m
se
The CSF lymphocytosis combined with a glucose greater than ha lf the serum level points
As
towards a viral meningitis. TB meningitis is associated with a low CSF glucose
Dr
Which one o f t he followin g is a Gram positive coccus?
Enterococcus faeca/is
m
se
As
Bacillus anthracis
Dr
Bacillus anthracis
-
~
m
se
Enterococci - Gram-positive cocci
As
Important for me Less · moc rtC~nt
Dr
A 39-year-old man presents w ith shortness of breath following one week of flu -like
sympt oms. He also has a non-productive cough but no chest pain. A chest x-ray shows
bilateral consolidation and examination reveals erythemat ous lesions on his limbs and
trunk. Which one of the following investigations is most likely to be diagnostic?
Cold agglutins
Sputum culture
Urinary antigen for Legionella
Serology for Mycoplasma
m
se
As
Blood culture
Dr
Cold agglutins
Sputum culture
Urinary antige~ for Legionella
Serology for Mycoplasma
Blood culture
Mycoplasma? - sero logy is diagnostic

m
se
The flu-like symptoms, bilateral consolidation and erythema multiform e point to a
As
diagn osi s of Mycoplasma. The most appropriate diagnostic t est is Mycoplasma serology
Dr
A new ly qualif ied staff nurse at the local hospital u ndergoes vaccination against hepatiti s
B. The following resu lts are obtained three mont hs after completion of the p rimary
cou rse:
Resu lt Anti-HBs : 10 - 100 miU/ ml
Referen ce An antibody level of > 100 miU/ml indicates a good immune response with protective
immunity
What is the most appropriate cou rse o f action?
Repeat cou rse (i.e. 3 d oses) o f hepatitis B vaccine
Repeat anti-HBs level in t h ree mont hs time
Give a cou rse of hepatit is B immune globulin (HBIG) + one f urther d ose of hepatit is
B vaccine
Give one fu rther d ose of hepatit is B vaccin e
m
se
As
Do a HIV test
Dr
I Repeat course (i.e. 3 d oses) of hepatitis B vaccine
Repeat anti-HBs level in three months time
-
Give a cou rse of hepatitis B immune globulin (HBIG) + one f urther d ose of
hepatit is B vaccine
I Give one further dose of hepatitis B vaccine
m
se
Do a HIV test
As
Dr
Which o f the follow ing is least recognised as a cause of a false posit ive VDRL test?
Pregnancy
SLE
Tuberculosis
m
se
HN
As
Dr
Pregnancy CD
SLE (fD
I Oral contraceptive pill
Tuberculosis
ED
(fD
m
se
HIV CD
As
Dr
A 54-yea r-o ld homosexua l man presents to the e me rgency department with fever and
ma la ise 24 hou rs after be ing treated for syphilis with intramuscular benzathin e penicillin
in his local GUM clinic. He has a flo rid maculopapu la r rash ove r his a rms, legs and to rso
which he tells you has been p resent for the last 2 weeks. The patient informs you he has
no sexua l contacts fo r the last 2 months and his last HIV test was pe rfo rmed 3 days ago
when he tested positive fo r syphilis a nd was negative. Observations a re no rma l and there
are no other find ings o n system ic exa mination.
What wou ld be the most appropriate response to this presentation?
Repeat HIV test, vira l load and CD4 count
Admit fo r CT head, lumbar p unctu re and observation
Reassu re the patient and d ischarge him
Repeat syph ilis sero logy and rep eat treatment if th is is positive
m
se
As
Refer to dermato logy for outpatient biopsy
Dr
Repeat HIV test, viral load and CD4 count
Adm it for CT head, lum bar punctu re and observation
Reassure the patient and discharge him
Repeat syph ilis serology and repeat treatment if this is positive
Refer to dermato logy for outpatient biopsy
The Jarisch-Herxheimer reaction is a known phenomenon following syphilis

treatment that does not require any specific treatment or investigations
Important for me l ess : m::~c rtc.nt
A flu-li ke reaction, known as the Jarisch-Herxheimer reaction, is a known phenomenon

following syphil is treatment with Benzathine penicilli n that is usua lly self li miting to 24-48
hou rs that it is important to inform patients about prior to treatment. As examinati on was
normal and there is no history of neu rological sympto ms th ere is no need to investigate
m
se
for neu rosyphi lis. Syphi lis serology will very likely still be positive 1 day after treatment
As
and there is no indication to repeat this.
Dr
37 years old American man ca me to yo ur cl inic with a histo ry of fever, arthralgia and
headache one week befo re the o nset of a red itchy a rea at the site of p revious tick b ite on
his left fo rea rm. On examination of the a rea, it ap pears to b e ova l and slightly raised
erythema. Serology confirms Lyme disease. You sta rted the patient o n d oxycycline cap
100 mg PO once d a ily.
Two d ays later the patient was b rought by his brothe r to the eme rgen cy department
g asp ing his breath and im mediately died of card iac a rrest.
What was the most li ke ly cause of his sud den death?
Sepsis
Heart b lo ck
Mening oencephalitis
Myoca rditis
m
se
Doxycycline s ide effect
As
Dr
Sepsi s CD
Heart b lock ED.
Mening oencephalitis (D
Myocarditis fD
Doxycycline side effect m
Heart b lock is an important cause o f death in Lyme disease

Lyme disease should be suspected in endemic areas like United state pat ients w ith
erythema chronicu m migrants.
Heart b lo ck is one of the most serious presentations of Lyme disease that can cause
m
cardiac arrest.
se
Sepsis, mening oencephalitis and myocarditis are unlikely t o cause su dden d eath.
As
Doxycycline has no proa rrhythmic si de effects.
Dr
A 44-year-old homosexual man present s to your GUM cl inic with a 3-day history of
diarrhoea, He has no history of recent fo reign t ravel and is normally fit and well. His
abdomen is soft, non tender and he has normal observations. His last sexua l encounter
was 2 weeks ago. Tests fo r Chlamydia trachomatis,Neisseria gonorrhoea, HJV and Syphilis
are negat ive. A stool sa mple is sent for cultu re and grows Shigella.
What is the most su itab le management plan?
Start loperam id e and review in 48 hours
Adm it to t he loca l infectious diseases unit for IV Met ronidazole
Reassu re the pat ient t his is a commensal bacteria unlikely to be t he cause o f their
symptoms
Advise t he patient t o increase t heir fluid intake an d seek medical attention if t hey
become unwell, or d evelop bloody diarrhoea.
m
se
As
Inform Public Health England
Dr
Start lo pe ram ide and review in 48 hours
Adm it to the local infectious diseases unit for IV Metronidazole
Reassure the patient this is a commensal bacteria unlikely to be the cause o f their
-
~
m
sympto ms
Advise the patient to increase their fluid intake an d seek medica l attention if
they beco me unwell, or d evelop bloody diarrhoea.
Inform Public Health England
Shigella infection is usua lly se lf limiting a nd does not require a ntibiotic treatment;
antibiotics are ind ica ted fo r pe ople with seve re disease, who are
immu nocom prom ised o r with b loody d iarrhoea
Shigella infect ion is usually self- limiting a nd does not require antibiotic treatment;
antibiotics are indicated for people with severe disease, who are immunocomp romised or
with b loody diarrhoea. Th is patient sounds fa irly well; hospital a dmission would be
m
se
inapp ropriate and Shigella is only notifiab le if food po iso ning is suspected. Antimoti lity
As
drugs are not recommended in infective diarrhoea
Dr
A 25-year-old man is bitt en by his assailant during a fight outside a nightclub. Alongside
Streptococci spp. and Staphylococcus aureus, which of the following organisms is most
likely to be isolat ed?
Eikonella corrodens
Acinetobacter baumannii
m
se
As
Enterococcus faeca/is
Dr
Pseudomonas aeruginosa «ED
I Eikonel/a corrodens
Ci.D
CD
Acinetobacter baumannii GD
Enterococcus faeca/is fiD
Eikenel/a is notable as a cause o f infections fo llowing human bites

m
se
As
Eikonel/a corrodens is fou nd in around 10-30% of human bite wounds.
Dr
Which one of the followin g organisms causes erysipelas?
m
se
As
Dr
-
~
m
se
As
Dr
A 23-year-old stu dent retu rns from India and develops a febrile illness. Following
investigati on he is diagnosed as having Plasmodium vivax malaria. Th is area is known to
harbour chloroquine-resistant strains of Plasmodium vivax. What is the most appropriate
initial management to treat the acute infection?
Primaquine
Atovaquone-proguanil
Quinine
Doxycycline
m
se
Artemether-lumefantrine
As
Dr
Primaquine
Atovaquoner roguanil
Quinine
Doxycycline
Artemether-lumefantrine
-
~
Non-falciparum malaria (acute infection), treatm ent of choice: artemisinin-based

com bination therapy (ACT) or chloroquine
For non-falciparum malaria:

• in areas which are known to be chloroquine-sensitive then WHO recommend either
an artemisi nin-based com bination therapy (ACT) or chloroquine
m
se
• in areas which are known to be chloroquine-resistant an ACT should be
As
Dr
What is the mechanism o f action of the antiviral agent ribavirin?
Inhibits DNA polymerase GD

Inhibits uncoating of virus in the cell GD
Protease inhibitor GD
Nucleoside analogue reverse t ra nscri ptase inhibitor GD
m
se
As
Interferes w ith th e capping of v'ral mRNA ED
Dr
Protease inhibit or
Nucleoside analogue reverse transcri ptase inhibitor
Interferes with the capping of v'ral mRNA
Ribavirin - guanosine an alog which inhibits inosine monophosphate (IMP)
m
dehydrogenase, interferes with the capping of viral mRNA
se
As
Dr
A 23-year-old presents 3 weeks after a hiking trip in the Scottish Highlands. This morning
whilst eating breakfast he noticed that the left side of his face was not moving. He repo rts
feeling generally unwell for the past couple o f weeks with muscle pains, fever and
lethargy. For the past couple o f days, he has suffered fro m palpitations and noted a ring-
like rash with a central redness over his chest. He is diagnosed with disseminated Lym e
disease.
Oral co-amoxiclav
Oral amoxicillin
Intravenous amoxicillin
Intravenous ceftriaxone
m
se
As
Intravenous teicoplanin
Dr
Oral co-amoxiclav
Oral amoxicillin
Intravenous amoxicillin
Intravenous ceftriaxone
Intravenous teico planin
IV ceftriaxone shou ld be used as first-line treatment of Lyme disease with

disseminat ed or central nervous system involvement
Intravenous ceftriaxone is the antibiotic of cho ice in disseminat ed Lyme disease with oral
d oxycycline being used in early disease. The European version of Lym e disease can be
associated w ith facial nerve palsy with otherwise non-specif ic sympt oms, resu lting in an
incorrect diagnosis of Bells Pa lsy (Cooper et al). Studies suggest that between 3.5 and
10% of patients w ith Lyme disease go on to d evelop a facial nerve palsy an d t his shou ld
be considered as a different ial in patient s presenting w ith unilateral facial weakness.
This patient is a hiker and has likely been b itten by a t ick during his recent t rip. His initial
symptoms of muscle ache and fever are typical of the early/loca lised disease. As t he
condition p rog resses patients d evelop dissem inated disease and can p resent with
erythema chronicum migrans or 'bulls-eye' rash, bells palsy, palp itations, dizziness or
symptoms of meningism.
Oral co-amoxiclav is not used in t he treatment of dissem inated Lyme disease.
Oral amoxici llin can be used in early disease where doxycycline is contraindicated,
however, wou ld not be appropriat e in th is case.
Int ravenous ceftriaxone is the f irst choice antibiot ic not intravenous amoxici llin.
Int ravenous teicoplanin would not b e the f irst- line t reat ment in this patient.
Reference:
Cooper L, Branagan -Harris M, Tuson R, Nduka C. Lym e disease and Bell's pa lsy: an
s em
ep id emiological stu dy of diagnosis and risk in England. Br J Gen Pract 2017; 67 (658):
As
e329-e335.
Dr
A 22-year-old woman presents with lethargy, pyrexia and headaches. She is a student and
returned from a holiday in Ibiza ten days ago. These sympto ms have been present for the
past six days and s he is wondering whether she may need an antibiotic. She a lso has a
history of menorrhagia and is concerned that she may be anaem ic. Cli nical examination
reveals a te mperature of 37.9°( and marked cervical lymphadenopathy. You o rder a fu ll
blood count which is re ported as follows:
Hb 12.1 g/dl
wee 13.1 8
109/1
Lymphocytes 6 .2 * 109/ 1
Film Atypical lymphocytes seen
HIV seroconversion
m
se
Septicae mia secondary to streptococcal th roat infection
As
Dr
ashimoto's thyroiditis
Infectious mononucleos is
HN seroconversion
Septicaemia secondary to streptococcal throat infection
m
Atypical lym phocytes - ?glandu la r feve r
se
As
Dr
A 19-year-old student is brou ght to th e Emergency Department by friends due to a
severe headache and drowsi ness. On examination he has a w idespread purpuric rash.
Meningococcal infection is strongly suspect ed but he is known t o be penicillin allergic
(previous anaphylaxis). What is the antibiotic of choice?
Chloramphenicol
Meropenem
Teicoplanin
Erythromycin
m
se
As
Cipro floxacin
Dr
Chloramphenicol crD
Meropenem CD
Teicoplanin .
(D
Erythromycin G'D
m
se
Ciprofloxacin flD
As
Dr
A 40-yea r-old woman who is known to be HJV pos itive is adm itted to the Emergency
Department following a seizure. Her pa rtner reports that she has been having headaches,
night sweats and a poor a ppetite for the past four wee ks. Blood tests and a CT head a re
arranged:
CD4 89 u/1
CT head Single homogenously-enhancing lesion in the right parietal lobe
Primary CNS lymphoma
Tuberculosis
Progressive multifoca l leukoencep halopathy
Cryptococcus
m
se
As
Toxo plasmos is
Dr
I Primary CNS lymphoma
Tuberculosis
Cryptococcus
Toxo plasmosis
HN, neuro symptoms, single brain lesions with homogenous enhancement - CNS
lymphoma
This is a difficu lt question. Toxop lasmosis is the most common cause of b rain lesions in
HN patients. However, around 80% of t oxo plasmosis cases involve mult iple lesions and
m
se
the history is suggestive of lymphoma. Cerebral tubercu losis is much less common t han
As
lymphoma in HN.
Dr
Which one o f the following is least likely to result from Streptococcus pyogenes i nfection?
Rheumatic f ever
Scarlet fever
Cellulitis
Type 2 necrotizing fasciitis
m
se
As
Pneumonia
Dr
Rheumatic fever CfD
Scarlet fever GD
Cellulitis CD
Type 2 necrotizing fasciitis CfD
Pneu monia ED
m
se
As
Streptococcus pyogenes ra rely causes pneumo nia.
Dr
A 19-yea r-old man presents 3 days after returning from a backpacking trip across Brazil.
He complains of a sudden onset fever, headache, joint pains and rash all over his body.
He has no existing health conditions and is not on any medication.
On examination he has a petechial rash on his limbs. He has no focal neu rology and no
signs of meningism.
Hb 100 g/ 1
Plat elet s 80 ~ 109/ 1
WBC 4 .0 * 109/ 1
Eosinophils 0.4 * 109/ 1
Viral hepatitis
Chagas disease
Dengue fever
Malaria
m
se
As
Bacterial me ningitis
Dr
Viral hepatitis m
Chagas disease fD
I Dengue fever GD
Malaria CD
•
Dengue fever is fo und in South America (as well as South East Asia) and presents like this
with sudden onset fever and arthra lgia combi ned with low platelets an d haemorrhage in
the case of Dengue haemo rrha gic fever. Cha gas disease (American trypa nosomiasis) is
also fou nd in this area but would usually present with mild features and you wou ld expect
m
se
to see raised eosinophils. Viral hepatitis and malaria are less likely to present with a
As
petechial rash. Bacterial meningitis is unlikely as there are no signs of meningism.
Dr
A 35-year-old homosexual man is referred to the local genitourinary cl inic fo llowing the
development of a solitary painless penile ulcer associated with painful inguinal
lympha denopathy. He has recently developed rectal pain and tenesmus. What is the most
likely diagnosis?
Herp es simplex infection
Syphilis
Granuloma inguinale
Chancroid
m
se
As
Lym phogranuloma venereum
Dr
Syphilis
Granuloma inguinale
Chancroid
I Lymphogranuloma venereum
Genita l ulcers
• painfu l: herpes much more common than chancroid
• painless: syphilis more common than lymphogranuloma venereum
Lym phogranuloma venereum usually involves three stages:

• 1 - small painless pu stule which lat er forms an ulcer
• 2 - painful inguinal lymphadenopathy
m
se
• 3 - proctocolitis
As
Dr
A 55 -year-old man who was admitted followi ng a stroke two weeks ago is reviewed.
Yest erday he started to have a t emperature and b ecome more confused. A septic screen
has shown radiological evidence of pneumonia. On examination his respirat ory rate is
36/min, pulse 112/ min, oxygen saturations of 95% on room air and blood pressure of
102/ 66 mmHg. What is the most appropriate antibiotic to use?
Teicoplanin
Cefuroxime
Amoxicillin
Imipenem w ith cilastatin
m
se
As
Piperacillin with t azobact am
Dr
Teicoplanin
Cefuroxime
Amoxicil lin
Imipenem with cilastatin
Piperacillin with t azobact am
m
se
Cefuroxime is a second generation cephalosporin and is therefore a poor choice as it has
As
limited action against Gram-negative bacteria.
Dr
Which one o f the fo llowin g statements is true regardi ng Listeria monocytogenes?
Multip li es rap id ly at high temperatures
The organ ism is resista nt to amp icill in
It is a Gram neg ative bacill us
It is diag nosed by the p resence of urinary antigen
m
se
May cause ataxia
As
Dr
Multiplies rapidly at high temperatures GD
The orp anism is resistant to am picillin CD
It is a Gram negative bacillus CD
It is diagnosed by the presence of urinary antigen 6D
m
se
May cause ataxia tiD
As
Dr
A 35-year-old man returns from a two week holiday in Italy. He has a 10 day history of
rectal bleeding associated with lower back pain. On exam inati on there is a painful
swelling of his rig ht kn ee. What is th e most likely diagnos is?
Gonococcal septicaemia
Amoebiasis
Crohn's disease
Tuberculosis
m
se
As
Ulcerative colitis
Dr
Gonococcal septicaemia
Amoebiasis
Croh n's disease
Tuberculosis
Ulcerative colitis
Gonococcus contracted via ana l sex may cause proctitis. The knee swe ll in g seen in this
m
se
patient is s epti c arthritis, which is chara cte ristic of the second stage of dissem inated
As
g ono coccal infectio n. Proctitis may prese nt with e ither lowe r ba ck o r recta l pa in
Dr
A 23-yea r-old medica l student is seen in a genitourinary medicine clinic for a painless
lesion on the g lans of his penis. He describes a 2-week history of the les ion that starte d as
a small erythematous pa pu le and has now progressed to ulceration. This was associated
with fevers, sweats and general malaise. He has returned from his elective in the
Caribbean and adm its to an episode o f unprotected sex with a local resident.
On exam ination there was a lx2cm pa inless ulce r on the g lans o f his penis. You note
groove sign with lympha denopathy above and be low the left inguinal ligament only.
What organism is cause of the patients p resentation?
Treponema pallidu m
Chlamyd ia trachomatis
Haemoph ilus ducreyi
Klebsiella
m
se
As
Gonorrhoea
Dr
Treponema pallidum ED
Chlamydia trachomatis tD
Haemoph ilus du creyi GD
Klebsiel la CD
Gonorrhoea m
Lymphogranu lo ma ve nereu m - Chlamydia trachomatis

This patient is presenting with the classic features o f Lymphogranulo ma venereu m (LGV).
This tropical sexually trans mitted d isease can b e caused by multiple serovars of Chlamyd ia
Trachomatis. The bacte rium gains entry throu gh breaches in the e p ithelial/mucous
membranes, travelling through the lymphatics via macrophages to local nodes. It is
endemic to Africa, Ind ia, Ca rib bean, central America and southeast Asia.
The d isease p resents in two stages:
Primary stage: Self-limitin g painless genita l ulcer at the s ite of inoculation 3-12 d ays later.
Secondary stage: Presents 1-6 months later with unilateral pa inful

lympha den itis/lymp hangitis. The site of inoculation dictates symptomatology, if recta lly,
then tenesmus, proctocolitis, strictures and fistulas can ensue. Cervicitis and urethritis are
also common features. Enlarged lym p h nodes are known as b uboes, they a re ohen
painfu l and can lead to thinning of the overlying skin causing abscesses. Groove sign is
sepa ration inguinal nodes by the ingu inal ligament and is characteristic of the d isease.
Diagnosis is achieved by enzyme linked immunoassays or polyme rase chain reaction of

infected samp le areas/pus. Acute and convalescent sera can be used, but req uires two
samples 2 weeks apart.
Treatment invo lves antibiotics, e ither doxycycline o r macrol id es (azithromycin o r

erythromycin) and potential surgica l drainage/ aspiration of the bu boes or abscesses.
s em
Complications of the d isease inclu de : genital elephantiasis, hepatitis, infertility, p elvic

As
inflammato ry d isease, arthritis and fitz hugh curtis syndrome.

Dr
A 58-year-old caucasian male originally f rom t he United Kingdom (UK) now living in East
Africa ha s returned to the UK on holiday. He has become unwell in t he last two d ays,
complaining of a head ache, rigors, vomiting, fever, abdominal pain and passing little
amounts o f dark red urine. On examination, t here is hepatosplenomegaly, j aundice and
anaemia. Urinalysis reveals blood only and microscopy showed no red cells. Of the
following opti ons, what is t he most likely diagnosis?
Leptospirosis
Pyelonephritis
Schistosomiasis
m
se
As
Blackwater fever
Dr
Leptospirosis GD
Acute viral hepatitis D
~yelonephri t is
Schistosomiasis
•fD
I Blackwater fever
.,
Blackwater feve r is a ra re com plication of mala ria which ca n be fatal. It is caused by la rg e
intravascular haemo lysis resulting in haemoglobinu ria, anaem ia, jaundice and acute
kidney injury. Urine is classica lly b lack o r d a rk red in colour.The cause of the massive
hae mo lysis is unknown. The treatment is with antimala ria ls, intravenous fluid s and in
some cases dia lysis. Urinalysis reveals blood which is not seen on microscopy as it is
haemoglo bin uria.
Schistosomiasis has an acute o nset which includ es symptoms of feve r, chills, headache
a nd fatigue but sympto ms of haematu ria d o not come till the chronic p hase as a result o f
bladd e r fibros is and calcification, th is presents more insidiously. In ad dition, in
schistosom iasis, urine microscopy wo uld s how red ce ll casts. Acute hepatitis is a
cons id eration but no rmally resu lts in a p rodroma l p hase of flu-like symptoms lasting 1-6
weeks before jaundice a ppears and wou ld not usua lly cause ol ig uria . Severe leptosp irosis,
known as Weil 's di sease, can result in renal failure and jaundice but also tend s to cause
pulmona ry haemorrhage and shows signs of bleed ing. Furthermore, the re is usually a
re levant occupati ona l histo ry resu ltin g in exposure to infected rat urine. Pyeloneph ritis
em
wou ld cause leu cocytes and nitrates to be positive on urinalysis and would not cause
s
As
hepatosp le nomegaly.
Dr
A 42-yea r-old female p resents to the Emergency Department. She is known to be an
intravenous drug user a nd sometimes practices skin popping. She has multiple sores and
wounds. She is complaining of dou ble vision, difficulty swallowing, slurred speech and
weakness of the a rm muscles. Her arms are weak and floppy. You suspect that a bacteria l
toxin is causing her symptoms. What is the mechan ism of actio n of the most likely toxin?
Chloride channel blocker
Inhibition of the release of acetylcholine at synapses
Inhibition of the release of g lycine and gamma-amino butyric acid at synapses
Sodium channel blocker
m
se
As
Nicotinic acetylcholine receptor blocker
Dr
Chloride channel blocker CD
Inhibition of the release of acetylcholine at synapses ED

Inhibition of the release of glycine and gamma-amino butyric acid at synapses 6D
Sodium channe l bl ocker aJ
Nicotinic acetylcholine receptor blocker CD
Botulinum t oxin inhibits the release of acetylcholine at synapses

The patient has wound botu lism, as characterised by descending flaccid paralysis and
cranial nerve signs. Intravenous drug users are at higher risk of botulism, particularly if
they engage in skin popping or muscle popping. A patient with tetanus from a wound
would present with spasms and stiffness of the muscles rather than flaccid weakness.
Botulinum toxin works by inhibiting the release of acetylcholine at synapses of the

nervous system, both peripherally and centrally. Tetanus toxin inhibits the release of
inhibitory neurotransmitt ers (glycine and GABA at synapses). Tetrodotoxin, produ ced by
several fish species including pufferfish, is a sodium channel blocker. Curare, the poison
used t o tip arrows by the native people of Central and South America, is a nicotinic
acetylcholine receptor blocker. Chlorotoxin, from the deathstalker scorpion, is a chloride
channel blocker.
em
Botulinum neurotoxins: mechanism of action

s
As
https://www.ncbi.nlm.nih.gov/pubmed/23201505
Dr
A 27 -year-old student presents to the GP with a 24 -hour history of explosive diarrhoea
and vom iting. On further questioning, he has not noticed any blood in his stool, ha s no
history of foreign travel. He tells you he has been eatin g rice kept warm in a rice cooker
for several days.
What is the likely pathogenic organism underlying his symptoms?
Bacillus cereus
Campylobacter jejuni
Shigella flexneri
Norwa lk virus
m
se
As
Dr
Bacillus cereus
-
~
Shigella flexneri
Norwalk virus
Bacillus cereus characteristically occurs after eating rice that has been reheated
This young gentleman is likely to have toxigenic food poisoning from Bacillus cereus.
Bacillus cereus spores germinate in cooked rice and produce toxin if the cooked produ ct
is kept insufficiently ch illed. S. au reus will also cause a toxig enic food poisoning but the
specific history in this case makes this a less likely und erlying organ ism. Equally Norwalk
virus can cause explosive diarrhoea and vomiting but is not associated with any specific
food stuffs.
m
se
Campylobacter and Shigella cause bacterial food poisoning and wou ld likely have a longer
As
history with b loody diarrhoea.
Dr
Which one o f t he followin g featu res is not associated w ith Lyme disease?
Jarisch -Herxheimer react ion
Meningitis
Prolonged PR interval on ECG
Erythema marginat um
m
se
As
Arthralgia
Dr
Jarisch -Herxheimer reaction
Meningitis
Prolonged PR int erval on ECG
Erythema marginatum
Arthralgia
-
~
m
se
As
Lym e disease is associated w it h erythema ch ronicum migrans
Dr
A 44-year-old farme r presents to the Emergency Department due to a high temperature
and confusion. On exam in ation his pu lse is 124 bpm, blood pressure 84/56 mmHg and
temperature 39.8°C. He has a genera lised erythematous ras h which is starting to
desquamate on his pa lms and is also noted to have a paronychial infection of a fingernail
on the left hand. What is the most likely d iagnosis?
Paraquat overdose
Leptospirosis
Staphylococcal toxic shock syndrome
Disseminated herpes simplex infection
m
se
As
Organophosphate poisoning
Dr
Paraquat overdose m
Leptospirosis GD
Staphylococcal toxic shock syndrome GD
Disseminated herpes simplex infection CD
m
se
Organophosphate poisoning CD
As
Dr
For a patient undergoin g an elective splenectomy, when is the optimal time to give the
pneumococca l vaccine?
Four weeks before surgery
One week before surgery
Immediately following surgery
Two weeks after su rgery
m
se
At least one month after surgery
As
Dr
Four weeks before surgery
One week before surgery
Immedtately following surgery
Two weeks after su rg ery
At least one month after su rgery
The current British National Formulary recom mends giving t he vaccine at least 2 weeks
m
se
before elective splenectomy. The refore 4 weeks is the best response from the given
As
options.
Dr
A 30-year-old man presents to the emergency department 4 weeks after return ing from a
two -week business trip to India. For the past week he has felt genera lly unwell with fever
and lethargy. Last night he started to pass bloody diarrhoea and have high fevers.
On examination his temperature is 38.2°(, pulse 102/m in, blood pressure 104/68 mmHg.
Tender hepatomegaly is noted on examination.
Bloods show the following:
Hb 116 g/ 1

8
W BC 13.6 109/1
CRP 156 mg/1
ALP 168 u/1
ALT 68 u/1
yGT 205 u/1
Albumin 37 g/1
What is the most likely causative organism/virus?
Hepatitis A virus
Plasmodium fa/ciparum
Entamoeba histolytica
Giardia Iamblia
em
s
As
Dr
Hepatitis A virus CD
Plasmodium fa/ciparum CD
Entamoeba histolytica CD
Giardia Iamblia GD
Campylobacter jejuni CD
This patient p resents with dysentery and hepatomegaly. The unifying dia gnosis is
amoebiasis with an amoebic liver abscess. A diffe rentia l diag nosis here wou ld be
Escherichia coli which can cause both dysentery as well as a pyogenic liver abscess.
m
Giardia Iamblia does not typi cally cause b loody diarhoea.
se
As
Campylobacter jejuni is not a cause o f hepatomegaly.
Dr
A 19-yea r-old medical stu dent undergoes p rimary immunisation against hepatitis B. His
post immunisation blood s are reported as follows:
Anti-HBs < 10 m!U/ml
What is the most appropriate cou rse of action?
Give one further dose of hepatitis B vaccine
Do a HIV test
Test fo r cu rrent o r past hepatitis B + repeat course (i.e. 3 d oses) of vaccine
Give two fu rther doses of hepatitis B vaccine
m
se
Give a course of hepatitis B immune globulin (HBIG) + one fu rther dose of hepatitis
As
B vaccine
Dr
Give one further d ose of hepatit is B vaccin e
Do a HIV test
Test for current or past hepatitis B + rep eat cou rse (i.e. 3 d oses) of vaccin e
Give two f urther doses of hepatiti s B vaccine
m
Give a cou rse o f hepatitis B immune g lobulin (HBIG) + one f urth er d ose of
se
hepatit is B vaccin e
As
Dr
A 34-year-old HIV positive man is being treated for Pneumocystis carinii pneumonia with
co-trimoxazole. Arterial blood gases show a p02 of 8.2 kPa . What drug should be ad ded
to treatment?
Merope nem
Chloramphenicol
Steroids
Nebulised fluconazole
m
se
Magnesium sulphate
As
Dr
Meropenem CD
Chloramphenicol CD
Steroids GD
Nebulised fluconazole CD
m
Magnesium sulphate
se
As
Dr
A 32-year-old HIV positive man presents to the emergency department with a painful,
swollen leg. He has a history of poor adherence with his medication and is currently not
t aki ng antiretrovirals; his most recent blood t ests from a year previously show a
det ect able viral load. On examination, there are multiple purplish nodules in the skin
overlyi ng the poplitea l fossa.
What is the most likely underlying viral cause for his pathology?
Ebstein Barr Virus
Human Herpes Virus 8
Human Papilloma Virus
Hepatitis B
m
se
As
Human T -Lymphotrophic Virus
Dr
Ebstein Barr Virus CD
I Human Herpes Virus 8 ED

Human Papilloma Virus tiD
~Hepatitis B
Human T -Lymphotrophic Virus «D
•
Ka posi 's sa rcoma is caused by HH V-8 infection in HIV positive individuals
This is a classical presentation of Kaposi's sarcoma, which is caused by HHV8 virus

individuals with HIV. It is an example of an AIDS -defining illness.
All of the other options are vira l precipitant s for other cancers that do not fit the stem.
• Ebstein Barr Virus is associated with Hodgkin's lymphoma
• Human Papilloma Virus is associat ed w ith ce rvical cancer in women and throat and
anal cancer in men
• Hepatitis B is associated with Hepatocellular carcinoma
• Human T- Lymphotrophic Virus is associated with adult T-celllymphoma
People with poorly controlled HIV are more likely t o develop the viral-related ca ncers
listed above; this is partly related to the increased rates of these viral infections in people
living w ith HIV and also relates t o the impaired immune function. The development of m
se
anti -retroviral drugs has significantly reduced the rat es of virus -related ca ncers in people
As
living w ith HIV.

Dr
•
A 47 -year-old lady is referred by her GP with a two day history of fever and headache. She
is normally fit and well and has no past medical hist ory of not e. On examination you not e
nuchal rigidity. Investigations show the following:
Serum glucose 4 .9 mmoljl
Lumbar puncture reveals:
Opening pressure 14 cmCSF
Appearance Cloudy
D I
Glucose 1.7 mmoljl
Prot ein 1.9 g/ 1
White cells 900 I mm• ( 90% polymorphs)
What is the most likely infective ag ent?
E. coli
Enterovirus
m
se
As
Dr
Enterovirus
6 years - 60 yea rs age group are at risk from meninigitis caused by Streptococcus
pneumomae
The CS F resu lts a re consistent with bacte ria l mening iti s (low glucose, hig h p ro te in, high
m
se
po lymorp hs). In this ag e g rou p Streptococcus pneumoniae and Neisseria meningitidis a re
As
the most co mmo n ca uses o f bacte ria l mening itis.
Dr
A phlebotomist gives herself a needl estick injury whilst taking blood from a patient who is
known to be hepatitis B positive. The phlebotomist has just started her job and is in the
process of being immun ised for hepatitis B but has only had one dose to date. What is
the most appropriate action to minimise her risk of contracting hepatitis Bfrom the
needle?
No action needed, complete hepatitis Bvaccination cou rse as normal
Give an accelerated cou rse of the hepatitis Bvaccine + hepatitis B immune globulin
Give hepatitis B imm une globu lin + oral ribavirin for 4 weeks
m
se
As
Give hepatitis B imm une globu lin
Dr
A phlebotomist gives herself a needlestick injury whilst takin g blood from a patient w ho is
known to be hepatitis B positive. The phlebotomist has just started her j ob and is in the
process of being immunised for hepatitis B but has only had one dose to date. What is
the most appropriate action to minimise her risk of contracting hepatitis B from the
needle?
No action needed, complete hepatitis B vaccination cou rse as normal
Give oral ribavirin for 4 w eeks
Give an accelerated cou rse of the hepatitis B vaccine + hepatitis B immune

globu lin
Give hepatitis B immune globulin + ora l ribavirin fo r 4 weeks
m
se
Give hepatitis B immune globulin
As
Dr
A 25-yea r-old sexually active woman presents with dysu ria and urgency. A urine dipstick
is positive fo r leukocytes and nitrites. Urine cu lture and gra m staining reveal a gram -
positive o rganis m in clusters that is coagulase-negative.
What is the most li kely causative organism?
Escherichia coli
Staphylococcus saprophyticus
Proteus mirabilis
m
se
As
Klebsiella
Dr
Escherichia coli GD
Staphylococcus aureus GD
I Staphylococcus saprophyticus
Proteus mirabilis
eD
.
(D
Klebsiella D
Staphylococcus saprophyticus can common ly cause UTI in sexua lly active young
women
Staphylococcus saprophyticus is the second most commo n cause of UTis in sexua lly active
young women (E. coli is most common). It is a g ram-positive coccus that grows in clusters
and is coagulase-negative.
Escherichia coli is a g ra m-negative bacteria.
Staphylococcus aureus is gra m-positive that grows in clusters but is coagulase-positive.
Proteus mirabilis is gram -negative bacilli and is urease -positive.
Klebsiella is a g ram-n egative bacill i.

m
se
As
All of these bacteria can cause UT!s.

Dr
A 27 -yea r-old ma le presents with ma la ise, pyrexia, lym p hadenopathy and a
maculopapu lar rash. The Monospot test is negative. Given a history of high -risk sexual
behaviou r you a re asked to exclude a HIV seroconversion illness. What is the most
appropriate investigation?
Antibodies to HIV-2
gp120 polymerase chain reaction
p24 antigen test
CCRS polymerase cha in reaction
m
se
As
Antibodies to HIV-1
Dr
Antibodies to HIV-2
gp120 polymerase cha in reaction
p24 antigen test

-
"""
CCRS l olymerase cha in reaction
m
se
As
Antibodies to HIV -1
Dr
A 30-year-old man present s to the acute medical receiving ward, one week after return ing
from Tanzania. He has developed a high fever, 38.9, which started abruptly, headache and
genera lised severe joint pain prevent ing him f rom walking. You note his f inger looks
swollen. There is no rash. He has been taking his antimalarial pills. His b lood resu lts are
as fo llows:
Hb 160 g/ 1
WBC 6 * 109/ 1
Septic arthritis
Malaria
Chikun gunya
Zika
m
se
Dengue
As
Dr
Septic arthritis CD
Malaria fD
Chikungunya ED
Zika (D.
Dengue GD
Severe joint pain and high fever point to chikungu nya after return from Africa. The
absence of a rash makes chikungunya more likely tha n dengue. In add ition, a feature
which points to chikungu nya is the severe joint pain which is often debilitating and
norma l blood results (with dengue in some cases there are low platelets). Zika is not as
common in Africa and tends to produce milder symptoms including low-grade fever
(most cases are in South America). Mala ria is less li kely as he was taking his anti-malarial
m
se
pills, in addition, joint swelling is not a feature of malaria. Septic arthritis more commonly
As
affects one joint at a time were as this ma n has general ised severe joint pain.
Dr
A 56-year-old farmer presents with a painless black eschar on his cheek w ith surround ing
swelling and mild fever. The eschar started initially as an itchy boil- like lesion which
became enlarged. In the last week, he had been visiting ru ral fa rms in the Tu rkey to help
with agricu lture work. What diagnosis wou ld need to be considered first?
Necrotic ulcer
Anth rax
Cellulitis
Necrotising spider bite
m
se
As
Scrub typhus
Dr
Necroti c ulcer fD
Anthrax GD
Cet litis a
Necrotising sp ider b ite fD
Scrub typhu s CD
A black escha r with oedema is characteristic of anthrax. There a re occasio na l outbreaks in

central Asia an d Africa (ref: WHO). The cutaneous fo rm is the most common, caused by
hand ling infected animals resu lting in farmers being at risk. In this case, anthrax wou ld
need to be co nsidered and ruled out first. Scrub typhus would also give an eschar but
wou ld be accompanied by o ther symptoms such as muscle pa in, cough, and GI upset. A
m
se
necrotic ulcer is unlikely as it does not usually present on the face. There is no history of
As
s pider bite making necrotizing spid er bite less likely.
Dr
A 42-year-old businessman presents to General Practice after returning from a trip to
Thailand, 4 weeks ago, with an ulcer on his penis. He has a prior history of treated syphilis.
On examination, you note a non-painful chancre on the shaft of t he penis. There is no

penile discharg e and no lymphadenopathy is noted.
Which of the follow ing test s are more likely to reflect a repeat infection with treponema
pallidum?
Enzyme immunoassay
Treponema pallidum haemagglutination assay
Rapid plasma reagin
Chemiluminescence immunoassay
m
se
As
Treponema pallidum particle agglutination assay
Dr
Enzyme imm unoassay
Treponema pallidum haemagg lutination assay
Rapid plasma reagin
Chem il uminescence immunoassay
Treponema pallidum particle agglutination assay
The answer is the rap id p lasma reag in test which is a cardiolipin test which becomes
-
~
negative after treatment.
The enzyme immunoassay, trepo nema I pa ll idum haemagglutination assay,

chemiluminescence immu noassay and treponema pallidum particle agglutination assay
m
se
are a ll treponemal-specific antibody tests which remain positive after the first infection
As
and wou ld not provide evidence for a repeat infectio n.
Dr
A 19-year-old man presents with dysu ria associated with a watery discharge from his
urethral meatus. A urethra l swab shows non -specific urethritis and urine is sent for
Chlamydia/gonococcus. What is the most appropriate antibiotic to use?
Erythromycin
Ciprofloxacin
Metronidazole
Cefixime
m
se
As
Azithromycin
Dr
Erythromyci n fD
Ciprofloxacin GD
I Metronidazole fD
Cefixime .
CD
I Azithromycin CD
Chlamydia - treat with azithromycin or doxycycline

Gonorrhoea would be demonstrat ed by the presence o f Gram negative diplococci on the

swab. As the swab showed non -s pecific urethritis a diagn osis o f Chlamydia is most likely.
m
se
The 2009 SIGN guidelines suggest azithromycin should be used first-line due to
As
pot entially poor com pliance w ith a 7 day course of doxycycl ine.
Dr
Which of the following is true regarding the Salmonella s pecies?
Rose spots appear in a ll patients with typho id
They a re normally present in the gut as co mmensals
They a re anaerobic o rgan isms
A relative b radycardia is often seen in typhoid fever
m
se
Salmonella typhi can be catego rised into type A, Band C
As
Dr
Rose spots appear in all patients with typhoid
They are normally present in the gut as commensals
They are anaerobic organisms
I
A relative bradycardia is often seen in typhoid fever
m
se
As
Salmonella typhi can be categorised into type A. B and C
Dr
A 24-year-old male attends the cl inic fo r a yellow fever vaccine before travelling t o South
Ame rica. He has no past medica l history and takes no regular medicines. He st ates that he
also had a varicella zost er vaccination a few weeks ag o.
What is the minimum int erval requ ired between the last vaccination?
1 week
2 weeks
3 weeks
4 weeks
m
se
As
1 year
Dr
1 week CD
2 weeks fiD
3 weeks fiD
4 weeks GD
~
1 year m
Live vaccines given by injection may be either given co nco mitantly or a minimum
interval of 4 weeks apart to prevent risk o f immunological interference
m
Live vaccines can be given on the same day. If not given on the same day, t hen there
se
must be a 4 week int erval between fu rther live vaccinations to p revent the risk of
As
immunolog ica l interference.
Dr
You a re reviewing a 31-year-old ma n in the live r cl inic. He is currently on triple thera py for
hepatitis C. What is the best way to assess his response to treatment?
Alanine transaminase leve l
Anti-HCV antibo dies
Viral load
Prothrom b in time
m
se
Hepatitis C genotype
As
Dr
Alanine transaminase level
Anti-HCV antibodies
•
(tD
~al load GD
Prothrombin time CD
m
se
•
As
Hepatitis C genotype
Dr
A 27-year-old man who has recently moved to the UK f rom Uganda presents complaining
of fatigue and purple skin lesions all over his body. On examination he has multiple raised
purple lesions on his trunk and arms. You also noti ce some smaller purple lesions in his
mouth. He has recently started taking acyclovir for herpes zoster infection.
Dermatofibroma
Kaposi's sa rcoma
Drug reaction to acyclovir
Psoriasis
m
se
As
Haemangioma
Dr
Dermatofibroma CD
I Kaposi 's sarcoma fD

Drug reaction to acyclovir GD
Psoriasis m
Haemangioma CD
~
Ra ised purple lesions is a classic description of Ka posi 's sa rcoma sugg esting he has
underlying HIV infection. HIV has a high prevalence in Uganda and the recent herpes
zoster infect ion suggest s he may have underlying immunocompromise.
Dermatof ibromas are usually small pink/ red no dules that are characteristica lly very firm
and wou ld not be found in t he mouth. Psoriasis presents w ith red, sca ly lesions and again
is not seen on mucosal surfaces. A drug react ion is unlikely to p resent like this. A
m
se
haemangioma can present wit h a purple raised lesion but again it wou ld be unusual to
As
see them in the mouth and Kaposi's sarco ma is much more likely in th is case.
Dr
A 62-year-old man presents to the emergency department with a p roductive cough of
green sputum and occasiona l bloody specks. On examination his temperature is 38.3°(,
respiratory rate 23/min, heart rate 100/min and there is leh basa l coarse crackles with a
small cold so re above his lips.
Streptococcal pneumonia
Vi ral pneumon ia
Klebsiel la pneumonia
m
se
As
Legionel la p neu monia
Dr
I Streptococcal pneumonia
Viral pneumon ia
I Mycoplask a pneumonia
Klebsie lla pneumonia
Legione lla pneumonia

-
"""'
Th is patient is most likely to be suffe ring from p neumon ia secondary to streptococcal

pneumoniae. It is the most common cause of commun ity acquired pneumonia and
fu rthe r clues to this be ing the diagnosis is the evidence o f a cold sore and the b lood
stained sputum .
For exam purposes, particular dia gnos is of commun ity acquired pneumonia have clues in
the q uestions. Kle bsiella is associated with cardiomyopathies and alcoho lics, with upper
lobar invo lvement, whereas Mycoplasma occurs in epid emics with skin chang es a nd some
haematological invo lvement. Legionella typically is a water borne infection with
hyponatraem ia and ga stroenterologica l sym ptoms.
m
se
As
Bacte ria l Pneumonia - http://emedicine.medscape.com/ article/ 300157 -overview
Dr
A 37-year-old woman who is being treated as an inpatient for Mycop lasma pneumon ia is
reviewed. Unfortunately she is unable to tolerate clarithromycin due to severe nausea.
What is the most suitable alternative antibiotic?
Linezolid
Cefaclor
Ciprofloxacin
Co -amoxiclav
m
se
As
Doxycycline
Dr
m
se
Mycoplasma pneumonia - treat with doxycycline or a macrolide
As
Dr
A 3 1-yea r-old female p resents to the genitourinary med icin e clinic due to four fleshy,
protu berant lesions on her vulva which a re slightly pigmented. She has recently starte d a
re lationship with a new partner. What is the most app ropriate initia l management?
Oral aciclovir
Topical podophyllum
Topica l aciclovir
m
se
As
Electrocaute ry
Dr
Oral aciclovir
~pical podophyllum
Topical aciclovir
Electrocautery
Genita l wart treatment

• multiple, non-keratin ised warts: topical podo phyllum
• solitary, kerati nised warts: cryotherapy
m
se
As
Cryotherapy is also acceptable as an initial treatment for genital warts
Dr
A 45 -yea r-o ld female presents to the Emergency Depa rtment three days after returni ng
from Tha iland compla ining o f seve re muscle ache, feve r and head ache. On exam inatio n
she has a widesp rea d macu lo papula r rash. Results show:
Malaria film : negative
Hb
Pit
W BC 2.4 *109/ 1
ALT 14 6 iu/1
Hepatitis A
Japa nese encep halitis
Rheumatic feve r
Ma la ria
m
se
As
Dengue fever
Dr
Hepatitis A
Japanese e ncephalitis
•
GD
l r eumatic fever
Malaria
-
CD
I Dengue fever tiD
m
se
As
The low platelet count and raised transam inase level is typical of dengue fever
Dr
A 25 -year-old man who is taking immunosuppressive therapy for Adult onset Still's
disease, and has come into contact with a child who has chicken pox. He is varicella zoster
IgG antibody negative. He has a small number of early chicken pox blisters and you
decide to start aciclovir therapy.
Which o f the follow ing fits best w ith the mode of act ion of aciclovir?
DNA polym erase inhibitor
DNA gyrase inhibitor
Reverse transcriptase inhibitor
NS3/4A inhibito r
m
se
As
NSSA inhibit or
Dr
DNA polymerase inhibitor ED
DNA gyrase inhibitor C!D
I Reverse transcriptase inhibitor GD

NS3/4A inhibitor m
NSSA inhibit or m
Aciclovir is much more specific for vira l than mammalian DNA polymerase
Aciclovir is phosphorylated after entry into herpes infected cells to form aciclovir
triphosphat e. The first st ep in this process is depen dant on the presen ce of HSV-coded
thymidine kina se. Aciclovir triphosphat e act s as an inhibitor of, and substrate for, th e
herpes -specific DNA polymerase, preventing further viral DNA synthesis without affecti ng
normal cellular processes. It is 10-30 times more specific for viral DNA polymerase versus
the human enzyme.
Bact erial DNA gyrase is the t arget of quinolone antibi otics. Reverse transcriptase is an
enzyme t arget for the treatm ent of RNA viruses such as HIV. NS3/ 4A and NSSA are both
m
se
t arget s in the treatment of hepatitis C. Modern antivirals which t arget NS3/ 4A and NSSA
As
have revolutionised the treatment of hepatitis C, bringing cu re into focus for the first time.
Dr
A 67 year patient with kn own emphysema presents to the Emergency Department with a
two week hist ory of cough productive of bl ood stained sputum. Chest X-Ray shows a
circular area of dense right upper lobe consolidati on. Despite seven days of intravenous
antibiotics (piperacillin and t azobactam) his condition has not improved. An urgent
inpatient bronchoscopy reveals no endobron chial lesion but broncho-alveolar lavage
reveals an underlying pathogenic organism. Ziehl-Nielson staining is negative. What
organism would you suspect ?
Aspergillus fumigatus
m
se
As
Dr
Aspergillus fumigatus
PseudoL onas aeruginosa
This patient is likely to have develop ed an asp ergilloma in an emphysematous cavity,

-
~
which explains the lack o f im proveme nt with broad s pectrum intrave nous a ntibiotics,
haemoptysis and che st X-Ray find ing s. Moraxe lla and pseud omonas a re usually se nsitive
m
to pipera cill in + ta zobactam a nd do not classically ca use cl inical haemoptysis. M.
se
tuberculosis is unlikely give n the neg ative Ziehl- Nielson staining . Burkh olderia is typically
As
an infective orga nism in cystic fibros is patients, not tho se with emphysema.
Dr
A 34-yea r-old man from Venezuela presents with a flu-like illness and periorbita l oede ma.
Genera lised lymphadenopathy is noted . A diagnosis of Chagas' d isease is confirmed on
blood smear. What is the most a ppro priate treatment?
Benznid azole
Sodium stibog luco nate
Metro nidazole
Pentamidi ne
m
se
As
Atova quone-p rogua nil
Dr
Benznidazole eD
Sodium stibogluconate fD
Metronidazole CD
Pentamidine fD
m
se
As
Atovaquone-proguanil fD
Dr
A 29-year-o ld woman develops severe vom iting four hou rs after having lunch at a local
restaurant. What is the most like ly causative o rganism?
Escherichia coli
Shigella
Campylobacter
Salmonella
m
se
As
Dr
Escherichia coli CD
Shigella
Campylobacter
•
fD
Salmonella CD
Staphylococcus aureus flD
m
se
The short incubation period and severe vom iting point to a diagnosis of Staphylococcus
As
aureus food poisoning.
Dr
A 19-yea r-old woman is reviewed in the g enitourinary medicine cl inic. She presented with
vaginal discharge and dysuria. Microsco py of an end oce rvica l swab showed a Gram-
negative coccus that was later ide ntified as Neisseria gonorrhoea. This is her third episod e
of gonorrhoea in the past two years. What is the most likely complication from repeated
infection?
Fitz-Hugh -Curtis syndrome
Cervica I cancer
Arthropathy
Inferti lity
m
se
As
Uterine abscess
Dr
Fitz-Hugh-Curtis syndrome GD
Cervica I cancer m
Arthropathy fD
I Infertility GD
Ut erine abscess fD
Inferti lity secondary t o pelvic inflammatory disease (PID) is the most commo n
complication of gonorrhoea. It is the second most common cause of PID after Chlamydia.
Fitz-HughCurtis syndrome (a complication o f PID) and arthropathy may occur but are fa r
less common.
m
se
As
Lym phogranuloma venereum is caused by Chlamydia trachomatis.
Dr
Which of the follow ing anti-retroviral drugs is a known inducer of cytochrome P450?
Nevi rapine
Ritonavir
Saquinavir
Nelfinavir
m
se
As
Zidovudine
Dr
I Nevi ra pine fD
Ritonavir fiB
I .nav1r.
I saqu1 CD
Nelfinavir CD
Zidovudine fD
HN : anti-retrovirals - P450 interacti on

• nevirapine (a NNRTI): induces P450
• p rotease inhibit ors: inhibits P450
m
se
As
Like o t her p rotease inhibitors, ritonavir is a potent inhibitor o f t he P450 system
Dr
A phlebotomist gives herself a needlestick inju ry whilst takin g blood from a patient who is
known to have the HIV infectio n. What is the chance that the phlebotomist will develop
HN?
0.03%
0.3%
1%
3%
m
se
As
5-10%
Dr
0.03% 6D
0.3% C1'D
1% fl'D
3% fl'D
5-10% .
(D
m
se
As
The transmission rate of HIV is relatively low compared t o hepatitis Band C.
Dr
A 48 year old farmer attends the emergency department 7 days after cutting his arm from
fall ing on barbed wire in his field. He complaints of fever, headache and painfu l spasms in
his neck and back which last several minutes.
You suspect tetanus and he tells you he has completed a course of tetanus vaccination
previously.
Tetanus booster
IM t etanus immunoglobulin
Tetanus antitoxin
Flucloxacillin
m
se
As
Ci profloxacin
Dr
Tetanus booster
IM tetanus immunoglobu lin
Tetanus antitoxin
Fl ucloxacill in
Ciprofloxacin
In this case there is a high risk wound and symptoms so teta nus immunuglobulin wo uld
be advised alongsid e a muscle relaxa nt such a s diazepam, and ventilato ry support if
need ed. A teta nus bo oster is not recommend ed in the UK if the pati ent is already
immunized . Teta nus antitoxin may be used in deve loping countries a s it is cheaper b ut it
has a higher rate of ana phylaxis and a s horter half life so is no t reco mmend ed in the UK.
High risk wou nd s

• Wounds burns needing surg ery d elayed more tha n 6 hours
• Wounds conta minated with soil
• Com pound fractures
m
se
• Wounds containing foreign bodies
As
• Wounds/ burns in p eo ple with systemic sepsis
Dr
A 27 -year-old woman who is 10 weeks pregnant presents w ith 'cystitis'. She describes a
two day history of dysuria, suprapubic pains and frequency. There has been no vaginal
bleeding. Urine dipstick is positive for leucocytes and nitrites. Her temperature is 37.6°C.
Oral nitrofu rantoin
Await the midstream specimen of urine (MSU) result
Oral trimethoprim
Oral ciprofloxacin
m
se
As
Topical clotrimazole
Dr
Ora l nitrofurantoin
Await the midstream specimen of urine (MSU) result
Ora l trimethoprim
-
~
Ora l ciprofloxacin
Topica l clotrimazole
This p regnant lady has symptoms consistent with a urinary tract infection. The BNF
recom mend that trimethoprim is avoided in the first trimester as it is a folate antagonist.
m
se
Ciprofloxacin is contraindicated throughout pregnancy. As this patient clea rly has a UTI
As
and is pyrexial s houl d be treated straightaway, rathe r than waiting for the MSU,
Dr
A 34-year-old sewage worker presents with a 3 days history o f lower back pa in, fever,
mya lgia, fatigue, jaundice and a subconjunctival haemorrhage. He has no past medica l
history and has not been abroad in the last 6 months.
Na• 135 mmol/1
K• 5. 2 mmol/1
Urea 10 mmol/1
Leptospirosis
Cysticercosis
Glomerulonephritis
Hepatitis A
m
se
As
Hepatitis E
Dr
Leptospirosis fD
Cysticercosis m
Glome rulonephritis CD
Hepatit is A fD
Hepatit is E CD
Sewag e wo rkers are at risk of leptosp irosis w hich is t ransmitt ed t hrough rat urin e. It
typically presents as above and can p rog ress to renal fail ure. Cysticercosis would not
cause j aundice or renal failure. Glomerulonephritis should not cause j aundice o r
m
se
su bconjunct ival haemorrhage and acut e viral hepatitis wou ld not normally cause renal
As
failure and would be unlikely w ithout any t ravel hist ory.
Dr
What is the first line antibiotic in the treatment of Shigella dysentery?
Flucloxacill in
Vancomycin
Ciprofloxacin
Metronidazole
m
se
As
Am pici llin
Dr
Flucloxacillin m
Vancomycin m
Ciprofloxacin e:D.
Metronidazole tD
m
se
m
As
Am picillin
Dr
Which of the following antiretroviral drugs is most characteristically associated w ith
nephrolithiasis?
Zidovudine
Didanosine
Indinavir
Ritonavir
m
se
As
Nevi ra pine
Dr
Zidovudine GD
Didanosine CD
Indinavir flD.
Ritonavi~ f!D
m
se
Nevi ra pine .
GD
As
Dr
A middle -a ged man is diagnosed w ith nasopharyngeal carcinoma. What type of virus
fam ily is associated with th is malignancy?
Reovirus
Herp esvirus
Parvovirus
Adenovirus
m
se
As
Hepadnavirid ae
Dr
Reovirus m
Herpesvirus CD
Parvovirus
Adenovirus
L fJD
fD
Hepadnaviridae CfD
m
se
As
The Epstein -Barr virus is one o f the herpes viruses.
Dr
A 19-year-old female returns f rom Ghana. She p resents with pyrexia (40°C). She
complain s o f bloody stoo ls p receding t his. On examination, she has abdominal distension,
hepatosplenomegaly and rose spots on her abdomen. Before empirical treatment has
started she passes away due to bowel perforation, resu lting in overwhelming sepsis.
Which organism is responsible for t his type of pat hology?
Giardia Iamblia
Salmonella typhi
Treponema pallidum
m
se
As
Dr
Giardia Iamblia
Salmonella typhi
Treponema pallidum
I Staphylococcus aureus
Salmonella typhi infection ca n cause rose spots on the abdomen

Rose spots appear in Salmonella typhi infections. They a lso appea r in C.psittaci infections
although it is more associated with typhoid tha n psittacosis.
Giardiasis wou ld not present this severely and acutely.
Syphi lis would present with painless chancre.
Staphylococcus aureus wou ld p resent within hours following ingestion and it is associated
m
with violent vom iting .
se
Streptococcus pneumoniae does not usually cause gastroenteritis. As
Dr
A 55-year-old man is referred to the medical admissions unit. He recently returned from a
holiday in Italy and has failed to respond to a cou rse of co-amoxiclav for a suspected
lower respirat ory tract infection. Chest x- ray shows bilateral infiltrates. Bloods are as
follows:
Na• 122 mmol/ 1
K• 4.3 mmolfl
urea 8.4 mmol/1
Legionella pneumonia
Pneumocystis carinii pneumonia
Pulmonary eosinophilia
m
se
As
Dr
Dr
As
s em
A 45-yea r-old ma le presents with yellow disco lou ration of his na ils. On exa mination he
has th ickened ye llow toe nails. You decide to treat him with terbinafine .
What is the mechanism of action of terb inafine?
Interacts with microtubu les to disrupt mitotic spind le
Inhibits the funga l enzyme squa lene epoxidase
Binds with ergosterol
Converted to 5-fluorouracil
m
se
As
Inhibits synthesis of beta-gluca n
Dr
I
Interacts with microtubu les to d isrupt mitotic s pind le
Inhibits the fungal enzyme squa lene epoxidase

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~
Converted to 5-fluorouracil
Inhibits synthesis of beta-glucan
Terb inafine in hibits the fungal enzyme squalene epoxidase, causing cellular death
Terb inafine inhibits the funga l e nzyme sq ua lene epoxidase, causing cellula r death. It is an
antifung al medi cation used to treat ringworm, pityriasis ve rsicolor, a nd fu ngal na il
infections.
Griseofulvin inte racts with microtubules to disrupt mitotic spindle.
Amphote ricin B binds with e rgosterol fo rming a transmemb rane channel.
Flucytos ine is converted by cytosine deaminase to 5-fluorou racil, which in hibits

thymidylate synthase and disru pts fungal p rote in synthesis.
m
se
As
Caspofu ngin inhibits synthesis of beta-gluca n, a majo r funga l cell wall com ponent
Dr
A 38-yea r-old HIV-positive wo ma n who is 38 weeks into her first p reg nancy comes to the
obstetric clinic for review. She has been compliant with medication and her viral load has
been consiste ntly <50 copies. She wou ld like to have a vag ina l delivery and is keen to
breastfeed ah er the b irth.
What wou ld you advise her rega rd ing b reastfeeding?
She can b reastfeed regardless of the viral load
Breastfeed ing is not recom mended
She can b reastfeed as long as the baby is on the neonatal antiretroviral therapy
She can b reastfeed to a maximum of approximately lOOml a day
m
se
As
She can b reastfeed as long as the vira l load remains at <50 copies
Dr
She can b reastfeed regardless of the viral load fD
Breastfeed ing is not recommended f:D
She can b reastfeed as long as the baby is o n th e neonatal a ntiretroviral therapy 8
She can b reastfeed to a maximum of approximately l OOml a day fD
She can b reastfeed as long as the vira l lo ad rema ins a t <50 co pie s 8
In the UK a ll HIV positive women shou ld be advised not to b reastfeed

In the UK a ll HIV positive women should be advised not to breastfeed, hence on ly o ption
m
se
2 is co rrect. It is not advisab le to brea stfeed reg ardless of the vira l load, the amount of
As
b reastfeed ing or whethe r s he o r the baby is o n the antiretroviral therapy.
Dr
A 34-year-old man from Swaziland presents the the emergency department with a 3 day
history of f ever, shortness of breath and a dry cou gh. His past medica l history includes
tub erculosis and HIV and his most recent CD4 count is 150.
On examination: heart rate 100/ min, blood pressure 110/ 80mmHg, res piratory rate
28/min, oxygen saturation 98% on air at rest, dropping to 80% on wa lki ng. His
t emperature is 38.5°C. On auscultation, his chest is clear.
How wou ld you treat this man?
IV cefotaxi me
Oral ciprofloxacin
IV tazocin
Oral rifa mpici n, isoniazid, pyrazinamide and ethambutol
m
se
As
Oral co-trimoxazole
Dr
IV cefotaxime
Oral ciprof loxacin

-
"""
IV tazocin
Oral rifa mpicin, isoniazid, pyrazinamide and ethambutol
Oral co-trimoxazole
This man has pneumocystis j irovecii pneumonia (PCP) w hich is occu rs in HIV pos it ive
patients with a low CD4 cou nt. It classically presents with a fever, dyspnoea, dry coug h,
m
exercise induced desaturation and very few chest signs. It is treated with oral co -
se
As
trimoxazole or IV pentamidine in severe cases.
Dr
A 50-yea r-old sewage wo rke r presents with a one week history of feve r and feeling
genera lly unwell. Which one of the following features wo uld be least consistent with a
diagnosis of leptospirosis?
Meningism
Conjunctiva l erythe ma
Productive cough
Decreased urine output
m
se
As
Severe myalgia
Dr
Men ingism
Conjunctival erythema
--
~
Productive cough
Decreased urine output
Severe mya lgia

-
"""'
m
Pulmonary complications can occur in leptospirosis but genera lly happen in severe and
se
late-stage disease. Seve re disease may resu lt in acute respiratory d istress syndrome o r
As
pulmonary haemorrhage.
Dr
A 33-yea r-old primigravida wo ma n p resents to he r GP at 22 weeks gesta tion with a 2-day
history of pa inful sha llow ulcers on the labia and va gina; she has had one prior outbreak
of herpes 2 yea rs previously with a viral swab performed at that time positive for HSV2.
She is otherwise well and her 20-week scan was normal. She is concerned about how HSV
may a ffect her preg nancy and whethe r it will be safe for her to deliver vaginally.
What should you advise her?
There is high risk of b lood borne neonatal transmission o f HSV regardless of

treatment
All antiviral medications no rmally used in he rp es are teratogenic and should be

avoided
Ib uprofen and sa lt water bathing are recom mend ed for analgesia
Most women with outb reaks of recu rrent HSV d uring p regnancy a re recom mend ed
to de live r by elective caesa rean section
m
se
As
Su ppressive treatme nt with aciclovir from 36 weeks gestation may be considered
Dr
There is high risk of b lood borne neonatal transm ission of HSV regardless of
treatment
All a ntiviral med ications normally used in herpes are teratogenic and should be
avoided
Ibu profen and salt water bathin g are recommended for analgesia
Most women with outbreaks of recu rrent HSV during p regna ncy a re
recommended to deliver by e lective caesarean section
Su ppressive treatment with aciclovir from 36 weeks g estation may be considered CfD
Recurrent herpes outbreaks in pregnancy should be treated with suppress ive

the ra py; risk of transmission to the baby is low and aci clovir is safe to use in
p regnant women
Aciclovir, while not licensed for use in p regnancy, is commonly used in pregnancy and is
thought to b e safe; valaciclovir and famciclovir should be avo ided. Sup pressive treatme nt
is o h e n considered fro m 36 weeks to reduce asym ptomatic shedding and risk of
m
se
transm ission during d elive ry. Vagina l delivery is usually anticipated in recu rrent ge nita l
As
herpes. Ibuprofen is contraind icated in preg nancy Dr
A 31-yea r-old wo man who is known to be HIV pos itive presents fo llowing a positive
p regnancy test. Her last menstrual period was 6 weeks a go. The last CD4 count was 420 •
10 6/ 1and she d oes not take any a ntiretroviral therapy. What is the most app ropriate
management with regards to a nti retroviral therapy?
Check CD4 at 12 weeks and initiate antiretroviral thera py if CD4 count is less tha n
350 . 106/1
Do not give antiretroviral therapy
Sta rt a ntiretrovira l therapy at 20-32 weeks
Sta rt a ntiretrovira l the rapy at 10-12 weeks
m
se
As
Sta rt a ntiretroviral the rapy immediately
Dr
Check CD4 at 12 weeks and initiate antiretroviral therapy if CD4 count is less
than 350 • 10
I Do not give antiretroviral therapy

'----
Start antiretroviral t herapy at 20-32 weeks

-.
CD
Start antiretroviral t herapy at 10-12 weeks CD
I Start antiretroviral t herapy immediately f.D.
m
Following the 2015 BHIVA guidelines, it is now recommen ded that patients start HAART
se
as soon as they have been diagnosed with HIV, regardless of w hether they are p regnant
As
or not, rather than waiting until a particular CD4 count, as was previously advocat ed.
Dr
A 44-year-old fa rmer p resents with heada che, fever and muscle aches. He initially thoug ht
he ha d a bad co ld but his symptoms have g ot prog ress ively worse over the past week.
During the review of systems he reports nausea and a decreased urine output. On
examination his temperature is 38.2°C, pulse 102 1 min and his chest is clea r.
Subconjunctival haemorrhages are noted but there is no evidence of jaundice. What is the
most li kely diag nosis?
Lyme disease
Legionella pneumonia
Listeria
m
se
Leptospirosis
As
Dr
Lyme disease
I Legfonella p neumonia
Listeria
Leptospirosis
m
The main clue in t he question is t he patients occupation. Mycop lasma and Legionella are
se
less likely due to the absence o f chest symptoms and signs. Liver failu re is seen in on ly
As
10% of patients w ith leptospirosis ..
Dr
You are an F2 workin g in general pract ice. Last week you saw a 17-year-old fema le w ith
acne vu lgaris w hich is causing her significant distress and started her on tetracycl ine. She
has come back to see you to day complainin g about a side effect. Which side effect is she
most likely to be experiencing?
Headache
Red rash on her face and neck
Dizziness
Dry lips and tongue
m
se
As
Ringing in her ears
Dr
Headache
I Red rash on her face and neck
Dizziness
Dry lips and tongue
Ringing in her ears
Tetracyclines can cause photosens itivity

The correct answer is 2. Tetracyclines are ohen prescribed for acne and can cause a
photosensitive skin rash. This appears as a red rash on area s o f skin exposed to t he sun.
Other skin rea ctions to tetracyclines include exfoliative dermatitis and Stevens-Johnson
syndrome.
Nausea and headaches a common side effect of many medications but are not usually a
significant p roblem with tetracyclines. Tetracyclines can cause grey discolouration of the
teeth in neonates if t hey are given to pregnant women in t he second or third trimester
but not if given to children or adu lt s. Dry lips and to ngue are a side effect of vitamin A
m
d erivatives, including retinoin and isotretinoin, w hich might be prescribed further down
se
As
the line in severe acne. Tetracycli nes are not known to cause dama ge to the hearing,
unlike gentam icin, f urosemide and cisplat in.
Dr
A 57 -yea r-old b usinessman p resents to th e emergency d epa rtment with feve rs, myalg ia
a nd headache which have b een o ngoing fo r the pa st 10 d ays. He also repo rts that he has
noticed the beg inn ings of a rash on his face and trunk, which you would d escribe as
ma culop apu la r. He has no sig nificant past medica l history, an d recently returned from a
trip to Bangkok th ree weeks a go, whe re he a dmits to having intercou rse with a local sex
wo rker. He cannot remember if he used protection. Otherwise he made sure to take
a ppropriate p recautions with malaria l pro p hylaxis and pre-trave l vaccines.
Which of the fo llowing tests wou ld b e most likely to give a diagnosis in th is history?
Mala rial films
HIV antibody test
CD4 cou nt
P24 antige n
m
se
As
Dengue serology
Dr
Ma la ria l films CD
HN antibody test CD
CD4 cou nt CD
P24 antige n (D
Dengue serology CD
HN antibody testing is most re liab le 3 months post exposure

This p atient's symptoms a re most like ly second ary to an acute HIV seroconvers ion
synd rome. This occurs most com mon ly 1-4 weeks from time of infection with the virus
a nd in the majo rity of patients, is accompanied by a flu- like illness with a macu lo pa pula r
rash. Th is illness ma rks the beginning o f HIV antibody product ion, but this test is still
ohen negative du ring the p rocess. p24 antigen howeve r is most oh en p ositive for the first
3-4 weeks following exposu re, while the antibo dies can take up to 3 months to be
d etected .
Mala ria is unl ikely g iven this patie nt's use of pro p hylaxis and that Bangko k has a relatively
m
se
low risk of malaria transmiss ion. Dengue fever, a lthough ca pab le p rod ucing similar
symptoms, o h en causes feve r fo r a sho rte r du ration. As
Dr
A 32-year-old oil worker presents by ambulance to the Emergency Department following
his return from Angola. His w ife reports that over the past 24 hours, the patient has
become progressively more drowsy with fevers ongoing for the past 5 days. On
examination, the patient is unresponsive to voice and is visibly clam my. His observations
are as follows:
Heart rate 120 beats per minute
Blood pressure 100/ 60 mmHg
Respiratory rate 32 breaths per minute
SpQ2 96% on 1Sl Q2
Initial investigations are as follows:
Hb 78 g/1
Platelets 90 8
109/1
WBC 20 8
109/1
Na• 140 mmol/ 1
K• 5.6 mmolfl
Urea 15 mmol/ 1
Bilirubin 70 IJmolfl
Malarial Films P. falciparum species seen, 12% parasitaemia
Given this patient's condition, w hat treatment(s) should be commenced?
Chloroquine
Artesunate and exchange tra nsfusion
Artesunate
Doxycycline
em
s
Quinine + Doxycycline
As
Dr
Chloroqu ine
I Artesunate and exchange transfusion
Artesunate
~xycycline
Quinine + Doxycycline
Exchange transfusion should be cons idered in cases of severe pa rasitaemia (> 10%)
This patient has presented with features suggestive o f severe malaria, which is confirmed
by his blood results an d clinical observations.
Falciparum malaria warrants aggressive treatment g iven its potential complications. These
occur due to the parasites ability to sequester blood cells in capillary b ed s, caus ing
ischaemia.
Patients with severe malaria should be treated with IV artesunate, and in cases where
pa rasitaem ia > 10% is seen, consid e ration should be given to the performa nce o f
exchange transfusions.
Most falciparum malaria is now resistant to ch loroquine med ications, so this option is m
se
inco rrect. Quinine and d oxycycline may be used fo r some cases o f falciparum malaria,
As
however, this p ractice is no longer first-line.

Dr
A 34-yea r-old man with a past history of HIV infection presents to the Em ergency
Department w ith watery diarrhoea. Crypto sporidium infecti on is co nfirmed on ZN
staining. What is t he most suitable mana gement?
Met ronidazole
Sulfad iazine + pyrimethamine
Suppo rtive thera py
Rifa mpicin + etham buto l + clarithromycin
m
se
As
Co -tri moxazo le
Dr
Metronidazole
Sulfadiazine + pyrimethamine
I Supportive therapy
Rifa mpicin + ethambutol + cla rithromycin
Co-trimoxazole
-~
m
Su pportive thera py is the mainstay of treatment in Cryptosporidium diarrho ea
se
As
Dr
A 29-year-old wo man present s t o the genitou ri nary medicine clinic for treatment of
recurrent genital warts. Which one the following viruses are most likely to be responsible?
m
se
As
Dr
Human pap illoma virus 16 & 18 ED
Human pap illoma virus 13 & 17 m
Human papi lloma virus 6 & 11 eD
Genita l warts- 90% are caused by HPV 6 & 11

m
se
As
Types 6 and 11 are responsible for 90% of genit al warts cases
Dr
A 21-year-old female comes to see her GP complaining of a three day history of dysuria,
frequency and a mild fever. She has no abdominal or loin pain and a urine dipstick done
at the practice shows 2+ leucocytes but negative fo r blood, protein and nitrites.
Which of the following organisms is the most likely cause of the infection?
Escherichia Coli
Staphylococcus saprophyticus
Proteus mirabilis
m
se
As
Dr
Escherichia Coli CD
I Staphylococcus saprophyticus eD
Proteus mira bitis CD
Pseudomonas aeruginosa CD
~
•
This patient has symptoms of a lower urinary tract infection which shou ld be treated with
antibiotics. The clue to finding the correct a nswer is the fact that d espite being leucocyte
positive, the urine d ipstick is nitrite negative. Gram negative organisms test pos itive on
the nitrite test as they convert nitrates to nitrites for energy. Gram positive o rganisms a re
m
se
unable to reduce nitrate to nitrite and therefore, test negative. As sta phylococcus s pecies
As
are the only gram positive o rganisms of the a nswers g iven, this is the correct answer.
Dr
A 56-year-old diabetic man was admitt ed with pyrexia and rigors secondary to an
infected diabetic foot ulcer and commenced on IV Flucloxacillin. The wound swab grew
methicillin resistant Staphylococcus Aureus (MRSA) and he was commenced on an
alternative N antibiotic. With in an hour of administration the patient developed an itchy,
erythematous maculopapular rash, which became diffuse covering >80% of his body
surface area. He also began to complain of hearing loss in his right ear.
What antibiotic is likely to have been prescribed?
Teicoplanin
Co-Amoxiclav
Clindamycin
Vancomycin
m
se
As
Cefuroxime
Dr
Teicoplanin GD
Co -Amoxiclav CD
Clindamycin CD
Vancomycin GD
Cefuroxime CD
Vancomycin is a glycopepti de antibiotic, which works by b locking cell wall subunit

assembly (sepa rate from beta lactams) .The antibiotic has extensive gram pos itive cover
and is commonly used to treat MRSA and Clostridium difficile.
The characteristic side effects include: Ototoxicity, nephrotoxicity and red man syndrome.
Red man syndrome is associated with flushing or a maculopapular rash. The proposed
m
se
mechanism is non lgE mediated mast cell degranulation. Red man syndrome is more
As
commo n w ith higher flow rates o f infusion. Treatment includes antihistamines.
Dr
A 30-yea r-old man comes for review. He lives with a woman who has recently been
diagnosed with having tu berculosis. The man was born in the UK, has no past med ical
history of note and is currently asymptomatic. What is the most appropriate test to check
for latent tuberculosis?
Heaf test
Mantoux test
Sputum culture
Chest x-ray
m
se
As
Interferon-gamma blood test
Dr
Heaf test
Mantoux test
Sputum cu lture
Chest x-ray
Interferon-gamma b lood t est
The two main test s used for screening in the UK are the Mantoux (skin) test and the
interferon-g amma (blood) test. Whil st the use of the interferon-gamma t est is increasing
it is still reserved for specific situations, none of which ap ply in this case. Please see the
m
NICE gui delines fo r more d etails.
se
As
The Heaf test is no longer used in the UK.
Dr
A 58-year-old man presents with fever, chi lls and back pain for the past fo ur weeks. A
chest x-ray and urine culture are unremarkable. Around two months ago he went to stay
with fa mily on a Cypriot sheep fa rm. A chest x-ray and urine culture are unremarkable. A
diagn osis of Brucellosis is suspected. Which one of the following test s is most likely to
confirm the diagnosis?
Stool culture
Blood cultures
Brucella serology
Liver biopsy
m
se
Urinary antigen
As
Dr
Stool culture CD
Blood cu ltures (D
Brucella serology 6D
Liver biopsy
-
m
se
Urinary ant ig en f.D
As
Dr
A 24-year-old man attends your GUM clinic for results of his recent tests. He f requently
engages in unprotected sex w ith multiple partners. You note he had a mildly raised
Venerea l Disease Research Laboratory (VDRL} test at 1:8. He did however have a negative
EIA and TPPA test. You suspect it cou ld be a false positive test resu lt.
Which of t he follow ing would be useful at dete rmining a cause?
HN test
Rheumatoid factor
Serum electrophores is
Varicella serology
m
se
Mycoplasma serology
As
Dr
HN t est
Rheumatoid factor
Serum electrophoresis
Varicella sero logy
Mycoplasma serology
False p ositive VDRL/RPR: 'SomeTim es Mistakes Happen ' (SLE, TB, malaria, HIV)
The answer is HIV t est. The VDRL test is very sensitive for syphilis infections and titres can
be used to t rack treatment and progression. It is, however, prone t o many false posit ives.
Th is is defined by a positive VDRL in the absence of a pos it ive EIA/TPPA (which, in
contrast, stay positive lifelong after infection).
Fa lse positives are usually due t o a reaction of antibodies t o the cardiolipin -lecith in-
cholesterol reagent in t he RPR/VDRL t ests.
Syst emic lupus erythematous, HIV, anti phospholipid syndrome and TB infection are classic
m
se
causes of this. Other Treponema I infections like yaws and pinta can also cause false
posit ives, but this would not occur with atypica l bact eria such as Mycoplasma.
As
Dr
A 57 -year-old fema le p resents with headache and fever to t he Emergency Department.
On examination neck stiffness is noted along w ith a positive Kernig's sign. A lumbar
puncture is performed and reported as follows:
CSF culture Gram positive bacilli
What is the most likely causat ive orga nism?
Cryptococcus
E. coli
m
se
As
Dr
Cryptococcus
Haemopf ilus influenzae
E. coli
m
se
Listeria monocytogenes - Gram-positive rod
As
Dr
Which one o f t he followin g is a Gram negative coccus?
m
se
As
Dr
Enterococf us faecalis
-
~
m
se
Moraxel/a catarrhalis - Gram - negat ive cocci
As
Dr
Following a diagnosis of tetanus, what is the most appropriate antibiotic therapy to give
with human tetanus immunoglobu lin?
IV clarithromycin
IV benzylpenicillin
IV gentam icin
IV metronidazole
m
se
As
IV ciprofloxacin
Dr
IV clarithromycin .
(D
IV benzylpenicillin eD
IV gentamicin CD
IV metronidazole ED.
m
se
IV ciprofloxacin GD
As
Dr
A 87 yea r old lady presents to the Emergency De pa rtment with a two day histo ry of new
confusio n. Her hea rt rate is 120 b eats per minute, b lood p ressure 95/ 45 mm Hg and
te mperature 38.4°C. You suspect urina ry sepsis a nd a fte r taking urine and b lood cultures
you sta rt a ppro priate treatment with intravenous fluids an d bro ad s pectrum antibiotics.
Late r th at d ay the micro biology lab p hones to info rm you the microscopy of the urine
sam ple s hows Gram positive cocci in cluste rs. What is the likely organ is m in this case?
Escherichia coli
Staphlococcus saprophyticus
m
se
As
Staphlococcus aureus
Dr
Escherichia coli
-
~
Staphlococcus saprophyticus
Enterococcus 1aeca/is
Staphlococcus aureus
-~
Prompt treatment o f sepsis is essential to improve patient outcomes. Broad spectrum

antibiotics should be given promptly after microbiolog ical specimens a re taken. Antibiotic
therapy should be altered when the causative organism is known. In this case a Gram
positive cocci in clusters grown from the urine is most likely to be 5. saprophyticus. S.
aureus is a common pathogen but is unusual in uri nary infections. Although f. coli and K.
m
se
pneumoniae a re common urina ry pathogens they are both Gram negative bacilli.
As
Enterococcus commonly fo rms chains on microscopy.
Dr
A 28-yea r-old student is ad mitted o ut o f hours to the infectious diseases ward with
sus pected malaria fo llowing a backpacking trip a round South East Asia. Malaria l films a re
as fo llows:
Thick film Parasite burden of 1. 5%
Thin fil m Non-falciparum malaria - Looks like Plasmodium knowlesi
On ad mission, the patient is system ically we ll with o bservations at follows:

HR 90bpm
BP 123/ 75 mmHg
RR 16 breaths per minute
Oxygen Sats 97% on air
Temp 36.40
Althou gh being relative ly we ll o n first ad mission, you are call ed to review he r ove rnig ht a
few hou rs later, due to her cond ition wo rse ning . You a rrive to find her o bservatio ns as
fo llows :
HR llObpm
BP 105/ 65 mmHg
RR 25 breaths per minute
Oxygen Sats 93% on air
Temp 38.40
Which o f the fo llowing attributes make Plasmodium know/esi infectio ns particu la rly
d a nge ro us?
Cyto ad herence
Hypnozo ite fo rmation
Short e rythrocytic rep lica tio n stag e
Resista nce to treatment

sem
As
Slow g rowth leading to late presentation

Dr
Cytoad he rence CD
Hypnozoite formatio n EID
I Short erythrocytic replication stage CD

Resistance to treatment CD
Slow growth leading to late presentatio n f!D
P. knowlesi ha s the shortest eryth rocytic replication cycle, leading to high parasite
counts in s hort periods of ti me
Plasmodium sp. have two re pro ductive cycles; an exo -e rythro cytic cycle which occu rs in
he patocytes, and an erythrocytic cycle which occu rs in the red blood cells. The length of
the e rythrocytic cycle va ries fro m species to s pecies, with P. knowlesi having the fastest
cycle at a ro und 24 ho urs. The end stage in the cycle invo lves lys is of the re d cells and
re lease o f ad d itio nal paras ites, meaning that P. knowlesi is capab le of pro d ucing ve ry hig h
pa rasite counts in a short s pace of time.
Fo r this reason, in Plasmodium knowlesi infectio n, seve re pa rasitaemia should be de fined

as >1%, whe reas in othe r species, >2% is a ma rke r o f seve re pa rasitaem ia.
In regards to othe r o ptio ns, Plasmodium ovate and Plasmodium vivax can fo rm em
hypnozoites, causing cl inical infection long ah er patients leave malaria l area s.
s
Cytoad he rence is a n attribute displayed by red ce lls infe cted by Plasmodium fa/ciparum
As
pa rasites.
Dr
Which one o f t he followin g featu res is least likely t o occur in a patient w ith visceral
leishmania sis?
Massive splenomega ly
Diarrhoea
Pyrexia
Pancytopaenia
m
se
As
Grey skin
Dr
Massive splenomegaly GD
I Diarrhoea ED.
Pyrexia
Pancytopaenia CD
•
Grey skin &D
m
The most common sympto ms seen in patient s with visceral leishmaniasis are pyrexia,
se
As
splenomegaly (which is often massive), weight loss and night sweats. Pancytopaenia
occurs secondary to hypersplenism. Diarrhoea is not a typical f eature
Dr
A 36-year-old man presents t o his fa mily physician com plaining of swallowing difficu lty.
He reports that a f ew ti mes he has been vomiting undigested food. He does not smoke or
t ake alcohol. He has never had such symptoms in the past. He has no significant past
medical or fam ily hist ory.
He works as a wildlife photographer and has repeatedly traveled t o Argentina, Brazil, and
Bolivia in the past. As far as he can remember he never had any se rious infection w hile
traveling except for the one time he ha d a swollen right eye w hich resolved now. A
barium swallow revealed a bird's beak app earance of the esophagus.
Which of the follow ing conditions does this patient most likely su ffer fro m?
African trypanosomiasis
Visceral leishmaniasis
Giardiasis
Cryptosporidiosis
m
se
As
American trypanosomiasis
Dr
African trypa nosomiasis
[ :sceral le ishm niasi s
Giardiasis
Cryptospo ridiosis
Ame rican trypanosom iasis
Trypanosom ias is: African -form causes s leep ing sickness and American -form causes
Chagas' disease
This patient presented with the si gns and symptoms consistent with a diag nosis of
Chagas disease. The d isea se is caused by a protozoal infection by the o rga nism
Trypanosoma cruzi a nd is also known as Ame rica n trypanosom ias is. The triatom ine b ug, a
type of red uviid bug, tra ns mit the disease via a painless fly and is common in South
Ame rica.
The acute stage of the d isea se is chara cterized by the pe riorbita l sig n, a lso known a s the
Romana sign. Later o n, patients d eve lop dilated cardio myo pathy and gastro intestinal
p ro b lems such as meg acolon and megaesop ha gus. Neu ro log ical invo lvement includ es
neu ritis which produces altered sensation a nd reflexes. Treatment is with a comb ination
of Sulfad iazi ne an d pyrimetha mine.
(First 2017, p152-154).
1: African trypa nosom iasis is caused by the p rotozoal o rgan ism Trypanosoma brucei. The
disease is also known as sleeping s ickness a nd is tra ns mitted by the Tsetse fly via a pa inful
b ite. Symptoms include lymphadenopathy, somno le nce, extreme lethargy, fever, and
heada ches. Treatme nt is with suram in a nd me la rsop ro l if the central nervous system is
involved .
2: Viscera l le ishman iasis is caused by the protozoa l o rga nism Leishmania donovani. The
disease is transmitted by the sa nd fly. Clinical man ifestation of the disea se inclu des fever,
weight loss, hepatosp leno mega ly and hematolog ical distu rbances su ch a s pancytopenia.
3 : Gia rdiasis is caused by the protozoal o rganism Giardia /amblia. lt typica lly includ es
g astro intestina l symptoms such as loose stools, fatty d ia rrhea, flatu le nce and b loating .
The d isease is tra nsmitted by cysts in wate r. It is common amon g trave lers a nd hikers who
are often exposed to less hygienic sources of water. It is treated with the antibiotic
metro nidazo le.
4: Cryptosporidiosis is caused by the protozoa l o rga nism Cryptosporidium. The d isease is

transm itted by the oocysts in wate r. In people with AIDS, the d isea se is severe and consist
of severe d ia rrhea. However, in people who are not im munosupp ressed, the presentation
includes a mild watery stool, bloating a nd flatulence. A pub lic health app roach to
em
p reve nting the disease is to filter water supp lies. Nitazoxanid e can be used fo r treatment
s
As
in ind ividua ls who are not immunosu ppressed.

Dr
A 28-year-old male presents with shortness of breath, dry cough and fever for one week.
Prior to this, he ha d been generally unwell for several months complaining of weight loss,
fatig ue, generalised lymphadenopathy and mya lg ia . He admits to using intravenous d rugs
in the past.
O bservatio ns revea l 02 sats 88% on a ir, hea rt rate 112 bpm, b lood pressure
124/85mmHg, respi ratory rate 24/mi n and temperatu re 37.8°C. His chest is clea r and
heart sounds are no rmal. On mobilising his 02 sats drop to 75% on a ir and he is acutely
short of b reath.
Chest x-ray shows bilateral perih ila r shadowing.
Arterial blood gas on 5 litres of oxygen shows:
pH 7.41
Pa02 8 .9 kPa
PaC02 3.6 kPa
What is the most appropriate treatment for this patient?
Amoxicil li n and clarithromycin
Co-trimoxazole
Co-trimoxazole and prednisolone
Doxycycline
sem
Oseltamivi r
As
Dr
Amoxicillin and clarithromycin
Co-trimoxazole
Co-trimoxazole and prednisolone
Doxycycline
Oseltamivir
This patient has Pneumocystis jirovecii pneumonia most likely on a background of

undiagnosed HIV infectio n. Treatment for pneumocystis pneumonia is with oral co-
m
se
trimoxazole or IV pentamidine if oral antibiotics or not to lerated. Steroids are also given if
As
there is severe hypoxaemia, as in this case.
Dr
A 24-yea r-old man is admitted to the Emergency Department with breathing difficulties
and confusion three weeks after returning from a holiday in Ca mbodia. His partner says
he has had 'the flu' for the past two weeks. A blood film is positive for malarial parasites
and a chest x-ray and arterial blood gases suggest acute respiratory distress syndrome. A
diagnosis of severe fa lciparu m ma laria is suspected. What is the treatment of choice?
Intravenous artesunate
Intravenous clindamycin + oral artemether-lumefa ntrine
Intravenous artemether-lumefantrine
Oral atovaquone-proguanil
m
se
As
Intravenous quinine
Dr
Intravenous artesunate
Intravenous clindamycin + ora l artemether-lumefantrine
Intravenous artemether-Iumefantrine
Oral atovaquone-proguanil
Intravenous qu inine
-
~
m
Severe falciparum malaria - intravenous artesunate
se
As
Dr
A 30-year-old man p resents f or review two weeks aher returning from a camping holiday
in the New Forest. For the past few d ays he has felt general unwell with lethargy and
arthralgia. On examination he has a rash consistent with erythema chronicum migrans.
What is the most appropriate t est to p erform given t he likely diagnosis?
ELISA t est for antibo dies t o Borrelia burgdorferi
Polymerase chain reaction for Borrelia DNA
Bloo d cultures
Bloo d film
m
se
As
Bone marrow biopsy
Dr
I ELISA t est for antib_o_d_ie_s_t_o_______e_o_
rr_e_lia- burgdorferi
Polymerase cha in reaction for Borrelia DNA
Blood cu ltures
Bone marrow biopsy
ELISA is the first- line investigation for suspected Lyme disease in pat ient s with no
history of erythe ma migrans
m
Serolog ical test s are t he most app ropriate first line investigation for diagnosing Lyme
se
disease. ELISA t ests are p referred to Western blot s as they are more sensitive.
As
Dr
A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks
she is pregnant. This is confirmed with a positive pregnancy test. She is known to be HIV
positive. Wh ich one of the following should NOT be part of the management plan t o
ensure an optimal outcome?
Oral zidovudine for the newborn until 6 weeks of age
Maternal antiretroviral therapy
Encourage breast feeding
Intra partum zidovudine infusion
m
se
As
Elective caesarean section
Dr
Oral zidovudine for the newborn until 6 weeks of age
Maternal antiretroviral therapy
I Encourage breast feeding
Intrapartum zidovudine infusion
Elective caesarean section
The BHIVA guidelines suggest vaginal delivery may be an option for women on HAART
-
~
who have an undetectable viral load but whether this will translate into cl inical practice
remains to be seen
In t erms of breastfeeding the BHIVA guidelines state the following:
All mothers known to be HJV positive, regardless of antiretroviral therapy, and infant PEP,
m
se
should be advised to exclusively formula feed from birth.
As
Dr
A 27-year-o ld woman develo ps fever and lymph nod e swelling after being scratched by
her cat. Which one o f the orga nisms is respo nsible fo r cat scratch d isease?
Bordetella pertussis
Moraxella catarrhalis
Bartonella hense/ae
Francisel/a tularensis
m
se
As
Yersinia enteroco/itica
Dr
Bordetella pertussis CD.
Moraxella catarrhalis CD
Bartonella hense/ae GD
Francisella tularensis CD
Yersinia enteroco/itica CD
m
se
Cat scratch disease - caused by Bartonella hense/ae
As
Dr
What is the first line treatment in hydatid disease?
Metronidazole
Cipro floxacin
Itraconazole
Albendazole
m
se
As
Sodium stibog luconate
Dr
Metronidazole fD
Cipro floxacin f.D
fD
..
Itraconazole
Albendazole
m
se
Sodium stibog luco nate tiD
As
Dr
You attend a meeting with the hospita l ma nagement. There is cu rrently an increased
incidence of MRSA septi caem ia in the hospita l and a strategy is being d rawn up to tackle
this. What is the most effective sing le step to red uce the incidence o f MRSA?
The use of personal protective equipment for staff in clud ing gloves and ap rons
Hand hyg iene
Screening patients for MRSA on admission
Cohort nursing
m
se
As
Limiting the number of visitors
Dr
The use o f personal protective equipment for staff in clud ing gloves and aprons CD
Hand hyg iene GD
Screening patients for MRSA on admission CD
l loho rt nursing D
Limiting the number of visitors D
m
se
Whilst tackling MRSA requires a mu lti-p ro nged approach the evidence base demonstrates
As
that hand hyg iene is the s ingle most important step
Dr
You are p honed for advice. The parents of a 19-yea r-o ld man have just been messaged by
their son who is currently backpacking in Thailand. Ea rlier in the day he was b itten by a
dog whilst staying in a rural community. Prio r to travell ing, he received vaccinatio n
agai nst rabies a s he was going to be visiting many rural a reas. What is the most
appropriate advice?
He should increase his flui d intake by a round l l a day as a p recaution
He should be p rotected g iven the p revious vaccination b ut shoul d monitor fo r any

changes in sa livation over the next 72 hours
He should see a local doctor to request antibiotic therapy
He should urgently seek local medica l attention for consideration of booster

vaccination + antibiotic therapy
m
He should take the next flight ho me so he can b e observed for any symptoms of
se
As
rabies
Dr
Yo u a re pho ned for advice. The parents o f a 19-year-old man have just b een messag ed by
their son who is cu rrently backpacking in Thailand . Ea rlier in the day he was bitten by a
d og whilst staying in a rura l community. Prior to trave ll ing, he rece ived vaccination
a ga inst rabies as he was g oing to be visiting ma ny ru ra l areas . What is the most
appropriate a dvice?
He should increase his flu id intake by a rou nd l l a d ay as a precaution
He should be p rotected given the p revious vaccination but sho ul d monitor fo r

any cha nges in salivation ove r the next 72 hours
He should see a local d octor to request antibio tic therapy
He should urgently seek loca l medical atte ntion for consideratio n o f booster
vaccination + antibiotic therapy
He should take the next flight ho me so he ca n be observed for a ny sympto ms o f CD

rabies
Rabies is nearly always fata l if untrea ted. Whilst you are not exp ected to remember all the
countries where there is a high risk o f rabies it is clear that being b itten by a dog in a rural
area re presents a ris k. He need s to urgently see a local doctor as b ooster va ccinatio n is
m
se
indicated to minimise his risk of d eveloping rabies. Flying home sim ply d e lays the most
impo rta nt interventio n. As
Dr
A 24-year-old patient presents to the Emergency Department with watery diarrhoea. He
returned from holiday in Tanzania yesterday. Which of the following pathogens is the
most likely to be responsible for this presentation?
Enterotoxigenic E. coli
Non-typhoidal Salmonella
Campylobacter spp
Vibrio cholerae
m
se
Giardia Iamblia
As
Dr
Enterotoxigenic E. coli ED
Non-typhoidal Salmonella m
I Campylobacter spp CD
Vibrio cholerae f1D
Giardia Iamblia flD
All t he listed opt ions are potent ial causative organisms of an acut e wat ery diarrhoeal
illn ess.
Worldwid e, entero toxigenic E. coli (ETEC) is t he most com mon cause o f diarrhoea in
travellers. There is, however, geographical variat ion - Campylobacter is more common in
travellers in Sout h East Asia.
Diarrhoea in cholera is classically painless, 'rice -wat er', stoo l. While cho lera is seen
worldwide, it is less common as a cause o f diarrhoea in travellers.
Diarrhoea in acut e giardiasis is classically fou l-smelling and fatty, and associat ed w ith
abd om inal cramps and bloating. The incubat ion period for acute infection is one to two
weeks.
Non-typhoidal Salmonellae are anot her common cause of diarrhoea worldwide. They are
the most commo n cause of food -borne disease in the United States. The incubat ion m
se
period is up to t hree days.

As
Dr
, r , / 1' Tn"'' r,..,

A 24-yea r-old heterosexual man p resents to GUM w ith a history of dysuria, urethra l
irritat ion and milky d ischa rge f rom the urethra. Urethral microscopy revea ls > 10
polynuclear lymphocytes per field but no gonorrhoea is seen and urine dip is normal. He
did a home test 3 d ays ago when his symptoms started and Chlamydia and Gonorrhoea
NAATs were negat ive. His urine dipst ick is normal. His last sexual encounter was 3 weeks
ago. You make a clin ical dia gnosis of non specific urethritis (NSU).
What is the most ap propriate action to take?
Start o ral d oxycycline for 1 week
Reassu re the patient; his symptoms w ill resolve spont aneously
Tell the patient to rep eat his Chlamydia and Gonorrhoea tests in 2 weeks' t ime.
Start o ral aciclovir
m
se
As
Refer to urology for their assessment and opinion
Dr
Start ora l d oxycycline for 1 week
Reassure the patient; his symptoms will resolve spontaneously
Tell the patient to repeat his Chlamydia and Gonorrhoea tests in 2 weeks' time. flD
Start ora l aciclovir
Refer to urology fo r their assessment and opinion

-
"""'
Non s pecific (no n g onococcal) urethritis is a com mo n p resenta tion where
inflammato ry cel ls but no g onococcal bacte ria are seen o n swa b; it requ ires
treatment with doxycycl ine o r azithro myci n
The presence of pus cells on urethral swab suggests a diagnosis of non-specific urethritis,
which commonly presents with symptoms similar to these. BASHH recommend treating
with ora l doxycycline. The window period for Chlamydia and Gonorrhoea tests is genera lly
2 weeks so the ho me test he did is likely to be accu rate; while retesting may be
appropriate it should not delay treatment, and should not be delayed further.
m
As there is no evidence of gonococcal bacteria on microscopy there is no indication to
se
treat as Gonorrhoea. There is no current indi cation to refer to Urology and no current
reason to treat the patient for HSV. As
Dr
What percentage o f patients who contract the hepatit is C virus will become ch ron ically
infected?
30-35%
55-85%
90-95%
5-10%
m
se
As
15-20%
Dr
30 -35% GD
55-85% CD
90-95% .
(D
5-10% GD
15-20% GD
m
se
Hepatit is C - 55-85% become chronica lly infected
As
Dr
Which one o f the followi ng is least associated with a false negative tubercu lin skin test?
Lymphoma
Miliary tuberculosis
Sarcoid osis
m
se
As
HIV
Dr
Lymphoma
Miliary tuberculosis
-
. .wr
Sarcoidosis
HN
m
se
As
Severe renal fai lure may cause a fa lse negative test but CKD stage 3 wou ld not.
Dr
Which one of the followin g statements regard ing toxop las mos is is true?
It is a type of flagellate
Congenital toxoplasmosis results in optic nerve atrophy
Ceftriaxone shou ld be used in itially in patients with HIV-associated toxoplasmosis
The cat is the only known anima l reservoir
m
se
As
infection is usua lly self-limiting
Dr
It is a type of flagellate
Congenital toxoplasmosis results in optic nerve atrophy
Ceftriaxone should be used initially in patients with HN -associated

toxoplasmosis
The cat is the only known animal reservoir
m
se
infection is usually self-limiting
As
Dr
A 34-yea r-old man from Zimbabwe is adm itted with abdom inal pain to the Emergency
Department. An abdom inal x-ray reveals urinary bladder cal cification. What is the most
Iikely cause?
Schistoso ma mansoni
Sarcoidosis
Leishmanias is
Tuberculosis
m
se
As
Schistosoma haematobium
Dr
Schistosoma mansoni
Sarcoidosis
Leishmaniasis
Tu berculosis
-
~
Schistoso ma hae matobiu m
Schistoso ma haematobium causes haematuria
m
se
As
Schistosomiasis is the most common cause of b ladder calcification worldwide
Dr
A 28-yea r-old ma n who is im mu nosuppressed secondary to HIV infecti on is admitted to
hospita l with dyspnoea and a dry cough. His chest x-ray shows bilateral interstitial
pulmona ry infiltrates and he is started on co-trimoxazo le empirically. The following
morn ing he complains of a sudden worsening of his dyspnoea associated with left-s ided
chest pa in. Which complication is most like ly to have developed?
Empyema
Pulmonary embolism
Acute respirato ry d istress syndrome
Pericarditis
m
se
As
Pneu motho rax
Dr
Empyema
Pulmonary embolism
Acute respiratory distress syndrome
Pericarditis
Pneumothorax
m
se
Pneumocyst is j iroveci p neumonia - pneumotho rax is a com mon complication
As
Dr
A 39-yea r-old man returns from a two week bus iness tri p to Kenya. Four weeks after his
return he presents complaining of malaise, headaches an d night sweats. On exam in ation
there is a symmetrical erythematous macu lar rash over his trunk a nd limbs associated
with cervical and in guinal lym phadenopathy. What is the most likely dia gnos is?
Typhoid feve r
Tuberculosis
Dengue fever
Schistosomiasis
m
se
As
Acute HIV infection
Dr
Man returns from trip abroad with maculopapular rash and flu-like illness - think
HN seroconversion
m
Stereotypes are alive and well in t he M RCP exam. For quest ions involving bu sinessmen
se
always consider sexua lly t ra nsmitted infections. The HIV p revalence rate in Kenya is
As
currently around 8%.
Dr
A 20-yea r-o ld ma n who p resented with pe rsistent diarrhoea a nd a bdo minal bloating after
returning from a gap year in Africa is diagn osed as having stro ngylo id iasis. How wou ld
the Strongyloides stercora/is o rganism initia lly e nte red his body?
Sexua l tra nsm issio n
Faecal-o ral route
Penetrated t he skin
Respiratory d ro plet route
m
se
As
Mosqu ito ve ctor
Dr
Sexua l transm ission
Faecal-o ra l route
Penetrated the s kin
Respiratory d roplet route
Mosquito vector
Strongyloides stercora/is gains access to the body by penetrating the skin

m
se
This typically occu rs via the soles of the feet but au toi nfection in the perianal area may
As
also occur.
Dr
A 46-year-old woman presents 3 d ays after returning from a safari holiday in Ta nzania.
She complains of fever, chills, myalgia and malaise which started 2 days ag o and now
com plains o f d aytime somnolence and night tim e insomnia. Her husband also reports she
has b een acting strangely. She says she to ok malarone as anti malarial p rophylaxis and
had all the recommended vaccines before travelling. A HJV t est was neg ative.
On examination her temperature is 38.5°C, heart rate 90/min, b lood p ressure 118/ 90
mmHg, respirat ory rate 18/ min.
What is the most likely diagnosi s?
Cerebral malaria
Human African Trypano som iasis
Yellow fever
Tuberculosis meningitis
m
se
As
Bact erial meningitis
Dr
Cerebral malaria CD
I Human African Trypanosom iasis
Yellow fever
fD
.
(D
Tuberculosis meningit is m
~
Bact erial meningitis
•
The reversa l of t he sleep wake cycle is typica l of t rypanosomiasis (African sleeping
sickness) and ca n be accompanied by behavioural changes. Cerebral malaria wou ld be
unlikely given that she took malarone and reversa l of t he sleep-wake cycle would not be a
feat ure. TB meningitis is also very unlikely in t his la dy, especially in the absence of HIV or
o t her immunosuppressive illness. Bacterial meningitis again does not cause reversal of t he
sleep-wake cycle and t he onset is quite long for bacterial meningit is. Yellow fever is found
m
in Tanzania (a lthough t he risk is low) and the init ial symptoms may be similar but the later
se
stages involve jaundice, abdominal pain and bleeding not behavioural and sleep
As
disturbances.
Dr
A 17-year-old man attends the loca l sexua l hea lth cli nic. He has developed a large,
keratinised genital wart on the shaft of his penis. This has been p resent for a round three
months but he has been too embarrassed to p resent before now. What is the most
appropriate initial management?
Topical aciclovir
Cryotherapy
Electrocautery
m
se
As
Topical podophyllum
Dr
Topical aciclovir m
I Cryotherapy eD
Topical salicylic acid CD
Electrocautery fD
Topical podophyllum 6D.
Genita l wart treatment

• multiple, non-keratin ised warts: topical podophyllum
• solitary, keratinised warts: cryotherapy
m
se
As
As the wart is keratinised cryotherapy should be used initially
Dr
A patient who was an intrave nous drug user in the 1990s as ks for a hepatitis C test. What
is the most appropriate action?
Refer him for pre-test counsell ing to discuss the pros an d cons of testing
Advise him that no accurate test is currently ava ilable but that he should undertake
normal precautions
Arrange a n a nti- HCV a ntibody test
Arrange a HCV RNA test
m
se
As
Refer him to g astroenterology fo r a liver biopsy
Dr
Refer him for pre -test counsell ing to discuss the pros an d cons o f testing
Advise him that no accu rate test is currently available but that he should
-
"""
unde rtake norma l precautions
Arrange an anti- HCV antibody test
Arra nge a HCV RNA test
Refer him to gastroente ro logy fo r a live r bio psy
m
se
As
HCV RNA tests a re normally only o rd ered following a positive antibody test.
Dr
A 32-yea r-old woman attends the e mergency department 8 d ays aher returning from a
Safari holid ay in Uganda with headache, fever, muscle pa ins and malaise. She adm its she
did not have any vaccinations before she went and d id not ta ke antimalarial p rophylaxis.
She has no past medica l history and is not taking any other medications.
Her temperature is 39.5°C, blood pressure 100/70 mm Hg, heart rate 110/min, respiratory
rate 20 b reaths/min, oxygen satu rations 98% on a ir. Her b lood su gar is 2.8 mmoi/L.
Her bl ood film shows P. falciparum with 5% parasitaemia
How would you treat her?
Oral artesunate combination therapy
Oral chlo roq uine
IV a rtesu nate
IV mefloquine
m
se
As
IV qui nin e
Dr
Oral artesunate combination t herapy
Oral ch loroquine
IV artesunate
IV mef loquine
IV quinine
This lady has severe falcipa rum malaria as she has a high parasit aemia (> 2%),
hypoglycaemia an d a high t emperature. The latest WHO guidelines recommend IV
artesunate as 1st line t reatment for severe fa lciparum malaria . IV quinine can be used if
artesunate is not available but is inferior to artesunat e. Ch loroquine shou ld be used wit h
caut ion as there is high level o f chloroquine resistance in some areas of t he world. If she
had non -severe fa lciparum malaria then artesunate co mbination therapy should be used.
Criteria for severe falcipa rum malaria
• High parasitaemia (>2%)

• Hypoglycaemia
• Severe anaemia
• Renal fa ilure
• Pulmonary oedema
• Metabolic acidosis
• Abnormal bleeding
• Multip le convu lsions
• Seizures
• Shock
Management
• Severe falciparum, malaria IV artesunate
• Non -severe falciparum malaria oral artesunate co mbination therapy (ACT)
• Non -falciparum malaria ora l ACT or chlo roqu ine if not resistant
em
Sources: WHO management of severe malaria

s
As
http:/ /apps.who.i nt/iris/ bitstrea m/10665/79317/ l / 97 89241548526eng.pdf?ua = 1

Dr
A 74-year-old female presents with headache and neck stiffness to the Emergency
Department. Following a lumbar puncture the patient was started on IV cehriaxone. CSF
cultu re grows Listeria monocytogenes. What is the most appropriate treatment?
Add IV amoxicilli n
Change to IV amoxicillin + gentamicin
Add IV ciprofloxacin
Add IV co-amoxiclav
m
se
As
Continue IV cehriaxone as monotherapy
Dr
Add IV amoxicillin
I Change to IV amoxicill in + gentamicin
Add IV ciprofloxacin
( 1d IV co-amoxiclav
Continue IV ceftriaxone as mon otherapy
m
se
The current BNF suggests treatment with amoxicillin/ampicillin +gentamicin. Treatment
As
should be for at least 10-14 days
Dr
A 26-yea r-old man presents to you r sexual health clin ic with a history of swoll en ing uinal
lymph nod es and feve r 1 month after he ha d rece ptive anal inte rcourse with a casua l male
pa rtner. He tells yo u his last HIV test was 2 months previously and this is the on ly sexual
contact he has ha d in the last 6 months.
What is the most ap propriate cou rse of action to determ ine his HIV status?
Advise the patient it is too ea rly to test fo r HIV; ask him to retu rn in 2 weeks a nd
then at 3 month s
Request a com bined antigen (P24) and antibody test
Ask the patie nt to return in 2 months for a n RNA PCR test
Perform a b edside 'Po int of Care' antibody only test a nd reassure the patient if th is
is norma l
m
se
As
Ta ke a full blood count for CD4 count
Dr
Advise the patient it is too ea rly to test for HIV; a sk him to retu rn in 2 weeks a nd g
then at 3 month s
I Request a combined antigen (P24) and antibody test
Ask the patient to return in 2 months for a n RNA PCR test
Perform a bedside ' Point of Care' anti body only test a nd reassure the patient if
this is normal
Ta ke a full blood count for CD4 co unt
p24 testing can be used 4 week after an exposure and is often used in combination
with the HIV antibody test in clinical practice
A co mbined p24/ Antibo dy test is the most appropriate test used in clinica l practice as this
has a 4 week window period. Bedside a ntibody o nly test may not b e accurate for a recent
risk less tha n 6 weeks ago. RNA PCR is sometimes used as a scree ning test but there is no
m
se
rea son to d e lay testing . CD4 count needs to b e checked shoul d the patient be HIV
As
positive but will not g ive you any info rmation about his HIV status
Dr
A 23 -year-old man is admitted to the Emergency Department with an evolving purpuric
rash, pyrexia and confusion. His GP ha d given him intramuscular benzylpenicillin in the
surgery and dialled 999. Which one of the following investigations is most likely to reveal
the diagnosis?
Urinary antigen
Blood PCR for meningococcus
Blood culture
CT head
m
se
As
Lumbar puncture
Dr
Urinary antig en
Blood PCR for meningococcus
Blood culture
CT head
Lu mbar puncture
m
se
The blood cultures are likely to be negative as antibiotics have already been given. PCR
As
has a sensit ivity of over 90%.
Dr
A 34-year-old female is admitted to hospital w ith fever, rigors and myalgia. She reports
being bitten by her rabbit 4 days prior.
On examination, you notice an ulcer around the site of the bite with tender regional
lympha denopathy. On closer inspectio n o f the lymph nodes, you no tice pus com ing out
from them.
Blood tests reveal:

Hb 119 g/ 1
WBC 12.4 8
109/1
Na• 128 mmol/ 1
K• 3 .7 mmol/1
Urea 11.3 mmol/ 1
Creatinine 187 mol/ 1
Bilirubin 30 mol/1
ALP 85 u/1
ALT 111 u/1
Albumin 37 g/1
Creatine k inase 831 iu/L
Legionella
Tularaemia
Psitt acosis
s em
As
Leptospirosis
Dr
Legio nel la
Mycoplasma p neumonia
Tularaemia
Psittaco sis
Leptospirosis
Tula rae mia is a zoonotic infe ct io n involving the microorga nism F. tularensis co mmonly
transm itted throu gh la gomorp hs su ch as ra bb its, ha res and pikas but a lso in aq uatic
ro de nts - beavers and mus krat - a nd ticks. It ca n present in a va riety of fo rms . Com mo nly,
it produces a n e rythemato us pa pule -ulce rative lesio n at the s ite o f the bite with reactive
a nd ulcerating regional lymphade no pathy. It is treated with antibiotics such as
d oxycycline.
Psittacosis, legio nella a nd mycop lasma tend to prese nt with a n atypical p neumo nic
pattern. Le ptosp irosis is associated with contact with ve rmin and ca n present with liver
m
se
invo lve ment a ssociated with th romb ocytopaenia a nd a n acute kidney inju ry which is not
As
me ntioned here.
Dr
A 54-yea r-old man p resents to a sexua l health clinic with positive sero logy fo r syphilis,
which was found d uring routine work up for an insura nce medica l. He travels a g reat d ea l
for work and states he has on occas ion pa id for sex with male sex workers in Thailand . He
has never ha d a syphilis test befo re and is very shocked as he feels well a nd is comp lete ly
asymptomatic. He is re luctant to have treatment for his syphilis as he feels very well and
asks you how he can have syphilis if he doesn't have symptoms.
Which of the following should you advise hi m?
Asym ptomatic (latent) infection implies late disease
Sym ptomatic syphilis requires repeated antibiotic treatments; latent disease

requires a one o ff treatment only
Spontaneous clea rance of Treponema pallidum does not occur
Only symptomatic patients need treatment for syphilis
m
se
Almost a ll patients with syphilis will d escribe a chancre as their first symptom
As
Dr
Asymptomatic (latent) infection implies late d isease
Symptomatic syphilis requires repeated antibiotic treatments; latent disease

requires a one off treatment only
Spontaneous cleara nce of Treponema pallidum does not occu r
Only symptomatic patients need treatment for syphilis
Almost all patients with syphilis will d escribe a chancre as their first symptom
-
~
Late nt syphilis (i.e a symptomatic syph ilis) can occu r at a n ea rly and a late stage a nd
requires the sa me antibiotic treatment
Syphilis can be present without any symptoms at e ithe r an early o r a late stage; these a re
called 'early latent' (less than 2 yea rs since last negative syphil is test) and 'late latent'
(more than 2 yea rs since last negative test). Whether the syph ilis is latent o r causing
symptoms d oes not a lte r the treatment; this is only affected by whether syphilis has not
been tested for in the last 2 yea rs, in which case further doses a re requ ired, o r if
neu rosyphilis is suspected. Many patients with syphilis a re unaware of having had a
m
se
chancre and this is sometimes picked up incidenta lly on clinica l exa mination. There is no
As
known cleara nce o f Treponema pallidum without antibiotic treatment Dr
A 24-year-old student returns fro m a gap yea r in Malawi complaining of visible
haematu ria, dysuria and urinary frequency. She says she felt well throu ghout her trip but
experienced an itchy rash on her legs a few hours aher swimming in Lake Malawi which
has now resolved.
Her blood results show:
Hb 98 g/1
WBC 9 .0 * 109/ 1
Neutrophils 4 .0 * 109/ 1
Lymphocytes 2.5 * 109/ 1
Eosinophils 0 .5 * 109/ 1
How wou ld you treat her?
Albendazole
Trimethoprim
Prednisolone
Doxycycline
m
se
Praziquantel
As
Dr
Albendazole CD
Trimethoprim m
r :rednisolone CD
Doxycycline GD
Praziquantel GD
This wo man is li ke ly to have sch istosoma haematobiu m (schistosom iasis/ bilharzia) from
the sym ptoms a nd ra ised eosinophils. She has a lso swam in Lake Ma lawi which is a big
risk facto r fo r getting schistosomiasis . The schistosoma pa rasite enters the skin fro m the
wate r which can cause an initia l itch as in the case fo llowed by symptoms above . It is
treated with praziquantel. Albend azole is a nother a nti- pa rasitic drug but is not used in
schistosom iasis. Doxycycline may be used to treat chlamydia b ut this is unlikely,
Trimetho prim wou ld b e used to treat a UTI but this is u nlike ly due to the p resentation a nd
ra ised eosino phils. Glo me rulonephritis may p resent in a simila r way to this and is treated
with p red nisolone is some cases but aga in the initia l itch and raised eosinop hils point
mo re towa rd schistosom iasis.
m
se
As
Source: WHO
Dr
A 45-yea r-old man presents to the Emergency Depa rtment due to severe pain in the
perinea l area over the past 6 hou rs. On exa mination the skin is ce llulitic, extremely tender
and haemo rrhagic bu llae are seen. What is the most appropriate manageme nt?
IV antibiotics + surg ical debridement
IV antibiotics
IV corticosteroids
Plasma exchange
m
se
As
Urgent microscopy of wound swab
Dr
IV antibiotics + surgical debridement
r:
IV antibiotics
corticosteroids
Plasma exchange
Urgent microscopy of wound swab
Surgical referral is the single most important step in the management of necrotising
m
se
fasciitis. There has been little change in th e morta lity of necrotising fasciiti s since the
As
introduction of antibiotics
Dr
A 65-year-old man who has recently move to the UK from India presents with mu ltiple
pa le patches on his skin. He has no previous med ical problems and is not taking any
med icatio ns. On examination he has 10 hypopigmented patches with reduced sensation.
You suspect lepromatous lep rosy.
Rifampicin, dapsone and clofazim ine for 12 months
Dapsone, ethambutol and pyrazinamide for 12 months
Dapsone and ethambutol for 6 months
Rifampicin and isoniazid for 6 month
m
se
As
Rifampicin and dapsone for 6 months
Dr
I Rifampicin, dapsone and clofazimine fo r 12 months
Dapsone, ethambutol and pyrazinamide for 12 months
Dapsone and ethambutol for 6 months
I Rifampicin and isoniazid for 6 month
Rifampicin and dapsone for 6 months
This man has multibacillary leprosy (>6 lesions) so should have triple therapy w ith
rifampicin, dapsone and clofazimine for 12 months. For paucibacillary leprosy (5 or less
lesions) you shou ld give rifampicin and dapsone for 6 months.
m
se
As
Source: BNF
Dr
A 34-year-old man from West Africa is admitted due to confusion associated wit h left-
sided weakness and ataxia. He is know n to be HIV posit ive but is not on anti -retroviral
treatment. The follow ing results are obtained:
CD4 43 u/1
Low attenuation diffusely.

CT head
No mass effect or enhancement
Toxo pla smos is
Tub erculosis
Progressive multifocalleukoencepha lopathy
Cryptococcus
m
se
As
Cerebral lymphoma
Dr
Toxoplasmosis
Tuberculosis
Cryptococcus
-
~
Cerebral lymphoma
- ...wr
HN, neuro symptoms, w idespread demyelin ation - progressive multifocal
m
leukoencephalopathy
se
As
Dr
A 69-year-old man is brought into the emergency department by ambulance, with a few
days history of increasing shortness of breath, fever and a p roductive cough.
On review, you find:

HR 105 bpm
Oxygen saturation 90 % on air
BP 100/ 65 mmHg
Temp 38 .90C
Respiratory Rate 32 breaths per minute
Chest X- ray Right mid-zone cavity with surrounding consolidation
The patient is started on oxygen, antibiotics and IV fluids and his observations improve to
the point where taking a history is easier. He reports that he no rm ally keeps fit and has no
other long-term health conditions, but that he has been more tired for the past few
weeks. He explains further that he and his wife both caught a 'bad cold' from their
grandchildren about a month ago.
What is the most likely cause for this gentleman's symptoms?
Lung cancer
Klebsiella pneumoniae infection
Staphylococcus aureus infection
Pulmonary tuberculosis
em
s
Streptococcus pneumoniae infection

As
Dr
~ng cancer •
Klebsiella pneumoniae infection GD
I Staphylococcus aureus infection CD
Pulmonary tuberculosis f.D
Streptococcus pneumoniae infection a
Staphylococcus aureus is associated wit h cavitating lesions when it causes
pneumon1a
Th is gentleman like ly developed influenza a few weeks prior to his presentation at the
emergency department, w hich is associated with the development of S. aureus
pneumonia following resolution.
S. aureus is associated with the development of cavitating lung lesions in the context o f
pneumonia, especially when caused by strains capable o f p roducing a cytotoxin known as
Panton-Valent ine Leukocidin. This cytotoxin can often lead necrotic, hemorrhagic
pneumonia and length stays in intensive care units for t he patients affected.
Although lung cancer, Klebsiella pneumoniae, and pu lmonary t ubercu losis are all
associated w ith cavitating lung lesions, these causes are less likely for t he following
reasons:
• Squamous cell carcinoma is the most common oncolog ica l cause of cavitating lung
lesions, which is often linked to a history o f smoking. The question gives us no
informat ion to suggest the patient is a smoker.
• Klebsiella pneumoniae is often associated a causative pathogen of pneumonia in
patients with a history of alcoholism
• Pu lmonary tuberculosis often causes a more drawn out, subacute presentat ion and
is often associated with immunosuppression and other co morbidities
s em
As
Streptococcus pneumoniae is not associated w ith cavitating lung lesions.

Dr
A 50-year-old man is admitted w ith sepsis o f unknown origin. He has ha d t hree set s of
blood cultures taken. The micro biology laboratory phone t he ward w it h so me prelim inary
results about a bacterium growing from the first set of cu ltures. Which o f the following
findings wou ld make you concerned that t he bacterium isolated is Staph au reus?
Bacteria seen in dip lococci pairs
Poor upt ake of gram stain
Coagu lase t est pos it ive
Ra pid growt h on MacConkey agar
m
se
As
Haemolys is on b lood agar
Dr
Bacteria seen in diplococci pairs GD
Poo r upta ke of gram sta in
•
I Coagulase test pos itive GD
Rapi d growth on Ma cConkey a ga r fD
Haemo lysis o n b lood aga r .
(D
Staph aureus is a coagu lase pos itive Staph

The coagulase test is used to differentiate between different Staphylo coccus species and
o hen retu rns from the lab before determination of the exact species. Stap h au reus is the
mo st important of the coagulase positive Stap hylococcus species and is highly
m
pathogenic. Coagulase-negative Staph species are most likely to be skin com mensal
se
organisms of relative ly low pathog en icity, such as Staph epidermid is or Staph
As
saprophyticus, altho ugh some may still cause d eeper infectio n o r sepsis.
Dr
Which one of the following is the most likely presentation of Staphylococcus aureus food
poisoning?
Tenesmus
Watery diarrhoea
Dysentery
Severe vom iting
m
se
As
Presentation 24-48 hours aher eating affected food
Dr
Tenesmus
Watery diarrhoea
Dysentery
Severe vomiting
Presentation 24-48 hours aher eating affected food

-
""""
m
se
As
Severe nausea and vomiting are caused by ent erotoxins A-E
Dr
Infection with Schistosoma haematobium is most strong ly associated with:
Transitiona l cell bladd e r cancer
Lung cancer
Hepatoma
Vu lval carcinoma
m
se
As
Squamous cell blad der cancer
Dr
Transitional cell bladd er ca ncer
Lung ca ncer
Hepatoma
Vu val carcino ma
-
~
Squamous cell b ladder cancer
m
se
Schist osom ias is is a risk factor fo r Squamous cell b ladder cancer
As
Dr
A patient is prescribed zanam ivir (Relenza) for suspect ed influenza. Which one of the
following underlying problems may increase the likelihood of side-effects?
A history o f aspirin sensitivity
Epilepsy
Asthma
Renal impairment
m
se
As
Concurrent use with drugs that prolo ng the QT int erval
Dr
A history of aspirin sensitivity
Ep ilepsy
Asthma
Renal impa irment

-
~
Concurrent use with drugs that prolong the QT interval

--
~
m
se
As
Zanamivir (Relenza) may induce bronchospasm in asthmatics.
Dr
A 48-yea r-old man with a past medical history of poorly controll ed HN is a dmitted with
shortness of b reath. He a lso co mplains of haemo ptysis. Imag ing and b lood tests confirm
a d ia g nosis o f invasive asperg illosis. He is treated with amphotericin B.
What is the mechanism of action of am photericin B?
Inhibits DNA polyme rase
Converted to to 5-fluoro ura cil
Binds with ergostero l
Inhibits synthesis of beta-glucan
m
se
As
Interacts with microtubules to disrupt mitotic spind le
Dr
Converted to to 5-fluorouracil
Inhibits synthesis of bet a-glucan

-
~
Interacts with microtubules to disrupt mitotic spindle
Amphotericin B binds with ergosterol, a component of fungal cell membranes,

form ing pores that cause lysis of the cell wal l and subsequent funga l cell death
Am photericin B binds with ergosterol, a component of fungal cell membranes, forming

pores that cause lysis of the cell wall and subsequent fu ngal ce ll death.
Flucytosine is converted by cyt osine deaminase to 5-fluorouracil, which inhibits

thym idylate synthase and disrupts fu ngal protein synthesis.
Caspofungin inhibits synthesis of beta -glucan, a maj or fu ngal cell wa ll component.
m
Griseofulvin interacts with microtubules to disrupt mitotic spindle.
se
As
Anti viral agent s such as aciclovir inhibit vira l DNA polymerase.
Dr
A 74-yea r-old woman has a chest x-ray organised by her GP due to a ch ron ic cough. The
chest x-ray shows a cavity in the left upper zone inside o f which there is a solid mass. An
aspergi llo ma is suspected. What is the most appropriate next test?
Sputum cu lture
Serology fo r Aspe rgillus pre cipitins
Blood cu lture
Bronchoscopy with b iopsy
m
se
As
Transthoracic fine needle b io psy
Dr
Sputum culture
Serology for Aspergillus precipitins
Blood culture
-
~
Bronchoscopy w ith biopsy

-
~
m
se
As
Transthoracic fine needle biopsy
Dr
A 34-year-old lady presents to the GP with worsening nausea an d fatigue over a 2 week
period. On examination, there is a yellow t inge t o the sclera of her eyes. She lives in a
remot e fishin g village and consumes a diet high in seafood. She d oes not smoke or
consume alcoho l. She does not repo rt any weight loss or other constitutional features.
Her LFTs are as fo llows:
ALP 160 ujl
ALT 550 u/1
yGT 30 u/1
Albumin 3 5 g/ 1
Other routine blood results are within normal limits.
Gilbert's syndrome
Pancreati c ad enocarcinoma
Hepatitis B
Hepatitis C
m
se
Hepatitis E
As
Dr
Gilbert's syndrome
Pancreati c ad enocarcinoma
Hepatit is B
Hel atit is C
Hepatitis E
Hepatit is E is associated with faeca l-o ral sprea d, common ly affecting shellfish and pork
p roducts. Blood resu lts show elevated b ilirubin and signif icant transaminitis.
This lady has no constitut ional symptoms, making a pancreatic adenoca rcinoma less
likely. As well, pancreat ic cancer ra rely occu rs b efore age 40.
m
se
Hepatitis Band C are b lo od-borne viruses and t here is no relevant history in th is lady's
As
case.
Dr
Which one of the followin g tests is most likely to remain positive in a patient w ith syphilis
d esp ite treatment?
Wassermann reaction
Rapid plasma reagin (RPR)
Venerea l disease research laboratory (VDRL)
Blood culture
m
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As
Treponema pallidum haemagglut ination test (TPHA)
Dr
Wassermann react ion
Rapid plasma reag in (RPR)
Venereal disease research laboratory (VORL)
Blood culture
m
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As
Treponema pal/idum haemagglutination test (TPHA)
Dr
A 31-year-old man from Russia who is known to be HN positive presents w ith pu rp le
plaques on his skin. W hich of t he follow ing viruses is thought to be t he cause o f Ka pos i's
sarcoma?
HTLV-1
HN -2
HHV-8
CMV
m
se
As
HPV-8
Dr
HTLV-1 m.
HIV-2 f.D
HHV-8 GD
CMV f.D
HPV-8 GD
m
se
Ka posi 's sa rcoma -caused by HHV-8 (human herpes virus 8)
As
Dr
A 33-yea r-o ld man who is HIV positive is ad mitted to the Emerge ncy Depa rtment with
confusion and drowsiness. He has b een co mpla in ing of head aches fo r a number o f days .
On exam ination heart rate is 90/ min, blood p ressu re 104/78 mmH g a nd temperature is
37.2°C. He is confused givin g a Glasgow Coma Scale (GCS) score of 14. There is no
photopho bia o r neck stiffness.
His infectious diseases consultant reports that he is p rescribed highly active antiretrovira l
treatment (HAART) but his complia nce is poo r and he often misses clin ic appointments.
A CT b ra in is requested:
CT brain (with contrast): Multiple hypodense regions predominantly in the basal ganglia which show
ring enhancement. Minimal surrounding oedema . No mass effect .
Progressive multifoca l leukoencephalopathy
Cryptococca l infection
Cere bral toxoplasmosis
CMV e ncepha litis
m
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As
Tuberculosis
Dr
Progressive mult ifocal leukoencephalopathy
Cryptococcal infection
I Cerebral toxop lasmosis
CMV encephalit is
Tuberculosis
HN, neuro symptoms, multiple brain lesions w ith ring enhancement -

t oxoplasmosis
m
se
Cerebral toxop lasmosis is t he most common neurologica l infection seen in HIV, occurring
As
in up to 10% of pat ients
Dr
A 12-year-old girl is prescribed oseltamivir for susp ected influenza. What is the
mechanism of action o f oseltam ivir?
Interferes w ith th e capping o f viral mRNA
Neuraminidase inhibit or
m
se
As
Prot ease inhibitor
Dr
Inhibit s RNA polymerase CD
Interferes with th e capping of vira l mRNA CD
~uraminidase inhibito r eD
Inhibit s DNA polymerase CD
m
se
Protease inhibitor tiD
As
Dr
A woman who is 14 weeks p regnant p resents as she came into contact w ith a child who
has ch ickenpox arou nd 4 days ago. She is u nsu re if she had the co ndition herself as a
child. Blood tests show the following:
Varicella I gM Negative
Varicella I gG Negative
Varicella zost er immunoglob ulin
No action required
IV aciclovir
Varicella zost er vaccination
m
se
As
Varicella zost er vaccination + varicella zoster immunoglobulin
Dr
Varicella zoster immunoglobulin
No action required
IV aci clovir
Varicella zost er vaccination
Varicella zoster vaccination + varicella zoster immunoglobulin
Chickenpox exposure in pregnancy - if not immune give VZIG
m
se
As
The negative IgG indicat es no previous exposure to chickenpox
Dr
A patient who has recently returned from the Ivory Coast presents with cyclical fever and
head ache. He is found to have splenomega ly on examination. Following a blood film he is
diagnosed as having Plasmodium vivax malaria. He is treated in itia lly with ch lo roqu ine
then later given primaqui ne. What is the benefit of the p rimaqu ine?
Destroy live r hypnozoites and prevent relapse
Reduce the risk of chloroquine-related retino pathy
Reduce the incidence o f chloroqu ine resistance
Cover Plasmodium ovate in case of co-infection
m
se
As
Prevent immatu re trophozoites forming gamatocytes
Dr
I Destroy liver hypnozoites and prevent relapse
Reduce the risk of chloroquine-related retinopathy
I Reduce the inci dence of chloroqu ine resist ance
Cover Plasmodium ovate in case of co- infection
Prevent immature t rop hozoites forming gamatocytes

-
~
Primaquine is used in non -falciparum malaria to destroy liver hypnozo ites and
m
se
p revent relapse
As
Dr
A 45-year-o ld butcher from Poland presents to your clinic with a history of a painful bump
on the back of his hand that he describes as 'like an insect bite' that has since ulcerated
and scabbed over. He is concerned it could be a form of skin tumour as the scab is black
and hard . The scab is painless but he has some tender lumps in his axilla. He is normally
fit and well and has no system ic symptoms.
Ciprofloxaci n
Metronidazole
Flucloxacillin
Clot rimazole
Doxycycline
m
se
As
Submit answer
Dr
Anthrax presents w ith a black eschar that is typically painless; it is t reated with
ciprofloxacin
The question stem g ives a classical history of a black escha r characteristica lly seen in
cutaneous anthrax. The patient has 2 risk factors for the d isease (being a butcher and
hailing from Eastern Europe).
The most common t reatment for cutaneous anthrax is ciprofloxacin.
Anthrax (bacillus anthracis) is a spore-forming gram-positive rod and gram stain wou ld be
a sensible initial test whilst awa iting confirmatory test.
[ .. I a• tt Discuss Improve ]
Next question )
Anthrax
Anthrax is caused by Bacillus anthracis, a Gram posit ive rod. It is spread by infected
carcasses. It is also known as Woolsorters' disease. Bacillus anthracis produces a tripartite
protein toxin
• protective antigen
• oedema factor: a bacterial adenylate cyclase which increases cAM P
• lethal facto r: toxic to macrophages
Features
• causes painless black eschar (cutaneous 'malignant pust ule', but no pus)
• typically painless and non-tender
• may cause marked oedema
• anthrax can cause gastrointestinal bleeding
Management
• the current Health Protection Agency advice for the initia l management of
s em
cutaneous anthrax is ciprofloxacin

As
• further treatment is based on microbiolog ical investigations and expert advice

Dr
A 28-year-o ld woman presents to the hospital with severe neck pain, shortness of breath
and swelling around her left j aw, on a background of a week's history of pharyng itis, with
some d ifficu lty swallowing. She is normally fit and well, has no recent foreign travel and is
fully vaccinated. She works as a doctor and had been unable to attend her own GP.
On exam ination, she is tachycardic and hypotensive. There is unilateral cervical

lymphadenopathy and she has signifi cant tonsi llar swelling. Her chest is clear.
You suspect Lem ierre's syndrome.
Which one of t he following sequelae is the patient at high risk of?
Internal carotid artery d issection
Septic pulmonary embol i
Digital ischaemia
Amaurosis fugax
m
se
As
Submit answer
Dr
Internal carotid artery dissect ion
Septic pulmonary emboli ..,..

~
Digital ischaemia
Amaurosis fugax
Patients with peritonsillar abscesses can develop Lemierre's syndrome

(thrombophlebitis of the IJV) - this can present with neck pain, and can result in
septic pulmonary embolism
Patients w ith peritonsillar abscesses can develop Lem ierre's syndrome (thrombophlebitis
of t he internal jugu lar vein)- this can present with neck pain and can resu lt in sept ic
pu lmonary embolism.
The commonest bacterial cause of Lemierre's syndrome is Fusobacterium. Coxiella

burnetti causes Q fever.
Treatment is with IV antibiotics.
Pat ients w ith Lemierre's syndro me often have high fevers (39-41°().
As Lem ierre's syndrome involves venous thrombophlebitis of t he external j ugular vein,

digital ischaemia, amau rosis fugax and myoca rdial infarction are less likely than
pu lmonary emboli.
Next question )
Lemierre's syndrome
Lem ierre's syndrome is an infectious thrombophlebit is of the int ernal jugu lar vein.
It most often occurs secondary to a bacterial sore throat caused by Fusobacterium

necrophorum leading to a peritonsillar abscess. A combination of spread of the infection
laterally from the abscess and compression lead to t hrombosis of the IJV.
em
Patients w ill present with a history of bacterial sore throat followed by neck pain, stiffness
s
As
and t enderness (may be mistaken for mening itis) and systemic involvement (fevers, rigors,
etc).
Dr
A 19-year-o ld woman presents to the emergency department with a history of confusion,
severe malaise, vomiting, fever and a 'sunburn like' rash involving her upper body, palms,
soles and lips.
She is normally fit and well. Her only past medica l history of note is menorrhagia; she has
been referred by her GP to gynaecology regarding this. She takes tranexamic acid as
required. She recently returned from a holiday in lbiza.
On exam ination, she is pyrexial, hypotensive, and has diffuse macular erythroderma with
red oral mucosa. Glasgow coma scale 14/15, her neu rolog ical examination is normal. Her
chest is clear and abdomen is non-tender.
Initial blood test s find elevated creatinine kinase, an elevated creatinine level and
deranged liver funct ion t ests.
Blood cult ures are positive for Staphylococcus aureus.
Other microbiologica l tests are negat ive includ ing serology for rickettsia, leptospirosis,
and measles.
Which of the following factors is most likely to be contributory to this patient's

presentat ion?
Underlying pneumonia
Recent foreign travel
Tampon use
Excess alcohol consumption
Cellul itis secondary to eczema

s em
As
Submit answer
Dr
Underlying pneumonia
Recent foreign travel
Tampon use
Excess alcohol consumption
Cellulitis secondary to eczema
Tampon use is a risk factor for staphylococcal toxic shock syndrome

ImP-orta nt for me less important
The stem is describing toxic shock syndrome secondary t o Staphylococcus aureus

infection.
Tampon use is a major risk factor for this illness; particularly the use of tampons for
prolonged periods of time.
Pneumonia and skin infections are also associated with toxic shock syndrome but are less
likely in this case are t here are no signs of them on clinical exam ination.
Foreign travel and alcohol consumption are not linked to toxic shock syndrome.
[ .. I at tt Discuss (1) Improve ]
Next question )
Staphylococcal toxic shock syndrome
Staphylococcal toxic shock syndrome describes a severe systemic reaction to

staphylococcal exotoxins. It came to prom inence in the early 1980's following a series of
cases related to infected tampons
Centers for Disease Control and Prevention d iagnostic criteria

• fever: temperature > 38.9°C
• hypotension: systol ic blood pressure < 90 mm Hg
• diffuse erythematous rash
• desquamation of rash/ especially of t he palms and soles
• involvement of three or more organ systems: e.g. gastrointesti nal (diarrhoea and
vomitingt mucous membrane erythema, renal failure, hepatitis/ t hrombocytopenia,
CNS involvement (e.g. conf usion)
s em
As
Dr
After a trip to a petting zoo, a 78-year-old woman presents with severe watery diarrhoea
leading to dehydration, mild fever and cramping mild abdominal pains. She is normally fit
and well and is treated with IV fluids.
You later hear reports that several others became unwell after visiting t he sa me site. You
are contacted by Public Healt h Eng land who suspect cryptosporidiosis and ask you to
perform tests to confirm this.
What test is most appropriate for this pu rpose?
Blood film
Ziehi-Neelsen staining on st ool sample
Stool culture
Blood culture
No diagnostic test available
m
se
As
Submit answer
Dr
Blood film
Ziehi-Neelsen staining on stool sample
Stool cu lture
~.fa
Blood culture ~
No diagnostic test available
Cryptosporid ium can be diagnosed by modified Ziehi-Neelsen stain ing of stool to

revea I red cysts
Ziehi- Neelsen (acid-fast) staining on stool sample is commonly used to revea l

characteristic red cysts of Cryptosporidium.
Blood culture and stool culture are important tests in patients presenting with severe
gastroenteritis but in this instance, the question states that PHE wish to confirm
cryptosporidiosis and therefore the d iagnostic test is more appropriate.
Blood film m ight be considered if suspecting haemolytic-uraemic-syndrome secondary to

E. coli.
Next question )
Cryptosporidiosis
Cryptosporidiosis is the commonest protozoa l cause of diarrhoea in the UK. Two species,
Cryptosporidium hominis and Cryptosporidium parvum account for the majority cases.
Cryptosporidiosis is more common in immunocompromised patients (e.g. HIV) and young

children.
Features
• watery diarrhoea
• abdomina l cramps
• fever
• in immunocompromised patients the entire gastrointestinal tract may be affected
resulting in complications such as sclerosing cholangitis and pancreatitis
Diagnosis
• stool: modified Ziehi-Neelsen stain (acid-fast stain) of the stool may reveal the
characteristic red cysts of Cryptosporidium
Management
s em
• is largely supportive
As
• nitazoxanide is licensed in the US for immunocompetent patients

Dr
A 45-year-o ld man presents to a sexual hea lth clinic with a history of a solitary pa inful
ulcer on the glans of his penis which came up 3 days previously. On examination, the
ulcer is 2cm in diameter, irregular and there is unilateral tender inguinal
lymphadenopathy. He has recen tly returned from a charity expedition to Africa. He is
normally sexually active with his wife.
Which of the following bacteria should be screened for as part of his investigations?
Haemophilus ducreyi
Streptococcus mitis
m
se
As
Submit answer
Dr
Chlamydia trachomatis EB
Staphylococcus aureus CD.
I Haemophilus ducreyi CD
Streptococcus mitis
•
CD
Chancroid is an important d ifferential diagnosis of genital ulcers if there is a history

of foreign travel, particu larly if associated with unilateral, painful ingu inal lymph
node enlargement
Chancroid shou ld be considered g iven the physical signs listed and recent foreign travel.
Sex worker use is anot her risk factor that may be pert inent.
The main differential d iagnosis (syphilis) is not listed as an option.
Chlamydia trachomatis can cause lymphadenopathy and buboes in the cont ext of
lymphogranu loma venereum but this would more typica lly have associated recta l
symptoms.
Mycoplasma genitalium is usually asymptomatic in men but where pathogenic tends to

cause dysuria and t esticular pa in.
Streptococcus mitis is a commensal bacteria of the throat and Staphylococcus aureus a

commensal of the skin.
Next question )
Chancroid
em
Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital

s
ulcers associated with un ilateral, painful ingu inal lymph node enlargement. The ulcers
As
typically have a sharply defined, ragged, undermined border.

Dr
A 55-year-o ld, normally fit and well woman presents with a 1-week history of worsening
dysarthria, diplopia, and dysphagia. Her husband has noticed her eyelids drooping and
they have attended as she is now having diffi culty lifting her head up. Her symptoms
started 2 days after a takeaway meal deal for one and she had experienced some mild
loose stools t hat evening.
On exam ination she has 2/5 power in her upper limbs, hypotonia with reduced reflexes, a
dry mouth and dilated pupils. Sensory exa minat ion is normal.
What is the most likely bacterial pathogen?
Clostridium per{ringens
Clostridium tetani
Clostridium botulinum
Clostridium dif{icile
Clostridium sordellii
m
se
As
Submit answer
Dr
Clostridium perfringens CfB
Clostridium tetani GD
I Clostridium botulinum
Clostridium difficile
CD.
CD
Clostridium sordellii CD.
Clostridium botulinum presents with flaccid para lysis, whereas Clostridium tetani
presents w ith spastic paralysis
The presentation is one of flaccid paralysis, secondary to botulinum toxin w hich can be
spread via food.
Clostridium tetani causes a spastic pa ralysis.
Clostridium perfringens commonly causes skin infections and gas gang rene.
Clostridium difficile does cause diarrheal illness but does not cause para lysis.
Clostridium sordellii is a very rare cause of post-part um and post-terminat ion sepsis.
Next question )
Clostridia
Clostridia are g ram-positive, obligate anaerobic bacilli.
C. per{ringens
• produces a -toxin, a lecithinase, which causes gas gangrene (myonecrosis) and
haemolysis
• featu res include t ender, oedematous skin w ith haemorrhagic blebs and bu llae.
Crepit us may present on palpation
C. botulinum
• typically seen in canned foods and honey
• prevents acetylcholine (ACh) release lead ing to flaccid paralysis
C. difficile
• causes pseudomembranous colitis, typically seen after t he use of broad-spectru m
ant ibiot ics
• produces both an exotoxin and a cytot oxin
em
C. tetani
s
• produces an exotoxin (tetanospasmin) that prevents t he release of glycine from

As
Renshaw cells in the spinal cord causing a spastic paralysis

Dr
A 26-year-o ld man presents to his GP with a 1-week history of a 1em black scab on his
left calf and the subsequent development of a non-blanching raised rash over his torso
and limbs. He t ells you the rash initially started on his hands and feet and then spread. He
also complains of a cough, mild headaches and malaise and has a fever on init ial
exam ination.
He has recently returned from backpacking around south-east Asia and Australia.
What is the most likely diagnosis7
Scrub typhus
Bacillus anthracis
m
se
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Submit answer
Dr
Scrub typhus
Meningococcal meningit is
l sacillus anthracis
In a patient with a black eschar and a vascu litis rash/ typhus (caused by rickettsia)
shou ld be considered
Importa nt for me Less important
The history of a black eschar and vasculitic rash should prompt consideration of scrub
typhus which is caused by Orientia tsutsugamushi and is found in South East Asia and
northern Austra lia.
Henoch Schonlein Purpura, polyarteritis nodosa and meningococcal mening itis wou ld
cause a vasculitic rash but are not associated with escha r.
Bacillus anthracis would account for t he eschar but not typically a vasculitic rash.
Next question )
Typhus
Overview
• rickettsial diseases
• transm itted between hosts by arthropods
• cause widespread vasculitis
Features
• fever, headache
• black eschar at site of original inoculation
• rash e.g. maculopapular or vasculitis
• complications: deranged clotting, renal fa ilu re/ DIC
Rocky Mountain spotted fever

• caused by R rickettsii
• initially macular rash or hands and feet then spreads
em
Tick typhus
s
• caused by R conorii
As
• rash initially in axilla t hen spreads

Dr
A 19-year-o ld woman presents with a 1-week history of severe pharyngitis and
progressive neck swelling and a 1-day history of chest pain and shortness of breath.
She is normally fit and well and has no recent history of foreign travel. She is unsure of
the family history of cardiac d isease as she was adopted as a toddler.
On exam ination, she has bilatera l cervical lymphadenopathy and tonsillitis. She has a m ild
fever, heart ra te 42 bpm. She has no clubbing or peripheral cyanosis. There are no audible
murmurs.
ECG shows complete heart block wit h a ventricular escape rhyt hm at a ra te of 40 bpm.
CRP and troponin are elevated.
What is the most likely underlying pathogen?
Coxsackie virus
Salmonella typhi
Corynebacterium diphtheriae
m
se
As
Submit answer
Dr
Coxsackie virus
Salmonella typhi
Corynebacterium diphtheriae
One of the sequelae of diphtheria is cardiovascu lar disease; notably heart block
Diphtheria is a rare infection due to the routine vaccination of children in the UK. It
presents with severe tonsillit is, neck swelling. Sequelae include myocarditis and rhythm
abnormalities (in particular heart block); the latter is associated with poor prognosis.
Streptococcus viridans is a cause of infective endocarditis.
Streptococcus pyogenes is a group A beta haemolytic strep known to cause rheumatic

fever.
Coxsackie virus and Salmonella typhus are known causes of myocarditis but wou ld not
classically cause severe tonsillitis.
[ .. I a• tt Discuss Improve
Next question )
Diphtheria
Diphtheria is caused by the Gram positive bacterium Corynebacterium diphtheriae
Pathophysiology
• releases an exotoxin encoded by a ~ - prophage
• exotoxin inhibits protein synthesis by catalyzing ADP-ribosylation of elongation
factor EF-2
Diphtheria toxin commonly causes a 'diphtheric membrane' on tonsils caused by necrotic

mucosal cells. Systemic distribution may produce necrosis of myocardial, neural and renal
tissue
Possible presentations
• recent visitors to Eastern Europe/Russia/Asia
• sore throat with a 'diphtheric membra ne' - see above
em
• bu lky cervical lymphadenopathy

s
• neuritis e.g. cranial nerves

As
• heart block
Dr
An HIV positive patient presents for his regular clinic check-up having start ed
antiretrovirals a few months previously. He is well and has an undetectable viral load on
Truvada (emtricitabine/tenofovir) and raltegravir.
His blood tests are unremarkable apart from having a CD4 count of 184 cells/mm 3 .
Which drug shou ld be added to his prescription for preventive pu rposes?
Aciclovir
Co-tri moxazole
Prednisolone
Rifampicin
Nitrofurantoin
m
se
Submit answer
As
Dr
Aciclovir GD
I Co-trimoxazole CD.
..CD
Prednisolone
Rifampicin
Nitrofurantoin
• .
All patients with a CD4 count lower than 200/mm 3 should receive prophylaxis
against Pneumocystis jiroveci pneumonia
Impo rta nt fo r me Less important
All patients with a CD4 count lower than 200 cells/mm 3 should receive prophylaxis against
Pneumocystis jirovecii pneumonia.
Aciclovir is sometimes used as longterm herpes suppression treatment in patients with

both HIV and HSV.
The other answers are not routinely used as prophylaxis.
Next question )
H IV: Pneumocystis jiroveci pneumonia
Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the
term Pneumocystis carinii pneumonia (PCP) is still in common use
• Pneumocystis jiroveci is an unicellu lar eukaryote, generally classified as a fungus but
some authorities consider it a protozoa
• PCP is the most common opportunistic infection in AIDS
• all patients with a CD4 count < 200/mm3 should receive PCP prophylaxis
Features
• dyspnoea
• dry cough
• fever
• very few chest signs
Pneumothorax is a common complication of PCP.
Extrapulmonary manifestations are rare (1-2% of cases), may cause

• hepatosplenomegaly
• lymphadenopathy
• choroid lesions
Investigation
• CXR: typically shows bilateral interstitial pu lmonary infiltrates but can present with
other x-ray findings e.g. lobar consolidation. May be normal
• exercise-induced desaturation
• sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to
demonstrate PCP (silver sta in shows characteristic cysts)
Management
• co-trimoxazole
• IV pentamidine in severe cases
• steroids if hypoxic (if p02 < 9.3kPa then steroids reduce risk of respiratory failure by
50% and death by a third)
m
se
As
CT scan showing a large pneumothorax developing in a patient

Dr
with Pneumocystis jiroveci pneumonia

A 25-year-o ld man recently diagnosed with HIV presents to the emergency department
with a 1-week history of severe malaise/ fever/ and haemoptysis with widespread
lymphadenopathy. He had previously been well and had started anti-retroviral treatment
1 month previously having been d iagnosed with HIV 12 weeks ago. His VIDAS test at
diagnosis suggested he had fairly recently contracted the virus.
Blood tests from 1 week previous noted reduced viral load (200) and increased CD4 count
(568 cells/mm 3 ) than 2 months prior.
What is the most likely diagnosis7
Cryptosporid iosis
Hairy cell leu kaemia
Immune reconstit ut ion inflammatory syndrome secondary to pulmonary

tuberculosis
Seroconversion
m
se
As
Submit answer
Dr
Cryptosporidiosis
Hairy cell leukaemia
Immune reconstitution inflammatory syndrome secondary to pulmonary

tuberculosis
Seroconversion
Immune reconstitution inflammatory syndrome can occur in HIV positive patients

when starting anti-retrovirals; this is an immune phenomenon that resu lts in the
clinical worsening of a pre-exisiting opportunistic infection
Immune reconstitution inflammatory syndrome can occur in HIV posit ive patient s when
starting antiretrovirals; this is an immune phenomenon that results in the cl inical
worsening of a pre-existing opportunistic infection.
IRIS can be difficu lt to d iagnose and often microbiologica l tests are negative. IRIS may be
the unmasking of a pre-existing infection but it may also represent newly acqu ired
infection. IRIS can be life-threatening and require hospital admission.
Tuberculosis is the most common cause of IRIS.
IRIS can be distinguished from ARV failu re by monitoring response t o t reatment- typically
patients with IRIS will have low viral loads and higher CD4 counts whereas in treatment
failure high viral load and low CD4 count wou ld be typical.
Seroconversion is usua lly a mild flu-like illness prior to diagnosis. Hairy cell leukaem ia
would not normally present in this way.
Pneumocystis jirovecii pneumonia would present in a similar way but is unlikely given he
has a CD4 count of > 200 cells/mm 3 .
Immune reconstitution inflammatory syndrome
Immune reconstitution inflammatory syndrome is a condition generally associated with

HIV/immunosuppression/ in which the immune system begins to recover/ but then
s em
responds to a previously acquired opportunistic infection with an overwhelming

As
inflammatory response that paradoxically makes the symptoms of infection worse.

Dr
A 45-year-old woman is seen by her nep hrologist following allogeneic renal transplant for
end -stage rena l failure. She continues to take prednisolone, azathioprin e and ciclosporin.
What complication is th is patient most at risk of?
Lung cancer
Ovarian carcinoma
Breast cancer
m
se
As
Dr
Lung cancer
Ovarian carcinoma
Breast cancer
I Squamous cell carcinoma
Patients who have received an organ t ransp lant are at risk of skin cancer
(particu larly squamous cell ca rcinoma) due t o long-term use o f
immunosuppressants
Patients on long-term immunosuppression for organ transplantation require regular

monitoring as they are at increased risk o f skin malignancy. Patients should be educated
m
se
about minimising sun exposure to redu ce the risk o f squamous cell carcinomas and basa l
As
cell carcinomas.
Dr
Which one o f the fo llowin g is least associated with retro peritonea l fibrosis?
Ried el's thyroid itis
Previous radiotherapy
Inflammato ry abdom ina l a o rtic aneu rysm
Methyserg ide
m
se
As
Sulphonamides
Dr
Riedel's thyroiditis GD
Pret ous radiotherapy (D
Inflammatory abdomi nal aortic aneurysm GD

Methysergide f.!D
m
se
As
Sulphonamides CD
Dr
A 63 -year-old with a background history of type 2 diabet es mellitus, hypertension,
osteoarthritis and ischaemic heart disease is admitted to hospital with a right lower lobe
pneumonia. On admission his urea and electrolytes are as follows:
Na• 134 mmol/ 1
K• 4.2 mmolfl
Urea 9.8 mmolfl
On review of his medical records, his bloods three months ago showed the following:
Na• 135 mmol/ 1
K• 4.1 mmolfl
Urea 4.3 mmolfl
Which of the following of his regular medications is it safe t o continue?
Metfo rmin
Low -dose aspirin
Ramipril
Ibuprofen
em
s
As
Bendroflumethiazide
Dr
Metformin CD
I Low-dose aspirin GD
Ra mipril GD
Ibuprof en CD
Bendrof lumethiazid e flD
NSA!Ds should be stopped in AKI except asp irin at cardia- prot ective d ose
All of t hese medicat ions at full d ose are either nephrotoxic o r can b ecome toxic w hen
someone's renal fu nct ion is reduced. Asp irin at cardia -protective d oses (75 mg daily)
however is not sufficient t o cause a reduction i n renal funct ion and shou ld be cont inued
when so meone has an acute kidney injury. All other NSA!Ds and as pirin at full d ose
should be st opped to protect renal fu nction as t hey can cause vasoconstriction resulting
in a reduction in GFR.
ACE -i nhib ito rs actively reduce t he GFR by causing vasodilation o f t he efferent arteriole
and reducing t he glomerular filtration pressure. Because of t his, t hey should always be
st op ped in acut e kidney injuries as t hey can p recipitat e acute end-st ag e rena l failure. This
is in contrast t o their role in t he management o f diabetic nep hropathy where they have a
reno -prot ective role by p revent ing f urther d amag e to the glomeru lus. However, even in
these cases, if the renal fu nction det eriorates acutely the ACE inhibitor would be st opp ed
(at least temporarily) t o allow t he kidneys to recover.
All diuret ics have a nephrotoxic effect as t hey prevent f luid being reabso rbed into t he
cap illaries f rom t he t u bules and hence the blood f low t hrough t he cap illaries is lower. This
resu lts in a reduction in t he d elivery o f oxygen to t he dist al ends of t he syst em and can
resu lt in hypoxia and p recipit at e acute t ubular necrosis. Although b endroflu met hiazide is
a relat ively weak diuret ic it should still be stopped unt il renal function has recovered.
Metformin does not cause d amag e to t he kidneys but as it is renally cleared, it could build
em
up due t o renal failu re. This wou ld risk it causing a lact ic acidosis, esp ecially i n the cont ext
s
As
o f an infection.
Dr
A patient develops membranoproliferative glomerulonephritis secondary to partial
lipodystrophy. Which type of complement is likely to be low?
C3
C4
C2
C9
m
se
As
C6
Dr
I C3
C4
CD
(D.
C2 f.D
~C9 -
C6
-
Membranop ro liferative glomerulonephritis (m esangiocapillary)
• type 1: cryoglobulinaemia, hepatitis C
m
• type 2: partial lipodystrophy
se
As
Dr
A 74-yea r-old man with stage IV ch ron ic kidney disease secondary to type II diabetes
mell itus is admitted to the acute med ica l assessment ward with symptoms of
b reathlessness and reduced exercise tole rance. He is otherwise system ically well. His
b lood results are as follows:
Haemoglobin 80 g/1
Mean Corpuscular Volume 90 f1
Mean Corpuscular Haemoglobin 30 pg
Urea 17 mmol/ 1
eGFR 8 mlfmin/1.73m2
Given the likely cause of this patient's anaemia, which of the following compounds is the
patient most li kely to be deficient of?
Vita min 812
Ferritin
Folate
Erythropoietin
m
se
As
T3/T4
Dr
Vita min B12 CD
Ferritin .
(D
Folate CD
Erythropoietin GD.
3 /T4
-
Chronic Kidney Disease often leads to anaemia due to reduced levels of
erythropoietin
In many cases of advanced renal failure, the kidneys' ability to produce erythropoietin is
reduced, leading t o anaemia of chronic disease. There are several factors involved in renal
anaemia, however a lack of erythropoietin is the most significant contri but or.
Typically this deficiency manifests as a normochromic, normocytic anaemia, as seen in this

patient 's blood results.
m
se
In Vitamin Bl2/ Folat e deficiency and some cases of hypo/hyperthyro idism, a macrocytic
As
anaemia is seen. l ow ferritin levels will lead to a microcytic anaemia. Dr
A 31-year-old man was found unconscious on the street and brought by ambulance t o
the emergency department. He has a background of epilepsy and i ntravenous drug
abuse. On examination he is lethargic but no signs o f focal neurology. Pupils normal size
and both equally reactive to light. Blood pressure 138/ 82 mmHg, heart sounds normal.
His left calf was mildly swollen and warm to t ouch. He was catheterized and a residual
volume of 340 ml o f dark urine was collected. Ultrasound of his renal tracts was normal.
Hb 136 g/ 1
WBC 6 .85 8
109/ 1
Na• 134 mmol/ 1
K• 3 .9 mmol/1
Urea 9 .1 mmol/1
Urinary Na• 58 mmol/ 1
Which of the follow ing investigations is more useful t o identify the cause of his acute
kidney inj ury?
Antico nvulsants serum levels
Serum creatine kinase (CK)
Liver function t est and coagu lation t est
Blood cultures and midstream specimen of urine

s em
CT-an giogram rena l arteries an d left lower limb

As
Dr
Anticonvulsants serum levels
I Serum creatine kinase (CK)
Liver function t est and coagulation t est
Blood cu ltures and midstream specimen of urine
CT -an giogram renal arteries an d left lower limb
Rhabdomyolysis can cause parenchymal acute kidney injury and is characterised by

elevated plasma creatine kinase (CK)
The most likely cause fo r the acute kidney inj ury in the scenario is the deposit of
myoglobin. Creatine ki nase is released into blood stream in case of a muscle injury,
prevalent after seizu res, crush syndromes, traumatic muscle inj ect ions, fall, drugs su ch as
statins, malignant neuroleptic syndrome o r rheumatological diseases such as
dermatomyositis. It is a marker of possible acute kidney injury but what physically
damage the glomerulus and kidney tu bules is the deposit of myoglobin. It is characterised
by dark urine and stro ng positivity fo r ' Blood' in urine dipstick, althou gh it is not blood.
This p ositivity is due to similar heme group that myoglobin and haemoglobin share.
Some deranged levels of anticonvulsants can indeed cause renal impaired but unlikely in
this acut e scen ario.
Liver function t est and coagu lation could provide information liver failure and but not
useful to identify the most likely cause of his acute kidney injury if there is no hist ory of
hepatitis or liver cirrhosis.
Blood cu ltures and midstream specimen of urine are unlikely to account for his raised
creatinine unless in the presen ce of sepsis.
Finally, aCT-a ngiogram is useful if bilateral renal arteries stenosis is suspect ed, especially
em
if the a patient 's creatinine raises after being commenced on an angiot ensin-converting-
s
As
enzyme inhibitor.
Dr
A 65-year-old man is seen in the Emergency Department co mplaining of muscle
weakness and letharg y. Ad mission b loods show t he followi ng:
Na• 138 mm ol/ 1
K• 6 .6 mmolfl
urea 9.2 mmol/1
An ECG is done which shows no acute changes.
What is the most appropriate init ial treatment to lower t he serum potassium level?
Int ravenous bicarb onate
Haemodialysis
Insu lin/dextrose infusion
Int ravenous ca lcium gluconate
m
se
As
Oral calcium resonium
Dr
Intravenous bicarbonate
aemodialysis
Insulin/dextrose infusion
Intravenous calcium gluconate
Oral calcium resonium
m
se
Calcium gluconate wou ld stabilise the myocardium but would not reduce the serum
As
potassium level.
Dr
A 38-year-old wo man presents fo r review of her hypertension. She was diagnosed 6
mont hs ago, her blood pressure has b een refract ory to a com bination of amlodipine and
ram ipril. On examination, heart rate is 80bpm and blood pressu re is 170/ lOOmmHg.
Investigations:
Serum pot assium 2.9 mmoljl (3 .5-5 .0)
Plasma aldosterone ( after 30 minutes supine) 600 pmoljl ( 135-400)
Plasma renin activity (after 30 minutes supine) 6 .8 pmoljmtjhr (l.l -2.7)
What is the most likely cause of her hypertension?
Bartter syndrome
Bilateral rena l artery stenosis
Phaeochromocytom a
Pregnancy
m
se
As
Primary hyperaldosteronism
Dr
Bartter syndrome
Bilateral renal artery stenosis
Phaeochromocytoma
Pregnancy
Primary hyperaldosteronism
Primary hyperaldosteronism, bilatera l rena l artery stenosis and Bartter syn drome are
associat ed w ith hypokalaemia due ra ised serum aldosterone.
Aldosterone is elevated in bilat eral renal artery st enosis and Bartter syndrome due to
reduced renal perfusion. Aldosterone is high in primary hyperaldosteronism due to (most
commo nly) an aldosterone p roducing adenoma.
However, seru m renin is usually low in primary hypera ldosteronism due t o the resulting
hypertension causing excessive renal perfus ion, which resu lts in decreased ren in
p roduction (negative feedback mechanism). High renin levels are seen in renal artery
stenosis and Bartter syndrome as a mechanism t o improve renal perfusion.
Renal artery stenosis is associat ed with hypertension and may b e associat ed with
abd ominal b ruits caused by turbu lent f low within the st enosed arteries.
Bartter syndrome is associat ed with normotension.
The commonest cause o f bilateral rena l artery stenosis is atherosclerosis. However, in this
scena rio the patient is young and no cardiovascular risk fact ors are mentioned. Another
em
cause of bilatera l ren al artery stenosis, which shou ld be consid ered in t his patient, is
s
As
f ibrom uscular dysplasia, w hich can result in a non -atherosclerotic renal artery stenosis.
Dr
A 62-year-old man is admitted to resus w ith a low GCS. Blood gases taken on admission
show the following:
pH 7.23
pC02 2.2 kPa
p02 13.8 kPa
IV access is obtained and b loods are taken. He is given supportive care w ith oxygen and
f luid s. Rena l function resu lts show :
Na• 143 mmol/ 1
K• 4 .2 mmolfl
Urea 2. 1 mmolfl
Glucose 7. 1 mmolfl
Which one of the following diagnoses would be most co nsistent with these results?
Massive pu lmonary embolism
Met hanol poisoning
Paraquat poisoning
Diabetic ketoacid osis

em
s
As
Addisonian crisis
Dr
Massive pu lmonary embo lism
Methanol poisoning
Paraquat poisoning
Diabetic keto cidosis

-
"""
Addisonian crisis
This patient has a raised anion gap metabo lic acidosis which may be caused by methanol
m
se
po ison ing . Massive pu lmonary embolism is un like ly given the p02 as is diabetic
As
ketoacid osis given the blood g lucose.
Dr
A 25-year-old woman wit h a history of end-stage renal disease secondary to focal
segmental gl omeru losclerosis p resents to t he Emergency Department. For the past 12
months she has used Continuous Ambu latory Peritoneal Dialysis (CAPO). She feels
genera lly unwell with abdominal pain and a fever. She also describes her last bag as being
'cl oudy'. Which organism is most likely to be responsible for this presentat ion?
Enterococcus
Streptococcus agalactiae
m
se
As
Escherichia coli
Dr
Streptococcus pyogenes GD
Enterococcus fD
I Staphylococcus epidermidis ED
Streptococcus agalactiae fD
m
se
Escherichia coli 6D
As
Dr
Which o f t he following fact ors would suggest that a pat ient has p re-renal u raemia rat her
t han established acut e tubu lar necrosis?
Urine sodium = 70 mmoi/L
Fractional urea excret ion = 20%
No response to fluid challenge
Urine:plas ma urea ratio 5:1
m
se
As
Specific gravity = 1005
Dr
Fractional urea excretion = 20%
No response to fluid challenge
Urine:plasma urea ratio 5:1

-
""""
ATN o r prerena l uraemia? In prerenal uraemia think of the kidneys hol ding o n t o
m
se
sodium to preserve volume
As
Dr
Which one o f the following features is least likely to be seen in Henoch-Schonlein
purpura?
Abdominal pain
Renal fa ilure
Polyarthritis
Thrombocytopenia
m
se
As
Purpuric rash over buttocks
Dr
Abdominal pain GD
~nal failure GD
Polyarthritis fD
I Thrombocytopenia CD
m
se
Purpuric ra sh over b uttocks CD
As
Dr
A 45-year-old woman with nephrotic syndrome is not ed to have marked loss of
subcutaneous tissue from the face. What is the most likely underlying cause of her renal
disease?
Membranop roliferative glomerulonephritis type II
Focal segmental gl omeruloscleros is
Minimal change glomerulonephritis
m
se
As
Membranou s glomerulonephritis
Dr
I Membranoproliferative glomerulonephritis type II
Focal segmental glomerulosclerosis
~nimal change glomerulonephritis

Membranous glomerulonephritis
-
~
Membranop ro liferative glomerulonephritis (m esangiocapillary)

• type 1: cryoglobulinaemia, hepatitis C
• type 2: partial lipodystro phy
m
se
This patient has partial lipodystrophy which is associated with membranopro liferative
As
glomerulonephritis type II
Dr
You a re a sked to see a 69-year-old woma n with a backg rou nd histo ry of Alzhe ime r's
d e mentia a nd chronic kidney d isease who was a dmitted to the ward with pneu monia and
worseni ng confusion two days a go. The nurses repo rt that her urine out put has been
fall ing steadily over the last 12 hou rs. She has been treated with intravenous co-a moxiclav
and genta micin and regularly takes paraceta mol, a mlod ipine, furosemide and metopro lo l.
Her observations show a pu lse rate of 9 1 bpm, a resp iratory rate of 19 breaths per minute,
oxygen saturations of 99% on air and a b lood p ressure of 143/ 81 mmH g.
Her bloods on a dm ission show the following:
Hb 123 g/ 1 Na• 139 mmol/ 1
Platelets 45 1 * 109/1 K• 4 .9 mmol/1
WBC 11.9 8
109/ 1 urea 9.4 mmol/1
Neuts 9 .7 * 109/ 1 Creatinine 163 ~mol/1
Lymphs 1.4 * 109/ 1 CRP 179 mg/1
The last blood test from her GP showed the following urea and e lect ro lytes:
Na• 137 mmol/ 1
K• 4 .6 mmol/1
urea 6 .1 mmol/1
A urine dip is performed which shows the following :

Protein ++
Blood Trace
Leucocytes +++
Nitrites Negative
Given the urine dip result, which of the following is the most likely cause of her acute
kidney injury?
Acute tubular necrosis d ue to rhabdomyolysis
Acute interstitia l nephritis due to co-a moxiclav
Renal hypo -p erfusion due to sepsis
Bladder outlet o bstruction d ue to infection

s em
Glomeru lonephritis due to lgA nep hropathy

As
Dr
Acute tubular necrosis due to rhabdomyolysi s
I Acute interstitial nephritis due t o co-amoxiclav
Renal hypo-p erfusion due to sepsi s
Bladder outlet obst ruct ion due to infect ion
Glome rulonephritis due to lgA nep hropathy
Urine dip can b e used to differentiate acute tu bular necrosis from acute interstitial
nephrit is in AKI
The key to answering this question is using the urine dip results. The presence of protein
effectively rules out a p re-renal or post-renal cause and the lack of nit rites ru les out
inf ection. When trying to different iate between the two intrinsic renal causes, it helps to
understand how each of them affect the kidney. Acute interst itial nephritis is an
inf lammatory process so t here is a higher w hite cell content in the urine, while acute
tubular necros is is not so the urine has no cellular component. A glomerulonep hrit is
wou ld induce a nephritic syndrome with blood present in t he urine.
Given that in this case her urine conta ins a high w hite cell count and only a t race of b lood,
you can safely rule out a nep hrit ic syndrome. In acute tubu lar necrosis you wou ld not
expect there to be far more leu cocytes than red cells so this is also unlikely. The dip would
however fit with a diagnosis of acute interstitial nephritis w hich is know n t o b e caused by
em
administration of penicilli n-based antibioti cs. Treat ment wou ld invo lve stop ping the
s
As
causat ive drug and supp ortive management w ith flu ids.
Dr
Where is the site of action of spironolactone?
Proximal convoluted tubu le
Cortical collecting duct
m
se
As
Macula densa
Dr
Proximal convoluted tubu le
Ascending loo p of Henle

-~
Cort ical collecting duct

- ........
Macula densa
m
se
Spironolactone acts on the cortica l co llecting duct s as a diuretic
As
Dr
A 39-year-old woman with syst emic lupus erythemat osus presents for review in the
rheumatology cl inic. On examination mild pedal oedema is noted and the blood pressure
is slightly raised at 160/92 mmHg. Dipstick urine on arrival at cl inic shows protein + +,
blood+ + +. Further investigations reveal the following
Bicarbonate 2 2 mmol/ 1
Urea 7.1 mmol/1
24-hour urinary protein 2.6 g
What is the renal biopsy most likely to show?
Diffuse proliferative glomerulonephritis
Mesangiocapillary glomerulonephritis
Rapidly progressive glomerulonephritis
m
se
As
Minimal change disease
Dr
I Diffuse proliferative glomerulonephritis
Diffuse proliferative glomerulonephritis is the most common and severe form of

renal disease in SLE patients
Diffuse proliferative glomerulonephritis is the most common and severe form of renal
disease in SLE patients. The following features are supportive of this diagnosis:
• haematuria
• proteinuria
m
se
• oedema
As
• hypertension
Dr
Autosomal dominant polycystic kidney disease type 1 is associated with a gene defect in:
Chromosome 4
Chromosome 8
Chromosome 12
Chromosome 16
m
se
As
Chromosome 20
Dr
Chromosome 4 tiD
Chromosome 8 fD
Chromosome 12
Chromosome 16
•
GD
Chromosome 20 m
m
se
ADPKD type 1 = chromosome 16 = 85% of cases
As
Dr
A 43-yea r-old man is ad mitted to hospita l with pyelonep hritis d ue to a u reteric stone. He
is subsequently treated with intravenous antibiotics and e ndoscopic stone retrieva l. He
makes a g ood recovery cl inica lly but after a few d ays his renal function b eg ins to
d eteriorate and he d evelops an acute kidney injury. He is a pyrexial, his p ulse rate is 67
b pm, b lood p ressure is 134/ 89 mmHg a nd he is catheterised and his urine o utput is
a pproximate ly 60 ml p er hour.
A urine dip is performed which shows the fo llowing:

Prot ein ++
Leucocytes +
Nitrites Negative
Blood Trace
What is the most li kely cause of his acute kidney inju ry?
Ongoing urinary tract infection
Trimethoprim therapy
Bladder outlet obstruction
Renal hypo-p erfus ion
m
se
As
Gentamici n therapy
Dr
Ongoing urinary tract infectio n
Trimethoprim thera py
Bladder outlet obstruction
Renal hypo-perfusion
I
Gentamici n therapy
Gentamicin causes an intrinsic AKI

The urine dip shows proteinuria which would only be present with an intrinsic renal AKI.
Given he has been treat ed for pyelonephritis, t reatment with gentamicin would be the
most likely cause o f an intrinsic renal AKI in this gentleman.
His blood pressure and heart rate do no suggest he is under-perfusing his kidneys and
bladder outlet obstruction is not possible if he has a urine output o f 60 ml per hour.
m
se
Ongoing infection is also unlikely given he is apyrexial an d nitrit es are negative on the
As
urine dip. Trimethopri m is not known to cause intrinsic renal damage.
Dr
A 60-year-old wo man with a history o f hypothyroidism and inflammatory arthritis is
admitted ah er slipping on ice and falling over. Some routine blood tests are performed:
Na• 14 1 mm ol/ 1
K• 2.9 mmol/1
urea 5.2 mmolfl
Which one o f the following is most likely to explain these results?
Renal tubular acidosis (type 1)
Aspirin overdose
m
se
As
Conn's syndrome
Dr
Aspirin overdose
Conn's syndrome
Renal tubular acidosis cause s a norma l anion g a p

The low bicarbonate suggests an acidosis. The an ion gap is however no rmal, (141 + 2.9) -
(114 + 16) = 13.9 mmol/1. The differential d iagnosis is, the refo re, causes o f a metabolic
acidosis with a norma l anion gap.
Aspirin and d iabetic ketoacidos is cause a metabolic acid osis associated with a raised
anion gap. Conn's syndrome would explain the hypoka laemia but it do es not cause a
metabolic acidosis.
m
Renal tubular acidosis type 4 is associated with hyperkalaemia. The correct answer is,
se
As
the refo re, renal tubular acidosis type 1, wh ich is likely to be second ary to this patient's
inflammatory arthritis.
Dr
Which one of the following types of glomerulonephritis is most cha ract eristically
associat ed with Goodpasture's syndrome?
Ra pidly progressive glomerulonephritis
m
se
As
Focal segment al glomerulosclerosis
Dr
Diffuse proliferative glomerulonephritis .
(D
I Mesangiocapillary glomerulonephritis GD
Membranous glomerulonephritis GD
I Rapidly progressive glomerulonephritis GD

Focal segmental glomerulosclerosis m
Rapi dly progressive glomerulonephritis, causes:
• Goodpasture's
• ANCA positive vasculitis
Goodpasture's syndrome is rare condition associat ed with both pulmonary haemorrhage
m
se
and rapidly progressive glomerulonephritis. It is caused by anti-glomerular basement
As
membrane (anti-GBM) antibodies against type IV collagen
Dr
A 72-year-old woman who has been on the wa rd for the past five days is noted by the
nurses not to be passing much urine. She was admitted originally with pneumonia but has
since developed diarrhoea . Blood tests show her creatinine has increased from 98 to 172
IJmol/1. Which one o f the following test s is most useful when dete rmining whether there is
prerenal uraemia or acute tubu lar necrosis?
Serum urea level
Haemoglobin concentration
Plasma osmolality
Urinary urea
m
se
As
Urinary sodium
Dr
Serum urea leve l
~~globin concentrat ion

Plasma osmolality
Urinary urea
m
se
Uri nary sodium
As
Dr
A 55-year-old presents to the Emergency Department with shortness-of -breath since the
morn ing. Last month he was admitted following an i nferior myocardial infarction. He was
started on aspirin, at orvast atin, lisinopril an d bisopro lol. An echocardiogram performed
fo llowing the myocardial infarction showed normal left ventricular function. He is still a
smoker despite repeat ed att empts to give up.
Examination today reveals bibasal crackles wh ilst the chest x- ray shows upper lobe
diversion and p erihilar shadow ing. The ECG and cardiac enzymes are normal.
What is the most likely cause of his breathlessness?
Phaeochromocytom a
Fibromuscul ar dysplasia
m
se
As
Anterior myocardial infarcti on
Dr
( 1fective endoca rditis CD
Phaeochromocytoma
Fibromuscula r dysplasia
•
GD
I Renal a rtery stenosis GD

Anterior myocardial infarction
•
Flas h pu lmo na ry oedema, U&Es worse o n ACE inhibitor, asymmetrica l kidneys -
renal a rte ry stenosis - do MR an giography
Renal a rte ry stenosis may cause sudden onset or 'flash' pu lmonary oedema. A myocardial
infarctio n is unlikely g iven the normal ECG and cardiac enzymes. Chest pa in would also be
m
se
expected in a 55-year-old patient with no history of diabetes. Fibromuscular dysplasia is
As
generally seen in young woma n.
Dr
A 33-yea r-old man p resents with a one d ay history of pain and swelling in the right
testicle. Around fou r weeks ago he returned from a ho liday in Spain but reports no
dysuria or urethral discharge. On examination he has a tender, swollen right testicle. On
exa mi nation the heart rate is 84/min and his temperature is 37.1°C. What is the most
IM ceftriaxone stat + oral doxycyline for 2 weeks
Oral doxycycline + metron idazole for 2 weeks
Oral trimethopim fo r 2 weeks
Oral azithro mycin stat dose
m
se
As
Oral ciprofloxacin for 2 weeks
Dr
IM ceftriaxone stat + oral doxycyline for 2 weeks ED
Oral doxycycline + metronidazole for 2 weeks (fD
Oral trimethopim for 2 weeks CD

Oral azithromycin stat dose (fD
m
se
As
Oral ciprofloxacin for 2 weeks CD
Dr
A 35-year-old woman presents with a one week history of progressive leg swelling. Her
past medical history includes type 2 diabetes which is d iet-controlled . On examination,
there is bilatera l p itting oedema up to her knees and periorbital oedema. Her
observations are heart rate 88/ mi n, b lood p ressure 151/9lmm Hg, oxygen saturations
97%, temperature 37.1°(, and respiratory rate 14/min. Urine dipstick shows protein+ ++.
Two days later, she complai ns o f left-sided flank pain and haematuria.
What complica tion has occurred?
Haemorrhage into renal cyst
Splenic infarction
Renal vein throm bosis
Haemolytic crisis
m
se
As
Ureteric stone
Dr
Haemorrhage into renal cyst
Sp lenic infarction
Renal vein thrombos is
Haemolyti c crisis
Uret eric st one
Nephrotic syndrome is associated with a hypercoagulable state due to loss of

antithrombin III via the kidneys
Nep hrot ic syndrome is associated wit h a hypercoagu lable state due to loss o f
ant it hrombi n III via t he kidneys. The most co mmon site of t hrombosis is the renal vein but
patients are also at risk of deep vein thromboses and pulmonary embolis ms.
Haemorrhage into a renal cyst may p resent with f lank pain and haematuria but th is
history is not sugg estive o f renal cystic disease.
Splenic infarction can o ccu r in hyperco agulable states b ut t his is less common t han renal
vein throm bosis in nephrot ic syndrom e. Furthermore, haematuria is not a feature o f
splenic infarction.
Haemolyt ic crisis occurs in sickle cell disease, not nephrotic syndrome.

s em
As
Uret eric sto nes are not associated with nephrotic syndrome.
Dr
A sample of tissue from a renal biopsy is viewed using an electron microscope. Podocyte
fusion is seen. Which one o f the following types o f glomerulonephritis is most associated
with this finding?
Membranous glomeru lonephritis
IgA nephropathy
m
se
As
Dr
I Igt nephropathy
I Minimal change glomerulonephritis
Podocyte fusion is seen in minimal cha nge glomerulonephritis but may occasionally be a
m
se
featu re of foca l segmental glomerulosclerosis as well. Minimal change glomerulonephritis
As
however is far more commo n
Dr
Which one of the following types of glomerulonephritis is most characteristically
associated with partial lipodystrophy?
m
se
As
Rapid ly progressive glomerulonephritis
Dr
Mesangiocapillary glomerulonephritis (membranoproliferative)

• type 1: cryoglobu linaemia, hepatitis C
• type 2: partial lipodystrophy
Type 2 mesangiocapillary glomerulonephritis is associat ed with partial lipodystrophy.

Type 1 is seen in association with hepatitis C and cryog lobulinaemia
m
se
Mesangiocapillary glomerulonephritis is sometimes referred to as membranoproliferative
As
glomerulonephritis
Dr
Which one of t he followin g stat ement s reg arding t he assessment of p rot einuria i n
pat ients w ith ch ron ic kid ney disease is NOT true?
Albumin:creatinine ratio (ACR) is more sensit ive than protein:creatinine ratio (PCR)
An ACR of 30 mg/mmol is approximately equa l t o a PCR of 50 mg/mmol
An ACR sample is collect ed over 24 hou rs
Wome n typ ica lly have higher AC R values
m
se
As
An ACR of 3.8 mg/ mmol in a diabetic man is clinically significant
Dr
Albumin:creati nine ratio (ACR) is more sensitive than protein:creatinine ratio (PCR)(D
An Acr o f 30 mg/mmol is approximately equal t o a PCR o f 50 mg/mmol
An ACR sample is co llected over 24 hours
Women typically have higher ACR values
m
se
As
An ACR of 3.8 mg/m mol in a diabetic man is clinically significant
Dr
You are the ST2 worki ng in the oncology out-patient cl inic. Your next patient is a 67-year-
o ld man with castrate resistant/ hormone resistant metastatic p rostate cancer. Six months
a go at his last clinic review he was commenced on a docetaxel-based chemotherapy
regimen. Unfortunately, his disease has continued to progress. He is keen to pu rsue
fu rther treatment options and has been doing some resea rch of his own on the internet
and asks you about the possibility of sta rting treatment with abirate rone acetate. What is
its mechanism of a ct ion?
5 alpha -reductase inhibitor
Gonadotropin-releasing ho rmone (GnRH) agonist
Disrupts microtubules the reby stopping cell d ivision
Cytochrome P450 17 alpha-hydroxylase inhibitor
m
se
As
Alpha -blocke r
Dr
5 a lpha-red uctase in hibitor
Gonadotro pin- releasing ho rmo ne (GnRH) agonist
Disrupts microtubules the reby stopping cell d ivision
I Cytochrome P450 17 alpha-hyd roxylase inhibitor
Alpha-blocke r
Ab iraterone acetate is a selective androgen synthesis inh ibito r that works by b locking
cytochrome P450 17 a lpha-hydroxyla se. It blocks and rogen p roduction in the testes and
ad rena l g lands, and in prostatic tumour tissue. Abirate rone is adm inistered ora lly in
comb ination with pred nisolone. In a phase III cl inical trial in men with castrate refractory
p rostate cancer who had yet to receive chemothe rapy, the combination of a biraterone
a nd p redn isolone resulted in a significant surviva l b enefit compared to placeb o and
p rednisolone (prog ression free surviva l 16.5 months vs. 8.3 months). It is indicated fo r
treating metastatic castration resistant (ho rmone-relapsed) p rostate cancer in ad ult men
who a re asympto matic or mildly symptomatic aher failure of androgen d eprivation
therapy in whom chemotherapy is not yet clinically ind icated . It is also ind icated fo r
m
se
treating metastatic castration resistant prostate cancer in men whose disease has
As
p rogressed on or aher a d ocetaxel-based chemotherapy reg imen.
Dr
Which one of the following is not a risk factor for the development of ca lcium oxalat e and
ca lcium phosphat e renal stones?
Bendroflumethiazide
Ami nophylline
Acet azolamide
Furosemide
m
se
As
Prednisolone
Dr
Bend rof l u methiazid e ED
Aminophylline tiD
Acet azolami de .
(D
Furosem ide CD
Predniso lone «D
m
se
Bendro flumethiazid e may help prevent the format ion of ca lcium based rena l stones. It
As
may however theo retically increase the risk of urate based st ones
Dr
!1. 67 -yea r-old man p resents with p olyuria. His past medica l history includes hypertension
md bipolar diso rde r. His cu rrent medi cations include lisino pril, amlodipine,
)endro flumethiazi de, lithiu m and zop iclo ne . He s mokes 20 cigarettes/day and drinks
u ou nd 50 units of alcohol/week. He rep orts that his symptoms have been p resent fo r
u ou nd two months and have been getting wo rse. Some basic fasting bloods a re done:
149 mmol/ 1
3.8 mmol/1
urea 8 . 1 mmolfl
Glucose (fasting) 6.5 mol/ 1
Nhat is the most like ly unde rlying cause o f his symptoms?
Syndrome of inap propriate AD H secreti on second ary to lung ca ncer
Diabetes mellitus
Side-effects of ben droflum ethiazid e
m
Cra nia l diab ete s insipidus seco nd ary to lithium
se
As
Nep hrog e nic diabetes insipid us secon da ry to lithium

Dr
Synd rome of inappropriate ADH secretion secondary to lung cancer
ID~etes mell itus
Side-effects of bendroflum eth iazide
Cran ia l diabetes insipidus secondary to lithium
I Nephrogen ic diabetes insipidus secondary to lithium
m
se
The fasting b lood glucose is e levated a nd suggests a diag nosis o f impa ired fasting
As
glycaemia, rather tha n d iabetes mellitus. It certa inly isn't hig h eno ugh to be sympto matic.
Dr
A 45-yea r-old man with a history o f alcoholic liver disease p resents with abdominal
distension. Examination revea ls tense ascites which is dra ined . What is the ap propriate
type of diuretic to help prevent rea ccu mu lation o f ascites?
Aldosterone antagon ist
Loop diuretic
Thiazid e diu retic
Osmotic diuretic
m
se
As
Carbonic anhydrase inhi bito r
Dr
I Aldosterone antagonist CD
Loop diuretic tED
Thiazide diuretic
•
Osmotic diuretic
Ca rbonic anhydrase inhi bitor

•CD
Asc ites - use spironolactone

Aldosterone a ntagon ists su ch as spiro nolactone a re used in high doses to he lp prevent
m
se
the formation of a scites in patients with chroni c live r disease. A loop d iuretic may need to
As
be add ed in patients who d on 't respond
Dr
A 79-year-old co mpla ins of lower urinary tract symptoms. Which one of the following
statements rega rding benign prostatic hyperplasia is incorrect ?
Goserelin is licensed for refractory cases
Side-effects of 5 alpha -red uctase inhibito rs inclu de ejaculation diso rde rs and
gynaecomastia
Possible presentations include recurrent urinary tract infection
5 alp ha -red uctase inh ibito rs typica lly d ecrease the prosta te specific antigen level
m
se
As
Mo re common in b la ck men
Dr
Gosere lin is licensed fo r refractory: cases
Side-effects of 5 alpha -red uctase inhibitors include ejaculation diso rders and
gynaeco{nastia
Possible presentations include recurrent urinary tract infection
5 alpha-reductase inhibitors typically decrease the p rostate specific antigen levelf::D
Mo re common in bla ck men

-
""""
m
se
As
Goserelin (Zoladex) is not used in the management o f ben ign p rostatic hyperp lasia
Dr
A 50 year-old man with dialysis dependent chronic kidney disease is awaiti ng renal
transplant. He co mplains of fatigue. On examination you not e heart rat e 95 beats p er
minute, soh ejection syst olic murmur that doesn't radiate and pallor. There were no other
abnormal features.
What is the most likely cause of his fatigue?
Heart fa ilure
Endocarditis
Uraemic en cephalopathy
Anaemia
m
se
As
Hyperkalaemia
Dr
I Heart fa ilure CD
Endocardit is fD
Uraemic en cephalopathy CD
I Anaemia fZD.
Hyperkalaemia CD
~
Anaemia is extremely common in chronic kidney disease. It is often caused by iron
m
se
d eficiency or erythropoietin d ef iciency. The man in t his case has a few signs and
As
sympt oms of anaemia - t achycardia, fatigue, pallor and an aortic flow murmur.
Dr
You are asked to review a 75-year-old female on the surgica l wards due t o hyperkalaemia.
Resu lts are as fo llows:
Plasma Urine
Na• (mmol/ 1) 129 5
K• (mmol/ 1) 6.8
Urea (mmol/1) 26 350
Creatinine (~mol/1 ) 262
Osmolality (mosmolfkg) 296 470
Acute tubular necrosis
Hyperos molar non -ket otic coma
Hydronephrosi s
Preren al acute kidney injury
m
se
As
Pyel onephritis
Dr
ATN o r prerenal uraemia? In prerenal uraemia think of the kidneys holding on to
sodium to preserve volum e
m
se
The low urine sodium points towards prerenal acute kidney injury, as does the
As
urine:plasma osmolality and urea ratio.
Dr
Which one o f t he followin g statements is t rue regarding aut osoma l recessive polycystic
kidney disease?
Onset is typically in the third decade
Liver involvement is rare
Is due to a defect on chromosome 16
More common than autosomal dominant polycystic kidney disease
m
se
As
May be diagnosed on prenata l ultrasound
Dr
Onset is typically in the thi rd decade CfD
Liver involvement is rare CfD
Is due to a defect on chromosome 16 CD
More common than autosomal d ominant polycyst ic kidney disease
•
m
se
e:D
As
May be diagnosed on prenatal ultrasound
Dr
A 32-year-old male presents to his GP with swelling of his feet and hands and feeling
lethargic. On examination, he has pitting oedema in both his upper and lower limbs and
he appears to have peri-orbital oedema. His abdomen is distended and shifting dullness
is present and there are coa rse crackles audible on auscultation of both lung bases. A
urine dip shows the following:
Leucocytes negative
Nitrites negative
Blood negative
Protein +++
pH 6
Glucose negative
What is the most likely underlying pathology?
Granulomatosis with polyangiitis
Goodpasture's disease
m
se
As
Dr
I Gra nulo matos is with po lya ngiitis
Goodpasture's disease
I Focal segmental glome rul oscleros is
Minimal cha nge d isease
The lack of blood in the urine indica tes this to be a purely nep hroti c syndrome. Give n the
patient's ag e, the most likely cause of this would be a foca l segmental glo merulosclerosis.
Minimal cha nge d isease wo uld have been the most likely d ifferential of a nep hrotic
syndrome we re the patient a child . Althou gh membra nous g lom erul opathy can cause a
ne phrotic syndrome, it is not as common as either of the two other ca uses a bove.
Mesangiocapillary glome rulonephritis causes a nep hritic syndrome with at lea st a sma ll
amount of blood being p resent in the urine, which is absent in this patient.
Granu lomatosis with po lya ngiitis is asso ciated with a more nep hritic picture.
m
se
Goodpasture's is associated with haematu ria and con current pulmona ry disease in which
As
hae moptysis is a fea ture, neither of which this patie nt has. Dr
Which of the following types of renal stones a re said to have a semi-opaq ue a ppeara nce
on x-ray?
Calcium oxalate
Cystine stones
Urate stones
Xanthine stones
m
se
As
Triple phosphate stones
Dr
Calcium oxalate
Cystin e stones
Urate stones
Xanthine stones
Triple phos phate stones

-
~
Renal stones on x-ray

• cystine stones: sem i-opaque
m
• urate + xanthine stones: radiolucent
se
As
Dr
A 26-year-old man with loin pain an d haematuria is found to have autosomal dominant
polycystic kidney disease. A defect in w hich one of the following genes is likely to be
respo nsible?
Fibrillin -2 gene
Polycystin gene
Fibrillin -1 gene
Von Hippei- Lindau gene
m
se
As
PKDl gene
Dr
Most cases of autosomal dominant po lycystic kidney disease (ADPKD) are due to a
m
se
mutation in the PKDl gene. The PKDl gene encodes for a po lycystin -1, a large ce ll-
As
su rface g lycoprotein o f unknown function
Dr
A 45-yea r-old woman with type 1 diabetes mell itus is reviewed in the diabetes cli nic.
Three months ago her blood tests were as followed:
K• 4.5 mmolfl
Creatinine 116 lJmol/ 1
eGFR 47 mljmin
At the time she was started on lis inopril to treat both the hypertension and act as a
renoprotective agent. Lisinopril had been titrated up to treatment dose. Her current
bloods are as follows:
K• 4.9 mmol/1
Creatinine 123 lJmol/ 1
eGFR 44 mljmin
Of the following options, what is the most approp riate course of action?
Stop li sinopril and arrange investigations to exclude renal a rtery stenosis
Switch to a angiotensin 2 receptor blocker
Switch to a different ACE inhibitor
No action em
s
As
Reduce dose o f lisinopril

Dr
St op lisinopril and arrange investigations to exclude renal arte ry stenosis
Switch to a angiot ensin 2 recepto r blocker

-
~
Swit ch to a different ACE inhibitor
I No action
Reduce dose o f lisinopril
m
se
The small change in both the creatinine and eGFR are accept able and below the threshold
As
where ACE inhibitors should be stopped
Dr
Which one of the following types of glomerulonephritis is most cha racteristically
associat ed with streptococcal infect ion in children?
m
se
As
Dr
-
~
Ra pi dly progressive glomerulonephritis
Diffuse proliferative glomerulonephritis, causes:

• post-streptococcal
m
• SLE
se
As
Dr
Fanconi syndrome is associated with each one of the following, except
Hydronephrosis
Osteomalacia
Am inoaciduria
Glycosuria
m
se
As
Proximal renal tubular aci dosis
Dr
I Hydronephrosis
Osteomala cia
Aminoaciduria
~ycosuria
m
se
As
Proximal renal tu bular aci dosis
Dr
A 29-year-old man has his renal function checked. The eGFR is calcu lated t o b e 54
mljmin. Which one of the following facto rs is most likely t o explain this unexpectedly low
result?
Drinking a large amount o f milk
Being dehydrat ed when the blood sample was taken
Being very t all
Excessive alcoh ol intake
m
se
As
La rge muscle ma ss secon dary to b ody building
Dr
Drinking a large amount of milk
Being dehydrated when the b lood sample was taken
Being very ta ll
Excessive alcohol i ntake
Large muscle mass secon dary to bo dy building
m
se
The eGFR is often inaccurat e in people w ith extremes o f muscle mass. Body builders often
As
have an inappropriately low eGFR.
Dr
Which one of the following may be useful in the prevention of oxalate renal stones?
Ferrous sulphate
Thiazide diuretics
Lithium
Pyridoxine
m
se
As
Allopurinol
Dr
Ferrous sulphate m
Thiazide diuretics ED.
Lithium m
Pyridoxine CD
m
se
Allopu rinol GD
As
Dr
A 20-yea r-old woman presents with a 5-day h istory of painless light b rown colou red
urine. She has experienced 3 episodes of this over the 5 d ays. There is no dyspa reunia,
urg ency or pa in elsewhere. As o f now, she is a febrile though she a lludes to being ill with a
respiratory infection around three weeks ago.
Urine dipstick revea led protein and b lood.
Post streptococcus glomerulo nephritis (PSGN)
UTI
Pyelonephritis
Alpert's syndrome
m
se
As
IgA nephropathy
Dr
Post streptococcus glomeru lonephritis (PSGN)
UTI
Pyelonephrit is
Alport's syndrome
IgA nephropat hy
PSGN d evelops 1-2 weeks after URTI. Ig A nephropathy develop s 1-2 d ays after URTI
The symptoms, previous illness and prot einuria point to PSGN. This is a d elayed anti body-
mediat ed disease following inf ection of t he pharynx or ski n causing nep hritic syndro me.
Pyelonephriti s and a UTI wou ld p resent different ly inclu ding symptoms such as fever,
dysuria and pain. Alport's is charact erised by haemat u ria, sensory hearing loss and ocular
m
se
dist u rbances. IgA nephropathy wou ld occur a few days after the respiratory infection
As
rat her than weeks.
Dr
A 44-year-old male w ith a background of multiple myeloma presents to the haematology
clinic with swelling of the lower limbs. Blood tests showed low albumin levels and an urine
dipstick was positive for protein. He has a kidney biopsy and stains positively for Congo-
red which combined w ith polarised light, appears apple-green. What is the most likely
diagnosis?
Amyloi dos is
IgA nephropathy
m
se
As
Syst emic lupus erythematous
Dr
Amyloidosis
Minimal change d isease
IgA nephropathy
Membranous g lomeru lone phritis
Patients with mu ltiple mye loma are at risk to deve lop AL a myloidosis which can present
as nephrotic syndrome like in this case. Such histopathological findings are only
characte ristic of amyloidosis and not the other 4 options.
Under e lectron microscopy, min ima l change d isease resu lts in diffuse loss of visceral
epithelial cells' foot p rocesses, vacuolation and growth of microvill i on the visceral
epithelial cells. Under light microscopy, ve ry minimal changes are noted .
IgA nephropathy is characterised by deposits of immunog lobulin A in a g ranu la r pattern

in the mesangium seen on im munofluorescence.
In membranous g lomeruneph ritis, the basement membrane is observed to be diffusely

thickened. Us ing Jones' stain, the basement membrane appears to have a 'spiked' or
'holey' appea rance.
Systemic lupus erythematous can lead to membranous glomerulonephritis which is due

em
to immune comp lex deposition along the glomerular basement me mbrane. This appea rs
s
As
as a granular appearance on immunofluorescence testing.

Dr
A 62-year-old man attends your clinic. He has a history of hypertension and atrial
fibrillation for wh ich he is anticoagu lat ed with warfarin. A urine dipstick ta ken 8 weeks ago
during a routine hypertension clinic appointment showed blood + with leu cocytes +. An
initial urine microscopy and culture shows no growth. This result has b een repeat ed on
two further occasions with the same finding.
What is the most appropriat e action?
Take no further action
Sen d a 24-urine sample for protein estimation
Refer to nephrology
Refer to urology
m
se
As
Sen d a further urine microscopy
Dr
I Post streptococcus glomerulonephritis (PSGN)
UTI
Pyelonephritis
Alport's syndrome
IgA nephropathy
PSGN d evelops 1-2 weeks after URTI. Ig A nephropathy develop s 1-2 d ays after URTI
The symptoms, previous illness and prot einuria point to PSGN. This is a delayed antibody-
mediated disease fo llowing infect ion o f the pharynx or skin causing nephrit ic syndrome.
Pyelonephrit is and a UTI wou ld p resent different ly inclu ding symptoms such as fever,
dysu ria and pain. Alport's is characterised by haematuria, sensory hearing loss and ocu lar
m
se
disturbances. IgA nephropathy would occur a few days after t he resp iratory infection
As
rather t han weeks.
Dr
You are working on a general med ica l wa rd and are reviewing the blood resu lts and
observations charts of your patients. Which of the below patients meets the criteria for an
acute kidney injury?
Patient with a potassium of 6.7 mmoi/L
Patient whose creatinine has increased from 78 to 100 micromoi/L over 48 hours
Patient with a creatinine of 150 micromoi/L, whose most recent creatinine 12

months a go was 110 micromoi/L
70kg patient who has produced 20-25ml of urine per hour for each of the last 7
hours
m
se
As
Patient with an eGFR of 60
Dr
Patient with a potassium of 6.7 mmoi/L
Patient whose creatinine has increased f rom 78 t o 100 micromoi/L over 48 hours f!D
Patient with a creatinine o f 150 micromoi/L, whose most recent creatinine 12
mont1 ago was 110 micromoi/L
70kg patient w ho has produced 20-25ml of uri ne per hour for each o f t he last 7
hours
Patient with an eGFR of 60
Urine output of < 0.5 ml/kg/ hr ove r 6 consecutive hours constitutes an acute kidney
InJUry
The correct answer is t he patient who has p ro duced 20 -25ml o f urine per hour o ver t he
last seven consecutive hou rs. He shou ld be p roducing more t han 35m I per hour for his
weight.
The patient w ith a pot assium o f 6.7 may have hyperkala emia from mult iple causes ot her
t han acut e kidney inj u ry. The seco nd patient has a creatinine rise o f 22 micro moi/L i n 48
hours, which d oes not meet the acut e kidney inj u ry def inition o f a rise of > 26 in 48 hours.
The th ird pati ent has a < 50% increase in creatinin e and t his may not have occurred
within t he last 7 d ays as his most recent reading was 12 months ago. The pat ient w it h a
single eGFR rea ding o f 60 may have an AKI or chronic kidn ey disease b ut more reading s
are required to assess t he trend.
s em
NICE CKS. Acut e kidney inj ury

As
Dr
An 8-year-old boy prese nts to his GP with swelling around his eyes and lim bs, ti redness
and weight gain. The GP performs a urine dip. What is the most likely underlying
pathology in this child?
IgA nephropathy
Glomerulosclerosis
Type I diabetes mell itus
m
se
As
Dr
IgA nephropathy
r :nimal change d isease
Glomeru losclerosis
Type I diab etes mell itus
Membranous g lomeru lonephritis
Minimal change d isease is the most common cause o f nephrotic syndrom e in a

child
Important for me Less ' m::~c rtont
The correct answer is 2. Th is child is p resenting with nephrotic synd rome. The classic triad
o f neph rotic syndrome is proteinuria, hypoalbuminaem ia and oedema. The most common
cause of nephrotic syndrome in children is minimal change d isease, which accounts for
around 80% of cases in children. Minimal change d isease accounts for only 10-25% of
cases of neph rotic synd rome in adults.
m
se
KDIGO clinica l p ractice guideline for glomerulonephritis
As
http://kdig o.org/clinicalpracticegu idelines/pdf/KDIGO-GN -Guideline.pdf
Dr
A 28-year-o ld female undergoes a re nal transpla nt for foca l segmental
glomerulosclerosis. With in hours of the operatio n the patient becomes unwell with
features consistent with severe systemic inflammatory response synd rome. The patient is
im mediately taken back to theatre a nd the transplanted kid ney is removed. What type of
im munoglobu lin s are responsible for the grah rejection?
IgE
IgM
IgG
IgD
m
se
As
IgA
Dr
IgE GD
Ig M tiD
~ GD
IgD m
IgA fD
m
se
Hyperacute g raft rejection is due to p re -existent antib od ies to HLA antig ens a nd is
As
the refo re IgG med iated
Dr
A 25-year-old man presents w ith haematuria, fever, vo miting and fatigue. He has a
creatinine of 342, having previously had a creatinine of 95 when it was last checked 2
years ago. In the emergency department, he coughs up a small amount of bloody sputum
and then has a nosebleed. He also complains of an earache. From this information, which
of t he following conditions is most likely?
Pneumonia
Granulomatosis with po lyangiitis
m
se
As
Chu rg-Strauss syndrome
Dr
Pneumonia m
I Granulomat osis with polyangiitis ED
Syst emic lupus erythematosus m
Goodpasture's syndrome eD
Churg -Strauss syndrome (fD
The presence of upper respiratory tract si gns points towards granulomatosis with
polyangiitis in a patient w it h rapidly progressive glomeru lonephritis
The correct answer is 2. This patient has an acute kidney injury, fever, and upper
respiratory tract signs. The presence of upper respirato ry t ract or ENT signs points
towards gra nulomatosis with polyangiitis (GPA, previously ca lled Wegener's syndrome). A
pat ient w ith Goodpasture's syndrome is likely to present w ith haemoptysis but wou ld not
be expected to have ENT signs such as epistaxis or an earache. Ot her ENT signs in GPA
include crusting around t he nost rils, sinusitis or sinus pain, hearing loss, or a blocked or a
m
runny nose.
se
As
https:/ /www .nhs.uk!co nd iti o ns/gran uIom atos is-with -po lyangi it is/
Dr
A 62-year-old man is diagnosed with renal cell cancer. Which one of the following
hormones is least likely to be present in excessive levels?
Erythropoietin
Parathyroid hormone
Growth hormone
ACTH
m
se
As
Renin
Dr
Erythropoietin fiD.
Parathy oid hormone GD
Growth hormone crD
ACTH CD
m
se
Renin GD
As
Dr
A 10-year-o ld boy is taken to see the GP by his mother. Fo r the past two days he has had
a so re throat associated with blood in his urine. There is no s ign ificant past med ical
history. The GP suspects glome rulonephritis and refers the patient to hospita l. What
wou ld a renal biopsy most likely show?
Prol iferation of endothel ia l cells
No change
Mesangial hypercellu larity
Base ment membrane thickening
m
se
As
Capillary wall necrosis
Dr
Proliferation of endothelial cells GD
..
No change GD
I Mesangial hypercellularity
Basement membrane thickening fl'D.

Capillary wall necrosis
•
m
se
This boy is likely to have IgA nephropathy. Histological features include mesangial
As
hypercellularity an d positive immunofluorescence for IgA & C3
Dr
What is the mechanism of action of goserelin in prostate cancer?
And rogen receptor antagonist
Oestrogen agonist
GnRH agonist
Luteinising hormone recepto r antagonist
m
se
As
GnRH antagonist
Dr
And rogen receptor antagonist
Or trogen agon ist
GnRH agonist
Luteinisin g hormone recepto r antagonist
GnRH antagonist
-
~
m
se
Goserelin (Zoladex) is a synthetic GnRH agon ist wh ich provides negative feedback to the
As
anterio r pituitary
Dr
Each one of the following is a recognised side-effect of eryt hropoietin, except:
Urticaria
Hypertension
Bone aches
Long bone fractures
m
se
As
Pure red cell aplasia
Dr
Urticaria GD
Hypertension tED
f.D
..
Bone aches
I Long bone fractures
m
se
Pure red cell aplasia fD
As
Dr
A 13-year-old g irl develops pu rpu ra on her lower limbs and buttocks associated with
microscopic haematuria. A d iagnosis of Henoch-Schonle in pu rpu ra is made. Her urea and
electro lytes show mild renal impairment that is still present 4 weeks later, although she
does not requ ire any specific thera py. What is the most likely renal outcome?
Hypertension with in 20 yea rs
Persistent p roteinuria
End stage rena l fa il ure
Full renal recovery
m
se
As
Frequent relapses
Dr
A 13-year-old girl d evelops purpura on her lower limbs and b utt ocks associated with
microsco pic haematu ria. A diagnosis o f Henoch -Schonlein purpura is made. Her urea and
electrolytes show mild renal impairment that is still present 4 weeks lat er, althou gh she
d oes not require any sp ecific therapy. What is t he most likely renal outco me?
Hypertensi on with in 20 years CD

~rsistent p roteinuria CD
End stage renal failure m
I Full renal recovery CD
m
se
Frequent relapses tED
As
Dr
A 55-year-o ld male is being eva luated for persistent p roteinu ria . He has a past med ica l
history of mu ltiple myelom a that has recently relapsed. He undergoes renal biopsy. Lig ht
microscopy with Co ngo red stai n reveals apple-green birefrin gence under polarised light.
Alport syndrome
Focal segmental glomeruloscleros is
Goodpasture syndrome
Acute post-streptococcal glome rulonephritis
m
se
Amylo idosis
As
Dr
I Alport syndrome
Focal seg me ntal g lome ruloscle ros is
Goodpastu re syndro me
Acute post-stre ptococcal g lom e rulonephritis
Amyloidosis
Amylo idosis biopsy findings - Congo red sta in shows apple-green bire fringence
under polarised light
Primary amylo id osis can b e seen in patients with immune dyscrasias such as mu ltiple
mye loma. Amylo idosis is a te rm which d escribes the extracell ula r d e positio n of an
insolub le fibrilla r prote in te rmed a myloid. It can affe ct any o rgan in the body. The
diag nosis of a mylo id osis is confirmed via a bio psy with Co ngo red sta ining showing
a pple -green bire fring ence und er po la rised lig ht.
AIpo rt syndrome (mutatio n in type IV colla ge n) wou ld result in a 'basket weave'

a ppea rance o n electron microscopy. It causes eye p ro blems, g lomerulonephritis and
sensorin eura l deafness.
Foca l seg me ntal gl omeruloscle ros is would show segmenta l sclerosis a nd hya linosis on
lig ht microsco py a nd effacement of foot process o n e lectron microscopy (simila r to
min imal change di sease).
Goodpast ure syndrome wou ld result in crescentic glomerulo nep hritis. Glomeruli ap pea r
li ke a cresce nt moon on lig ht microscopy a nd immunofluorescence.
Acute post-streptococcal gl omerulone phritis wou ld show enlarged a nd hypercellular

glomeruli with 'sta rry sky' (gra nula r) a ppea ra nce o n lig ht microscopy and
em
im munofluoresce nce, respectively. The re are sub ep ithelial immune co mplex hum ps on
s
As
electro n microscopy.
Dr
Yo u are a medica l senior house officer sta rting a Saturday shift cove ring the renal ward.
The night shift d octor is hand ing ove r the unwel l patients to yo u. Which o f the patie nts
be low with acute kidney inj ury shou ld b e referred to day fo r urg ent re nal rep la cement
the rapy?
Patient with potassium o f 6.8 who has had 3 courses of med ical management of
hyperkalaemia but with no reductio n in his potass ium leve l
Patient with eGFR < 5
Patient who has had 10m I of urine o utp ut over the last 24 ho urs
Patient with stage III acute kid ney inj ury an d only one kid ney
m
se
As
Patient who has p reviously had acute kidney inj ury three times b efore
Dr
I Patient with potassium of 6.8 who has had 3 courses of med ical management of
hyperkalaemia but with no reduction in his potassium leve l
Patient with eGFR < 5

GD
-
~
Patient who has had 10m I of urine output over the last 24 hours
Patient with stage III acute kidney inj ury and only one kid ney
Patient who has previously had acute kidney injury three times before
In AKI, hyperka laeamia which is refractory to medical management is an indicato r

for renal replacement therapy
NICE states that the below criteria are all indications fo r re nal replacement therapy in
acute kid ney injury - but all o nly if refractory to medica l management:
1. Hyperka laemia
2. Meta bolic acidosis
3. Symptoms o r co mp lications o f uraemia e.g. perica rditis o r encephalo pathy
4. Severe pu lmonary oedema
NICE: Acute kidney injury; prevention, detection and ma nagement

s em
https://www.nice .o rg.uk/g uidance/ cg169/ chapter/l -Recommenda tio ns#manag ing-acute-

As
kidney-injury
Dr
Which one o f the following diseases would give a positive cyanide-nitroprusside test?
Bartter's syndrome
Cryog lobu linaem ia
Cystinuria
m
se
As
Cystinosis
Dr
Bartter's syndrome
._______.
m
Cryoglobulinaemia tiD
I Cystinuria ED
Paroxysmal nocturnal haemoglobinuria «D
Cystinosis GD
m
se
As
The cyanide-nitroprusside test wou ld also be positive in homocystinuria
Dr
Each o f the following is a risk factor for renal st one formation, except:
Cadmium
Hyperparathyroidism
Dehydration
m
se
As
Cystinosis
Dr
Renal tubular acidosis GD
Cadmium 6D
Hyperparathyroidism
Dehydration
•
CD
Cystinosis ED
m
se
As
Cystin uria, not cystinosis, is a risk factor for renal stone formation
Dr
A 65-year-old man with a history of hypertension is reviewed. As part of routine blood
t ests to monitor his renal fu nction whilst taking ram ipril the following blood tests are
received:
Na• 140 mmol/ 1
K• 4 .8 mmolfl
Urea 6 .2 mmolfl
eGFR 68 ml/min
A urine dipstick is subsequently performed which is normal and a renal ultrasound sound
shows normal sized kidneys with no abnormality detected. What stage of chronic kidney
disease does this patient have?
No chronic kidney disease
m
se
Chronic kidney disease stage 1 As
Dr
No chronic kidney disease
Ctronic kidney disease stage 4
CKO: on ly diagnose stages 1 & 2 if su pporting evidence to accompany eGFR

m
se
Chronic kidney disease is only diagnosed in t his situation if supporting t ests such as
As
urinalysis or renal ultrasound are abnormal
Dr
A mutatio n in the gene that e ncodes a quapo rin 2 is most likely to resu lt in:
Histiocytosis
Alpert's syndrome
Diabetes insipidus
m
se
As
Medullary sp onge kidney
Dr
Histiocytosis
Alpert's syndrome
Diabetes insipidus
m
se
As
Medullary sponge kidney
""'
Dr
A 54-year-old woman is admitted to the Emergency Department following what sounds
like an episode of vasovagal syncope. Blood gases on admission show a met abolic
acidosis. Blood tests are reported as follows:
Na• 143 mmol/ 1
K• 3.0 mmolfl
urea 4 .0 mmolfl
Which one of the following is most likely to explain the metabolic acidosis?
Lithium overdose
Aspirin overdose
Recent myocardial infarction
Alcoholic ketoacidosis
m
se
As
Uret erosigmoidostomy Dr
Lit hium overdose
Aspirin overdose
Recent myocard ial infarct ion
Alcoho lic ketoacidosis

-
~
Uret erosigmoid ostomy
Uret erosigmoid ostomy- normal anion gap metabolic acid osis

The anion g ap is normal, (143 + 3.0) - (116 + 18) = 12 mmol/1, which is consist ent w ith a
m
se
ureteros igmoidostomy. Aspirin overdose, myocardial infarct ion and alcoholic ketoacidosis
As
wou ld cause a raised anion gap
Dr
You are reviewi ng a 65-yea r-old in the renal clinic. He has been on haemodialysis for
chronic ki dney disease fo r the past 6 years. What is he most likely to die from?
Hyperkalaem ia
Maligna ncy
Dialysis related sepsis
m
se
As
Ischaem ic heart disease
Dr
Hyperka laemia GD
r r alig na ncy m
Dilated cardiomyopathy f!D
Dialys is related seps is f!D
lsc haem ic heart d isease GD
CKD o n haemodia lysis - most like ly cause o f d eath is IHD

m
se
As
Card iovascular events account for 50% of the morta lity in patients receiving dialysis.
Dr
Which one of the following stat ement s regarding minimal change glomerulonephritis is
incorrect?
Has a good prognosis
The maj ority of cases are steroid responsive
Is a common cause of nephrotic syndrome
Hypertension is found in approximately 25% of patients
m
se
Haematuria is rare
As
Dr
Has a good prog nosis
The majority of cases a re steroid responsive
Is a co1 mo n cause of nephrotic syndrome

-
~
Hypertension is found in approximately 25% of patients
Haematuria is rare
m
se
As
Hypertension and haem aturia are rare in minima l change glomeruloneph ritis
Dr
A 47 -yea r-old wo man presents with lo in pa in and haematu ria. Urine dipstick
d emonstrates:
Blood +++ +
Nitrites POS
Leucocytes +++
Prot ein ++
Urine cu lture shows a Proteus infection. An x-ray demonstrates a stag -horn calculus in the
left renal pelvis. What is the most likely composition of the rena l stone?
Xa nthi ne
Ca lcium oxalate
Struvite
Cystine
m
se
As
Urate
Dr
Xanthine
Calcium oxalate
•
CD
Struvite GD.
Cystine
Urate
•m
Stag -horn calcu li are co mposed of struvite and form in alkaline urine (ammonia
m
se
p roducing bact eria t herefore p redispose)
As
Dr
A 62-year-old man p resents w ith nocturia, hesitancy and terminal dribbling. Prostate
examination revea ls a mod erately enlarged prostate with no irregular features and a well
d efined median sulcus. Blood test s show:
PSA 1.3 ng/ml
Alpha-1 antagonist
5 alpha-reductase inhibitor
Non -u rgent referral for transureth ral resection of prost ate
Empirical t reatment w it h ciprofloxacin for 2 weeks
m
se
Urgent referra l to urology
As
Dr
Alpha-1 antagon ist
5 a lpha -reductase inhibito r

-
~
Non -urg ent re ferra l fo r transureth ral resectio n of prostate
Empirical treatment with ciprofloxacin fo r 2 weeks
Urg ent re fe rra l to uro logy
m
se
As
Alpha-1 anta gon ists a re first- line in patients with benign p rostatic hyperplasia
Dr
Alpert's syndrome is due to a defect in:
Fibri llin -2
Type II collagen
Fibri llin -1
Type N collagen
m
se
As
Type V collagen
Dr
Fibri llin-2 .
(D
Type II collagen GD
Fibri l 'n-1 .
(D
Type N co llagen (ifD
Type V collagen fD
m
se
Alpert's syndrome - type IV collagen defect
As
Dr
A 54-year-old man who has end stage diabetic nephro pathy is being assessed for a renal
transplant. When assessing the HLA matching between donor and recipient w hat is t he
most important HLA antigen to match?
DP
DR
m
se
As
A
Dr
DP .
(D
B CD
DR GD
c CD
A f.D
m
Renal t ransp lant HLA matching - DR is t he mo st important
se
As
Dr
You review a 42-year-old woma n six weeks following a renal transplant for focal
segmental glomerulosclerosis. Following the procedure she was discharged on a
combinatio n of tacrolimus, mycophenolate, and prednisolone. She has now presented
with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On
examination her sclera are jaundiced and she has widespread lymphadenopathy with
hepatomega ly. What is the most likely diagnosis?
Hepatitis C
Epstein-Barr virus
HIV
Hepatitis B
m
se
As
Cytomegalovirus
Dr
Hepatitis C .
(D
Epstein-Barr virus GD
HN m
Hepatitis B CD
Cytomegalovirus flD
Cyto meg alovirus is t he most co mm on and important viral infection in solid org an
transp lant recipients
m
Important for me Less : m ::~c rtC~nt
se
As
Ganciclovir is the t reatment o f choice in such patients.
Dr
What is the most likely outco me following the diagnosis of minimal change nephropathy
in a 10-year-old male?
Chronic kidney disease requiring renal replacement therapy within 30 yea rs
Full recovery and no further episodes
Full recovery but with later relapses
Chronic kidney disease not requiring renal repl acement therapy
m
se
As
Dr
Chronic kidney disease requiring renal replacement therapy within 30 years
Full recovery and no further ep isodes
I Full recovery b ut with later re lapses
Chronic kidney disease not req uiring renal replacement therapy
As l/3 of patients have infrequent relapses and l/3 of patients have frequent re lapses a
majority (2/3) will have later recurrent episodes. It is important however to stress to
m
se
patients that generally speaking the longer term p rog nosis in minimal change
As
glomerulonephritis is good .
Dr
A 73-year-old with a history of alcohol excess is admitted following a fall at home. On
admission the following blood results are obtained:
Urea 3. 5 mmoljl
Creatine kinase 180 u/1
Three days later the blood results are as follows:
Urea 14.5 mmol/ 1
Creatine kinase 4,400 u/1
Which one of the following wou ld have been most likely to prevent the deterioration in
renal fu nction?
Low dose dopamine
Urinary acidification
Intravenous fluids
Frusemide
m
se
Mannitol
As
Dr
Low dose dopa mine m
Uri nary acidification m
Intravenous fluids GD.
Frusemide m
Mann itol m
Collapse + ARF ~ rhabdomyolysis - treat with IV fluids
m
se
Intravenous fluids are the most important management step in the prevent of
As
rhabdomyolysis in such patients
Dr
A patient with type 1 diabetes mellitus is reviewed in the nephrology outpatient clinic. He
is known to have st age 1 diabetic nephropathy. Which of the following best describes his
degree of rena l involvement?
Latent phase
Hyperfiltration
End-stage renal failure
Overt nephropathy
m
se
As
Microa lbuminuria
Dr
Late nt p ha se .
(D
I Hyperfiltration CiD
End-stage renal failure m
~vert nephropathy CD
Microa lbuminuria ED
m
For the p urp oses of t he MRCP, increase in t he gl ome rular filtration rat e (GFR) is most
se
charact erist ic of sta ge 1 diab etic nephropat hy. It is how ever known that elevat ion of t he
As
GFR usually persists int o st age 2
Dr
A 40-year-old man presents t o the renal out-patient clinic after being referred by his GP
following an incidental finding of microscopic haematuria at an insurance medical. He has
never noted frank haematuria or renal angle pain befo re, and has otherwise been well. He
denies any recent upper respirat ory tract infections. There is no family history of renal
failure or renal disease, although his brother and father have previously seen specialists
because of 'blood in the urine', althou gh both have since been discharged. On
examination his blood pressure is 124/74 mmHg and his creati nine is in the normal range.
A renal USS performed by his GP at the time of referral is normal. What is the most likely
diagnosis?
Thin basement membra ne disease
IgA nephropathy
Renal lithiasis
Acute interstitial nephritis
m
se
As
Post streptococcal glomerulonephritis
Dr
I Thin basement membra ne disease CD
IgA nephropathy GD
Renal lithias is GD
Acute interstitial nephritis CD
m
se
As
Post streptococcal glomerulonephritis CD
Dr
Which one of the following factors is most associated with an i ncreased risk of developing
bladder cancer?
Strongyloides st ercora lis infection
Beryllium sa lt exposure
An iline dye exposure
Aflatoxin exposure
m
se
As
Long term phenytoin use
Dr
Strongyloides st ercoralis infection CD
Beryllium salt exposure m
An iline dye exposure CD
Aflatoxin exposure fD
m
se
As
CD
Dr
A 69-yea r-old man is started on tamsulos in for benign prostatic hyperplasia . Wh ich one of
the following best d escribes the s ide -effects he may experience?
Urgency + insomnia
Dizziness + postura l hypotension
Urinary retention + nausea
Urgency + e rectile dysfunction
m
se
As
Erectile dysfunction + reduced libido
Dr
Urgency + insomnia CD
Dizziness + postural hypotension GD
Urinary retention + nausea m
Urgency + erectile dysf unction m
m
se
Erectile dysfunction + reduced libido GD
As
Dr
A 20-year-old Nigerian fema le presents to the Emergency Department with chest pain.
She reports a long history of fatigue and joint pains. Examinatio n reveals a pericardiaI rub
and bilateral pitting oedema. Observations show on ly that she has a low grade pyrexia
37.7°( and blood pressure 170/100 mmHg. Urinalysis shows haematuria and nephrotic-
range proteinuria. A urine pregnancy test is negative. ECG shows saddle-shaped ST-
elevation in all leads. Of interest, her blood results show:
Urea 8. 2 mmol/1
eGFR 33ml/m/m 2
Which of the follow ing histopathological findings is most likely on renal biopsy?
Focal proliferative glomerulonephritis
Focal segmental glomeruloscleros is
m
se
As
Mesangial proliferative glomerulonephrit is
Dr
Foca l prolife rative glomerulonephritis f.D
Membranous glomeruloneph ritis ED
I Diffuse prolife rative glome rulonephritis CD

Foca l segmental glomerulosclerosis GD
Mesangial p roliferative g lomeru lone phritis mt
This question requi res you to diagnose the condition and then recall the associated
histopathology. Although they may not be encountered every day in cli nical p ractice, the
glomeruloneph ritides a re favou rites of the MRCP exa mine rs.
The presence o f hypertensio n, kid ney injury, proteinuria and haematuria point towards a
neph ritic pictu re o f kid ney insult.
The multisystem p resentation of fever, a rthralgia, pericard itis and nephritis associated
with the epidemiological clues (a young b lack female) suggest in this case a d iagnosis of
systemic lupus erythematosus (SLE).
m
se
The most commo n histologica l pattern seen in lupus nephritis is diffuse p roliferative
As
glomeruloneph ritis. Dr
A 72-year-old man is diagnosed w ith p rost ate cancer and goserelin (Zoladex) is
p rescribed. Which one o f the following is it most important to co-prescribe for t he first
three weeks o f t reatment?
Ta moxifen
Lansoprazole
Allopurinol
Cyproterone acetate
m
se
As
Ta msu losin
Dr
Tamoxifen CD
Lansoprazole CD
Allopurinol flD
Cyproterone acetate ED
Tamsulosin (fD
Ant i-androgen t reatment such as cyproterone acetate shou ld be co-prescribed w hen

starting gonadoreli n analogues due to the risk of tumour flare. This p henomenon is
secondary to init ial stimulation o f lute inising hormone release by the p ituitary gland
result ing in increased testoste rone levels.
m
se
As
The BNF advises starting cyproterone acetate 3 days before t he gonadorelin analogue.
Dr
A 45-year-old man is seen in the Emergency Department with nausea, pallor and lethargy.
He has no past medical history of note. A cannula is inserted and bloods show the
following
Na• 140 mmol/ 1
K• 6 .7 mmolfl
Urea 18.2 mmol/1
What is the most appropriat e initial management?
Nebulised salbutamol
Intravenous bicarbonate
Haemodialysis
Insulin/dextrose infusion
m
se
As
Intravenous calcium gluconate
Dr
~ebulised salbutamol
Intrave nous bicarbonate
Haemodialysis
Insu lin/ dextrose infusi on
Intravenous calcium g luconate
There is widespread variatio n in hyperka laem ia p rotocols . Some would o nly a dvocate
givin g calcium glu conate if there is evidence of ECG changes, or if the p otassium is> 7.0
mmol/1. If this info rmatio n is a bsent in a question it is safe r to assume that the point they
m
se
are 'getting at' is the priority of stabilising the myoca rdium, rathe r tha n lowe ring the
As
serum potassium.
Dr
A 32-year-old wo man comes t o the immunology clinic for review. She has a history of SLE
and stopped her medication prior to getting preg nant. She is now approaching 16 weeks
gestation. Unfortunately her j oint pains have returned, creatinine has risen from 90 !Jmol/1
t o 146 IJmol/1, with blood and proteinuria, despite high dose prednisolone.
Which of the follow ing is the most appro priate next st ep?
Azathioprine
Ciclosporin
Cycl ophosphamide
Methotrexate
m
se
As
Mycophenolate
Dr
I Azathioprine CD
Ciclosporin CD
Cyclophosphamide fiD
I Metht rexate .
(D
Mycophenolate CD
A la rge body o f evidence from the use of azathioprine in p regnancy for the treatment of
both rheumato logical cond itions and inflam matory bowe l disease, suppo rts its use.
Although it is less effective in the management of SLE with renal d isease versus other
options, ba lance of benefit risk makes it the prefe rred intervention.
Ciclosporin ap pears to b e associated with premature d e livery and low b irth weight,
although it does not seem to be associated with malfo rmations, this drives its use as an
alternative to azathio prine in patients who fail to gain control of their disease.
Cyclophosphamide, methotrexate and mycop henolate are all contraind icated for use in
p regnancy.
m
se
http://www.ncbi.nlm.nih.gov/pm c/articles/ PMC3237512/
As
Dr
A 27 -yea r-old man is investigated for haemoptys is. He is a non -smoker and has no
respiratory history of note. Whilst awaiting a bronchoscopy he beco mes letha rg ic and
ano rexic. Blood tests show the following:
Na• 141 mmol/ 1
K• 5.3 mmolfl
Urea 16 .7 mmol/ 1
Creatinine 27l i,Jmol/ l
A re na l b iopsy is performed and shows linea r lgG de posits a lo ng the basement

membrane.
What type of antibodies are most like ly to cause this type of p resentation?
cANCA
lgA
pANCA
Anti-nuclea r antibodies (ANA)
m
se
Anti-glomerular basement membrane (anti -GBM) antibodies As
Dr
cANCA
IgA
pANCA
Anti-nuclear antibodies (ANA)

-
~
Anti-g lomeru lar basement membrane (anti-GBM) antibodies
• IgG deposits on renal biopsy
• anti- GBM antibodies
The combination of haemoptsis, ren al fa ilure and linear IgG deposits points to a diagnosis
of Goodpasture's syndrome.
m
se
As
The ANCA-related nephropathies are associated with crescenti c glomerulonephrit is.
Dr
Each one of the following is associated with papilla ry necros is, except:
Acute pye lonephritis
Tub erculosis
Chronic analg esia use
Syphilis
m
se
As
Sickle cell disease
Dr
Acute pyelonephritis f!D
I Tuberculosis
L
GD
Chronic ana lg es ia use CD
~hilis GD
m
se
Sickle cell disease f!D
As
Dr
Each one of the fo llowing is a cause of cran ial diabetes insipidus, except:
Pituitary surgery
Lithium
Histiocytosis X
Craniopharyngioma
m
se
As
Post head-injury
Dr
Pituitary surgery CD
Lithium GD
Histiocytosis X tiD
Craniopharyngioma CD
Post head-injury CD
m
se
As
Lithium causes a nephrogenic diabetes insipidus
Dr
A 20-year-o ld man presents with facia l and ankle swell ing. This has slowly been
developing over the past week. During the review of systems he describes passing 'frothy'
urine . A urine dipstick shows p rotein++ +. What is the most like ly cause of this
p resentation?
IgA nephropathy
Membranoproliferative glomerulonephritis
Polycystic kidney disease
m
se
As
Membranous g lomeru lonephritis
Dr
IgA nephropathy
Mem branop roliferative glomerulonephritis
Mem branous glomerulonephritis
Nephrotic syndrome in children I young adu lts - min ima l change

glomerulonep hritis
Minimal change glomerulonephritis nearly always presents as nephroti c syndrome,

accounting for 75% of cases in children and 25% in adults. The majority of cases are
idiopathic and respond well to steroids.
m
se
As
Membranous glomerulonephritis wou ld be unusual in a 20-yea r-old.
Dr
Which one o f the following is least recognised as a cause of membranous
g lomerulonephritis?
Malaria
Lymphoma
Hepatitis B
Cryoglobulinaemia
m
se
As
Gold
Dr
Malaria fiD
I Lymphoma
Hepatitis B
GD
(£D
I Cryoglobulinaemia CD
m
se
Gold GD
As
Dr
A 34-year-old man who has injected heroin for the past 10 years is admitted to the
Emergency Department. You notice on the com puter that his serum creatinine has been
s lowly rising over recent yea rs. His latest results s how the following:
Na• 140 mmol/ 1
K• 4 .8 mmol/1
Urea 8 . 1 mmol/1
Urine dipstick Protein + +, nil else
What is the most likely cause of his deteriorating renal fu nction?
Focal segmental g lomeru losclerosis
Amyloidosis
Chronic pyelonephriti s
m
se
Renal vein throm bos is As
Dr
Focal segmental glomerulosclerosis GD
Amyloidosis fD
Mesangiocapillary glomerulonephritis GD
CD
Renal vein t hrombos is CD
m
se
As
Heroin is a known cause o f focal seg mental glomeruloscleros is.
Dr
A 43-year-old is referred to the renal clinic after presenting with peripheral oedema. He
has no past medical history of not e. Routine bloods ordered by his GP showed the
following:
Hb 14.1 g/dl
WBC 5.6 * 109/ 1
Na• 141 mmol/ 1
K• 4.8 mmol/1
urea 8 .3 mmol/1
ALP 84 u/1
ALT 22 u/1
yGT 33 u/1
Albumin 26 g/1
His urinary protein is 4.2g/24 hou rs. On examination in the clinic he has pittin g oedema of
the ankles and his blood pressure is 160/ 92 mmHg. A rena l biopsy is ordered and
Light microscopy
Mesangium : normal, with no hypercellularity. The capillary walls are thickened . Subepithelial deposits
are seen.
Given the likely diagnosis, w hich one of the follow ing drugs is most likely t o be b eneficial?
ACE inhibitor
Ciclosporin
Corticosteroid
Aspirin
sem
Cycl ophosphamide
As
Dr
I ACE inhibitor 6D
Ciclosporin m
Corticosteroid CD
Aspirin m
Cyclophosphamide fD
This patient has membranous glomerulonephritis. The history is typical w ith a middle-
aged man presenting with nephrotic syndrome and characteristic biopsy findings.
m
se
Corticosteroids by themselves have not been shown to be effect ive in membranous
As
glomerulonephritis. ACE inhibitors have however b een show n to reduce proteinuria.
Dr
A 24-yea r-old ma n who has a sister with adult polycystic kidney d isea se (ADPKD) asks if
he cou ld b e screened for the disease. What is the most a ppro priate screening test?
PKDl gene testing
CT abdo men
Urine microscopy
Ultra sound abd ome n
m
se
As
Anti-polycystin 1 antibodies leve ls
Dr
PKDl gene t esting fD
I cr abdomen CD
Urine microscopy CD
Ultrasound abdomen CD
Anti-polycystin 1 antibodies levels m
Ultrasound is the screening test fo r adult polycystic kidney disease

m
se
Genetic testing is still not routinely reco mmended fo r screening family members.
As
Sensitivity for ADPKDl is 99% fo r at-risk patients older than 20 years
Dr
A 56-year-old man who suffers from biventricular ca rdiac failure comes t o the clinic for
review. His symptoms are currently wel l controlled and he is t aki ng Ram iprillOmg,
spironolact one 25mg, bisoprolol 10mg, and furosemide 40mg. His main complaint is of
painful g ynaecomastia that he says has develop ed over the past 6 months. Physical exam
reveals a blood pressure of 125/ 80 mmHg, and no residual signs of ca rdiac failure. Renal
function is unchanged from 6 months earlier, with a stable creatini ne at 125 1-1mol;l.
Which of the follow ing is the most appro priate next st ep?
Check is prolactin level
Change the spironolactone t o eplerenone
Change the furosemide to indapamide
Stop the bisoprolol
m
se
As
Check his testosterone level
Dr
Check is prolactin level
Change the spironolactone to eplerenone
Change the furosem ide to indapam ide
Stop the b isopro lol
Check his testosterone level
Ep lerenone can be used in patients with troublesome gynaecomastia on

spirono lactone
This man has sta ble hea rt fa ilu re, his medication shou ld therefo re rema in unaltered if
possible. Sp ironola ctone d oes however interfe re with bind ing of testosterone to
and rog en rece pto rs, increase meta bolic clea rance of testoste ro ne, a nd results in in creased
metabo lism of and rog ens to estra diol. Th is is the likely cause of his gynaecomastia.
Eple renone is a n a lternative a ld oste ro ne a ntag onist and is a ssociated with u p to 20 times
less symptom burde n with respect to gynaecomastia. It is the refo re the most a ppro p riate
inte rventio n he re.
https://www.med icines.org.uk/emc/medicine/ 29837
At this sta ge the re is little to be g a ined by che cking the patie nt's testoste ro ne level until
the sp iro no lacto ne is disco ntinued. Although bisopro lo l may be associated with e rectile
dysfunction, this isn't mediated by a nti-a ndro gen activity, a nd it is not linked to the
d eve lop me nt of gynaecomastia. Cha nging the furosemide to a thiazide like d iuretic may
wo rsen sympto ms of hea rt fa ilure. Hig h levels of pro lactin a re a ssociated with
g alacto rrhoea, not with gynaecomastia. There is little value the refo re in checking p rolactin
em
levels he re.
s
As
I •• I •• I tt Discuss
Dr
Imp rove J
Each one of t he following is a cause of nephrogenic diab et es in sipidus, except:
Hypocalcaemia
Sickle-cell anaemia
Lit hium
Hypoka laemia
m
se
As
Demeclocycl ine
Dr
Hypocalcaemia CD
Sickle-cell anaem ia G'D
Lithium CD
Hypokalaemia G'D
m
se
Demeclocycline GD
As
Dr
A 35-year-old lady is fou nd to have abnorma l renal fu nction on routine blood tests
performed by her GP:
Na• 142 mmol/ 1
K• 4.1 mmolfl
urea 19 mmol/ 1
A renal tract ultrasound demonstrates 3 cysts on her right kidney and 4 cysts on the leh
with no visible hydronephrosis. She reports t hat her father suffered from kidney t rouble
and was on dialysis from age 45.
On what chromosome is t he most like ly mutat ion?
Chromosome 3
Chromosome 16
Chromosome 4
Chromosome 12
m
se
As
Chromosome 6
Dr
Chromosome 3
•
I Chromosome 16
Chromosome 4
GD
CD
I Chro_:osome 12 fD
Chromosome 6 CD
Th is patient has autosomal dominant polycystic kidney disease (ADPKD) as demonstrated
m
by her impaired renal function, bilat eral renal cysts, and positive family history. The
se
majority of patients with ADPKD have a mutation on chromosome 16, w ith the remaining
As
15% having a mutation on ch romosome 4.
Dr
A 5-year-old boy is seen in the Emergency Department due to lethargy and pallor. There
is no recent history of diarrhoea. The following results are obtained:
Hb 8.4 g/dl
Platelets 30 8
109/1
Urea 24 mmol/ 1
Urinalysis reveals proteinuria and haematuria. What is the most appropriat e

management?
IV cyclophosphamide
Ciprofloxacin
Oral prednisolone
IV methylprednisolone followed by oral prednisolone
m
se
As
Plasma exchange
Dr
IV cyclophospha mide
Ciprofloxacin
Oral p rednisolone
IV methylprednisolone followed by oral predniso lone
I Plasma exchange
There is no role for antibiotics, steroids or immunosuppressants in haemolytic uraemic
m
se
syndrome (HUS). Plasma exchange may be indicated, pa rticularly in severe cases of HUS
As
not associated w ith diarrhoea
Dr
A 45-year-old p resents to the Emergency Department with chest pa in. An ECG shows
anterio r ST elevation and he is thrombolysed with a ltep lase. His chest pa in settles and he
is started on aspirin, atorvastatin, bisopro lo l and ram ipril. Four days later his blood results
are as follows:
Urea 22 mmol/ 1
What is the most likely cause for the deterioration in renal function?
NSAID related nephropathy
Statin neph ropathy
Dressier's syndrome
m
se
As
Haemorrhage into rena l cyst
Dr
NSAID related nephropathy
Statin nep hropathy
Dressier's syndrome
Haemorrhage into rena l cyst
Flas h pu lmo na ry oedema, U&Es worse o n ACE inhibitor, asymmetrica l kidneys ~
renal a rte ry stenosis - do MR an giography

The re is likely underlying renal artery stenos is revea led by the ad dition of an ACE
inhibitor. Risk factors such as hypertension and hyperlipidaemia which have contributed
m
se
to the deve lopment o f his ischae mic heart disease a lso put him at risk of renal vascu lar
As
disease
Dr
A 54-yea r-o ld truck d river p resented to emerg ency d epartm ent with a new onset severe
back pa in radiating to h is groin. He required 10 mg of intravenous morphine to control
his pa in. He is not a smoke r b ut drinks 10-12 pints on weekend s. He has recently b een
diagnosed with esophageal cancer and has undertaken his first chemotherapy session the
p revious week. With rega rds to uric acid calculi, one of its remarkable characte ristic is:
They cannot be visualised by ultrasonogra phy (US)
They a re radiolucent
Ha rdly seen on p la in CT (CT KUB)
High solubility on acidic urine p H
m
se
As
Poo r response to medical treatment
Dr
They cannot be visua lised by ultrasonography (US)
They are radiolucent
Hardly seen on p lain CT (CT KU B)
High solubility on acidic uri ne pH
Poor response to medica l treatment

-
~
Uric acid nephrolithiasis are radiolucent, requiring ultrasonography or CT KUB

(without contrast)
Uric acid nephrolithiasis are radiolucent, requiring ultrasonography or CT KUB (without

contrast) inst ead of a plain f ilm. With ult rasonography can demonstrate a calcul i by an
echogenic foci with dist al acoust ic shadowing regardless of its nature. They respond well
t o medical t reat ment which includ es, hydrat ion, urinary alkalinizat ion and allopurinol if
m
se
raised uric acid levels. Uricosuric medications should be avoided, especially in renal
As
impairment, as it ca n precipit at e t he formation of new calcu li.
Dr
A 65 -yea r-o ld ma n presents with lower u rinary tract sym ptoms. For the p ast few mo nths,
he has had prob lems with u rinary urge ncy and has had severa l e pisodes o f incontinence
when he cou ld not reach the to ilet in time. He d escribes g ood urina ry flow with no
hesita ncy or straining . Urinalys is a nd prostate exa mination a re unrema rka ble .
Which one o f the fo llowin g medications is most like ly to he lp alleviate his sympto ms?
Alpha blocke r
Antimuscarinic
5-alpha red uctase inhibito r
Loop diuretic
m
se
As
Des mo press in
Dr
Alpha blocker
Anti muscarinic
5-alpha reductase inhibitor
Loop diuretic
Des mopress in
Antimuscarinic drugs are useful in patients with an overactive bladder

This patient has sympto ms of an overactive bladder. Conse rvative measures should be
discussed and bladder training offered.
m
se
As
Exa mples of suitable anti muscarinic drugs incl ude oxybutynin, tolterodin e and darifenacin.
Dr
A patient is seen in clinic complaining of abdominal pain. Routi ne bloods show:
Na• 142 mmol/ 1
K• 4 .0 mmolfl
Urea 7.0 mmolfl
What is the anion gap?
4 mmoi/L
14 mmoi/L
20 mmoi/L
21 mmoi/L
m
se
As
23 mmoi/L
Dr
4 mmoi/L CD
14 moi/L f.D
20 m moi/L CD
21 m moi/L CD
23 mm oi/L GD
The anion gap may be calculated by using (sodium + potassium) - (bicarbonate +

chloride)
m
se
As
= (142 + 4.0) - (104 + 19) = 23 mmoi/L
Dr
You are reviewing a 33-year-old man who has recently been diagnosed with adult
polycystic kidney disease in the rena l cl inic. You proceed to examine his cardiovascu lar
system. Which other feature are you most likely to find on examination?
Dilat ed cardiomyopathy
Mitral stenosis
Aortic st enosis
Renal bruit secondary to renal artery stenosis
m
se
As
Dr
Dilated cardio myo pathy
Mitral stenosis
Aortic stenosis
Renal bruit secondary to rena l a rte ry stenosis

-
. ..wl'
m
se
Mitral va lve prolapse
As
Dr
A 14-year-old girl is referred to the paediatric unit with reduced urine output and
lethargy. She has been passing bloody diarrhoea for the past four days. On admission she
appears dehydrated. Bloods show the following:
Na• 142 mmol/ 1
K• 4.8 mmol/1
Urea 10. 1 mmol/ 1
Hb 10.4 gfdl
MCV 90 fl
Pit 91 8
109/ 1
WBC 14.4 8
109/ 1
Given the likely diagnosis, w hich one of the following organisms is the most likely cause?
Campylobacter
Giardiasis
E. coli
Salmonella
em
s
Shigella
As
Dr
Campylobacter CD
Giardiasis m
I E. coli fZD
Salmonella m
Shigella f!D
m
se
Haemolytic uraem ic syndrome - class ically caused by E coli 0157:H7
As
Dr
A 60-year-old woman present s to her g enera l practice with signs of thirst and t iredness.
On further quest ioning, she also complains of polyuria and noct uria. As a resu lt a 24-hour
urine is collected, which returns showing a urine osmolality of 189 mOsm/ kg (500 -800
mOsm/ kg).
The general p ract itioner suspects a diagnosis of diabetes insipidus.
Which of t he following is a recognised cause of nephrogen ic diabet es insip idus?
Hyperkalaemia
Hypercalcaemia
Histiocytos is X
Hypermagnesemia
m
se
As
Hypernatraemia
Dr
Hyperkalaem ia f!D
Hypercalcaemia ED
. I.
H.IStiOcytOSIS X
t:D
Hypermagnesemia fD
Hypernatraemia t:D
The polyu ria and polydipsia, in co mbination with a dil ute uri ne suggest diabetes insipidus.
m
se
It is hypokala emia, not hyperkalaemia, that causes neph rogenic diabetes insipidus
As
whereas Histiocytosis X causes cran ial diabetes insipidus.
Dr
A 40-yea r-old man with a history o f psychiatric pro blems and epilepsy comes fo r review.
He complains that he is d rinking excessive a mounts of water and having to urinate
frequently. He ha s not lost any weight an d states that he is compliant with his current
med ications. Blood tests show the following:
145 mmol/ 1
4.1 mmolfl
Urea 6 .3 mmol/1
Creatinine 101J,Jmol/ l
Glucose (random) 6 .2 mol/ 1
Whi ch o ne of the fo llowing medications is most like ly to be resp onsib le fo r this

p resentation?
Carbamazepi ne
Fluoxetine
Olanzapine
m
Sodium valp roate
se
As
Lithium
Dr
Carbamazepine fD
Fluoxetine m
Olanzapine CD
Sodium valproate fD
Lithium f.D
m
se
This patient has probably developed nephrogenic diabetes insipidus secondary to lithium
As
therapy. Polyuria, polydipsia and a high -normal sodium are pointers towards this.
Dr
A 62-year-old man with a diabetic nephropathy and hypertension is reviewed . His current
med icatio n is insu li n, bendroflumethiazid e, ra mipril a nd am lodipine. On exa mi nation
b lood pressu re is 144/78 mmHg. Blood tests revea l the fo llowing :
Na• 139 mmol/ 1
K• 4.9 mmolfl
Urea 12.8 mmol/ 1
eGFR 29 ml/min
Renal function was s imilar to 3 months ago. What is the most appro priate action?
No change to his medication
Switch bendroflumethiazide to fu rosemide
Add a beta-blocker
Add sp ironola ctone
m
se
As
Stop ram ipril
Dr
No change to his med ication G:t
I Switch bendroflumethiazid e to furosemide &D

Add a beta-blocker f!D
Add sp ironola ctone f!D
Stop ram ipril ctD
As the eGFR is 29 ml/min switching bend roflumethiazide to furosem ide would be the next
m
se
step in controll ing his b lood p ressure. Please see the guidelines in the external links
As
section
Dr
A 45-year-old female with nephrotic syndrome develops renal vein thrombosis. What
changes in patients with nephrotic syndrome predispose to the development o f venous
thromboembolism?
Reduced excretion o f protein S
Loss o f antithrombin III
Reduced excretion o f protein C
Loss o f fibrinogen
m
se
As
Reduced metabolism of vitamin K
Dr
Reduced excretion of protein S
Loss of antithrombin III
Reduaed excretion of protein C

-
~
Loss of fibrinogen
m
se
Reduced metabolism of vitam in K
As
Dr
A 77 -yea r-old woman o n you r wa rd has ch ron ic kidney d isease. Blood resu lts a re below.
Yo u have b een asked to p rescribe a suitable the ra py.
Phosphat e 1.8 mmoljl
PTH 85 pg/ml
Of the fo llowing, which is most likely to correct vitam in D deficiency in you r patient?
Sando -K (effe rvescent potassium)
Calcium carbonate
Phosphate sa ndoz (effervescent phosphate)
Thia mine
m
se
Alfacalcido l
As
Dr
Sando -K (effe rvescent potassium)
Ca lcium carbonate
I Phosphate sa ndoz (effervescent phos phate)
Thiamine
Alfacalcidol
Alfacalcido l is used as a vita min D supp lement in end-stage renal d isease b ecause it
d oes not requi re activation in the kidneys
Vita min D has seve ral fo rms a nd req uires hydroxyla tio n in the kid neys b efore it is active.
In patients with seve re re nal impa irment, a lfacalcid ol d oes not req uire act ivatio n in the
kidneys a nd therefo re is useful fo r replaci ng vita min D.
Sa nd o -K a nd p hosphate sa ndoz wo uld increase potassium and phosp hate respectively so

wou ld not treat the patie nt.
Thia mine is a vita min B re placement.
m
se
Ca lcium ca rb onate is a p hosphate b inde r used in chronic kidney disease, but wou ld not As
su pp le me nt vita min D s pecifica lly.
Dr
A 69-year-old woman is admitted with a third ep isode of urinary tract infection over the
past 12 months, p roven on urine culture to be due to Proteus mirabilis. She also has right
loin pain. She has a past history of hypertension and a previous creatinine tested one
month earlier was elevated at 145 micromol/1. A plain x-ray to dis play ki dneys ureters and
b ladder and an ultrasound of the urina ry tract reveal a right sta ghorn calculus.
What is the stone likely to be composed of?
Calcium p hosphate
Urate
Magnesiu m ammonium p hosphate
Cystine
m
se
As
Oxalate
Dr
Calcium phosphate CD
Urate CD
I Magnesium ammonium p hosphate f1'D

Cystine CD
Oxalate fD
Mag nesiu m ammonium p hosphate, (also known as struvite), kidney stones are formed by
urea-spl itting bacteria, of which Proteus is an example . Mag nesium ammonium
phos phate stones can fo rm very la rge calculi known as staghorn calcu li which may
s ignificantly impact on renal functio n due to chronic obstruction and fa ilu re to clea r
urinary tract infection adeq uately. Treatment of the underlying urinary tract infection,
cou pled with a urology co nsult to assess the need fo r remova l o f any large r stones are the
cornerstone of management.
Calcium p hosphate rena l stones are associated with hyperpa rathyroid ism, and urate
m
se
stones are associated with gout. Cystine stones are seen in patients with in herited
As
cystinuria, and oxalate stones are primarily associated with s hort bowel synd rome.
Dr
A 10-yea r-o ld b oy is ad mitted to hospita l with dia rrhoea a nd lethargy. The re is a known
loca l outbreak of E co li 0157:H7 and his initia l blood s show evid ence of acute renal failure.
Given the likely dia g nosis, which one of the fo llowing investigatio n resu lts would be
expected ?
Increased prothrombin tim e
Thrombo cytos is
Frag me nted red blood cells
Rig ht-shih of the white blood cells
m
se
As
Ra ised serum hapto glo bin s
Dr
Increased prothrombin tim e
Th rombo cytos is
-
. ..wl'
r Fragmented red b lood cells
Right -shih of the white bloo d cells
Raised serum haptoglobin s
m
se
Seru m ha ptoglo bins (wh ich bind haemoglobin) and the platelet cou nt are d ecreased in
As
haemo lytic uraemic synd rome.
Dr
A 43-year-old man has a work-up for hypertension. He has found to have blood + on a
uri ne dipstick o f a freshly voided sample. Which one of the followi ng may account for this
finding?
Smoking
Exercise
Obesity
Eating red meat the previous day
m
se
Use of ramipril
As
Dr
Smoking
Exercise
-
......,
Obes ity
Eating red "jl eat the p revious d ay
m
se
Use of ramipril
As
Dr
Which one of the following types of glomerulonephritis is most cha racteristically
associat ed with Wegener's granulomat osis?
m
se
As
Dr
Focal segmental gl omerulosclerosis
Diffuse proliferative gl omerulonephritis
Rapi dly progressive glomerulonephritis, causes:

• Goodpasture's
m
• ANCA positive vasculitis
se
As
Dr
A 29-yea r-old man who is being investi gated for haemoptysis and a ch ron ic cough has a
blood screen:
Hb 12.9 g/dl
Pit 248 * 109/ 1
WBC 5.4 * 109/ 1
ESR 11 mm/hr
Na• 138 mmol/ 1
K• 5.0 mmolfl
Bicarbonate 19 mmol/1
Urea 14.0 mmol/ 1
Urine di pstick shows blood ++. What is the most likely diagnosis?
Lung cancer with renal metastases
Chu rg-Strauss syndrome
Renal cancer with lung metastases
m
se
Goodpasture 's synd rome
As
Dr
Wegener's granulomatosis fD
Lung cancer with renal metastases m
Churg-Strauss syndrome f.D
Renal cancer with lung metastases m
Goodpasture's syndrome GD
m
se
As
The age of the patient a nd normal ESR point to a diagnosis of Goodpasture's syndrome.
Dr
You review a 65 -year-old man with stage 5 chronic kidney disease in the renal outpatient
clinic. He has recently been started on erythropoietin inj ections. Wh ich one of the
following is the main benefit th is treatment?
Reduced proteinuria
Improved exercise tolerance
Reduced blood pressure
Improved renal function
m
se
As
Reduced long-t erm all-cause mortality
Dr
Reduced proteinuria m
I Improved exercise to lerance CD
Reduced blood pressure
Improved renal function

•
CD
Reduced long-term all-cause mortality 6D
m
se
Erythropoietin treat s CKD associat ed anaemia which in turn would improve exercise
As
t olerance. It does not improve renal function.
Dr
A 19-year-old woman is ref erred to the nephrology department after exp erienci ng several
episodes o f visible haematuria. There is no history of abdominal or loin pain. These
typically seem to occur within a day or two of developing tonsillitis. Blood pressure is
148/ 90 mmHg.
Urine dipstick is normal. Blood t est s show the follow ing:
Na• 14 2 mm ol/ 1
K• 4 . 1 mmolfl
Urea 3 .5 mmol/1
Given the likely diagnosis, w hich one o f the follow ing is a marker o f poor prognosis?
Female gender
Hypertension
Frank haematuria
Absence o f proteinuria
m
se
As
Development of the disease before the age of 20 years
Dr
Female gender
I Hypertension
Frank haematuria
I Abse1ce o f proteinuria
m
se
As
Development of t he disease before the age of 20 years
Dr
A 12-year-old boy is investigated for a purpuric rash on the ext ensor surfaces of his lower
legs. He also has a history of abdominal pain and an urticarial ras h. The follow ing results
are obtained:
Urine dipstick : blood ++
What would b e the likely finding on renal biopsy?
Linear IgG deposits
No change
Sclerosis with in the glomerulus
Mesangial hypercellularity
m
se
As
Basement membrane th icke ning
Dr
Linear IgG d eposits CD
No change CD
Sclerosis within the glomerulus CD
I Mesangial hypercellularity CD
Basement membra ne thickening f!D
m
se
As
Henoch -Schonlein purpura is associated with IgA nephropathy
Dr
A 68-yea r-old ma n p resents with symptoms o f nocturia and difficu lty in pass ing urine. He
is not known to have any previous p rostatic pro b lems and d en ies any dysu ria. Fo ll owing a
dig ita l rectal exa mination, he is started on finasteride and tamsu los in. Three months later
he presents to the emergency d e partment in u rinary retention an d is catheterized, and a
c ra ggy mass is felt on recta l exam ination. He is referred to a uro lo gist, and a prostatic
ultrasound and needle b iopsy are a rranged, and prostate seru m antigen (PSA) is
requested.
Which of the fo llowing factors is most likely to give a false negative PSA?
Ta msu losin
Finaste ride
Prosta tic needle biopsy
Prosta tic ultrasound
m
se
As
Recent catheterisation
Dr
Tamsu losin
Finasteride
Prostatic needle biopsy

-
~
Prostatic ultrasound
Recent catheterisation
Fina steride is the on ly factor likely to decrease the level o f serum PSA. Ta msulosin has no
effect on PSA, whil st p rostatic needle biopsy, US and cathet erisation have all been shown
to cause a transient increase in PSA. A PR examination may also cause a slight rise in PSA
levels. Therefore, t hese factors cou ld cause a fa lse pos it ive result, whilst fina steride is the
only possible factor which cou ld cause a fa lse negative one.
Source:
m
se
St urgeon, C. M., L. C. Lai, and M. J. Duffy. 'Serum Tumour Markers: How to Order and
As
Interpret Them.' BMJ (2009): 852 -58
Dr
A 33-yea r-o ld pregna nt woman presents fo r advice. She is known to have polycystic
kidney disease but is curre ntly well. He r fathe r a lso has po lycystic kidneys a nd is o n
dialys is . What is the cha nce her child will a lso have the disease?
50% if ma le
50%
25%
0%
m
se
As
100%
Dr
50% if male m.
I 50% GD
25% CD
0%
100%
•
CD
m
Polycystic kidney disease is usually inherited in an autosom al dominant fashion and hence
se
50% of her children will be affected, regardless of g ender. The autosomal recessive form is
As
rare and usually causes death in childhood.
Dr
A 25-yea r-old ma n has a rena l b iopsy due to wo rsening renal fu nction. This reveals linea r
IgG d epos its a long the basement memb rane. What is the most like ly d iagnosis?
System ic lupus e rythemato us
IgA nephropathy
Po st -streptococca I g lo meru loneph ritis
m
se
As
Goodpasture"s syndro me
Dr
IgA nephropathy
Post-streptococca l glomeruloneph ritis
• IgG dep osits on renal biopsy
• anti-GBM antibodies
m
se
As
These changes are characteristic of Goodpasture's syndrome.
Dr
A 34-yea r-old man is investigated for recu rrent re na l stones. He has been hosp ita lised on
mu ltiple occasions and has required lithotripsy three times. Investigations show the
fo llowing:
Calcium 2.08 mmol/1
Phosphate 0 .85 mmol/1
Parathyroid hormone 4.1 pmoi/L (normal range = 0 .8- 8 .5 )
24 hour urinary calcuium 52 1 mg/ 24 hours (normal r ange< 300)
Which one of the fo llowing treatments is most likely to reduce the incidence of renal
stones?
Pyridoxine
Bica rbo nate su pplements
Bisphos phonates
Pa rathyroid ectomy
m
se
As
Indapa mide
Dr
Pyridoxine
Bica rbonate su pplements
Bisphosphonates
Paratliyroidectomy
-
~
Indapamide
The fact that thiazide diuretics cause hypercalcae mia is sometimes confused with their
role in preventing calcium rena l stones - the hypercalcaem ia seen is secondary to
increased dista l tubular calcium resorption and hence lower calciu m concentration in the
urine.
There are some studies cu rrently loo king a t the ro le of b isphosphonates in hypercalciuria
m
se
but their long -term benefit is not yet established and thiazides remain the first-line
As
treatment.
Dr
A 52-year-old with a history of arthritis, previous gastric ulcers, diabetic and hypertension
has been vomiting and having diarrhoea for the last 12 hours. He ta kes naproxen,
misoprostol, levothyroxine, linagliptin and long-acting insulin. With regards to glomerular
filtration, which of the following can reduce glomerular filtration and contribute to
development of an acute kidney injury?
Naproxen
Misoprostol
Levothyroxine
Linagliptin
m
se
As
Long acting insulin
Dr
Naproxen CD
Misoprostol CD
Levothyroxine m
Linagliptin CD
~
Long act ing insulin m
NSA!Ds and ACE-inhibitors/ARB cause prerenal acute kidney injury by decreasing
the glomerular filtration
Non -st eroidal anti-inflammatory drugs (NSA!Ds), such as Naproxen are prostaglandin
inhibitors therefore they constrict the afferent arterioles caus ing prerenal acute kidney
inj ury by decreasing the g lomerular filtration.
Misoprostol is a prostaglandin analogue, therefore can dilat e the afferent arterioles and
does not reduce glomerular filtrate.
Levothyroxine and linagliptin has little or none effect on the kidneys. Moreover, because
linagliptin is not excret ed by kidneys it is not necessary t o reduce its dose in renal
impairment.
em
Long acting insulin is excret ed by the kidney (dose should be reduced in renal
s
impairment) but does not contribut e directly to glomerular filtration.

As
Dr
Autosomal dominant polycystic kidney disease type 2 is associated w ith a gene defect i n:
Chromosome 4
Chromosome 8
Chromosome 12
Chromosome 16
m
se
As
Chromosome 20
Dr
Chromosome 4 CD
Chromosome 8
•
Chromosome 12
Chromosome 16
•
tD
Chromosome 20
•
m
ADPKD type 2 = chro mosome 4 = 15% of cases
se
As
Dr
A 70-year-old man has b een admitted with abdominal pa in. The surgeons wish to
perfo rm a co ntrast-enhanced CT but a re concerned because he has chronic kidney
disease stage 3. His latest renal function is shown below:
Na• 142 mmol/ 1
K• 4.6 mmolfl
urea 8 . 1 mmol/1
Creatinine 130 1Jmol/ l
Which one of the followin g is the most important step in reducing the risk of co ntrast-
induced nephropathy?
Oral sodium bicarbonate p re- and post-procedure
Oral N-acetylcysteine pre- and post-procedure
Intravenous 0.9% sodium chlo ride p re- and post-procedure
Intravenous furosemide pre-procedure
m
se
As
Intravenous mannitol post-procedure
Dr
Oral sodium bicarbonate p re- and post -procedure
Oral N-acetylcysteine pre- and post -p rocedure

-
Intravenous 0.9% sodium ch loride p re- and post-procedure
Ir ravenous furosemide p re -procedure

-
"""'
~
Intravenous mannitol post - procedure
m
se
The evidence base is much stronger for volume expansion with normal saline tha n for N-
As
acetylcyst eine.
Dr
A 6-year-old boy is referred to clinic due to recurrent rena l calcul i. His grandmother also
had a similar problem. What is the most likely diagnosis?
Marfan's syndrome
Familial gout nephropathy
Homocystinuria
Cystinuria
m
se
As
Cystinosis
Dr
Marfan's syndrome m
- Familial gout nephropathy fD
Homocystinuria QD
I Cystinuria GD
m
se
CD
As
Cystinosis
Dr
Which one o f the following is not a featu re o f HIV-associated nephropathy?
Small kidneys
Normot ension
Elevated urea and creatinine
Prot einuria
m
se
As
Focal seg mental glomeruloscleros is on renal biopsy
Dr
I Small kidneys 6D
Normotension fD
~Yated urea and creatinine m
Proteinuria m
m
se
As
Focal segmental glomerulosclerosis on renal biopsy (D
Dr
An 18-year-old girl who is deaf and has a history of renal impairment is reviewed in cl inic.
She has previously been diagnosed with Alpert's syndrome but is thinking about having
children and asks about the risks of passing the cond ition on. What is the mode of
inheritance of AIport's syndrome in the majority of cases?
X- linked dominant
Mitochondrial
Autosomal recessive
Autosomal dominant
m
se
As
X- linked recessive
Dr
X-linked dominant fD.
Mitochon drial
Autosomal recessive
•
fl!D
Autosomal d~minant GD.
X- linked recessive flD
Alpert's syndrome - X-l inked dominant (in the majority)

m
se
Around 10-15% of cases are inherited in an autosomal recessive fashion with rare
As
autosomal dominant va riants also existing
Dr
Which one of the following is least recognised as an indication for plasma exchange?
Churg-Strauss syndrome
Myasthenia gravis
Cerebral malaria
m
se
As
Dr
Churg -Strauss syndrome

-
.....,
Myasthenia gravis
Cerebral malaria
Cerebral malaria is not a st andard indication for plasma exchange. Exchange transfus ions
have been tried but it is generally only justified when peripheral parasitemia is greater
m
se
than 10% of ci rcu lating erythrocytes. The role of blood transfusions remains contro versial,
As
as they are both expensive and potentially dangerous i n many malaria areas
Dr
A 24-year-old woman is diagnosed as having nephrotic syndrome after being
investigat ed for proteinuria. A diagnosis of minimal change glomerulonephritis is made.
What is the most appropriat e initial treatment to reduce proteinuria?
Prot ein restriction in diet
No treatment shown to effective
Ang iotensin-converting -enzyme inhibitor
Diuretic
m
se
As
Prednisolone
Dr
Protein restrictio n in diet
No treatment shown to effective
Angiotensin-converting -enzyme inhibitor

-
~
Diuretic
I Prednisolone
Minimal cha nge glomerulonephritis - prednisolone

m
se
Ang iotensin-converting-enzyme inhibitors may be used to reduce proteinuria in patients
As
with heavy prot einuria or who have a slow response to prednisolone
Dr
A 63 -year-old man is admitt ed with severe right sided loin pain to the Emergency
Department. A urine dipstick shows blood +++, leucocyt es +,protein+. An abdominal
radiograph is th erefore ordered which shows a stag-horn calculus in the right renal pelvis.
What are stag -horn calcu li normally composed of?
Xanthine
Magnesium ammonium phosphate
Calcium oxalate
Uric acid
m
se
As
Magnesium calcium phosphate
Dr
Xanthine
Magnesium ammonium phosphate
Calcium oxalate
Uric acid
Magnesium calcium phosphate
St ag-horn calcu li
• composed of Struvite (ammonium magnesium phosphate, triple p hosphate)
• form in alkaline urine (ammonia producing bacteria such as Ureaplasma
urealyt icum and Proteus the refore p redispose)
m
se
As
Dr
Which of the following factors would suggest that a patient has established acute tubu lar
necrosis rather than pre-renal uraemia?
Increase in urine output following fluid challenge
m
se
As
Fractiona l sodium excretion = 1.5%
Dr
Increase in urine output following fluid challenge

I
I Fractional sodium excretion = 1.5%
ATN o r prerenal uraemia? In prerenal uraemia th ink of the kidneys holding on t o
m
sodium to preserve volum e
se
As
Dr
You are prescribing maintenance fluids for a 60-yea r-o ld woman who has had a stroke.
Her most recent blood results are shown below:
Na• 140 mmol/ 1
K• 4 .0 mmol/1
Urea 5.0 mmol/1
She weighs 62 kg. What is the most appropriate amount o f potassium that s he should
receive over a 24-hour period?
20 mmol
40 mmol
60 mmol
80 mmol
m
se
As
120 mmol
Dr
20 mmol GD
40 mmol fiD
I 60 mmo l ED
80 mmol CD
120 mmol CD
When prescribing flu id s, the potassium requirement per day is 1 mmol/kg/ day
Converting this into real-world p ractice, NICE also recommend s that patients have 25 -
30ml/kg/day of water. As this pati ent weighs 62kg that means the patient shou ld receive
m
approximately 1.5 - 2L of fluid in a 24 hour period. If the patient is receiving 1-litre bags
se
o f fluid th en one s hou ld conta in 40 mmo l and the other 20 mmol potassium to ensu re an
As
a dequate potass ium intake.
Dr
A 34-year-old man presents to the Emergency Department with abdominal pain. This
started earlier on in the day an d is getting progressively worse. The pain is located on his
left flank and radiates down into his groin. He has had not had a similar pain before and is
normally fit and well. Examination reveals a man who is flushed and sweaty but is
otherwise unremarkable. What is the most suitable initial management?
Oral ciprofloxacin
I M diclof enac 75 mg
Immediate abdominal ultrasound
I M morphine 5 mg
m
se
As
I M diclof enac 75 mg + start bendroflumethiazide to prevent further episodes
Dr
Oral ciprofloxacin
I IM diclofenac 75 mg
Immediate abdominal ultrasound
I M morphine 5 mg
I M diclofenac 75 mg + start bendroflumethiazide to prevent fu rthe r episodes
Guidelines continue t o recommen d the use of IM diclofenac in the acute

management of renal colic
Th is man may need to be referred acut ely to the surgeons for pain relief and
investigations to exclude obstruction. It would not be suitable to start
bendroflumethiazide in the initial phase of the first episode. An immediate abdominal
m
se
ultrasound is not necessary as neither his age nor sympto ms point to a diagnosis of
As
abdominal aneurysm.
Dr
Which one of the following is t he most common type of SLE associated renal disease?
Class II: mesangial glomerulonephritis
Class III: focal (and segmenta l) proliferative glomerulonephrit is
Class IV: diffuse proliferative glomerulonephritis
Class V: diffuse memb ra nous glomerulonephritis
m
se
As
Class VI: sclerosing glomerulonephritis
Dr
Class II: mesangial glomerulonephritis
Class III: focal (and segmental) proliferative glomerulonephritis
Class IV: diffuse proliferative glomeru lonephritis
Class V: diffuse membranous glomerulonephritis
Class VI: sclerosing glomerulonephritis
Diffuse proliferative glomerulonephritis is t he most common and severe form of
m
se
renal disease in SLE patients
As
Dr
A 43 -year-old man is investigat ed for a painless testicu lar swelling. Following a biopsy, he
is diagnosed as having a seminoma.
Which one o f the following tumour markers is most specific for this condition?
AFP
LDH
hCG
S-100
m
se
As
CA 15-3
Dr
AFP CD
LDH CD
hCG ED
S-100 f!D
CA 15-3 CD
m
se
hCG is associated with testicular seminomas
As
Dr
Which one o f the following causes of g lo meru lonephritis is associated with no rmal
complement leve ls?
Post-streptococcal g lomeru loneph ritis
Mesangiocapillary g lo me rulonephritis
Subacute bacte rial endocard itis
Goodpasture's synd rome
m
se
As
Dr
Post-streptococcal g lomeru lonep hritis
Mesangiocapillary g lome rulonephritis
Subacute bacte rial end ocard itis
~odpasture's syndrome
Syste mic lupus erythematous
J
Goodpasture's synd rome is rare cond ition associated with both pulmonary haemo rrhage
m
se
and rapi dly p rogressive g lomeru lo neph rit is. It is caused by anti-g lomerula r basement
As
membrane (a nti-G BM) antibodies against type IV collagen. Complement levels are normal
Dr
A 33 -year-old man with a history o f coeliac disease is admitted for investigation o f
recurrent macroscopic haematuria. His urine is typically brown and there is no history of
passing clots. What is the most likely diagnosis?
IgA nephropathy
m
se
As
Dr
Diffuse proliferative glomerulonephritis GD
I IgA nephropathy GD
Membra nous glomeru lone phritis CD
Minimal change disease CD
Rapidly progressive glomerulonephritis GD
m
se
As
Th is man has IgA nephro pathy which is associated with coe liac disease
Dr
A 65-year-old man who is known to have colorectal cancer is referred to the renal cl inic.
His GP performed a prot ein-creatinine ratio as he had been complaining of 'frothy' urine.
The results suggest nephrotic range proteinuria which is confirmed on a 24-hour urinary
collection. Assum ing the proteinuria is related to his colo rectal cancer what is the renal
histology most likely to show?
m
se
As
Membranoproliferative glomerulonephritis
Dr
Mesangiocapillary glomerulonephritis .
(D
Minimal change glomerulonephritis CD

GD
.,
r Membranous glomerulonephritis
Membranoproliferative glomerulonephritis GD
Nephrotic syndrome - malignancies cause membranous glomerulonephritis

Patients with underlying malignancies such as lung, co lon and gastric cancer may develop
nephrotic syndrome as a para neoplastic comp lication. There appears to be an association
m
with HLA-DR3.
se
As
Lymphomas tend to be associated w ith minimal change disease.
Dr
A 31-year-old man presents t o his GP with a 2-month history of constant abdominal pain
and early satiety. He has hypertension for which he t akes enalapril.
On examination, he is mildly tender in both flanks. Well-circumscribed masses are

palpable in both left and right flanks. A soft systolic murmur is heard loudest at the apex.
His observations are heart rate 67/ min, blood pressure 152/ 94mmHg, temperature
37.2°(, respirato ry rat e 14/min, saturations 97%.
Which additional feature is most likely t o be found in this patient?
Hepatomegaly
Colonic polyps
Sensorineural dea fness
Angiofibromas
m
se
As
Thro mbocytopenia
Dr
Hepatomegaly ED
Colonic ~olyps f!D
Sensorineural d ea fness fD
Ang iofibromas fD
Th rombocytopenia CD
ADPKD is associated with hepato meg aly (due to hepatic cysts)

The patient in this case has autosoma l-d ominant polycystic kidney disease (ADPKD).
ADPKD often presents with abdominal pa in and early satiety as the kidneys occupy a
la rge volume of the abdomen. Traction on the kidney pedicle can also cause pain. The
presence of hypertension, bilateral flank masses and a systolic apica l mu rmur (su ggesting
mitral valve d isease) also point towards this diagnosis.
Extra-renal features of ADPKD includ e :

• Hepatic cysts which manifest as hepatomegaly
• Diverticulos is
• Intracran ia l aneu rys ms
• Ovarian cysts
Colonic polyps are not a feature of ADPKD.
Angiofibromas are a feature of tuberous sclerosis (patients with this disease may have
renal cysts). Tu berous sclerosis is usua lly diagnosed in chi ld hood and is associated with
ep ilepsy and cognitive impairment.
Sensorineural d ea fness is associated with AIport's syndrome . AIport's syndrom e typica lly
presents with haematuria and p rogress ive rena l failure, not re nal enlarge ment.
s em
Thrombocytopenia is not a feature of ADPKD.

As
Dr
I • I __ I - ~· I.
82-year-old female with a background of rheumatoid arthritis on maintena nce dose
prednisolone and sulfasalazine is admitted with det eriorating renal function. Urine dip
reveals protein + + +. She has previously suffered from a dist al radial fracture and is
currently complaining of numbness and tingling down the lat eral 3 l/2 digits of the
opposite hand.
Renal ultrasound reveals bilat erally enlarged kidneys and a subcut aneous abdominal fat
biopsy is positive after Congo red st aining. What is the most likely unifying diagnosis?
Diabetes
AL amyloidosis
AA amyloidosis
Waldenstrom macroglobulinaemia
m
se
As
Syst emic lupus erythematosus
Dr
Diabetes
AL amyloidos is GD
•
I AA amyloidosis CiD
Waldenstrom macrog lobulinaemia
•
System ic lupus erythematosus
•
Seco ndary AA a myloidosis is most likely g iven the backg round of rheumatoid arthritis
(the second most common cause after juvenile id iopathic arth ritis in the UK), heavy
proteinuria, a nd positive Congo red staining.
Diabetes wou ld be a possibility, however, it is not associated with a positive Co ngo red
staining. AL amylo idosis tends to be associated with an underlyin g haematolog ical
condition as opposed to an inflam matory problem. Again, Waldenstrom
m
se
ma crog lobulinaem ia and system ic lupus erythematosus would not cause a positive Congo
As
red staining.
Dr
A 54-yea r-o ld wo man with a histo ry me mbranous g lomerulonephritis seconda ry to
systemic lupus e rythe matous is ad mitted to hosp ita l. He r previous stable rena l function
has deterio rated ra pidly. On exam inatio n she has tendernerss in the left flank. The
fo llowing blood tests were o bta ined :
139 mmol/ 1
5.8 mmolfl
urea 24 mmol/ 1
Albumin 17 gf l
ESR 49 mm/hr
Urinary protein 14 g/24 hours
protein ++ +
Urine dipstick
blood ++
What has likely caused the su dde n d ete rio ration in renal functio n?
Exacerbatio n of SLE
Bilate ral hydronep hrosis
Acute interstitia l nep hritis

em
Ana lgesic nep hropathy

s
As
Dr
Exacerbation of SLE
Bilateral hydronephrosis
Acute interstitial nephritis
Analgesic nephropathy
Nephrotic syndrome predisposes t o thrombotic episodes, possi bly due to loss of

antithrombin III. These commonly occur in the renal veins and may be bilateral.
Membranous glomeru lonephritis is the most common glomerulonephro pathy linked to
renal vein thrombosis.
This patient had a number of common features seen in renal vein thrombosis, including
loin p ain and haematuria.
m
se
A greater rise in the ESR wou ld be exp ected if the renal failure was due to an exacerbation
As
o f SLE.
Dr
Why do patie nts with chronic kidney disease have a raised phosphate leve l?
Decreased renal excretion
Increased gut absorpti on
Hypervita minos is D
Primary hyperparathyro idis m
m
se
As
Decreased 25-alpha hydroxylatio n o f vitam in D
Dr
Decreased renal excretion
Increased gut absorpti on
m
se
Decreased 25-alpha hydroxylation of vitami n D
As
Dr
A 50-yea r-old Caucasian man was seen in general practise for review of his hypertension.
As the patient was leaving he describes the following lower urina ry tract symptoms:
urinary frequency, hesitan cy, nocturia, post micturition dribb ling and poor stream. The
general practitioner reviewed the patient two weeks later to fin d a vast improvement in
symptoms. On examination the patients p rostate wa s enla rged, firm, smooth, with a
mid li ne sulcus and no craggy e lements.
What anti -hype rtensive is the general p ractitioner likely to have started?
Amlod ipi ne
Doxazos in
Sp ironolactone
Indapa mide
m
se
As
Ramipril
Dr
Am lodipine m
I Doxazosin CD.
Spironolactone CD
Indapamide CD
Ra mipril m
The patient is describing obstructive prostatic sympt oms secondary t o likely b enign
m
se
prostatic hyperplasia (BPH). Doxazosin is an alpha-1 blocker commonly used t o treat both
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hypertension and BPH.
Dr
A 33-yea r-old is admitted to the Emergency Department with suspected re na l co lic. He
has a ultrasou nd that shows a probable stone in the left ureter. What is the most
appropriate next step with respect to ima ging?
Non -contrast CT (NCCT)
Micturating cystou rethrogram
Intravenous urography (IVU)
Plain ra diography KUB
m
se
As
MRI
Dr
Dr
As
sem
A patient is started on finasteride for the treatment of benign prostatic hyperplasia. How
long should the patient be told that treatm ent may take to be effective?
Within 8 hours of taking the tablet
Within 3 days
Up to 7 d ays
Up to 4 weeks
m
se
As
Up to 6 months
Dr
Within 8 hours of taking t he ta blet CD
Within 3 days fD
Up to Ldays CD
Up to 4 weeks tiD
I Up to 6 months ED
m
se
Finasterid e treatment of BPH may take 6 mont hs before result s are seen
As
Dr
A 17-year-old man is referred to the loca l nephrology unit for investigation. He reports
having several episodes of visible haematuria. There is no history o f abdominal or loin
pai n. These typically seem to occur within a day or two o f developing an upper respiratory
tract infection. Urine dipstick is normal. Blood t ests show the following:
Na• 14 1 mmol/ 1
K• 4.3 mmolfl
Bicarbonate 2 5 mmol/ 1
Urea 4 . 1 mmol/1
Chlamydia
Bladder cancer
IgA nephropathy
Rh inovirus-associated nephropathy
m
se
As
Post-streptococcal glomerulonephritis Dr
Chlamydia m
Bladde r cancer m
IgA nephropathy
I fD
Rh inovirus-associated nephropathy CD
m
se
Post-streptococcal g lomeru lonephritis GD
As
Dr
Which one of the following is not a risk facto r for the development of blad der cancer?
Occupational exposure to aniline dyes
Cyclophosphamide
Strongyloides infection
Smoking
m
se
As
Occupational history invo lving rubber manufacture
Dr
Occupational exposure to aniline dyes
Cyclophosphamide
-
~
I Strongyloides infection
Smoking
Occupational history invo lving rubber manufacture

-
~
m
se
Schistosomiasis rather than Strongyloides infection is associated with an increased risk of
As
bladder cancer
Dr
A 24 -yea r-old ma n p resents to his GP with facial swelling . Urine dip notes protein+ ++
and his b lood pressure is 124/68m mHg. He was treated with corticosteroid s for possible
mini mal change di sea se, but this had no effect.
He co nseque ntly was referred for re nal biopsy which s howed a spike and dome
appearance on electron microsco py. Which of these a ntibod ies is most asso ciated with
this conditi on?
Anti-ca rd ioli pin
Anti-GBM
Anti-GAD
Anti-phospholipa se A2
m
se
As
Anti-streptolysin 0
Dr
Anti-ca rdiolipin CD
Anti-GBM ED
Anti-GAD GD
I Anti-phospho lipase A2 fD
Anti-streptolysin 0 CD
Idiopathic membranous glomerulonephritis is related to anti- phospholipase A2

antibodies
Firstly, it is important t o det ermine whether this is a nephrotic or nephritic picture. The
proteinuria, oedema and normot ension all point towards the nephrotic syndrome. Of the
causes of nephrotic syndrome in a young adult, minimal change disease (MCD) and
membranous glomerulonephritis (MGN) are of the most co mmon. MCD oh en remits aher
corticosteroids, whereas MGN classically requires multiple therapies (chlorambucil and
ACE -inhibitors are ohen required). Irrespective of this point. the histology confirms
membranous glomerulonephritis.
Anti-phospholipase A2 antibodies are implicat ed in most idiopathic cases of MGN. The
m
se
remaining antibodies are associat ed with anti phospholipid syndrome, Goodpasture's
As
Disease, Type 1 Diabet es and Streptococcus pyogenes infection, respectively. These
Dr
produce different histological pictures.

A 62-year-old man with ch ron ic kidney disease secondary to diabet es mellitus is reviewed.
When assessing his estimat ed glomerular f ilt ration rate (eGFR), which o ne of the fo llowing
variables is not required by the Mo dification of Diet in Renal Disease (MDRD) equation?
Age
Serum creatinine
Ethn icity
Gender
m
se
As
Serum urea
Dr
Age m
Serum creatinine m
Ethn icity tED
Gent er fD
Serum urea CD
m
se
eGFR variables - CAGE - Creatinine, Age, Gend er, Ethnicity
As
Dr
A patient with sepsis is being treated in hospit al. Init ially, two SOOml bo luses of 0.9%
sod ium chloride are required to raise his systolic blood p ressure (BP) above 90mmHg.
Once the BP is in range the foundation doctor prescribes sodium ch loride 0.9%
maintenan ce fluid s at l l every 8 hours.
Which of the following comp lications is most likely to occur as a result of the choice of
f luid administered to th is patient?
Central pontine myelinolysis
Hyperchloraem ic metabolic acidos is
Hyperkalaemia
Hypochloraemic hypoka laemic metabolic alkalosis
m
se
As
Lactic acidosis
Dr
Central pontine myelinolysis
I Hyperchloraemic metabolic acidosis
Hyperkalaemia
Hypochloraemic hypokalaemic metabolic alkalosis
Lactic acidosis
-
""""
Use of 0.9% Sodium Chloride for fluid therapy in patients requiring large volumes =
risk o f hyperchloraemic metab olic acidosis
This patient has received 0.9% sodium chloride. Hyperch loraemic metabolic acidos is is a
known iatrogenic complication of using 0.9% sodium chloride in large volumes. In the
event of hyperchloraemia o r acidaemia, monitor ch loride levels daily. If resuscitation is
required Hartmanns can be used instead. If the patient now only requires maintenance
fluids NICE recommends considering 25-30 ml/kg/ day sodium chloride 0.18% in 4%
glucose (with potassium supplement as required). See compositions of commonly used
crystalloids for further inform ation:
https://www.nice.org.uk/guidance/ cg l74/resources/ co mposition-of-co mmonly-used-
crystalloids-table-191662813)
Central pontine myelinolysis is a co mplication o f co rrecting hyponatraemia t oo rapidly

which does not apply to this scenario.
Hyperkalaemia is not a complication of sodium chloride as it contains no p ot assium.
Hypochloraemic hypokalaemic metabolic alkalosis is co mmonly seen in children with

pyloric stenos is. It is not associated w ith 0.9% sodium chloride use.
em
Lactic acidosis It is not associated with 0.9% sodium chloride. A drug classically associated
s
with lactic acidosis is met formin.

As
Dr
A 38-year-old male is concerned as he has been passing very small amounts of
concentrated urine over the past few days despite drinki ng litres of wat er. He has j ust
finished a cou rse of antibiotics fo r tonsillitis and is f eeling generally well in himself. He is
apyrexial and has a blood pressure of 150/lOOmmHg. Previous blood pressu re rea dings
and kidney funct ion test s have been normal.
Urine dip stick- prot ein 1 +, blood 3+, nitrites negative.
Renovascular disea se
Acute tubular necrosis
Nephrotic syndrome
m
se
As
Nephritic syndrome
Dr
Renovascular disease
•
ED
Acute tubu lar necrosis CD
Nephrotic syndrome m
Nephritic syndrome 6D
This male has a type of nephritic syndrom e. This is indicated by the protei nuria,
haematu ria, oliguria and hypertension. The recent history of to nsillitis makes post-
streptococcal glomerulonephritis the most likely cause.
Renovascular disease in young people is most likely to be due to fibromuscular dysplasia

of the renal arteries. This presents gradually with hypertension that is res istant to
treatment and a declining renal function. This diagnosis is unlikely as the patients'
sympto ms are acute and previous blood pressure and renal function tests have been
normal.
Interstitial nephritis and acute tubu lar necrosis are usually caused by nephrotoxic drugs or
an infection. They usually present with acute renal fa ilure. The history above states the
patient has had an infection and has taken antibiotics recently, therefore, these answers
cou ld be co rrect. However, nephritic syndrome is more likely given the results of the urine
dipstick.
Nephrotic syndrome is unlikely. It usually presents with the triad of proteinuria, oedema
and hypoalbuminaemia.
em
s
As
Dr
A 27 -yea r-o ld man is diag nosed with Goodpastu re 's syndrome. Which o ne of the
fo llowing d oes not increase the likelihood o f a p ulmo nary haemorrhage?
Smoking
Inhalation o f hyd roca rbo ns
Male gender
Dehydratio n
m
se
As
Lowe r resp irato ry tract infection
Dr
Smoking
~
Inhalation of hydrocarbons
•
tiD
Male gender .
(tD
I Dehydration ED.
Lower respiratory tract infection m.
m
se
Dehydration may decrea se the likelihood of a pulmonary haemorrhage. Pulmonary
As
oedema is associated with an increased risk
Dr
Which one o f the following factors is most likely to invalidat e the use o f t he Modif ication
o f Diet in Renal Disease (MDRD) equation to calculate a pat ients eGFR?
Diuretic use
Pregnancy
Blood pressure o f 180/110 mmHg
m
se
As
Female gender
Dr
Diuretic use «D
~gnancy CD
Type 2 diabetes mellitus CiD
fslood pressure o f 180/110 mmHg CD
Fem ale gender tiD
m
se
As
GFR tends to increase during pregnancy although the eGFR may not reflect th is.
Dr
A 34-yea r-old man is investigated fo r recu rrent re nal stones. He has been hos pitalised on
mu ltiple o ccasions and has required lithotripsy three times. Investigations s how the
fo llowing:
Phosphate 0.85 mmol/ 1
Parathyroid hormone 4.1 pmoi/L (normal range = 0 .8- 8 .5 )
24 hour urinary calcuium 52 1 mg/ 24 hours (normal range< 300)
Which one of the fo llowin g treatments is most likely to reduce the incidence of renal
stones?
Pyridoxine
Bica rbo nate su pplements
Bisphos phonates
Pa rathyroid ectomy
m
se
As
Indapa mide
Dr
I Pyridoxine GD
Bica rbonate supplements GD
Bisphos phonates (D.
Parathyroidectomy CD
Indapamide CD
The fact that thiazide diuretics cause hyperca lcae mia is sometim es confused with their
role in preventing calcium renal stones - the hypercalcaemia seen is seconda ry to
increased d ista l tubular ca lcium resorption and hence lower calcium concentration in the
urine.
There are some studies cu rrently looking at the role o f bisphosp honates in hypercalciuria
m
se
but their long-term benefit is not yet estab lished and thiazides rema in the first- line
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treatment.
Dr
A patient is seen in clinic complaining of abdominal pain. Routine bloods show:
Na• 142 mmol/ 1
K• 4.0 mmolfl
Urea 7.0 mmolfl
What is the anion gap?
4 mmoi/L
14 mmoi/L
20 mmoi/L
21 mmoi/L
m
se
As
23 mmoi/L
Dr
~mmoi/L CD
14 m moi/L fD
20 m moi/L CD
21 m moi/L CD
I 23 mm oi/L fiD
The anion g ap may be calculated by using (sod ium + potassium) - (bicarbonate +

chlo ride)
m
se
As
= (142 + 4.0) - (104 + 19) = 23 mmoi/L
Dr
A 71-year-old man with chronic kidney d isease stage 3 is reviewed in the cardio logy cl inic.
He is known to have hypertension and ischaemic hea rt disease but a recent fasting
glucose result confi rmed he is not d iabetic. A recent early morning urine result is reported
as fo llows:
1 week ago 6 months ago
Na• 141 mmol/ 1 140 mmol/ 1
K• 4.1 mmol/1 4 .3 mmol/1
Urea 7. 2 mmol/1 6.3 mmol/1
Creatinine 98 IJmol/1 99 IJmol/1
1 week ago 6 months ago
Albumin :creatinine ratio 15.2 mg/mmol 2.6 mg/mmol
What is the most appropriate action?
Refer to a nephrologist
Repeat the sample
Obtain a 24-hour urine collection
Repeat using a late-evening sample

m
se
Arrange renovascular imag ing

As
Dr
Ref er to a nephrologist
Repeat the sample
Obtain a 24- hour urine collection
Repeat using a late-evening sample
Arra nge renovascular imaging
m
NICE recommend 'if the initial ACR is between 3 mg/ mmol and 70 mg/mmol, this shou ld
se
be confirmed by a subsequent early morn ing sample. If the initial ACR is 70 mg/ mmol or
As
more, a repeat sample need not be tested .'
Dr
Which one of the following is associated with a better prognosis in patients with IgA
nephropathy?
Heavy proteinuria at presentation
Male gender
Hyperlipidaemia
Fra nk haematu ria
m
se
As
ACE genotype DD
Dr
Dr
As
se
m
A 44-year-old man is referred to the renal team. He has a long histo ry of chronic sinusitis
and was investigated last year for haemoptysis but no cau se was foun d. A number of
recent urine dipstick test s has shown persistent microscopic haematuria.
Na• 140 mmol/ 1
K• 4.8 mm olfl
Urea 11.4 mmol/ 1
ESR 6 1 mm/hr
CRP 30 m g/ 1
anti-GBM Negative
cANCA ( PR3) Positiv e
pANCA (MPO) Negative
ANA Negative
Given the likely diagnosis, w hat findings wou ld be expected on renal biopsy?
Segmental tuft necrosis
Kimmelstiei -Wilson nodules
Crescentic glomerulonephritis
'Full-house' immunoglobulin deposition

sem

As
Dr
Segmental tuft necrosis
I
Kimmelstiei-Wilson nodules
Crescentic glomerulonephritis
-
'Full-house' immunoglobulin deposition
m
se
As
Dr
A 45-yea r-old man had presented with complaints of weight loss, chest pain, d ry cough
and b reathlessness. Blood tests revea led ra ised white cell count (WCC) and a lso revealed
an elevated lactose dehydrogenase (LDH) leve ls. A pla in ra diograph of the chest shows
multiple suspicious lesions suggestive of metastases to th e lung. A subsequent CT scan of
the chest showed the presence of a la rge anterior mediastinum irregular mass.
Extra-pulmonary tubercu losis
Cryptogenic organising pneumonia
Mediastinal germ cell tumour with lu ng metastases
Staphylococcal abscesses
m
se
As
Renal cell ca rcinoma with lung metastases
Dr
Extra-pulmonary tu bercu losis
Cryptog enic organising pneumonia
Mediastinal g e rm cell tu mour with lu ng metastases
Staphylococcal abscesses
Renal cell carcinoma with lung metastases

-
.....,
The med iastinum is the most common site of extragonad al germ cell t u mou r
(EGGCT)
The mediastinum is the most common site of extragonadal germ cell tumou r (EGGCT).
Mediastinal EGGCT will ohen present with chest pain, cough, dyspnoea, fever, weight loss
and anorexia. The most co mmon s ite within the actual mediastinum is the anterosuperior
compartment where they grow quickly, metastasising ea rly.
Extrapu lmonary tuberculosis is tubercu losis (TB) in another pa rt of the body other tha n
the lungs. This occurs more commonly in immu nosup pressed individua ls and younger
children. Spread to lymph nodes is frequent. Other sites of spread involve the central
nervous system, pleura, bones & joints.
Cryptogenic o rgan ising pneu monia (COP) smaller airway swelling within the lungs, ohen
referred to as bronchiolitis oblitera ns organising pneumo nia. It does encompass
symptoms that can do follow closely to a pneumonia infection with fever, fatigue,
coughing and shortness of b reath.
Renal cell carcinoma (RCC) classically p resents as a triad of flank pa in, haematuria and a
pa lpable abdom inal mass.
em
Staphylococcal abscesses are unlikely in this situation given the lack of fever or swing ing
s
pyrexia despite the p resence of a raised white cell count (WCC).

As
Dr
I • I __ I - ~· I.
Each one of the following is a cause of nephrogenic diabetes insipidus, except:
Hypercalcaemia
Demeclocycline
Histiocytosis X
Lithium
m
se
As
Hypokalaemia
Dr
Hypercalcaemia fD
Demeclocycline fD
Histiocytos is X GD
Lithium (D
l_
m
se
GD
As
Hypokalaemia
Dr
A 45-year-o ld who has deve loped chronic kidney disease secondary to focal segmenta l
glomeruloscle rosis is reviewed in the renal cli nic. Hi s renal functio n is deteriorating and
the eG FR is cu rrently 15 ml/min/1.73 m2 . The nephrologist is p la nning fo r haemodia lysis.
What is the p refe rred metho d o f access for haemod ia lysis?
Arteriovenous fistula
Tunelled venous catheter
Non-tunelled venous catheter
Arteriovenous g raft
m
se
As
Peritoneal catheter
Dr
Arteriovenous fistula
r
Tunelled venous catheter
~-tunelled venous cathete r

-
...wr
Arteriovenous g raft
Peritoneal catheter
m
se
Arte riovenous fistulas are the preferred method of access fo r haemodia lysis
As
Dr
A 38-year-o ld woman is referred by the general pract it ioner as her recent blood test
showed elevated creat inine and urea levels. Other blood test results are normal. She is
oliguric but could produce enough sample for urine dip. Her urine is negative for red
cells, nitrites and leucocyt es. She was recently started on Ramipril for hypertension 3
weeks ago.
She is otherwise well. Her observations are within normal limits. The renal ultrasound
shows two normal-sized kidneys with an unobstructed urinary system. Duplex ultrasound
showed stenot ic renal arteries. Su bsequent MR angiography confirmed the diagnosis wit h
the finding of 'string of beads' appearance of the rena l arteries.
What is the most likely cause of this presentation 7
Glomerulonephritis
Pyelonephritis
Fibromuscu lar dysplasia
Nephrotic synd rome
Nephrolithiasis
m
se
Submit answer
As
Dr
Glomerulonephritis CD.
Pyelonephritis CD.
I Fibromuscular dysplasia Gl
Nephrotic syndrome CfD
Nephrolithiasis GB
Consider fibromuscular dysplasia in young fema le patients who develop AKI after
the initiation of an ACE inhibitor
In young female patients who develop AKI after initiation of an ACE inhibit or,
fibromuscu lar dysplasia shou ld be suspected. In older persons, suspect atherosclerosis of
rena l arteries.
Fibromuscular dysplasia describes the proliferation of cells in the wa lls of the arteries
causing the vessels to bu lge or narrow. Th is most commonly affects women. These
patients are susceptible to AKI after the initiation of an ACE inhibitor. The classic
description is 'st ring of beads' appearance.
The normal urine dip resu lts ruled out glomeru lonephrit is and nephrotic syndrome as t he
cause of kidney failure. Glomeru lonephritis typically presents with haemat uria with the
presence of red cell casts. Nephrot ic syndrome presents with heavy proteinuria, oedema
and hypoalbuminaemia.
Nephrolithiasis typically presents with painful loin-to-groin pain. It does not cause acute
kidney injury unless bot h kidneys are affected. This was ru led out by the renal ultrasound.
Fibromuscular dysplasia
Renal artery stenosis secondary to at herosclerosis accounts for around 90% of renal
vascular d isease, with fibromuscular dysplasia being t he most common cause of t he
remaining 10%.
Epidemiology
• 90% of patients are female
Features
• hypertension
• chronic kidney disease or more acute renal failure e.g. secondary to ACE-inh ibitor
em
s
initiation
As
• 'flash' pulmonary oedema

Dr
A 23-yea r-old man p resents with recu rrent headaches. These typically occur 2 or 3 times a
month and are characterised by severe, right-sided headaches which are throbbin g in
natu re and last around 8-12 hou rs. When he gets the headaches he finds it hard to carry
on working and tends to go and lie down in a dark roo m. The headaches so far have
responded poorly to pa raceta mol.
Which one o f the followin g medications shou ld be prescribed to help reduce the
frequency of these headaches?
Ibu profen
Pizotifen
Propranolo l
Amitriptyline
m
se
As
Carbamazepi ne
Dr
Ibuprofen m
Pizotifen .
(D
Propranolol GD
Am itriptyline CD
Carbamazepine m
Migraine
• acute: triptan + NSAID or tript an + paracetamol
• prophylaxis: topiramate or propranolol
m
se
This is a classic history of migraine, prophylaxis should be offered with propranolol or
As
t opiramate.
Dr
A 34-year-old man has been brought in by his wife following a mechanical fa ll from
standing in which he hit his head and lost consciousness for around 10 seconds. He has
full memory of the events leading up to the fall, but no memory of the 30 minutes
following the fall. He has not vomited but complains of a headache. He has no past
medical hist ory of note.
On examination, he has a small laceration above his leh eye but no evidence of a basal
skull fracture. He scores 15 on the Glasgow coma scale and there is no neurologica l
deficit.
Arra nge a CT head scan within 1 hour of present ation
Arra nge a CT head scan within 8 hours of present ation
Discharge with head injury advice and advise his wife to observe him for the next
24 hours
Keep him in for observation for at least 8 hours
m
se
As
Dr
Arrange a CT head scan w ithin 1 hou r o f present ation
Arrange a CT head scan w ithin 8 hours of present ation
~charge w ith head inj ury advice and advise his wife to observe him for the next f D
I 24 hours
Keep him in for obse rvation for at least 24 hours
Over 30 minutes retrograde amnesia is an indication fo r aCT scan fo llowing a head

injury, not anterograde amnesia
NICE have published guidance on the need for CT imaging followi ng a head inj ury. The
question does not mention any o f the criteria that wou ld warrant an immediate CT scan
o f his head. This man also does not fulfil the criteria for a CT head w ithin 8 hou rs due to
his age, no past medica l history and relatively benign mechanism of injury. He does
describe some ant erograde amnesia, but he would require at least 30 minutes retrograde
amnesia immediately prior to the injury to warrant a CT head scan.
m
This man will require monitoring to look for concern ing features that may develop, but if
se
he is living with his wife it is reasonable for this to be done at home. Therefore, there is no
As
indication to admit him for observation.
Dr
Lateral medullary syndrome is caused by occlusion of which one o f t he following blood
vessels?
Anterior inferior cerebellar artery
Posterio r ce rebral artery
Late ral sinus t hrombosis
Middle ce rebral artery
m
se
As
Posterior inferior cerebellar artery
Dr
I Posterior cerebral artery
Late ral sinus th rombosis
I Posterior inferior cerebellar artery
Late ral medullary syndrome - PICA lesion - cerebella r signs, contralateral sensory
m
se
loss & ipsilateral Horner's
As
Dr
A 53-yea r-old woman presented with a sudden onset left-sided arm and leg weakness.
She has a background of atrial fibrillation, for wh ich she is anti-coagulated with warfarin,
and suffers from Alzheimer's dementia, for which she takes donepezil. She lives on her
own in a ground floor flat with ca rers helping with her activities of daily living twice daily.
Her fam ily live fairly close by. Recently she lost her husband who died from metastatic
lung cancer. She reports having fo rgotten to take her medications on several occasions.
On examination, she did not have any slurred speech but there was a right facial droop. A
reduction in power was noted in her left arm and leg. Her left plantar response was up-
going.
What is the first line investigation to further evaluate her symptoms?
Non-contrast MRI Brain
T2-weighted-fluid-attenuated inversio n recovery (FLAIR) MRI Brain
Contrast CT Head
Non-co ntrast CT Head
m
se
As
Diffusion-weighted MRI Brain
Dr
Non -contrast MRI Brain
T2-weighted-fluid -attenuated invers ion recovery (FLAI R) M RI Brain
Contrast CT Head
I Non-contrast CT Head
Diffusion -weighted MRI Bra in
Non -co ntrast CT head scan is t he first line radiological investigation for sus pected
stroke
This patient is presenting w it h sym ptoms and signs highly suggestive of an acute
cerebrovascu lar event. The first line investigation in t hese situations is to p erform a non -
contrast CT head scan to rule out a haemorrhagic event. Given t he pat ient's background
o f atrial fibrillation, the patient is at a higher risk of such events.
Diffusion -weight ed MRI b rain scans are generally done lat er to f urther investigat e the
early cha nges after a stroke event and diagnose vascular strokes by highlighting the early
p resence of hypoxic oedematous changes.
Using a contrast medium w ith CT head scans in the acute phase of stroke has not
g enerally been usefu l. Contrast CT head scans are more useful for d etecting cereb ral
metastases and abscesses.
Using fluid -attenuated inversion recovery (FLAIR) MRI imaging can aid in estimating an
onset of acute ischaemic stroke within six hou rs enabling more patients to receive
em
thrombolytic therapy, esp ecially when t he histo ry of onset remains unclear. T2-weighted
s
As
imaging is more sensitive than Tl-weighted imaging in d etecting ischemic changes.

Dr
A 64-yea r-old man p resents with a e ight-month history o f generalised weakness. On
exam ination he has fascicu lation and weakness in both a rms with absent reflexes.
Exa mination of the lower limbs revea l increased tone and exaggerated reflexes. Sensation
was normal and there were no cerebella r signs. What is the most likely diagnosis?
Progressive muscular atrophy
Amyotrophic lateral sclerosis
Vitamin 812 de ficiency
Syringomyelia
m
se
As
Multiple scle rosis
Dr
Amyotro phic latera l scleros is

-
~
Syringomyelia
Multiple sclerosis
'Fascicu lations' -think motor neu ron disease

m
se
These symptoms are typical of amyotrophic lateral sclerosis, the most common type of
As
motor neuron disease.
Dr
A 34-year-old fema le presents with vom it ing preceded by an occipital headache of acute
onset. On examination she was conscious and alert with photophobia but no neck
stiffness. CT brain is reported as normal. What is the most appropriate further
management?
CT brain with contrast
Repeat CT b rain in 24h
CSF examination
Cerebral angiography
m
se
As
MRI bra in
Dr
CT brain with contrast CD
Repeat CT brain in 24h f.D

CSF examination GD
Cerebral angiog raphy .
(D
MRI brain CD
If subarachnoid haemorrhage is suspected but the CT head is normal, a lumbar

puncture is required to confirm or exclude this diagnosis
m
se
If the CSF examination revea led xanthochrom ia, or there was still a high level of clinical
As
suspicion, then cerebra l ang iography would be the next step.
Dr
Anti-Hu CD
Anti-La fD
1 Anti-GAr ClD
Anti-Yo tiD
m
se
I Anti-Ri CD
As
I
Dr
Which one o f the fo llowin g s ide -e ffects is not recog nised in patients taking sod iu m
va lproate?
Alo pecia
Weig ht ga in
Hepatitis
Induction P450 system
m
se
As
Te rato genicity
Dr
A 54-year-old female with know n b reast cancer develops p rogressive motor disorder with
impairment of right arm funct ion. She is clu msy with all movements and exaggerated
'f linging' actions are noted on examination. There is a similar pattern in the right leg w ith
to a much lesser extent. There are no other ab normalities on neurological examination.
Where is t he lesion most likely to be?
Caudate nucleus
Lateral cerebellum
Pre-motor cortex
Sub-tha lamic nucleus
m
se
As
Temporal lobe
Dr
Cau dat e nucleus 6D.
Lateral cerebellum GD
Pre-motor cortex CfD
I Sub-thalamic nucleus CD
Temporal lobe CD
~
This is t he clinical p resentat ion o f hemiballismus. Hemiballismus is a movement diso rder

charact erised by very violent movement s o f the arm or limbs. People can seriously injure
themselves. Caused by a stroke or other lesion of t he subt halamic nucleus.
Movement disorders in ord er of least speed to fast est (DACB)

• Dyst on ia - fixated position
• Athetosis - Snake-like writ hing (slow)
• Choreiform - Li ke a d ance choreographer
m
• Ballist ic/ Ballismus/Hemiballismus - Fast f linging movements, ca n injure t hemselves
se
o r others 'like a ballistic missile' (memorisation metho d)
As
Dr
A 30-yea r-old lady presents with acute occipital headache associated with vom iting,
p hoto phob ia and stiff neck. Th ere is no history of rash o r fever. She has a past medical
history of phaeochromocytoma fo r which s he had su rgery. She reports that he r fathe r
died of kid ney cance r and her brothe r is blind in his rig ht eye due to a bleed in the eye.
What is the unifyin g d iagnosis?
Von Hipp el Lin dau disease
Multi ple e ndocrin e neoplasia type 1
Tub ero us sclerosis
m
se
As
Alport syndrom e
Dr
Von Hip pel Lin dau disease
Mu ltiple e t ocrine neoplas ia type 1
Tuberous scleros is
Alport syndrome
This patient has von Hippel Lindau disease which is cha racterised by retina l and cerebellar
haemangiomas, renal cysts with transformation to renal cell carcinoma, and
phaeochromocytoma. Neurolog ical signs can be d ue to compression by haemangiomas,
or an acute headache due to intracere bral or subarachnoid haemorrhage as in this
patient.
Exp lanation fo r other options:

• 1. Polycystic kidney d isease is associated with subara chno id haemorrhage d ue to
berry aneurysms, but the other pointers in the history of a phaeochromocytoma and
a family history of retinal b leeding and renal cell carcinoma do not fit with PKD.
• 3. Multiple endocrine neoplasia type 1 is associated with parathyroid disease,
pancreatic endocrine tumou rs and pitu ita ry tumours.
• 4. Tuberous sclerosis is associated with hamartomas of the brain, eye and kidneys
m
se
but would have characteristic skin signs present such as angiofibroma, shagreen As
patches and adenoma sebaceum.
Dr
• 5. AI port synd rome is not associated with intracerebra l bleeding.

A 33-yea r-old Indian man presented with a 5-day history of feve rs, vo miting and
dizziness. He had recently come back from a trip to Kera la and had b een treated with a
two-week course of cla rithromycin for a b out of pro longed severe sinusitis by his GP. This
was due to the fact that he had been suffering from seve re frontal headaches, d ifficu lty
slee ping and p eriorbita l swelling. He has a background o f tuberculosis (TB) and is
cu rrently on treatment with rifampicin and isoniazid.
On exam ination, the re was some slurring dysarthria and mi ld coa rse nystagmus to the
left. His o bservation shows a temperate of 38.3°C, pulse 93 b eats per minute, blood
p ressure 120/ BOmmHg and oxygen saturation 93% on room air.
TB meningitis
Cere bel la r metastases
Cere bel la r hae morrhag e
Cere bel la r abscess
m
se
As
Chronic s inusitis
Dr
TB meningitis
Cerebella r metastases
Cerebella r haemorrhage
Cere bel lar abscess

-
~
Chronic sinusitis
-
~
Cere bel la r abscesses a re most commonly caused by o togenic diseases like

masto iditis and si nusitis infections
Brain abscesses a re foca l areas of intracerebral pus collection which occur due to a
number of causes. In particular, cerebellar abscesses most common ly occu r due to
infections such as mastoiditis an d sinusitis infections.
Cerebellar hae mo rrhage is a more acute vascula r event wh ich would have a qu icker onset
and likely present with stronger neu rolog ical signs with sudden onset headache, d izziness,
vomiting, ve rtigo, truncal ataxia and impa irment o f consciousness.
Chronic s inusitis is referred to when the cavities a rou nd nasa l passages - known as sinuses
- rema in inflamed and swollen for at least 12 weeks, in spite of various treatment
attempts.
TB meningitis would p resent with fever and chills, neck stiffness, photophobia associated
with mental changes.
em
Cerebellar metastases would present with headaches (the most common symptom of
s
As
b rain metastases), nausea, vomiting, difficulty walking, seizures with speech distu rbance.
Dr
A 55-yea r-old man is referred to the neurology cl inic due to a resting tremo r and an
abnormal gait characterised by short, shuffling steps. Which one of the following features
would point towards a diagnos is of Parkinson's disease rather than parkinsonis m o f
another cause?
Asymmetrical tremor
Bra dykin esia
Impa irment o f vertical g aze
Confusion
m
se
As
Poor response to levodopa therapy
Dr
I Asymmetrical tremor C!D
Bradykinesia ED
Impairment of vertical gaze f.D
Confusion m
Poor response to levodopa therapy CD
m
se
Asymmetrical symptoms suggests idiopath ic Parkinson's
As
Dr
A man is recovering after having an operation to remove a meningioma in his left
t emporal lobe. What sort of visual field defect is he at risk of having following the
procedure?
Right inferior homonymous quadrantanopia
Right superior homonymous quadrantanopia
Left inferior homonymous quadrantanopia
Right homonymous hemianopia with macula sparing
m
se
As
Left superior homonymous quadrantanopi a
Dr
Right inferior homonymous quadranta nopia
Left inferior homonymous quadranta nopia
Right homonymous hemianopia with macula sparing
Left superior homonymo us quadrantanopi a
Visua l field defects:

• left homonymous hemianopia means visual field defect to the left, i.e. lesion
of right optic tract
• homonymous quadrantanopias: PITS (Parietal-Inferior, Tempora l-Su perior)
• incongruous defect s = optic tract lesion; congruous defects= optic radiation
m
lesion or occipital cortex
se
As
Dr
A 40-yea r-old man presents with a 4-d ay history o f vertig o. This seems to have followed a
viral upper respiratory tract infection in the past week. He is genera lly fit and well. His
symptoms a re associated with some nausea but there is no hearing loss o r tinnitus. On
exam ination fine horizontal nysta gmus is noted. What is the most likely diagnosis?
Vestibu lar neuronitis
Viral labyrinthitis
Transient ischaem ic attack
Acoustic neuroma
m
se
As
Meniere's disease
Dr
Vestibular neuro nitis
Viral la byrinthitis
f rr nsient ischaemic attack
Acoustic neuroma
Menie re's disease
m
se
The absence o f hearin g loss suggests a diag nosis o f vestibular neu ro nitis rather than viral
As
la byrinthitis.
Dr
A 57 -year-old Polish patient, who just moved to the UK 6 months ago, presents to the
emergen cy department following a fall. You notice that he has a wide-based gait, bilateral
hand tremor and a nystagmus.
Which medication is he likely t o be t aki ng?
Ethosuximide
Levetiracetam
Lamotrigine
Phenytoin
m
se
As
Sodium valproate
Dr
Ethosuximid e .
(D
Levetiracetam CD
Lamotrigine .
(D
Phenytoin CD
Sodium valp roate fiD
Phenytoin use is a cause of the cerebellar syndrome

The patient p resents wit h a cerebellar syndro me. Phenyto in use is a cause o f t he
cerebellar syndrome.
m
se
As
The ot her medications are less likely t o cause t he cerebellar syndrome.
Dr
You want to prescribe an antiemetic to a 19-year-old female who is having a migraine
attack. Which o ne of the following medications is most likely t o precipitate extrapyramidal
side-effect s?
Meptazinol
Ondansetron
Domperidone
Cyclizine
m
se
As
Metoclopramide
Dr
Meptazinol CD
Ondansetron CD
Domperidone tiD
Cyclizine m
Metoclopramide fD
m
se
As
Extrapyramidal side-effect s are particu larly common in children and young adults.
Dr
Acetazo lamide
Hig h flow oxygen
Pa racetamol and naproxen
Urgent CT head
Verapa mil
This patient presents with a cluste r hea dache. Cluster headaches are so named as clusters
of heada ches occur freq uently over a period o f weeks fo ll owed by pain free period s of
months to years.
The clinica l features include u nilateral hea daches almost always a ffecting the s ame side,
tea ring and red ness of the affected eye, rhinorrhoea and miosis +/-ptosis.
The pathop hys io lo gy of cluster head aches is u nclear. They occur more common in men
(5:1) a nd s mokers.
Abortive management of cluster headaches involves the use of 100% oxygen at at least
12 litres per minute via a no n-rebreatha ble mask and/ o r a subcutaneous o r nasal triptan.
First li ne long -term p reve ntative manag ement of cluster head aches is verapamil.
It is not recommended to offer paraceta mol, NSAIDS, opioids, ergots o r oral triptans for
the acute treatment of a cluster heada che.
(Sou rce: NICE headache guidelines)

http:/fwww.nice.org .uk/gu ida nce/ cg 150/ chapter/1 -recom mend atio n
em
s
As
Dr
A 36-yea r-old ma n p resents to the emergency d epartm e nt with a s evere left -s ided
headache with pain a round the left eye. He has had seve ral s imila r e p isod es ove r the last
2 weeks, lasting 40-60 minutes each. The heada ches a re associated with a runny nose. On
e xam ination, there is redness and tearing of his left eye.
What is the most a pp ropriate a cute mana gement?
Acetazolam ide
High flow oxygen
Pa racetamol and naproxen
Urg ent CT head
m
se
As
Verapa mil
Dr
A 24-yea r-old woman presents for advice. Over the past few months she has been having
increasing problems with migraine a round the time of menstruation. Her current mig raine
started a round 24 hours ago and has not responded to a combination of pa raceta mol
and aspirin. What is the most app ropriate next step to relieve her headache?
Codei ne
Ergotam ine
Sumatriptan
Venlafaxine
m
se
As
Norethisterone
Dr
Codeine CD
Ergotamine .
(D
I Sumatriptan GD
Venlafaxine m
Norethisterone CD
m
se
As
Oral mefanamic acid would also be a suitab le alternat ive.
Dr
A 78-yea r-old right-handed fema le is adm itted with an acute onset stroke of 2 hou rs
d u ratio n. The d ecision was taken by the stro ke team for thrombo lysis which cures her
sympto ms. She is su bseq uently tra nsferred to the high d ependency unit fo r closer
monito ring . Overnight, she ha s three bouts of vom iting and is seen by an FY2 who detects
a new o nset rig ht-left diso rientation a nd aca lculia.
An urgent CT scan is requested which reveals an intracere bra l hae mo rrhage. Which area
of the b ra in is most likely to have been affected?
Le ft tempora l lob e
Le ft parietal lo be
Right frontal lobe
Right te mpo ral lobe
m
se
As
Right parieta I lobe
Dr
Left t emporal lobe .
(D
Left pariet al lobe eD

Right frontal lobe .
(D
Right t emporal lobe fD

Right pariet aI lobe flD
This is a case of Gerstmann syndrom e. Gerstmann syndrome is a constellation of acalcu lia,
m
right -left disorientation, finger agnosia and agraphia. This occurs as a result of a deficit in
se
the angular and supramarginal gyri between the dominant pariet al and temporal lobes.
As
This can occur with space occupying lesions or in adults following a stroke.
Dr
A 25-yea r-old female with a history of dep ression presents to her GP with a two day
history of numbness affecting the C6 distribution in her right arm. There is no history of
neck pa in o r injury. Neu rological examination confi rms reduced sensation in that
dermatome but is otherwise unremarkable . She reports no s imilar episodes previously
a lthough does describe an episode th ree months ago of reduced vision and pa infu l
movements in her right eye. This resolved spontaneously and she d id not seek medical
attention. What is the most likely diagnosis?
Somatisation d iso rder
Multiple sclerosis
Syringomyelia
m
se
As
Conversion d isorder
Dr
Somatisation disorder
-
......,
Multiple sclerosis
Syringomyelia
Conversion disorder
-
......,
The symptoms three months ago were likely due to optic neurit is, a commo n p resenting
feature of mult iple sclerosis.
Whilst she has a d epression th is d oes not necessarily mean that her symptoms are due to
m
se
either a conversion or somatisation disorder. Depression is obviously very co mmon and
As
may indeed be one of the subtle manifestations o f multiple sclerosis.
Dr
Which one o f t he following features is most associated with temporal lobe lesions?
Astereognosis
Aud itory agnosia
Visual agnosia
Disinhibition
m
se
As
Expressive (B roca's) aphasia
Dr
Astereognosis
Auditory agnosia
Visual agnosia
Disinhibition
-
~
m
se
Temporal lobe lesions may cause auditory agnosia
As
Dr
You are exa mi ning a pati ent who complains of doub le vis ion. Whilst looking forward the
patient's right eye turns upwa rds a nd outwards. On attem pting to look to th e patient's
left the right eye e levates mo re as it moves media lly. On looking rig ht there is no obvious
squint. What is the most likely underlying p roblem?
Rig ht 6th nerve palsy
Rig ht 4th nerve palsy
Rig ht 3rd nerve pa lsy
Left 6th ne rve palsy
m
se
As
Dr
Right 6th ne rve palsy GD
I Right 4th nerve palsy CD

Right 3rd nerve palsy tiD
r :ft 6th nerve palsy CD
m
se
As
Left 3rd nerve pa lsy CD
Dr
A 69-yea r-old man who is known to have Alzheimer's disease is reviewed in clinic. His
latest Min i Mental State Exa mination (M MSE) score is 18 out of 30. What is the most
a ppropriate management?
Supportive ca re + mem antine
Supportive ca re + trial of cita lop ra m
Supportive ca re
Supportive ca re + donep ezil + low-d ose asp irin
m
se
As
Supportive ca re + donep ezil
Dr
Supportive care + memantine
Supportive ca re + trial of citalopra m
I Suppo rtive ca re
Supportive ca re + donepezil + low-dose aspirin

-
........
m
se
Supportive care + donepezil
As
Dr
A 65-yea r-old gentleman is referred to neuro logy outpatients with a rm pain, stiffness and
imbalance. Following investigations he is diagnosed with degenerative cervical
mye lo pathy. Unfortunately, he misses his next o utpatient clinic d ue to adm issio n with
acute coronary syndrome. He attend s his GP 2 months later and mentions his ongo ing
neu ro logical symptoms. Which of the following is the most impo rtant next step in his
ca re?
Refer to sp inal surgery o r neu rosurge ry
Refer for cervical ne rve root injections
Co mmence neuropathic ana lg esia
Rea ssu re the patie nt of his d iagnosis
m
se
As
Refer for phys iothe rapy
Dr
I Refer to spinal surgery or neurosurgery
Refer for cervical nerve root injections

-
~
Commence neuropathic ana lg esia
Reassure the patient of his diagnosis
Refe for physiotherapy

-
........
Management of patients w ith cervical myelopathy should b e by special ist sp inal services
(neurosurge ry or orthopaedic spinal su rgery). Decompressive surgery is the mainst ay of
treatment and has b een shown t o st op disease prog ression (B, false). Close observation is
an option for mild st able disease, but anything progressive o r more severe requires
su rgery t o p revent further d eterioration. Pre-operative p hysiotherapy should only be
init iated by specialist services, as manipulation can cause more sp inal cord damage.
The timing of su rgery is important, as any existing spinal cord dama ge can be permanent.
Treatment within 6 months offers the best chance of making a f ull recovery. At present
most patient s wait more than 2 years for a diagnosis [1).
Other incorrect options:

• Neuropathic analgesia is important for sympto matic relief but w ill not p revent
f urther cord damage.
• Physiotherapy d oes not replace su rgical opinion, it can in fact cause more sp inal
cord damage in patients yet t o receive surg ical treatment. It should therefore only
be initiated by sp ecialist services .
1. Behrbalk E, Sa lame K, Regev GJ, Keynan 0 , Boszczyk B, Lidar Z. Delayed diagnosis o f

cervica l sp ondylotic myelopathy by p rimary ca re physicians. Neurosurg Focus. 2013
em
Jul;35(l):El.
s
As
Dr
A 65-year old gentleman with a background of osteoarthritis and previous cervical
laminectomy fo r degenerative cervical myelopathy presents with a 2-month history of
worseni ng gait instab ility and urinary urgency. Which of the following is the most likely
explanation for his symptoms?
Transverse myelitis
Recu rrent degenerative cervical myelopathy
Multiple sclerosis
Cauda equina syndrome
m
se
As
Spinal metastases
Dr
Transverse mye litis
~urrent degenerative cervical myelopathy

Multiple sclerosis
Cauda eq uina syndrome
Postope rative ly, patients with cervica l mye lo pathy requ ire o ngoing fo ll ow-up as
patho logy ca n 'recur' at a djacent s pinal leve ls, which were not treated by the initial
d ecompressive surgery. This is cal led a djacent segment d isease. Furthermore, su rgery can
c hange sp inal dynam ics increasing the likelihood of other leve ls being affected . Patients
sometimes d eve lo p ma l-a lignment of the spi ne, inclu ding kyphos is and spondylolisthesis,
a nd this can a lso affect the s pinal cord. All p atie nts with recu rrent symptoms should be
eva luated urgently by specialist sp ina l services.
Transve rse myel itis usually p resents more acutely tha n in this case, with a sensory leve l
a nd up per motor neu ron sig ns b elow the leve l affected . It can occur in patie nts with
multip le sclerosis o r Devics disease (neu romyelitis optica). These patients tend to a lso
have featu res such as optic neuritis.
Cauda equ ina syndrome results from compress ion of the cau da equ ina and classically
includes leg weakness, saddle a naesthes ia a nd s phincter disturb ance. This gentlemans
history is much more likely to be in keeping with recu rrent ce rvical myelopathy, g ive n his
backgro und and g iven the subacute presentation
Sp inal metastases a re uncommon, especially in a patient witho ut a known primary. Give n

em
p revious DCM, recurrence is more like ly.

s
As
Dr
A 71-year-old man is reviewed following an ischaemic stroke. He is known to be
intolerant of clopidogrel. What is the most appropriate therapy to help reduce his cha nce
of having a fu rther stroke?
Aspirin + dipyridamole. Stop dipyridamole after 2 years
Dipyridamole. St op dipyridamole after 2 years
Aspirin lifelong
Warfarin
m
se
As
Aspirin +dipyridamole lifelong
Dr
Aspirin + dipyrid mole. Stop dipyridamole after 2 years
Dipyridamole. St op dipyridamole after 2 years
Asp irin lifelong
Warfarin
I Asp irin + dipyridamole lifelong
m
se
As
Please see the 2010 NICE guidelines for more details. The 2-year limit has now been
removed.
Dr
A 45-year-old female with a history of epilepsy is reviewed in the neurology clinic. Which
one of the fo llowing features is most likely to be attributable to sodium valproate
therapy?
Clubbing
Weight loss
Hirsutism
Renal impairment
m
se
As
Tremor
Dr
Clubb ing .
('D
Weight loss CD
Hirsutism eD
Renal impairment «ED
I Tremor fD.
Sodium valproate may cause tremor

Alopecia is much more common than hirsut ism in patients t reat ed w it h sodium valproate.
m
se
In the BNF t remor is listed as a 'less f requent' sid e effect whereas hirsutism is list ed as a
As
'very rare' sid e effect.
Dr
A 24 -yea r-old fema le presents to her GP due to increased frequency of migraine atta cks.
She is now having a rou nd fou r migra ines per month. Which type of med ication wou ld it
be most a p propriate to prescribe to reduce the frequency of migraine atta cks?
Sp ecific 5-HT2 ago nist
5-HTl a ntag onist
Tricyclic a ntidepressant
Beta - blo cker
m
se
Sp ecific 5-HTl ago nist
As
Dr
Mig raine
• acute: triptan + NSAID or triptan + paracetamol
• prophylaxis: topi ramate or propranolol
Topiramate is also recom mended by NIC Eas first-line prophylaxis aga inst migra ine.
m
se
However, given that she is female and of child-bearing age a beta-blocker (such as
As
propra nolol) is a better choice.
Dr
A 20-yea r-old man p resents to the neu rology clinic with a 6 month history of
d eteriorating ga it.
On exam ination he has a wide based ga it, with past po inting and high a rched feet. Knee
and ankle reflexes a re a bsent, b ut he has an extensor planta r response b ilatera lly.
Fun doscopy reveals a pale optic disc. The re is no impa irment of cognition.
Wilson's disease
Friedrich 's ataxia
Charcot- Marie-Tooth disease
Moto r neuron disease
m
se
As
Bardet-Biedl synd rome
Dr
Wi lson's disease
Friedrich's at axia
Charcot- Marie-Tooth d/sease
Motor neuron disease

-
~
Bardet-Biedl syndrome
The "yestjo g describes so meone with cerebellar signs, mixed lower motor neuron and
-~
upper motor neuron signs, pes cavus, optic atrophy with a normai!Q.
All of w hich would be p resent in Friedrich's at axia. This normally p resents in ch ildhood
and is autosomal recessive. Global sp inal cord and cerebellar degeneration give a mixed
patten of d eg eneration. Reti nal d egeneration is common, as are ca rdiomyopathies and
diabetes.
Wilson's disease can give ataxia due to excess co pper d eposition, however over
neurological features may be Parkinsonian in nature e.g. resting t remor and b radykinesia.
Wilson's d oes not give peripheral neuro pathy. A typical Kayser-Fleischer ring of co pper
may be seen in the iris of patients, no retinal changes are seen.
Charcot-Marie-Tooth (also known as hereditary mot or and sensory neuropathy), presents

with p es cavus and peripheral motor/sensory neuropathy, but would not give cerebellar
or visual sympto ms.
Motor neuron disease p resent s with mixed upper and lower motor neuron weakness - as
is seen here with absent tendon reflexes and extenso r p lant ars, however it d oes not give
cerebellar signs or affect the retina.
Bardet-Biedl syndrome is a rare autosomal recessive condition t hat gives retinit is

em
pigment osa, but also p resents with obesity, p olydactyly and frequently mental
s
As
ret ardation.
Dr
A 66-yea r-old woman is investigated fo r ascites and found to have ovarian cancer. She
presents due to 'unsteadiness'. On examination there is evidence of nystagmus and past-
pointing. Which one of the following antibod ies is most likely to be p resent?
Anti-H u
Anti-Yo
Anti-Ri
Anti-Ro
m
se
As
Anti-La
Dr
Anti-Hu QD
Anti-Yo CiD
Anti-Ri CD
Anti-Ro (D
Anti-La (D
m
se
Th is lady has developed cerebellar syndrome secondary to anti-Yo antibodies.
As
Dr
A 47 -year-old with polycythae mia is admitted t o the stroke unit with right leg weakness
and difficulty speaking. His speech is halti ng and labored, although the words he is saying
are making sense and he is not repeating himself. An M RI brain confirms a partial ant erior
circulation stroke affecti ng the middle cerebra l artery (MCA) territory.
Given his symptoms, w here is the most likely location o f the infarct?
Right superior t emporal gyrus
Left arcuat e fasiculus
Left inferior temporal gyrus
Right superior frontal gyrus
m
se
Left inferior frontal gyrus
As
Dr
Right superior t emporal gyrus
Left arcuat e fasiculus
Left inferior tempora l gyrus
Right superior frontal gyrus
Left inferior frontal gyrus
Broca's dysphasia: speech non-fluent, co mprehension normal, repetition good

Lesion
Type of dysphasia location Speech Comprehension Repetition
Wernicke's Superior Fluent Abnormal Good

(receptive) dysphasia t emporal
gyrus
Conduction Arcuat e Fluent Abnormal Poor

(associative) fasiculus
dysphasia
Broca's (expressive) Inferior frontal Non- Normal Good

dysphasia gyrus fluent
The middle cerebral artery supplies medial part of cerebrum co ntaining front al lobe and
em
medial temporal lobe and therefore supplies Broca's area in the inferior frontal gyrus.
s
As
Dr
A el derly lady patient presents with arthritic pa ins. At the end o f the consu ltation s he tells
you she has been to see a docto r at the memo ry clinic who diag nosed her with
Alzheimer's de mentia. She cannot remember why s he was not g iven a ny tablets to help
with this.
Which of the following wou ld rep resent a re lative contra indication to donepezil
prescription?
Patient on warfa rin
Mild Alzhe imer's dementia
Stage II renal impa irm ent
Resting bra dyca rd ia
m
se
As
Mini- mental state exa mi nation (MMSE) score of 18
Dr
Patient on warfarin
Mild Alzheimer's dementia

-
....,
St age II renal impairment
Resting bradycardia
-
....,
Mini-mental state examination (MMSE) score of 18
Donepezil is generally avoided (relative contraindication) in patients with

bradyca rdia and is used w ith caution in other cardiac abnormalities
Donepezil is not renally excreted and is therefore safe to give in renal failure. There is no
interaction between donepezil and wa rfa rin according to the BNF. It is licenced for use in
m
se
mild to mode rate Alzheimer's dementia (as indicated by an MMSE score of 18 in th is
As
question).
Dr
A 52-year-old gentleman w ith no past medical history presents to the emergency
department accompanied by his wife. His wife repo rted finding him confused earlier in
the day. Repetitive question ing was a prom inent feature. He was able to recognise his
wife and correctly reported his address and date o f birth to paramedics. On arrival to the
emergency department, he had recovered and was back to his normal self. The event
lasted approximately 3 hours. A full neurological examination was normal. What is the
most likely diagnosis?
Epilepsy
Transient psychogenic amnesia
Transient global amnesia
Brain tumour
m
se
Transient ischaemic attack
As
Dr
Epilepsy
Transient pst hog enic amnesia

-
~
Brain tu mour
Transient global amnesia is a cl inical syndro me of uncertain aetiology, characterised by a

discrete episod e lasting for a few hours (always less t han 24 hours) of antero grade
amnesia, retrograd e amnesia, repetitive question ing with an absence of other cognit ive or
neurological impairments.
Diagnostic criteria (in ad dition to t he above feat ures) are as fo llows; reliable witness to
ep isode, the absence of hea d t rauma or loss o f consciousness at the onset, p reserved
persona l id entity and absence of epileptic feat u res.
Epilepsy can present w ith discreet episodes of amnesia. This syndrome is called t ransient
ep ileptic amnesia. Features that suggest epilepsy are; shorter du ration (should be less
than 1 hour), mult iple attacks, onset on waking fro m sleep and accompanying ep ileptic
f eatures - e.g. motor aut omatism, stereotyped behaviours, limb shaki ng.
There are a sma ll number of case reports w here a b rain tumour has been implicated in
transient global amnesia, however, th is is very rare. A t ransient ischaemic attack can
p resent w it h iso lated amnesia, however, this again is exceedin gly rare.
Distinguishing transient global amnesia from transient psychogenic amnesia can be very
difficu lt, however, transient global amnesia is t he most likely diagnosis in th is case due t o
em
the clinica l features confo rming to the classical description of transient globa l amnesia so
s
As
closely.
Dr
A 32-year-old woman has been a dmitted to th e emergency department aher an accident
with a car. As she was crossing th e road she was hit by a car's bum pe r which made
forceful contact with her leg. On closer examination you notice that the inj ury has
manifested a foot d rop. Which of the following nerves has been damaged in th e accident?
Com mon peroneal nerve
Median neve
Medial p lantar nerve
Sa phenous nerve
m
se
As
Pudendal nerve
Dr
I Common peroneal nerve CD.
Median neve
•
Medial p lanta r nerve
•
p aphenous ne rve
•
Pu dend a l nerve
•
The common peroneal nerve p rovides sensation and motor function to the lowe r leg.
When co mpressed o r damaged it can cause foot d rop. This nerve crosses laterally to
curve over posterior rim of the fibula. It then divid es into the superficia l and deep
branches. It supplies the tibialis a nterior, extenso r hallucis longus, extensor dig itorum
longus and peroneus tertius. Combined, these allow dors iflexion of the foot. It is more
vulnerable to injury as it has a long course throughout the leg and is more superficia l than
m
se
other nerves. It is more pro ne to injury aher a direct insult. Median nerve and pud endal
As
nerves are not located in the leg.
Dr
An 84-year-old gentleman is seen in Neurology clinic with an abnormal gait. On
questi oning, you find that he has impairment of short-term memory and spatial
awareness on the Montreal Cognitive Assessment. He is accompanied by his wife w ho
reports that he has been having occasional incontinence of urine recently.
On examination, you notice that he has a magnetic gait and a postural tremor.
What is the likely underlying diagnosis?
Lewy body dementia
Idiopathic Parkinson's disease
Multiple systems atrophy
Normal pressure hydrocephalus
m
se
As
Prion disease
Dr
Lewy body dementia
Idiopathic Parkinson's disease
Multiple syst ems atrophy
Prion disease
The answer is normal pressure hydrocephalus w hich usually presents with a triad of
urinary incontinen ce, dementia, parkinsonian- like or magnetic gait.
Lewy body dementia wou ld present with visual hallucinations, idiopathic Parkinson's
disease is not necessarily immediat ely associated with urinary incontinence as a
prominent feature. Multiple syst ems atrophy typica lly has a cereb ellar com ponent and
m
se
Prion disease is linked typically w ith myoclonus and a rapidly prog ressive dementia in a
As
you nger age demographic.
Dr
Which one o f the following is a contraindication t o the use o f a triptan i n the
management o f migraine?
Concu rrent pizotifen use
Patients older than 55 years
A history o f epilepsy
Previous intracranial tumour
m
se
As
A history o f ischaemic heart disease
Dr
Concurrent pizotifen use CD
Patients o ld e r than 55 years CD
A history o f epile psy flD

Previous intracranial tumour fD
A history of ischaemic heart d isease GD
m
se
As
Cardiovascular d isease is a contra indication to triptan use
Dr
A 64-year-old man who is und er investigation for pa rkinsonian symptoms is b rought to
the GP by his wife . She is concerned her husband is becoming increasingly a gitated. The
GP p rescribes haloperidol. One week later the GP is ca lled out to see the patient as his
pa rkinsonian symptoms have deteriorated marked ly. What is the most li kely underlying
diag nosis?
Lewy body d ementia
Norma l pressu re hyd rocepha lus
Progressive supranuclear palsy
Multiple system atrophy
m
se
As
Dementia pugilistica
Dr
Lewy b ody d ementia
Norma l p ressu re hyd rocep halus
Mu ltiple system atro phy
-
~
m
se
As
Patients with Lewy body dementia a re extremely sensitive to neuro leptic agents
Dr
A 39-year-old-male present with morning hea daches associat ed with nausea for the last 2
months and an inability t o look upwards. On examination, while upgaze is diminished
bilaterally, downgaze is preserve and it is not corrected by the doll's-head-manoeuvre. On
examination of his pupils, his pupils constrict on accommodation but did not constrict on
exposure to light. One also notices some mild eyelid retraction bilaterally. Where is the
lesion localised to?
Frontal lobe
Dorsal midbra in
Ventral midbrain
Occipital
m
se
As
Cerebellar vermis
Dr
I Dorsal midbra in ED
Ventra l midbrain e:D
Occipital (fD
Cerebellar vermis f!'D.
Th is patient has Parinaud syndrome as a result of a lesion at the dorsal midbrain. Lesions
in the other four options do not result in Parinaud syndrome.
Rostral interstitial nucleus of medial longitudinal fasciculus lies at the dorsal midbrain and
control vertical gaze. They project to the vestibu lar nuclei. It result s in the following
symptoms:
• Upward gaze palsy, o ften manifesting as diplopia

• Pupillary light-near dissociation (Pseudo-Argyll Ro bertson pupils)
• Convergence-retraction nystagmu s
It's aetiology include:
• Brain tumours in the midbrain or pineal gland (pinealoma)
m
• Multiple sclerosis
se
• Midbrain stroke As
Dr
A 45 -year-old woman is found unconscious. Her neighbour t ells you that she was taking
multiple medications for depression and schizophrenia. She is brought in t o the
emergency department where she is unconscious, febrile at 40°C, syst olic blood pressure
of 180mmHg, heart rat e 140/min, and has muscle rigidity and no myoclonus.
Her CK is 68,000 iu/L.
Serotonin syndrome
Catatonia
m
se
As
Acute dystonia
Dr
Serotonin syndrome
- ~
Neuroleptic malignant syndrom e
Catatonia
-
~
Acute dyst onia
The key distractor for this question is serotonin syndrome. They have virtually identical
presentin g features. Myoclonus is the distinguishing feature of serotonin syndrome
(found only in serot onin syndrome). All the other features can be present in both
conditions. Muscular rigidity points more toward s NMS. Malignant hyperthermia is an
effect of volatile inhalational anaesth etic agents and the muscle relaxant succinylcholine.
It is caused by an aut osomal dominant mutation in ryanodine receptor type 1 which
encodes the calcium-release channel of the sarcoplasmic reticu lum, and CACNAlS, which
encodes the alpha subunit of the L-type calcium channel isoform of the sarcolemma
(dihydropyridine recept or).
Features of both NMS and serotonin syndrome.

• Severe muscular rigidity
• Hyperth ermia (t emperature >38°C)
• Autonomic inst ability
• Changes cognition or in the level of consciousness
• Rhabdomyolysis
em
• Recent com mencement or change of d ose of a medication

s
As
Dr
A 63-year-old woman with motor neuron disease is reviewed in clinic. Which one of the
fo llowing interventions will have the great est effect on survival?
Regular chest physiotherapy
Total parent al nutrition
Riluzole
Antioxidant supplementation
m
se
As
Non-invasive ventilatio n
Dr
A 63-year-old woman with motor neuron disease is reviewed in clinic. Which o ne of the
fo llowing interventions w ill have the great est effect on survival?
Regular chest physiotherapy
Total parental nutrition
Riluzole
Antioxidant supplementation
Non-invasive ventilation
m
se
Motor neuron disease - treatment: NJV is better than riluzole
As
Dr
A 29-year-old wo man with a past history of hypothyroidism presents t o the surgery
com plaining of wea kness, particularly of her arms, for the past four months. She has also
developed dou ble vision toward s the end o f th e day, despite having a recent normal
examination at the opticians. What is the most likely diagnosis?
Lamb ertEaton myasthenic syndrome
Polymyositis
Polymyalgia rheumatica
Multiple sclerosis
m
se
As
Myasthenia gravis
Dr
Lambert Eaton myasthenic synd rome f!D
Polymyos itis CD
I Pj'ymyalgia rheumatica CD
Multiple sclerosis CD
m
se
f1D
As
Myasthenia gravis
Dr
A 61-year-old man presents to his GP with recu rrent falls over the past few months. He
reports that his legs feel weak and he has recently had difficulty doing up the buttons on
his shirt. He reports no other sym ptoms and is otherwise well. His past medical history
includes hypertension for which he t akes amlodipine. On examination, he demonstrates
bilateral foot drop with a high stepping gait. Power is reduced throughout both upper
and lower limbs. Reflexes were brisk in the upper limbs but the knee and ankle reflexes
cou ld not be elicited. He demonstrated upgoing plantars. Coordination and sensation
were intact throughout.
Amyotro phic lateral sclerosis
Cervical spondylotic myelopathy
m
se
As
Lambert -Eaton myasthenic syndrome
Dr
Cervical spondylotic myelopathy
Charcot-Marie-Tooth disease
Lam bert -Eaton myasthenic syndrome
Amyotrophic lateral scleros is is associated with mixed UMN and LMN signs (usua lly
no sensory deficits)
Amyotrophic lateral scleros is (ALS) is a type of motor neurone disease (MND).

Degeneration of neurones in the motor cortex and in the ventral spinal cord produces
mixed UMN and LMN signs. There are no associated sensory deficits.
Guillain-Barre syn drome (GBS) is an inf lammatory p eripheral neuropathy so w ill not
present w ith upper motor neurone signs. There is nothing in t he history to suggest a
recent bacterial or viral infection. GBS is often accompanied by sensory disturbances (both
motor and sensory nerves of the peripheral nervous system are attacked by the immune
system).
Cervical spondylotic myelopathy - cervical spondylosis is the term used for osteoarthritis
of t he spine and can result in com pression of the sp inal cord. This is more likely to result
in LMN signs at t he level of the compression (ie. upper limb if the lesion is b elow CS) w ith
UMN signs below (in the lower limb). Patient s usually comp lain of neck pain and stiffness.
Charcot-Marie-Tooth syndrome - a heredit ary senso ry and motor peripheral neuropathy.

UMN signs are not present in these patient s. Patient s can p resent with lower motor
neurone si gns in all limbs and reduced sensation (more pronounced dista lly).
Lamb ert-Eaton myasthenic syndrome - a rare autoimmune disorder involving t he

em
neuromuscular junction, so UMN signs will be absent. This condition is associat ed with
s
As
small-cell lung cancer.

Dr
You are a GP reviewing letters for your patient s. The next letter you come across is from
an elderly gentleman you referred to the memory clin ic for increasing forgetfulness.
You note that he has been given a diagnosis of vascu lar dementia. Which of the following
treatments is most likely to have been recommended?
Tight contro l of vascular risk factors
Donepezil
Fluoxetine
Cognitive behavioural therapy
m
se
As
Memantine
Dr
I Tight control of vascular risk factors
Donepezil
~uoxetine
Memantine
Tight contro l of vascu lar risk facto rs, rather tha n anti dement ia medicati on, is
recom mend ed by NICE in vascular d ementia
m
Cholinesterase inhibitors are licenced for use in Alzheimer's and mixed dement ias. They
se
are not recommended for the t reatment of vascular dementia. NICE recom mend t ight
As
control of vascular risk factors in order t o slow p rog ression of t he disease.
Dr
A 42-yea r-old wo ma n with a history of myasthe nia gravis is admitted to the Emerge ncy
Department. She is currently taking pyridostigmine but there has been a sig nificant
worseni ng of her sympto ms following a ntibiotic treatment for a chest infectio n. On
exami nation she is dys pno e ic and cya notic with quiet breath sound s in both lu ngs. Other
tha n respirato ry sup port, what are the two treatments o f choice?
IV methylpred niso lone o r plasmapheresis
IV methylpred niso lone o r intravenous immunoglobu li ns
Plasmapheresis o r atropine
IV methylpred niso lone o r a tropin e
m
se
As
Plasmapheresis o r intraveno us im mun oglo bulins
Dr
IV methylpredn isolone or plasmapheresis
IV methylpredn isolone or intravenous immunoglobulins
Plasmapheresis or atropine
IV methylprednisolone or atropine
Plasmapheresis or intravenous immunoglobulins
This patient is having a myasthenic crisis. Opinions vary as to whether plasmapheresis or
m
se
intravenous immunoglobu lins should be given first- line. Plasmapheresis usually works
As
quicker but involves more expensive equipment
Dr
A 67-year old male recently attend ed A&E, w it h a 3 month hist ory of b ilat eral
paraesth esias and twitchin g affecting t he thu mb, first fi ng er and lateral fo rearm. He
d enied any t rauma. A MRI scan of his spine was performed and revealed cervica l canal
stenosis wit h mild cord co mpression. He was discharged and advised t o see his GP for
follow-u p. Which of t he followi ng is t he most appropriate initial st ep in management?
Ref er to sp inal su rgery services
Ref er for locally comm issioned cervica l ro ot injections an d review after 6 weeks
Enlist on t he weekly minor ops clinic for carpa l t unnel d ecompression
Commence neuropathic ana lg esia in the first inst ance and co nsider su rgical
evaluat ion if this does not work
m
se
As
Ref er to physiolo gy services and review in 6 weeks
Dr
I Refer to spinal su rgery services
Refer for locally co mmissioned cervical root injections an d review after 6 weeks
Enlist on the weekly minor ops clinic for carpa l tunnel d eco mpression
Commence neuropathic ana lg esia in the first insta nce a nd co nsider s urgical
evaluation if this does not wo rk
Refer to p hysio lo gy services and review in 6 weeks
Bilatera l media n nerve dysfunction is very sugg estive of a diagnos is of deg enerative
ce rvica l myelopathy (DCM) rather tha n bilatera l ca rpa l tunne l syndrome (optio n C). DCM
s ho uld be suspected in e lde rly patie nts p resenting with limb neu rology. His twitches a re
p ro bably fibrillations, a s ign of lower moto r neu ro n dysfunct ion.
Deg ene rative cervica l mye lopathy is associated with a d elay in d iagnosis, estimated to be
> 2 years in so me stud ies [1]. It is most com mon ly misd iag nosed as carpal tunne l
syndrome a nd in o ne study, 4 3% o f patie nts who underwent su rg e ry fo r degenerative
ce rvica l myelopathy, had been in itially diag nosed with carpal tu nnel synd rome [1].
Ma nag ement of these patients shou ld be by specia list sp ina l services (neurosurgery o r
o rthopaedic s pin al su rgery). Decom press ive su rgery is the ma instay of treatment and has
been shown to sto p d isease progression. Phys iothe rapy and analges ia d oes not rep la ce
su rgical opinion, thoug h they may be used along sid e (o ptions D and E). Nerve root
inj ections d o not have a role in mana gement (option B).
1. Behrbalk E, Sa lame K, Regev GJ, Keyna n 0, Boszczyk B, Lidar Z. Delayed diagnosis o f

ce rvica l sp ondylotic mye lopathy by p rimary ca re phys icians. Neurosurg Focus. 2013
em
Ju l;35(l):El.
s
As
Dr
A 23-year-old man is referred to neurology clinic. He describes episodes of leg weakness
fo llowing bouts of lau ghi ng whilst out with friends. The following weekend his friends
described a brief collapse following a similar episode. What is the most likely diag nosis?
Stokes-Adams attack
Cataplexy
Hypokalaemic periodic paralysis
Absence seizure
m
se
As
Myasthenia gravis
Dr
Stokes-Adams attack
I Cata plexy
I
Hypokalaem ic periodic para lysis
Absence seizure
-
....,
m
se
Myasthenia g ravis
As
Dr
A 62-year-old man is admitted to the Emergency Department with a left hemiplegia. His
symptoms started around 5 hours but he initially thought he had slept in an awkward
position. He has no past medical history of note but on examination is fou nd to have and
irregular pulse of 150 I min. The ECG confirms atrial fibrillation. ACT head is immediately
arranged and reported as normal. What is the most appropriate initial management?
Aspirin
Aspirin +dipyridamole
Alteplase
Warfarin
m
se
As
Aspirin + warfa rin
Dr
I Asp irin ED
Aspirin + dipyrid amole GD
Alteplase (iD
Warfarin GD
Aspirin + warfarin (fD
Rate control shou ld also be init iated. He is out sid e the th rom bolysis window so alteplase
is not an option. The 2004 RCP guidelines recommend that anticoagulation shou ld be
commenced 14 d ays aher an ischaemic stroke. Earlier anticoagulation may exacerbat e any
secondary haemorrhage.
m
se
As
Dipyridamole should not be used in the acute phase.
Dr
A 29-year-old female p resents complaining of weakness in her arms, leading t o increasing
difficu lties at work. On examination she has a bilateral pt osis and loss of t he red-reflex in
bot h eyes. Urine testin g also reveals glycosu ria. What is t he most likely diagnosis?
Myotonic dystrophy
Homocystinuria
Multip le sclerosis
Myasthenia gravis
m
se
As
HIV
Dr
Myotonic dystrophy
Homocystinuria
Multiple sclerosis
Myasthenia gravis
Dystrophia myotonica - DMl

• d istal weakness initially
• autosomal d om inant
• d iabetes
• dysarth ria
m
se
These features a re typica l of myoto nic dystro phy. The red -reflex is lost due to bilatera l
As
cata racts
Dr
You are on the night on-call team, a nd a 76-yea r-old woman on one of your wa rds has
developed increasing confusion. She is wandering around the ward asking for her
husband and is shouting at staff a nd other patients. She was admitted this morn ing with a
high feve r and a one-week history of a p roductive, pu ru lent cough. She also has a history
of Parkinson's disease.
Nursing staff have been unable to calm her a nd she has now started to throw objects a nd
hit staff members. The nu rses have however been able to give you the following obs:
Temperature 37 .s•c
Heart Rat e 105 bpm
BP 138/ 78 mmHg
Sa02 95% on room air
Blood glucose 5 mmoi/L
Which of the following is the most app ropriate treatment?
Immed iate re lease carbidopa-levodopa
Olanzapine
Lorazepam
Am itriptyline
sem
As
Ha loperidol
Dr
Immed iate release carbidopa- levodopa f.D
Olanzapin e CD
I Lorazepam CfD
Am itriptyline
Haloperidol
•
CID
Anti-psychotics should be avoided in delirious patients with a background of

Parkinson 's disease
This lady is currently suffering from delirium, a common issue in e lderly patients in
hospita l. The combinatio n o f an und erlying infection and the dark environment of the
wa rd at night are likely contributing to her acute confusional state.
Haloperidol and other antipsychotic medications a re reco mmend ed first-line treatment

options when nursing strateg ies have fa iled, however, these shou ld not be used in
patients with a background o f Parkinson's disease. Anti-psychotics often have strong a nti-
dopaminergic action, and as such in a patient with Parkin son's, they will make their
condition significantly worse. As such, lorazepa m is the most su itable option.
Immed iate re lease levo do pa wou ld not be helpfu l in this situation as this ladies confusion m
se
is not due to her Parkinson's d isease. While Parkinson's d isease can cause behavioural
As
changes, they tend to be more chronic, p rog ressive and less labile in natu re.
Dr
You a re ca lled to see a 62 -year-old female inpatient, with a known history of ep ilepsy,
who is having a seizure. The nurse who witnessed the seizure says it began by affecting
he r right hand before involving her entire right a rm and then progress ing to a loss o f
consciousness with her entire body shaking . What is the most like ly d iagnosis?
Generalised tonic-clonic
Focal impaired awareness seizure
Jacksonian march with secondary generalisation
Focal aware seizu re
m
se
As
Myoclonic
Dr
Gene ralised tonic-cl onic
Foca l impaired awarene ss seizure
I Jacksonian march with secondary genera lisation
Fo ca l awa re seizure
Myoclonic
A Jacksonia n ma rch is a type o f fo ca l awa re seizure.
Foca l highlig hts how it is focal e pilepsy that invo lves ab no rmal electrical activity in j ust
o ne part o f the b rain.
It cha racteristica lly sta rts by affect ing a periphera l body pa rt such a s a toe, fing e r o r
sectio n of the lip and the n sp read s q uickly 'ma rches' over the respective foot, hand o r
face.
m
se
In some with Jacksonia n ma rch seizures (as in this case), the e lectrical di sorder sp reads
As
o ve r large r a reas o f the b rain, causing the se izu re to d eve lo p into a to nic-clo nic seizu re.
Dr
A 19-year-old female presents complaining of visual disturbance. Examination reveals a
bitemporal hemianopia with predominately the lower quadrants being affected. What is
the most likely lesion?
Brainstem lesion
Craniopharyngioma
Frontal lobe lesion
Pituitary macroadenoma
m
se
As
Right occipital lesion
Dr
Brainstem lesion
Cra niopharyngioma
Frontal lobe lesion
Pituita ry macroadenoma
Bitemporal hemianopia
• lesion of optic chias m
• upper quadrant defect > lower quadrant defect = inferior chiasmaI
com press ion, co mmonly a pituitary tumour
• lower quadrant defect > upper quadrant defect = superior chias ma!
m
com press ion, co mmonly a craniopharyngioma
se
As
Dr
A 48-year-old male presents to t he Emergency d epartm ent w ith acut e visual chang es. He
has a past medical hist ory of hypertension an d type 2 diab etes mellitus.
On examination, his upp er and lower limbs are normal neurolog ically. On examination o f
his cranial nerves, you no te a homonymous hemian opia w it h central preservation.
Where is t he likely cause of his p roblems with in the central nervous system?
Optic tract
Optic radiati on
Optic chia sm
Optic nerve
m
se
As
Temporal lobe
Dr
Optic tract 6D
Optic radiation CD
Opt ic chiasm CD
Optic nerve CD
Tem poral lobe CD
The answer is the optic radiation. Lesions in t his area can cause a homonymous
hemianopia with macular sparin g which is as a result of collateral circu lation o ffered to
ma cular t racts by the mid dle cerebral artery.
Lesions in t he optic t ract also cause a homonymous hemianopia b ut without macular
m
sparing. Lesions in t he opt ic chiasm, optic nerve, and temporal lobe cause b itemporal
se
hemianopia, ipsilat eral co mplete b lindness, and superior homonymous quadrantanopia
As
respectively.
Dr
A 72-year-old man becomes conf used at t he end o f a charity walk for A lzheimer's. He is
b rought to t he hosp ital by paramedics because he repeatedly asked o th er att end ees on
the walk w hy he was t here and how he had g ot t here. There is no past medical history of
note and he takes no regular medicati on. He is orientated in time and person and knows
he ha s been broug ht to t he hosp ital. His b lood pressure is 123/ 82 mmHg, his p ulse is 70
beat s per minut e and regu lar. The neurologica l exam is unremarkab le, routi ne blood t ests
and CT head are normal. He gradually recovers over t he cou rse o f 3hrs.
What is the most ap propriate int ervention?
Asp irin
Clopidogrel
Reassu rance
Rivaro xaban
m
se
As
Warfarin
Dr
Asp irin fD
Clopidog rel GD
Reass u ranee CD
Rivaroxaban
•
Warfarin
•
The most likely diagn osis here, w it h acute onset o f ret rograde amnesia with preserved
o rientat ion and co nsciousness, is transient global amnesia, (TGA). The exact cause o f TGA
is unclear, alt houg h it may be similar in aetiology to migraines. Th ere is no evidence in
p rospective cohort st udies to suggest an associat ion between TGA an d increased risk of
st roke.
Asp irin and clopido grel, bot h antiplat elet ag ents, are not indicat ed here b ecause TGA
m
d oes not mark out t he pat ient as b eing at increased risk of ischaemic stroke. Rivaroxa ban
se
and warfarin are bot h indicated for ant icoagulation in patients w it h at rial fibrillat ion,
As
which hasn't been identified here.
Dr
A 68-yea r-old man undergoes a lumba r p uncture to investigate new confusion. His
platelet count is no rmal, and his clotting screen is within an acceptable range. The
procedu re is discussed with his family as he is unable to consent and they are happy with
the p rocedu re but want to ensu re that the possibility of post lumba r puncture headache
is min imalised. What factor has been demonstrated to increase the li keli hood of a post-LP
headache?
Small need le gauge
Replacing the stylet during the procedure
Keeping the beve l of the need le pa ra lle l to the dura
Early mobilisation following procedure
m
se
As
Use o f a Qu incke (sha rp) needle
Dr
Small needle gau ge
Replacing the stylet during t he procedure
Keep ing t he b evel of t he needle para llel t o the dura
Early mobilisation fo llowing procedure
Use of a Quincke (sharp) needle
Sharp needles have b een found to b e associat ed with a great er f requency o f post-lumbar
puncture headaches when compared t o atraumatic needles inserted using an introducer.
Using a small needle, replacing the stylet and maintaining the bevel parallel d ecreases the
chance of developing a p ost-lumbar puncture headache, w hilst early mobilisation has no
impact.
m
se
Johnson, Kimberley S., an d Daniel J. Sexton. 'Lumbar Punct u re: Tech nique, Indications,
As
Contraindications, and Complications in Adults.' UpToDat e. 3 Feb. 2016.
Dr
A 60-year-old gentleman with a background of lumbar spondylosis and chronic back pain
present s w ith gradually worsening bilateral upper limb paraesthesias and leg stiffness.
Which one o f the investigations below is diagnostic for his likely condition?
Nerve conductio n studies and EMG
MRI Cervical spine
MRI Lumbar Spine
CT C-spine
m
se
As
AP and lateral C-spine radiog raphs
Dr
Nerve conduction studies and EMG
MRI Cervica l spine
MRI Lumbar Spine
CT C-spine
AP and late ral C-sp ine rad iog rap hs
The presence of upper li mb neurological sympto ms indicates that there is pathology

either within his cervica l spinal cord or b rain. Brain disease is more like ly to cause
unilatera l prob lems.
A MRI lumba r sp ine would therefore not provide a unifying diagnosis here.
In the co ntext of known lumbar d egenerative sp ine, degene rative cervical mye lopathy is
the num ber one differentia l for this p resentation. An MRI of the cervical spine is the gold
standard test where ce rvical myelopathy is suspected. It may revea l disc deg eneration and
ligament hypertrophy, with acco mpanying cord signal cha nge. It is not unco mmon for
patients to suffer from ta ndem (cervica l and lumbar) stenosis.
Other a nswe rs:

• CT imaging is reserved for patients with contraindications to magnetic resonance
imaging. ACT mye logram is the first line investigation in this case
• Radiographs are not clinically useful in the worku p of these patients, though
osteoa rthritic cha nges (e .g . osteophytes) can be visible if they a re performed.
• Other investigatons (e .g. nerve conduction studies, EMG) may be performed when
the clinica l picture is unclea r. These can he lp to exclude mononeuropath ies and
other lower motor neu ron disorders. However, where there is strong clin ical
suspicion and the diagnosis is suspected, an MRI of the cervical spine should be
performed.
em
s
As
Dr
A 29-year-old man present s complaining of visual disturbance. Exam ination reveals a
right superior homonymous quadrantanopia. Where is the lesion most likely to be?
Optic chiasm
Left temporal lobe
Right t emporal lobe
Left optic nerve
m
se
As
Left pariet al lobe
Dr
Optic chiasm CD
I Left t emporal lobe ED

Right temporal lobe tlD
Left optic nerve CD
Left parietal lobe GD
Visua l field d efects:

• left homonymous hemianopia means visual field defect to t he left, i.e. lesion
of right optic t ract
• incongruous defect s = optic t ract lesion; congruous d efects= optic radiation
m
se
lesion or occip ita l cortex
As
Dr
A 23 -year-old woman undergoes a p lann ed lumbar puncture (LP) as part of neurolo gica l
invest igat ions for possib le mult ip le sclerosis. Duri ng t he consent p rocess, she exp resses
concern about a post -LP head ache. What is the mechanism o f post -LP headaches?
Vertebral body injury
Nerve injury
Bleeding into cerebrospinal fluid
Leakin g cerebrospinal fluid f rom the dura
m
se
As
Too much cerebrospinal f luid removed
Dr
Vertebral body injury
Nerve injury
Bleeding into cerebrospinal fluid
Leakin g cerebros pinal fluid from the dura
Too much cerebrospinal fluid removed
Leaking of cerebrospinal fluid from the dura is the most likely explanatio n for post-l umbar
puncture headaches. It is thought that ongoing leak of cerebrospinal fluid (CSF) through
the puncture site causes ongoing CSF loss, leading to low pressure. A post -LP headache is
typica lly front al or occipita l and occurs w ithin three days. It is normally associated with
worsening on standing and improvement when lying down. Treatment in severe cases
includes an epidural blood patch, but most resolve on their own.
m
se
Vertebral body injury, nerve inj ury and bleeding would not cause headaches, w hilst the
As
loss of cerebrospinal fluid volume during lumbar puncture does not cause pain.
Dr
A 55-yea r-o ld man presents d ue to a n uncontro llab le urge to move hi s legs during the
night-time. He has a lso experie nce the sensation of spide rs crawling over his legs. Simple
measu res such as wa lking a nd massag ing the affected li mb have not alleviated the
p ro b le m. What is the most a ppro priate medica l the rapy?
Select ive serotonin reuptake inhib itor
Low-d ose tricyclic antide pressa nt
Do pamine ag o nist
5-HT3 a ntag onist
m
se
As
Dr
Selective serotonin reupta ke inhib itor
Low-dose tricyclic antidep ressant
r
Dopam in e agon ist
5-HT3 antagonist
Dopamine antagonist
Restless leg syndrom e - management includ es dopam ine agon ists such as
m
se
ropinirole
As
Dr
You are reviewing a 22-year-old man who has developed headaches. Which one o f the
following featu res is most typical o f migraines?
Pain on neck flexion
Phonophobia
Epiphora
Recent vira l illness
m
se
As
Bilateral, 'tight -band' like pain
Dr
Pain on neck flexion m
Phonophobia GD
Epiphora GD
Recent viral illness
Bilateral, 'tight- band' like pai n

•
f.D
m
se
As
Phonophobia occurs in aroun d three-quarters of patients.
Dr
A 63-yea r-old man is diagnosed as having restless legs syndrome. What is the most
re levant blood test to p erfo rm?
ESR
Ferritin
Blood glu cose
Urea a nd e le ct ro lytes
m
se
As
Liver fu nctio n tests
Dr
ESR CD
I Ferritin ED.
Blood glucose CD
Urea and electrolytes fD
Liver function t ests CD
Restless legs syndrom e - ferritin is the single most important bloo d test
m
se
A case cou ld be made for all the above tests but a low seru m ferritin is most likely to be a
As
cause of secondary restless legs syn drome
Dr
A 45-yea r-old male presents with recent aggress ive behaviour, de pression, chorea and
athetosis. His father had similar symptoms at the age o f 65. A neurod egenerative disorder
with trinucleotide re peat expansion is suspected.
Which of the following trinucleotid e re peats is most likely p resent?
GAA
GCC
CGG
CTG
m
se
As
CAG
Dr
GAA CD
GCC .
(D
CGG GD
CTG fD
CAG CD
There is a repeat expansion of CAG trinucleotide in Hunt ington's disease

This patient has Huntington's disease, an autosomal dom inant co ndition, which has CAG
trinucleotide repeats.
Other important commonly tested t rinucleotid e repeat s:

• GAA: Friedrich Ataxia
m
• CTG: Myotonic dystrophy
se
As
• CGG: Frag ile X syndrome
Dr
A 25-year-old woman present s wit h recu rrent attacks of 'dizziness'. These attacks typically
last around 30-60 minutes and occu r every few days or so. During an attack 'the room
seems to be spinning' and t he patient often feels sick. These episodes are often
accompanied by a 'roa ring' sensation in the left ear. Otoscopy is normal but Weber's test
localises to the right ear. What is the most likely diagnosis?
Acoustic neuroma
Vestibu lar neurit is
Benign paroxysmal positional vertigo
Multiple sclerosis
m
se
Meniere's disease
As
Dr
Acoustic neuroma
Vestibu lar neurit is

-
~
Multip le sclerosis
Meniere's disease
m
se
As
In sensorineural hearing loss Weber's test loca lises to the contralateral ear.
Dr
A 70-yea r-old man is investigated for involuntary, jerkin g movements of his arms. His
symptoms seem to reso lve when he is asleep . Damage to which one o f the fo llowin g
structures may lead to hem iba ll ism?
Substantia nigra
Red nucleus
Subtha la mic nucleus
Glob us pa llidus
m
se
As
Frontal lobe
Dr
Substantia nigra CD
Red nucleus CD
Subthalamic nucleus fZiD

Globus pallidus flD
Frontal lobe
•
m
Hemiballism is caused by damage to the subthalamic nucleus
se
As
Dr
Which of the following features is least likely to be found in a patient with tuberous
sclerosis?
Shagreen patches
Cafe-au-lait spots
Retinal hamartomas
Axillary freckling
m
se
As
Renal angiomyolipomata
Dr
Shagreen patches GD
Cafe-au-lait spots CD
Retinal hamartomas «!D
I Axillary freckling eD
Renal ang iomyolipomata «!D
m
se
As
Axillary freckling is seen in neu rofibromatosis
Dr
A 17-yea r-old ma le presents to the emergency depa rtment (E D) following a head injury
during a rugby match.
His parents who witnessed the inj ury tell you he lost consciousness im mediately aher the
coll ision for a number of minutes. He was then a lert and himse lf for a couple of hours.
They have now bought him to ED as he beca me drowsy and was compla ining of a
headache.
On exam ination his Glasgow coma scale (GCS) is 12, the pupils a re unequal and there is a
clear swelling on the right s ide of the head.
Given the likely diagnosis of an intracranial haemorrhage, which vessel has most likely
been damaged?
Brid ging veins
Carotid artery
Circle of Willis
Dural artery
m
se
As
Midd le meningea l artery
Dr
Bridging veins
Carotid artery
Circle of Willis
Dural artery
Middle meningeal artery

-
~
Extradural or su bdural haemorrhage? Extradural = lucid period, usually fol lowing

major head injury. Subdural = fluctuating consciousness, often following trivial
injury in the elderly or alcoholics
This is a classic presentation o f an extradural haemorrhage with a Lucid interval after

which the patient deteriorates.
Tea ring of bridging veins is the primary pathology in a subdural haematoma.
Carotid artery - is not intracra nial.
The Circle of Will is is the most co mmon location for berry aneurysms t o bu rst - this resu lts
in a subarachnoid haemorrhage an d wou ld classically present with a 'thunderclap
headache'/
Dural artery - does not exist.

s em
Damage to the middle meningeal artery is the primary pathology in extradural

As
haematomas.
Dr
Which one of t he followin g side -effects is least associated with the use of levod opa?
Psychosis
'On-off' effect
Postural hypotension
Cardiac arrhythmias
m
se
As
Galactorrhoea
Dr
Psychosis .
(D
'On-off' effect CD
.____
Postural hypotension GD
I ·
Card'1ac arrh}'!hm1as flD
'I
m
se
Galactorrhoea ED.
As
Dr
A 33-year-old female with multiple sclerosis complains that her vision becomes blurred
during a hot bath. What is this an example of?
Uhthoff's phenomenon
Oppenheim's si gn
Werdnig-Hoffman's sign
Lambert's sign
m
se
As
Lhermitte's si gn
Dr
I Uhthoff's phenomenon flD
Oppenheim's sign m
Werdnig-Hoffman's sign m
Lam bert's sign CD
Lhermitte's sign «!D
This is Uhthoff's phenomenon. Lhermitt e's sign describes paraesthesiae in the limbs on
neck flexion
Opp enheim's sign is seen when scrat ching of the inner side o f leg lea ds to extension o f
m
the toes. It is a sign of cerebral irrit ation and is not relat ed to multiple sclerosis
se
As
Werdnig-Hoffman's disease is also known as spinal muscular atrophy
Dr
Which one o f the following is not a recogn ised adverse effect of phenytoin use?
Slurred speech
Nystag mus
Gynaecomastia
Dip lo pia
m
se
As
Ataxia
Dr
Slurred speech GD
Nystag mus .
(D
Gynaecomastia ED
Diplopia GD
m
se
As
Ataxia CD
Dr
A 35 -year-old man presents w ith progressive weakness of his hands. On examination you
notice wasting of the small muscles o f the hand. A diagnosis of syringomyelia is
suspect ed. Which one o f the follow ing features wou ld most support this diagnosis?
Hyper-reflexia in the upper limbs
Loss of vibration sensation in the hands
Loss of temperature sensation in the hands
Loss of light touch sensation in the hands
m
se
As
Fasciculation of the small muscles of the hand
Dr
Hyper-ref lexia in the upper limbs
Loss o f vi ration sensation in the hands
Loss of te mperature sensation in t he hand s
Loss of light touch sensation in the hands
Fasciculation of the small muscles of the hand
m
se
Syring omyelia - sp inothalamic sensory loss (pain and t emperatu re)
As
Dr
A 21-year-old with a know n Chiari 1 malformation und ergoes a sp inal M RI scan. The
imaging reveals a cervical and thoracic syrin gomyelia. On closer examination, t he patient
is noted t o have a cape-like loss of sensation to pain and t emperature, but normal fine
t ouch and prop rioception.
Which of the follow ing sp inal cord structure are affected in order t o cause t his pattern o f
signs?
Dorsal columns
Spinocerebellar tract
Anterior white commisure
Dorsal root ganglion
m
se
As
Corticospi nal tract
Dr
Dorsal columns
Spinocerebella r tract
-
~
Anterior white comm isure
Dorsal root g anglio n
Corticospi nal tract

-
. .wr
Syringo mye lia classically presents with cape-like loss of pain and temperature
sensation due to compression of the spinothalamic tract fibres d ecussating in the
anterio r white commissure o f the sp ine
As the syringomyelia progresses it will first cause co mp ression o f the spinothalam ic tract
as they decussate in the anterior white commissure. This results in loss of sensation of
pa in, temperature and non -discrimi native touch. A cape-like distribution is a classic
finding in syringomyelia.
The dorsal columns a re in the posterior columns and the remaining tract s are in the
m
se
lateral spinal cord a nd so a re not affected first. The d orsal root ganglia are not within the
As
s pinal cord, so wou ld not be a ffected at all.
Dr
Which one of the following antibodies is associated with ocular opsoclonus -myoclonus in
patients with breast cancer?
Anti-Hu
Anti-La
Anti-GAD
Anti-Yo
m
se
As
Anti-Ri
Dr
Alopecia
Weight gain
Hepatitis
-
. .wr
~uction P450 system

Teratogenicity
-
. .wr
m
se
As
Sodium valproate causes inh ibition of the P450 system
Dr
You are called to review a 55-year-old man on the wards w ho started fitting around 5
minutes ago. He was admitted t hree days ago follow ing an acute coronary syndrome. His
past medical history includes to nic-cloni c epilepsy which is generally well controlled on
sodium valproate. On your arrival he is still fitting. Oxygen saturations are 99% on 100%
oxygen an d his pulse rate is 96/min. Intravenous access is already in-situ . What is the
most app ropriate next step?
Observe for a further 5 minutes to see if the seizure stops spontaneously
Give IV loraze pa m
Give bucca l midazolam
Give IV phenytoin
m
se
As
Fast-bleep an anaesthetic doctor
Dr
Observe for a fu rther 5 minutes to see if the seizu re stops spontaneously
Give N loraze pam
Give b ucca l midazo lam
GiveN phenytoin
Fast-b leep an anaesthetic doctor
IV lorazepam is the first-line trea tment in patients with ea rly statu s e pilepticus
As the patient has intravenous access it is most appropriate to give a benzodiazepine

pa rentally due to the more certain absorption. Lo razepam may be repeated once after 10
minutes.
m
se
Intravenous phenytoin is the next line treatment if the seizure fa ils to stop. Gu idelines vary
As
at when this shou ld happen but genera lly 20-30 minutes is used as a cut-off.
Dr
A patient presenting to the eme rge ncy department undergoes aCT head scan. The report
describes a hypod ense collectio n around the convexity o f the b rain that is not limited to
suture lines.
What is the most li kely radiological diagnosis?
Subarachno id haemorrhage
Extradura l haematoma
Acute subdural haematoma
Chronic su bdural haematoma
m
se
As
Intracere bral haematoma
Dr
I Subarachno id haemorrhage f!D
Extradura l haematoma CD
Acute subdu ral haematoma GD
I Chronic su bdural haemato ma CD

Intracerebral haematoma CD
~
On CT imag ing, a ch ron ic subdural haematoma wil l appear as a hypodense (dark),

c rescentic collection a round the convexity of the brain
On CT imag ing, acute haematomas appear bright (hyperdense) whereas chronic

haematomas appear dark (hypodense). Extradural haematomas a re limited by suture lines
whereas subdura l haem atom as are not. Intra pa renchyma l haematomas arise within the
m
se
b rain substance. Suba rachnoid haemorrhage are typically seen as hype rdens ity within the
As
basa l cisterns and sulci of the su barachno id space.
Dr
How long should a patient stop driving for following a stroke?
No restriction unless physical/visual impairment
1 month
3 month
6 months
m
se
As
12 months
Dr
No restriction unless physical/visual impairment
11month
3 month
6 months
12 months
-
""""
m
DVLA advice post stroke or TIA: cannot drive for 1 month
se
As
Dr
A 52-year-old woman presents with a two week hist ory of dizzin ess w hen she roll s o ver in
bed. She says it feels like the room is spinning around her. Examin ation of her ears and
cranial nerves is unremarkab le. Given the like ly diagnosis o f b enign paroxysmal positiona l
vertigo w hat is the most appropriate management?
Trial of p rochlorperazine
Request MRI brain
Advise review by an optician
Perform Epley manoeuvre
m
se
As
Trial of cinnarizine
Dr
Trial of proch lorperazine
Request MRI brain
Advise review by an optician
Perform Epley manoeuvre
m
se
Trial of cinnarizine
As
~
Dr
Which one of the following is least associated with normal pressure hyd rocephalus?
Papilloedema
Dementia
Gait abnormality
m
se
Enlarged fourth ventricle
As
Dr
I Papilloedema
Dementia
..
(fD
Uri nary incontinence m.

IGa~t abnormality m
Enlarged fourth vent ricle G'D
Urinary incontinence + gait abnormality + d ementia = normal pressure
m
se
hydrocephalus
As
Dr
A 36-year-old man with difficu lt to control epilepsy is reviewed in cl inic. He is currently
t aking phenytoin but presents due to fatigue. A full blood count is performed:
Hb 10.1 g/dl
MCV 121 fl
Pit 234 * 109/1
wee 4 .6 *109/1
What is the most likely cause for his tiredness?
Iron deficiency
Vit amin 812 deficiency
Liver dysfunction secondary to phenytoin
Haemolytic an aemia secondary t o phenytoin
m
se
As
Folate deficiency
Dr
Iron deficiency CD
Vitamin 812 deficiency fD
Liver dysfunction secondary to phenytoin m
Haemolytic anae mia secondary to phenytoin CD
m
ED
se
Folate deficiency
As
Dr
A 34-year-old man who is known to suffer from com plex partial seizures is reviewed in
the neurology cli nic. He has not been able to tolerate either ca rbamazepine or sodium
valproate. What is t he most app ro priate next line drug?
Phenytoin
Lamotrigine
Ethosuximid e
Topiramate
m
se
As
Clonazepam
Dr
Phenytoin CfD
Lamotrigine GD
Ethosuximid e GD
Topiramate CD
m
se
m
As
Clonazepam
Dr
A 25-yea r-old female presents 5 d ays after discha rge fro m hospita l fo llowin g an
ad mission for suspected mening itis. A lumba r punctu re was performed which showed no
evidence of infection. Unfo rtu nately she d eve loped a head ache 48 hou rs after discharge.
This has now lasted 3 d ays a nd has fai led to settle with analgesia. Which one of the
fo llowing treatment optio ns shou ld be considered?
Intrathecal stero ids
Repeat lumbar puncture
Course of oral prednisolone
Blood patch
m
se
As
Intrave nous fluids o n top o f oral fluid intake
Dr
Intrathecal steroids
Repeat lumbar puncture
Coursj of oral prednisolone
Blood patch
m
se
As
Intravenous fluids on top of oral fluid intake
Dr
A 60-year-old wo man presents with a tremo r. Wh ich one of the following features would
suggest a diagnosis of essential tre mor rather than Parkinson's disease?
Difficulty in initiating movement
Tremor is worse fol lowing alcohol
Postural instability
Unilat eral symptoms
m
se
As
Tremor is worse when the arms are outstretched
Dr
Difficulty in initiating movement
I Tremor is worse following alcohol
Postural instability
Unilat eral sym ptoms
Tremor is worse when the arms are outstretched
m
Difficulty in initiating movement (bradykinesia), postural instability and unilateral
se
sympto ms (initially) are typica l of Parkinson's. Essential tremor sympt oms are usually
As
eased by alcohol.
Dr
A 27 -year-old female p resents compla ining of generalised wea kness. Exam inatio n of her
face reveals bilateral ptosis, dysarthric speech and a slow-relaxing g ri p. What is the most
like ly diag nosis?
Myotonic dystrophy
Myasthenia g ravis
Multip le scle rosis
m
se
As
Friedre ich's ataxia
Dr
Myotonic dystrophy CD
Myasthenia gravis ED
Multip le sclerosis tiD
Ataxic telangiectasia fD

• d istal weakness initially
• autosomal d om inant
• d iabetes
• dysarthria
The slow-relaxing grip may be noticed on initial han d -shake with the patient and is typica l
m
se
o f myotonic dystrophy. Dysarthric speech is seco ndary to myoto nia o f the tongue and
As
p ha rynx
Dr
A 59-year-old man is diagnosed w ith Parkinson's disease aher bein g referred w ith a
tremor and bradykinesia. His symptoms are now affecting his ability to work as an
accountant and are having a general impact on the quality o f his life. What treatment is
he most likely to be o ffered initially?
Levodopa
MAO-B inhibitor
COMT inhibitor
Dopamine antagonist
m
se
As
Dopamine agonist
Dr
Levodo pa CD
MAO-B inhibitor fD
Ct T inhibitor a
Dopamine antagonist .
(D
Dopamine agonist CD
m
Levodopa should be offered fo r patients with newly diagnosed Parkinson 's who
se
have motor symptoms affecting their quality of life
As
Dr
During a routine cranial nerve examination t he following f indings are observed:
Rinne's test : Air conduction > bone conduction in both ears
Weber 's test: Localises to the right side
What do these test s imply?
Left conductive deafness
Normal hearing
Right conductive deafness
Right sensorineural deafness
m
se
As
Left sensorineural deafness
Dr
m
se
In Webe r's test if there is a sensorineu ral problem the sound is locali sed to the unaffected
As
s ide (right) ind icating a prob lem on the left s ide
Dr
A 62-year-old man with a history of hypertension and epilepsy is not ed to have gingival
hyperplasia on examination in the ca rdiology clin ic. Which one of the following drugs is
most likely to be responsible?
Sodium valproate
Lisinopril
Atorvastatin
Nifedipine
m
se
As
Carbamazepine
Dr
Sodium valproate
.,
~inopril (D
Atorvastatin CD
I Nifedipine
.,
Carbamazepine CD
m
se
Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers and AM L
As
Dr
A 33-year-old male is adm itted with a subacute headache, confusion, and nausea. On
closer questioning, you note that this gentleman appears irritable, confused, and is
hearing voices. Prior to this, his wife reports he has had a recent vira l upper respiratory
tract infectio n. He is otherwise fit and well and takes no regular medications.
On exam ination, you note that he is neglecting to use h is right a rm . He is otherwise,

neurologically intact. A subsequent CT head revea ls no space occupying lesion, infarct or
bleed. Later, an MRI is performed which reveals b ilateral asymmetric and poorly
marg inated hyperintense T2-weighted and FLAIR lesions within the subcortical white
matter. A lum ba r punctu re reveals no oligoclo na l ba nds in the CSF.
What is the likely underlying diagnosis?
Alzheimer's disease
Multiple sclerosis
Men ingitis
Herpes simplex encepha litis
m
se
As
Acute disseminated encephalomyelitis
Dr
Alzheimer's disea se
Multiple sclerosis
r Meningitis
Herpes simplex encephalitis
I Acute dissem in ated encepha lomyelitis
The answer is acute disseminated encephalomyelitis which is a neu rolog ica l cond ition
which occu rs typically a few weeks following a vira l ill ness or vaccination. It can present
with motor weakness, encephalopathy, seizures and coma. It is found on T2-weighted
MRI imaging which revea ls poorly-defined hyperintensities in the subcortical white
matter. These lesions can deve lop throughout the course of the illness and hence serial
MRis may be required.
Multiple sclerosis is a differential diagnosis but is not necessarily definitively linked with a
m
preced ing illness. Alzheimer's disease and herpes encephalitis wou ld not present with
se
As
these MRI findings. The absence of prominent meningism featu res makes meningitis less
likely.
Dr
Which one of the following is most associated with a good prognosis in Guillain-Barre
syndrome?
Age> 40 years
Female sex
No history of a diarrhoeal illness
High anti-GMl antibody titre
m
se
As
Low peak expirat ory flow rate
Dr
Age> 40 years CD
Female sex fD
I No history of a diarrhoeal illness CD

High anti-GMl antibody titre G'D
Low peak expirato ry flow rate m
m
se
Preceding gastrointestinal infections are associated with a poor prognosis in Guillain-
As
Barre syndrome. The sex of the patient has not been shown to correlat e w it h out come
Dr
A 31-year-old man p resents around four weeks after a non-specific viral illness
characte rised by fever, lethargy and sore throat. For the past week he has noticed
increasing weakness in his leg s which has now started to extend to his arms. On
examination he has reduced power, reflexes and slightly reduced sensati on in his lower
limbs. A few days after admission he becomes short-of-breath. His forced vital cap icity
(FVC) starts to fa ll and he is t ransferred to ITU. Given the like ly diagnosis, what is t he
treatment o f cho ice
Neostigmine
Haemofi Iitration
m
se
As
Riluzole
Dr
Neostigmine
Haemofilitration
-
~
Riluzole
m
This patient has developed Guillain -Barre syndrome (GBS) secondary to a viral illness,
se
possibly t he Epstein-Barr virus. The ascending weakness and areflexia point to a diagnosis
As
o f GBS.
Dr
A 26-yea r-old woman is recovering on the wa rd following a subarachnoid haemorrhage 6
d ays ago. She has been managing to ma intain her oral fluid intake above 3 lit res per day
and her hea rt rate is 72 bp m at rest and he r blood p ressure is 146/ 88 mmHg at rest. Her
flu id balance shows that s he is net positive 650 ml over the last 6 days. Her daily b loods
s how the following :
Hb 134 g/ 1 Na• 129 mmol/ 1
Platelets 253 * 109/1 K• 4 .1 mmol/1
WBC 5.1 * 109/ 1 Urea 2.3 mmol/1
Neuts 3 .9 * 109/ 1 Creatinine 49 j.Jmol/1
Lymphs 1.2 * 109/ 1 CRP 12.3 mg/1
Paired serum and urine samples shows the following:
Serum Osmolality 263 mosm/1 Urine Osmolality 599 mosm/1
Serum Na• 129 mmol/ 1 Urine Na• 63 mmol/ 1
What is the most li kely cause for the patient's hyponatraemia?
Cerebral salt-wa sti ng syndrome
Iatrogenic fluid overload
Cra nia l diabetes insipi dus
Synd rome of in ap propriate anti-diuretic hormone secretion (SIADH)

sem
As
Adrena l insufficiency
Dr
Cerebral salt -wasting syndrome
Iatrogenic fluid overload
Cranial diabetes insipidus
I Syndrome of inappropriate anti -diuretic hormone secretion (SIADH)
Adrenal insufficiency
SIADH is a co mmon consequence of subarachnoid haemorrhage

The key to working out the cause here is looking at the paired serum and urine samples
and the fluid status. The patient is haemodynamica lly stable and has a positive fluid
balance which indicates the cause of the low sodium is unlikely to be diabetes insipidus or
adrenal insufficiency as these cause fluid depletion. The high urine sodium indicates either
excessive sodium loss or excessive wate r retention, were this iatrogenic then the urine
wou ld be as dilute as the serum.
Cerebral salt -wasting syndrome is known to occur following subarachnoid haemorrhage

but the sodium loss is accompanied by water loss as the kidneys are still functioning
normally so urine output is high and there is a relative fluid depletio n. In SIADH the
m
se
kidneys hold on to too much wate r, diluting the serum sodium and resulting in As
concentrated urine as in this case.
Dr
Which of the following visual field changes wou ld be most consistent with a leh parietal
lobe lesion?
Right homonymous hemianopia
Leh inferior homonymous quadrantanopia
Leh superior homonymous quadrantanopia
m
se
Right inferior homonymous quadrantanopia
As
Dr
Right homonymous hemianopia
Left inferior homonymous quadrantanopia
~ft superior homonymous quadrantanopia

Right inferior homonymous quadranta nopia
Visual field defects:

• incongruous defect s = optic tract lesion; congruous defects= optic rad iation
lesion or occipita l cortex
m
se
As
Dr
Which of the following features is least likely to be found in a patient with tubero us
sclerosis?
Adenoma sebaceum
Cafe-au -lait s pots
Retinal ha ma rtomas
'Ash-leaf' spots
m
se
As
Lisch nod ules
Dr
Adenoma sebaceum tiD
Cafe-au-lait spots f.ID
Retinal hamartom as tiD
'Ash-lj af' spots CD
Lisch nodules €D
m
se
As
Lisch nodu les are seen in neurofibromatosis
Dr
A 47 -year-old fema le is reviewed in the neurology clinic. She was diagnosed with epilepsy
whilst a teenager and her seizures are well co ntrolled. She is however concerned about
increasing numbness of her f ingers and soles of her feet. Which one of t he following
medications is most likely t o be responsible?
Phenytoin
Lamotrigine
Sodium valp roate
Ethosuximide
m
se
As
Levetiracetam
Dr
Phenytoin GD
Lamotrigine .
(D
Sodium valproate QD
Ethosuximide CD
Levetiracetam m
m
se
As
Peripheral neuropat hy is a know n adverse effect o f phenytoin
Dr
Neuropathic pa in characteristically respond s poorly to opioids. However, if standa rd
treatment options have failed which opio id is it most app ropriate to consider starting?
Trama dol
Mo rp hine
Codeine
Oxycodo ne
m
se
As
Buprenorphine
Dr
I Tramadol GD
Morphine m
I Codt ne .
(D
Oxycodone GD
m
se
Buprenorphine GD
As
Dr
A 67 -yea r-old man is reviewed in the falls clinic. Ove r the past few months he has
sustained a num ber of falls. His daughter repo rts that he is sta rting to 'shu ffle a round the
house' an d has particular pro b lems going up and down stairs. She a lso notes that he
a ppea rs to b e confused at times and often fo rgets his grandchildre n's names.
On exam ination he a p pea rs to move a nd fo llow commands slowly. There is a resti ng

tremor in the left hand more so than the right. So me rig idity is a lso noted when
exa mi ning his a rms. Examination of the cra nial nerves is un re ma rkab le other than a
pro b lem following movement in the vertical p lane.
Pa rkinson 's di sea se
Moto r neu ro n disease
Multip le system atrophy
Dementia with Lewy bodies
m
se
As
Pro gressive su pranuclear pa lsy
Dr
Parkinson's disease
Motor neuron disease
Mult iple system atrophy
Progressive supranuclear pa lsy
m
se
Progressive supranuclear pa lsy: parkinsonis m, impairment of vertical gaze
As
Dr
A 62-year-old man presents w ith left-sided eye pain and diplopia fo r the past 2 days.
Examination of his eyes shows his pupils equal and reactive to light with no proptosis.
There is however an apparent palsy of the 6th cranial nerve associat ed with a partial 3rd
nerve palsy on the left side. Examining the remaining cranial demonstrates hyperaesthesia
of the upper face on the left side. Where is the likely lesion?
Cavernous si nus
Orbit al apex
Pons
Cerebropontine angle
m
se
As
Medulla
Dr
Cavernous sinus CD
Orbital apex .
(D
Pons GD
Cerebropontine angle mt
m
se
•
As
Medulla
Dr
~
Cerebral palsy CD
I Charcot - Marie-Tooth GD
Guillain Barre syndrome m
Mononeu ritis multiplex fi!D
Duchenne muscular dystrophy 6D
Charcot-Marie-Tooth is a cause for dist al muscle wasting

This lady has features of dista l muscle wasting and weakness; both feat ures of Charcot-
Marie-Toot h disease.
Cerebral palsy is a disord er of movement and coordination that app ears in t he f irst few
years of life.
Guillain Barre Syndrome usually present s with an ascending w eakness, w ith a history over
d ays-weeks. Classically th is o ccurs after a recent resp iratory/GI infection.
Pain is a frequent symptom in Mononeurit is multiplex, often with both neuropathic pain
wit hin the area of sensory loss and a d eep pain in t he affect ed extremity.
m
se
Duchenne muscular dystrop hy typ ica lly affects males, and on ly very rarely affects fema les.
As
Dr
I T
A 28-yea r-o ld female has presented with symptoms of clums iness, and has noticed that
her legs are becomi ng a n unusual s hape. She states that the bottom o f her leg s a rou nd
he r ankles a re b ecom ing much thi nner, and feel weaker ove r the past few months. She is
q u ite concern ed, as she is usually qu ite a ct ive a nd fit, and has neve r rea lly ha d to come to
the doctors before.
Which o f the following is the most likely dia g nosis?
Cere bral palsy
Charcot-Marie-Tooth
Guil la in Ba rre syndro me
Mononeu ritis multiplex
m
se
As
Duchenne muscula r dystrophy
Dr
What is the mechanism of action of sumatriptan?
5-HT3 agonist
5-HT2 antag onist
5-HT2 agonist
5-HTl antagonist
m
se
As
5-HTl agonist
Dr
Triptans are serotonin 5-HTls and 5-HTlo recepto r agonists
m
se
As
Tripta ns are specific agonists of 5-HT lB/10 receptors.
Dr
A 43-year-old man is sus pected of having a common peroneal nerve palsy following a
f racture o f his f ibula. Each one of the following features may be seen in such lesions,
except:
Wasting o f t he anterior t ib ial and peroneal muscles
Weakness o f foot d orsiflexion
Weakness o f extensor hallucis longus
Weakness o f foot eversion
m
se
As
Sensory loss over t he medial aspect of the lowe r limb
Dr
Wasting o f t he anterior t ib ial and peroneal muscles
Weakness of foot d orsiflexion
I Weakness of extensor hallucis longus
Weakness of foot eversion
I Sensory loss over the medial aspect of the lowe r limb
Sensory loss over the d orsum of t he foot and t he lower lateral part of the leg is seen in a
m
se
com mon peronea l nerve palsy. The degree o f wasting would of cou rse depend on how
As
long the nerve palsy had been present
Dr
Which one o f the following is not a recognised causes of miosis?
Old age
Pontine haemorrhage
Holmes-Adie pupil
Argyii -Robertson pupil
m
se
As
Horner's syndrome
Dr
Ol d age flD
Pontine haemorrhage .
(D
I Holmes-Adie pupil
Argyii-Robertson pupil
CiD
@D
Horner's syndrome .
(D
m
se
Holmes -Adie pupil is a benign condition most commonly seen in women. It is one of the
As
differentials of a dilated pupil
Dr
A 59-year-old female continues to have chronic neuropathic pain fo r 12 months following
improvement of a dermatomal vesicular rash. She experiences minimal relief with
paracetamol and NSA!Ds. What is the next best treatment option?
Sertraline
Gabapentin
Aciclovir
Oxycontin
m
se
As
Morphine
Dr
Sertraline CD
I Gabapentin (D.
Aciclovir m
Oxycontin fD
Morphine fD
Postherpetic neura lgia result s from reactivation of the varicella -zoster virus acquired
during the primary varicella infection, or chickenpox. Although postherp etic neuralgia is
generally a se lf- limiting cond ition, it can last indefinitely and can be resist ant to the usual
pain medications. Anti-epileptic medications such as tricyclic antidepressants and
m
se
gabapentin are useful in people w ith neurogenic pain. Tricyclic's have a worse side effect
As
profile compared to gabapentin.
Dr
A 58-yea r-old lady presents to cl inic with a 6-month history of limb weakness and fa lls .
She has hypercho lestero laemia and takes simvastatin.
On exam ination, the re is wasting of the intrinsic hand muscles and left b iceps with
fascicu lations in the left biceps and shou lde r g irdle . The re is a g e nera lised wea kness with
brisk left biceps a nd bilate ra l knee reflexes and a right extensor planta r resp onse. The
sensatio n is no rmal throu ghout. Exam inatio n o f the cra nia l nerves was normal.
Com p ressive cervica l mye lo pathy
Moto r neurone disease
Multifoca l moto r neu ropathy with conductio n b lo ck
Myopathy
m
se
As
Myasthe nia g ravis
Dr
Compressive cervica l myelopathy
Mult ifocal motor neuropathy w ith conduction b lock
Myopathy
Myasthenia gravis
The clinica l descript ion is a subacute progressive weakness with a mixtu re of lower and
up per motor neurone signs without sensory involvement.
The diagnosis is motor neurone di sease. You wou ld suspect motor neurone disease in any
pat ient w ith a mixture of lower and u pper motor neurone signs w ithout sensory
involvement. Some pathologies ca n cause lower and upper mot or neurone sign s in
different parts of the body (e.g. syring omyelia). The fact t hat these paradoxica l signs co -
exist in t he same myotome cli nches t he diagnosis.
A cervical myelopathy wou ld not cause lower motor neurone signs.
m
se
Multifoca l motor neuropathy w ith conduction b lock, myopat hy and myast henia gravis
As
wou ld not cause upper motor neurone signs
Dr
A 34-year-old accountant presents with a one week history of pa in around his rig ht eye
occurring once or twice a day. They are described as being very severe and lasting
between 10-30 minutes each. He also describes a feeling of a blocked nose. What is the
treatment o f choice to treat this current episode?
Ibuprofen
Acetazolamide + topical pilocarpine
Prednisolo ne
Subcutaneous sumatriptan
m
se
As
Ergotamine
Dr
Ibuprofen
Acetazolamide + topical p ilocarpine
PreCiniso lone
Subcutaneous sumatriptan
Ergotam ine
Cluste r hea dache - acute treatment: su bcutaneous sumatri pta n + 100% 02
m
se
As
Standard analgesia is rarely effective in cluster headaches. 100% oxygen may also be used
Dr
What is the most com mo n clinica l pattern seen in motor neuron disease?
Progressive bulbar palsy
Sp inocerebella r ata xia
Relapsing -rem itting
m
se
As
Dr
Progressive bulbar pa lsy
f it nocerebella r ataxia
Relapsing-remitting
-
"""'
m
se
As
Amyotro phic latera l sclerosis
Dr
Which one o f the followi ng statements regarding absence seizures is incorrect?
Typica l age of onset o f 3-10 years old
Sodium valp roate an d ethosuximide are first-line treatments
Seizures may be p rovoked by a child hold ing their b reath
There is a good prognos is
m
se
As
Characteristic EEG changes a re seen
Dr
Typical age of onset of 3-10 years o ld CD
Sodium valproate and ethosuximide are first-line treatments flD
Seizures may be provoked by a child holding their b reath aD
There is a good prognos is fD
Characteristic EEG changes a re seen GD
m
se
As
Seizures are characteristically provoked by hyperventilation
Dr
A 56-yea r-o ld g entleman presents with lowe r limb stiffness a nd imb alance. His on ly past
me d ica l history of note is ca rpal tunne l syndro me that was diag nosed a year ago on
clinica l g rounds and has b een refractory to treatme nt with s plints a nd stero id injectio ns.
Which o f the fo llowing is most likely?
Cauda equ ina syndro me
Subacute co mbined d egene ratio n o f the cord
Dege ne rative cervica l mye lo pathy
Pa rkinso ns disease
m
se
As
Multiple sclerosis
Dr
Cau da eq uina syndrom e
Su bacute co mbined d egene ratio n o f the cord
I Degenerative cervica l myelopathy
Parkinso ns disease
Multiple sclerosis
The presentation of deg e nerative cervica l mye lopathy [DCM] is va riab le. Ea rly sym ptoms
a re often su btle and ca n va ry in severity day to day, making the d isease difficu lt to d etect
initially. However as a p ro gressive condition, wo rsening, dete rio rating o r new sympto ms
sho uld be a warning s ig n.
Othe r answers:
• Cau da e q uina syndrome results fro m compress ion of the ca uda e q uina and
classically includ es leg weakness, saddle a naesthesia and sphincte r d isturbance. It is
usually an acute syndrome with prog ressive sig ns. It does no t cause leg stiffness.
• Suba cute co mbined d eg ene ratio n of the cord results fro m long -standi ng vita mi n
B12 d eficiency, classica lly presenting as a posterio r co rd syndrome with impaired
p ro p rioception. It can feature both uppe r and lowe r motor neu ron sig ns. B12
d eficiency can be associated with several neu ro log ical features. These include a
mye lo pathy (classically the suba cute combi ned d eg ene ration of the cord),
neu ro pathy a nd p araesthes ias withou t neuro logi ca l s ig ns [3]. Su bacute co mbin ed
d eg eneration is extre me ly ra re in d eve lo ped cou ntries, though in tro p ical countries
it is freq uently the commonest cause o f non -trau matic mye lo pathy [4].
• Idio pathic Pa rkinsons di sease is a tetrad o f Tre mo r, Rigidity, Akin esia and Postura l
Insta bility (this can be remem bered using the TRAP mneu monic). In the early stages
pain is not a typica l feature and it d oes not cause nu mbness.
• Multip le Scle ros is [MS] can have a varia ble presentatio n, with both sensory a nd
motor sympto ms and sig ns. Infla mmatory changes a re often p resent at multiple
sites, which can cause symptoms at mo re than o ne s ite; a di ssociated sensory loss,
that is numbness at diffe re nt a nd un linked s ites, is a hallmark o f MS. Often patients
will recall previous episod es of od d neuro logical d eficits, which resolved . MS
p redom inantly affe cts wo ma n (3-4 times common) a nd usua lly presents befo re the
age of 45.
References:
1. Ba ro n EM, You ng WF. Cervical spondylotic myelo pathy: a brief review of its
patho physio lo gy, clinica l course, and d iag nosis. Neu rosu rg ery. 2007 Jan;60(1 Supp1
1):S35-41.
2. Behrbalk E, Sa la me K, Reg ev GJ, Keynan 0 , Boszczyk B, Lida r Z. Delayed dia g nosis of
ce rvical s pondylotic mye lopathy by primary ca re phys icians. Neurosu rg Focus. 2013
Ju i;35(1):El.
3 . Kuma r Nl . Neu ro logic aspects of coba la min (Bl 2) d eficiency. Handb Clin Neu ro l.
2014;120:915-26.
4 . Pinto WB, d e Souza PV, de Albuquerque MV, Dutra LA, Pedroso JL, Ba rsottini OG.
Clin ical and e pide mio lo gica l profiles o f non-traumatic myelo pathies. Arq Neu ro ps iquiatr.
2016 Fe b;74(2):16 1-5.
sem
As
Dr
A 29-year-old man with a history of schizophrenia is taken to the local Emergency
Department as he is generally unwell. He is currently taking olanzapine and citalopram.
On examination he is noted to have a t emperature of 37.0°( and his blood pressu re is
170/100 mmHg. Which other examination finding would best support a diagnosis of
neuroleptic malignant syndrome?
Ataxia
Hyperreflexia
Muscle rigidity
Tremor
m
se
As
Papilloedema
Dr
Ataxia CD
Hyperreflexia «D
r
Muscle rigidity GD
Tremo r m
m
se
Papilloed ema m
As
~
Dr
Which type o f moto r neuron d isease carries the worst p rogn osis?
Relapsing -rem itting
Progressive bu lbar pa lsy
Spi nocerebella r ataxia
m
se
As
Amyotrophic lateral scleros is
Dr
Relapsing-remitting fD
I Progressive bulbar palsy GD

Progressive muscular atrophy GD
Spinocerebellar ataxia fD
m
se
As
Amyotrophic lateral sclerosis CD
Dr
A 42-yea r-old wo ma n prese nts a s she has noticed a 'droop ' in the right sid e o f her face
s ince she woke up this morning. There is no associated lim b weakness, dysphag ia or
visual dist urba nce. On exa minatio n you notice right-sided upp er and lowe r facia l
pa ralys is. Which one o f the following featu res wou ld be most consistent with a d iagnosis
o f Bell's palsy?
Vesi cular rash around th e ear
Hyperacusis
Se nsory loss over th e di strib utio n o f the facial nerve
Pins and needles in the right a rm
m
se
As
Rh inorrhoea
Dr
Vesicular rash around the ear
~peracusis
Sensory loss over the distributio n of t he facial nerve
-
~
Pins and needles in the right arm
Rh inorrhoea
m
se
As
A vesicu lar rash aroun d t he ear would suggest a diagnosis of Ramsey Hunt syndrome.
Hyperacusis is seen in around a third of patients.
Dr
A 52-year-o ld o ld man who has a history of alcoho l excess is brought to the Emergency
Department by para med ics. He is a frequent attender and this time has a laceration on his
scalp following a fa ll. Whilst exam inin g hi m he seems confused and compla in s o f
proble ms with his vision. Which one of the following is the most com monly fou nd ocula r
abnormality in patients with Wernicke 's encephalo pathy?
Ophthalmoplegia
Late ral rectus palsy
Nystag mus
Mydriasis
m
se
As
Scotomata
Dr
Ophthalmoplegia CD
Lateral rectus palsy CD
Nystagmus CID
Mydriasis m
m
se
m
As
Scotomata
~
Dr
A 55-yea r-old ma n presents compla ining o f visual disturba nce . Exam in ation reveals a
right congruous homonymous hemianop ia with macula spa ring . Whe re is the lesion most
li kely to b e?
Right o ptic nerve
Right o ptic radiation
Left o ptic tract
Left occipital cortex
m
se
As
O ptic chia sm
Dr
Right optic nerve
Right optic radiat ion

•
C!D
Left optic tract «rD
Left occipital co rtex GD
Optic chiasm m
Visua l field d efects:

of right optic t ract
• incongruous defect s = optic t ract lesion; congruous d efects= optic radiation
m
se
As
Dr
A 69-year-old woman is brought to the emergency department with sudden onset
unsteadiness. On examination she is haemodynamically stable, has normal visual fields, no
ophthalmoplegia but a nysta gmus which is present at rest, loss of pinprick sensatio n over
the right trigeminal distribution but no facial weakness or loss of light touch sensation
over the face. She also has loss of pinprick sensation in the leh arm and leg although she
has 5/ 5 power in all limbs and preserved light touch sensation in all dermatomes.
This cl inical syndrome is most likely due to a stroke affecting which of the following
vascular t erritories?
Right posterior inferior cerebellar artery (PICA)
Leh posterior inferior cerebellar artery (PICA)
Right anterior inferior cerebellar artery (AICA)
Leh anterior inferior cerebel lar artery (AICA)
m
se
As
Basilar arte ry
Dr
Right posterior inferior cerebellar artery (PICA)
Left posteri~ferior cerebellar artery (PICA)
Right ant erior inferior cereb ellar artery (AICA)
Left ant erior inferior cerebellar artery (AICA)
Basilar arte ry
-
~
Late ral medullary syndrome can be caused by PICA strokes

Althou gh this seems like an obscure p resentation, the combinat ion of facial and
cont ralat eral body loss of pain sensation along wit h nystagmus and ataxia make up a
com mon syndrome called lat eral medu llary syndrome. It is an important syndrome to be
aware of as it is most often due to a stro ke affecting the post erior inferior cereb ellar
artery (PICA). It is t he most commonly survived st roke that affect s t he brain st em and is
com monly used as an exam question scenario. Given her symptoms, t his would be in
keeping with a right -sided posterior inferior cerebellar artery infarct .
An ant erior i nferior cereb ellar artery infarct wou ld present in the same way but wit h t he
additiona l sympt oms of a same-si ded facial weakness and loss of hearing. A basilar artery
infarct wou ld result in a locked - in syndrome w here the pat ient is unab le to move o r
com mun icate but is fully conscious. Bot h of t hese are more likely t o affect the aut onom ic m
se
centres in t he medulla and are associat ed w ith a higher mortality.

As
Dr
A 24-yea r-old female p resents with a headache. She has a past history o f epilepsy and is
known to suffer from migraines, but has previously managed attacks with a comb ination
o f paracetamo l and metoclopramide. This combination is however no t working for the
current episode.
What second line med ication is it most appropriate to use?
Code ine + paracetamol
Pizotifen
Zo lmitriptan + paracetamol
Methysergide
m
se
As
Ergotam in e
Dr
Codeine + paracetamol fD
Pizotifen fD
I Zo lmitriptan + paracetamol flD

Methysergide CD
Ergotamin e CD
Migraine
• acute: triptan + NSAID or t ript an + paracetamol
• p rop hylaxis: top iramate or proprano lol
m
se
Epilepsy is not a cont rai ndicat ion to the use of t riptans. Opioids are not recommended in
As
the management of migraine
Dr
You are asked to perform a neuro log ica l exam of t he lower limbs on a patient with
multip le sclerosis. Which one of the follow ing findings is least typical?
Decreased t one
Pat ellar clonus
Upgoing plantars
Weakness
m
se
As
Brisk ref lexes
Dr
Decreased tone e:D
Patellar clonus GD
Upgoing plantars C!D
Weakness CD
Brisk ref lexes GD
m
se
In multiple sclerosis there is demyelinat ion o f the central nervous syst em and hence upper
As
motor neuron signs are seen
Dr
You review a 65-yea r-o ld man who is cu rrently taking antipsychotic medication. His carers
have noticed that his movements have been very slow over the past few weeks. Which
one of the following wou ld suggest a diag nosis o f Pa rkinson's disease rather tha n drug -
induced pa rkinsonism?
Rig idity
Masked face
Bilatera l symptoms
Flexed postu re
m
se
As
Restlessness of arms and legs
Dr
I Rigidity eD
Masked face fD
Bilateral symptoms (f.D
Flexed posture GD
Restlessness of arms and leg s CD
Rigidity and rest tremor are uncommon in drug-induced parkinsonism. Masked face and
m
f lexed posture can be seen in both condit ions. Bilateral symptoms are more co mmon in
se
drug-induced parkinsonism. Restlessness o f arms and legs (akathisia) is a common sid e-
As
effect o f antipsychotics.
Dr
A 78-y ea r-o ld man is seen in the Memory clinic. His d aug ht er reports that fo r the past 12
months he has beco me increasing ly forg etf ul and has now started to wander arou nd at
night . A mini-mental test is perfo rmed and he scores 18 out of 30. Neurologica l
exam ination is unremarkable. A f ull blood screen is also requested, all of which comes
back as norm al. W hat is the m ost ap pro priat e next ste p?
Arra nge a MRI head
Perform carotid Dopplers
Give p ractical advice + advise fam ily t o contact Alzhe imer's Society
Prescri be as pirin + simvast atin
m
se
As
Prescri be d o nepezi l
Dr
I Arra nge a MRI head
Perform carotid Dopplers
Give p ractica l advice + advise family to contact Alzheimer's Society
Prescri be asp irin + simvast atin

-
~
Prescri be donepezil
m
se
Neuroimaging is required to diagnose dementia
As
Dr
A 31-yea r-old woma n presents with a 4 month history of headache. She has b rought a
heada che dia ry which d e monstrates that he r symptoms a re p resent o n arou nd 20-25 d ays
o f each month . The heada che is typically unilatera l a nd s he is currently taking
pa raceta mo l l g qd s a nd ibupro fen 400mg td s eve ryday to try and relieve her symptoms.
A diag nos is of medication overuse head ache is suspected. What is the most a ppropriate
ma nagement?
Add meto clopram ide + start propra nolol
Grad ually withdraw analgesics + sta rt pro pra nolol
Abruptly stop analgesics
Grad ually withdraw analgesics
m
se
As
Continue ana lgesics + start prop rano lo l
Dr
Add metocloprami de + start p ropra nolol
Gradually w ithdraw ana lgesics + start propranolol
Abruptly stop analg esics
Gradually withdraw analgesics
Cont inue ana lgesics + start prop ranolol
Medication overuse head ache

• sim ple analg esia + triptans: stop ab ruptly
• o pioi d an algesia: w ithdraw gradu ally
m
se
This answer may seem counterintuitive but it is line with recent guidelines from SIGN,
As
p lease see the link provided.
Dr
A 65-yea r-old ge ntleman is ad mitted to the med ical take with a progressive ly worsening
headache for 3 weeks. On closer questioning, he reveals it is wo rse first thing in the
morning b ut also exacerb ated by recu mbency an d coug hin g. He is also com pla ining o f
inte rmittent visua l disturbances and on fundoscopic exam inatio n, there is papilloedema
o f the right disc b ut o pti c atro phy o n the left.
A subseq uent CT scan is p erfo rmed re vea ling a s pace occupyi ng lesion. Whe re is the
space occupying les ion most likely s ituated?
Left temporal
Right frontal
Right tempora l
Left frontal
m
se
As
Left parieta l
Dr
Left tempera I
....__
tiD
Right frontal 6D
Right tempora l 6D
~ frontal ED
Left parieta l GD
This is an interestin g case of Foster-Kennedy synd rome. This syndrome reflects a frontal
lob e tumour- usually a meningioma in this age group - lea ding to ipsilateral optic
atrophy and papilloedema of the contralatera l optic nerve. The reason for the o ptic
m
se
a trophy is as a result of d irect damage from the s pace occupying lesion. Other causes are
As
AVMs and j uven ile nasopharyngea l angiofib roma .
Dr
A 39-year-old man is diagnosed as having cluster headaches. He ha s received
subcutaneous sumatripta n on two occasions but wou ld like to start medication to help
prevent further attacks. Of the following options, which one is the most su itable
treatment?
Atenolol
Am itriptyline
Sodium valp roate
Vera pa mil
m
se
As
Gabapentin
Dr
Atenolol GD
j .mitriptyline GD
Sodium valproate CD
I Verapa mil ED
m
se
As
Gabapentin CD
Dr
A 65-year-old man who is known to have metast atic co lo rect al cancer presents for review.
Since last been seen he rep orts being g enerally st iff and on examination is noted to have
diffuse hypertonia. Which antibodies are most likely to be responsible for t his
p resentation?
Anti-GAD
Anti-Ri
Anti-H u
Anti-La
m
se
As
Anti-Yo
Dr
Anti-GAD eD
Anti-Ri CD
Anti-Hu GD
Anti-La CD
Anti-Yo tiD
m
se
As
This patient has developed stiff person's syndrome.
Dr
A 54-year-old man presents w ith a persistent tremor. On examination there is 6-8 Hz
tremor of the arms w hich is worse when his arms are outstretched. His father suffered
from a similar complaint. What is the most suitable first-line treatment?
Amitriptyline
Propranolol
D-p enicillamine
Levodopa
m
se
As
Diazepa m
Dr
Am itriptyline
Propranolol
•em .
D-pe nicilla mine CD

Levo do pa fD
Diazepa m
•
Essentia l tremor is an AD condition that is made worse when arms a re outstretched,
ma de better by alcoho l and p ropranolol
m
se
This p atie nt has a typica l histo ry o f essentia l tre mo r. Pro pra no lol is generally consid e red
As
the first-line treatment
Dr
A 55-yea r-o ld female is ad mitted with a seizure. The seizure fa ils to res pond to rep eated
d ose of intravenous lo razepam. You decide to try a second li ne agent. Shortly a fter
administratio n of the d rug the patients blood pressu re d rops to 75/45 mm Hg.
What drug is most like ly implicated?
Sodium valp roate
Carbamazepi ne
Lamotrig ine
Phenytoin
m
se
As
Levetira cetam
Dr
Sodium valproate m
Carbamazepine (iD
Lamotrig ine
Phenytoin CD
•
Levetiracetam CD
Intravenous phenytoin can cause hypotension

Intravenous phenytoin can cause hypotension and bradyarrhyth mias. Phenytoin is

believed to protect against seizures by causing voltage-dependent b lock of vo ltage gated
m
se
sod ium channels. Phenytoin is also a class IB a ntiarrhythm ic drugs which b locks sodium
As
chan nels in the heart resulting in shortening of repola rization.
Dr
A 12-year-old boy is brought to the Emergency Department. He was hit on the side the
head by a cricket ball during a match. His teacher describes him initially collapsing to the
ground and complaining of a sore head. After two minutes he got up, said he felt OK and
continued playing. After 30 minutes he suddenly collapsed to the ground and lost
consciousness. What type of inju ry is he most likely to have sustained?
Cerebral contusion
Intraventricular haemo rrhage
Extradural haematoma
m
se
As
Su bdural haematoma
Dr
Gerebral contus ion
•m
Intraventricular haemorrhage m
I Extradural haematoma GD
Subdural haematoma CD
m
se
Head injury, luci d inte rval - extradural (ep idural) haematoma
As
Dr
Which one o f the following anti-epileptic drugs is most like ly to cause visual field defect s?
Lamotrigine
Phenytoin
Ethosuximide
Vigabatrin
m
se
As
Pregabalin
Dr
Lamotrigine GD
Phenytoin mt
Ethosuximide mt
I Vigabatrin ED
Pregabalin CD
m
se
V for Vigabatrin - V for Visual field defects
As
Dr
A 24-yea r-old woman who is 14 weeks p regnant presents with a severe migraine. She has
a long history of mig ra ine and stopped prop ranolol p rophylaxis when she found out she
was preg nant. Unfo rtu nately the heada che has not responded to paraceta mollg. What is
the most a pp ropriate next step?
Ergotami ne
Nasal zolm itriptan
Ibuprofen 400mg
Almotriptan 12.5mg
m
se
As
Codeine 30mg
Dr
Ergotamine CD
Nasal zolm itriptan .
CD
I Ibuprofen 400mg ED.
Almotriptan 12.5mg «D
m
se
Codeine 30mg (fD
As
Dr
A 73 -year-old femal e with a hist ory of recurrent fall s at home and alcohol excess is
brought to t he Emergency Department due to episod es of confusion over the past 5 days.
Between t hese ep isodes she is apparently her normal self. On examinat ion her GCS is
14/ 15 and she has nystagmus on left lateral gaze. What is t he most likely diagnosis?
Subdural haemorrhage
Meningitis
Herp es simplex encep halitis
m
se
Alzheimer's disease
As
Dr
I Subdural haemorrhage
~eningitis
Herp es simplex encephalitis
Alzheimer's disease
Fluctuating consciousness = subdural haemorrhage

The combination of falls, alcohol excess, fluctuating episodes of confusion and focal
neurology point s towards a diagnosis of subdural haemorrhage. The phrase 'fluctuating
m
se
conscious level' is co mmon in questions and should always bring t o mind subdural
As
haemorrhage
Dr
Which one of the following causes of peripheral neuropathy is most associated with an
axonal, rather than demyelinating, pathology?
Paraprotein neuropathy
Heredit ary sensorimotor neuropathies (HSMN) type I
Am iodarone
m
se
As
Vasculitis
Dr
Paraprotein neuropathy
Hereditary sensorimotor neuropathies (HSMN) type I
Am iodarone
-
~
I Vasculitis
m
se
As
The other causes are associated with a d emyelinating pathology
Dr
A 22-yea r-old man was seen in the Emergency Department after his mother re ported
three separate seizure episodes. He was unable to remember what happened and was
unawa re anyth ing was ha ppen ing at the time. His mother describes the e p isod es lasting
30 second s each and no obvious trigger. She reported that he lost consciousness and
began chewing and licking his to p lip, but d id not have any limb movements o r
incontinence. She also sa id that after each episode he strugg led to 'find his words' fo r at
least a minute.
What type of seizure and loca lising lobe does the above d escription co rrespond most to?
Focal awareness impaired, pa rietal lobe
Focal awa re, frontal lobe
Focal awareness impaired, frontal lobe
Focal awa reness impaired, tempora l lobe
m
se
As
Focal awa re, te mporal lobe
Dr
Foca l awa reness impaired, parietal lobe
~ocal awa re, frontal lobe

Foca l awa reness impaired, frontal lobe
I Focal awareness impaired, temporal lobe
Foca l awa re, te mpora l lobe
Lip smacking + post -icta l dysphasia are loca lising features of a tempora l lobe
seizure
A new classification for seizu res has replaced the fo llowing terms:
Simple pa rtia l = focal aware

Complex pa rtia l = foca l awa reness impaired
In this case the seizu re is focal awareness impa ired from the history.
The loca lising features of lip -s macking and post-icta l speech problems point towa rds the
m
temporal lobe
se
As
https:/jwww.epi lepsy.com/ a rticle/ 2016/12/ 2017 -revised-classificatio n -seizures
Dr
Each of t he fo llowing are causes of peripheral neuro pathy. Which one is associat ed with
p redominat ely sensory loss?
Dip hthe ria
Heredit ary senso rimotor neuropathies
Porphyria
Lead poison ing
m
se
As
Uraemia
Dr
Diphtheria
Hereditary sensorimotor neuropathies

-
.....,
Porphyria
Lead poisoning
m
se
Uraemia
As
I
Dr
Which one o f the followi ng featu res is most associated with parietal lobe lesions?
Gerstmann's syndrome
Perseveration
Cortica l blindness
Superior homonymous quadrantanopia
m
se
As
Wernicke's aphasia
Dr
I Gerstmann's syndrome ..
Perseveration GD
coe cal blindness (D
Superior homonymous quadrantanopia CD

Wernicke's aphasia G'D
m
se
Pariet al lobe lesions may cause Gerstmann's syndrome
As
Dr
An obese 24-year-o ld fema le present s with headaches and blurred vision. Examination
reveals bilateral blurring of the optic discs but is otherwise unremarkable with no other
neurological signs. Blood pressure is 130/ 74 and she is apyrexial. What is the most likely
underlying diagnosis?
Multiple sclerosis
Brain abscess
m
se
As
Idiopathic intracran ial hypertension
Dr
Multiple sclerosis
-
"""
Brain abscess
Idiopathic intracranial hypertension
Obese, young female with headaches I blurred vision think idiopathic intracranial
hypertension
m
se
The combination of a you ng, obese female with papilloedema but otherwise normal
As
neurology makes idiopathic intracranial hypertension the most likely diagnosis
Dr
Yo u review a 70-year-old woman fou r days a fter she was adm itted with a suspected
stro ke. Unfortunate ly she has been left with right sided sensory loss a ffecting he r a rms
more than the leg s and a right sided ho monymous hem iano pia. Functional ly she has
difficulty dressing her self. Exa mination of he r cran ia l nerves is unremarkable. What a rea is
the stro ke most li kely to have affected?
Midd le cereb ra l artery
Lacu nar
Anterior cereb ral a rtery
Po sterior ce reb ra l artery
m
se
As
Po sterior inferior cere bellar artery
Dr
Middle cerebral artery
Lacunar
-.....,
Anterior cerebral arte ry
Posterior cerebra l artery

--
~
Contralateral hemiparesis and sensory loss with the upper extremity being more
affect ed t han t he lower, contralateral homonymous hemianopia and aphasia -
m
se
middle cerebral artery
As
Dr
A 34-yea r-o ld ma n with a histo ry o f migra ine finds that paracetamol taken at th e
recom mend dose often fa ils to relieve his acute a ttacks. He drinks 12 units of alcoho l pe r
week and smokes 15 ciga rettes per day.
What factor is likely to contribute to this p roble m?
Bacterial overg rowth
Delayed gastric emptying
P450 enzyme induction
First pass metabolis m
m
se
As
P450 enzyme inhibition
Dr
Bacterial overgrowth
Delayed ga stric emptying
P450 enzyme induction
First pass meta bo lism
P450 e nzyme inhibition
Patients with migra ine experie nce d elayed ga stric e mptying during acute attacks. For this
reason analg es ics a re often com bined p rokineti c ag e nts su ch as metoclopramide.
m
se
Pa racetamol metabolism would not be s ig nificantly affected by changes in P450 enzym e
As
a ctivity (e.g. through smoking o r d rinki ng)
Dr
A 52-year-old man is p rescribed apomorp hine. What type o f receptors d oes apomorphine
act on?
Op ioid receptors
GABA receptors
Cholinergic receptors
Dopamine recepto rs
m
se
As
Musca rinic receptors
Dr
Opioid receptors CD
GABA receptors G'D
Cho ine rgic receptors m
Dopamine receptors CD
Musca rinic receptors CD
Apomorphine - d opamine receptor agonist

m
se
Apomorphine is one of the o lder dopamine receptor ago nists. Newer agents such as
As
ropiniro le a nd caberg o line have since been developed
Dr
A 25-yea r-old man p resents fo r review. For the past yea r he has been experiencing
headaches. These a re now occu rring a round 5-6 times p er month and typically 'last all
d ay' when they occu r. Th ey a re not associated with any fo rm o f aura. A typical head ache
is d escribed as a severe throbbi ng on both sides of his head associated with nausea and
lethargy. When he g ets such a headache he typica lly goes to bed so he can 'sleep it o ff' as
activity such as walking o r clim bing the stairs makes it worse. Befo re going to b ed he
typica lly takes o ne o f his father's diclofenac tablets which seem to help.
Neuro logica l exa mination is unrema rkable.
Migraine
Cluster hea dache
Medicatio n -ove ruse head ache
Tens ion head ache
m
se
As
Raised intracran ia l p ressu re
Dr
I Migraine
Cluster headache
Ir.:IVIedication-oveI ruse headache

Tens ion headache
- ~
Raised intracran ia l p ressu re
This headache is ve ry like ly to represent a mig raine. Much of the history is very typica l,
except that the majority of patients usu ally have uni lateral symptoms.
m
se
The re is no evidence of the kind of med ication overuse that ca n result in regula r
As
headaches.
Dr
Which one of the following medications is most useful for helping to prevent attacks of
Meniere's disease?
Promethazine
Prochlorperazine
Betahistine
Chlorphenamine
m
se
As
Cinnarizine
Dr
Dr
As
se
m
A 52-yea r-old man with a history o f epilepsy is reviewed. Since having his med ication
change he has experienced a 'num bness' of his ha nds and feet. On examination he has
reduced sensation in a glove-and-stocking distribution associated with a reduced ankle
reflex. He is also noted to have lympha denopathy in the cervical a nd inguinal reg ion and
some bleeding around the gums. Which one o f the following medications is he most
like ly to have been takin g?
Carbamazepi ne
Phenytoin
Topira mate
Sodium valproate
m
se
As
Lamotrig ine
Dr
Carbamazepine fD
Phenytoin GD
Topiramate CD
I
Sodium valp roate flD
m
se
m
As
Lamotrigine
Dr
Which of the follow ing investigations is the most important for diagnosing degenerative
cervical myelopathy?
Nerve conductio n studies and EMG
MRI Cervica l spine
CT myelogra m
CT C-spine
m
se
As
AP and lateral C-spine radiog raphs
Dr
--
Nerve conductio n studies and EMG CD
I MRI Cervical spine .

GD
CT myelogram m
CT C-spine
•
AP and late ral C-spine rad iographs
•
An MRI of the cervica l spine is the gold standard test where ce rvica l myelopathy is
suspected. It may reveal disc degeneration and ligament hypertrophy, with accompanying
cord signa l change.
Other answers:
• CT imaging is reserved fo r patients with contra indications to mag netic resonance
imaging. ACT myelogram is the first line investigation in this case.
• Radiographs are not clinically useful in the workup of these patients, though
osteoarthritic changes (e.g. osteophytes) can be visible if they are performed.
• Other investigatons (e.g. nerve conduction studies, EMG) may be performed when
the clinica l p icture is u nclea r. These can help to exclude mononeuropath ies and
other lower motor neu ron disorders. However, where there is strong cl in ical
m
se
suspicion and the diagnosis is suspected, an MRI of the cervical spine should be
performed. As
Dr
A 62-yea r-old man is seen in the rapid access transient ischaemic attack clin ic following
three episodes over the past two weeks of trans ient left sided weakness. What is the most
appropriate advice to give with regards to d riving?
Cannot drive for 12 mo nths
Cannot drive until investigations complete
Inform DVLA but can continue driving
m
se
Cannot drive for 1 month
As
Dr
Cannot drive until investigations complete
Info rm DVLA but can continue driving
Cannot drive for 3 month~
Cannot drive for 1 month
m
se
DVLA advice post multiple TIAs: cannot drive for 3 months
As
Dr
A 55-yea r-old man is diagnosed with amyotrophic lateral sclerosis. Wh ich one of the
following drugs has been shown to confer a survival benefit?
Rituximab
Riluzole
Interferon-beta
Cyclophospha mide
m
se
As
Interferon-alpha
Dr
Rituximab
Riluzole CD
•
Interferon- beta G'D
l crclophosphamide CD
Interferon-a lpha «tiD
m
se
Motor neuron disease - riluzole
As
Dr
Which one of the followin g factors indicates a poor p rognosis in patients w it h multiple
sclerosis?
Relapsing -rem itting disease
Presence of sensory symptoms
Young age of onset
Male sex
m
se
As
Long interval between first two relapses
Dr
Relapsing -rem itting disease f!D
Presence of sensory symptoms f!D
Young age of onset ED
I Male sex tD
m
se
Long interva l between first two relapses m
As
Dr
A 43-year-old woman with multiple sclerosis presents for review. She is having increasing
problems with painful involuntary contractions of the leg muscles. What is the most
appropriat e first-line therapy?
Ref erra l for relaxati on therapy
Baclofen
Diazepa m
Dantrolene
m
se
As
Natalizumab
Dr
Referra l for relaxation t herapy
Baclofen
Diazepam
Dantrolene
-
"""
m
se
As
Natalizumab
Dr
A 37-year-old female patient is brought into the emergency department with a 5-day
history of altered personality, visual and auditory hall ucinations. On palpation of the
abdomen, a mass is felt in the left iliac fossa. Ultrasound abdomen suggests a left ovarian
tumou r. Her basic observations are as follows:
Oxygen saturation 99% on air
Heart rate 98 beats/minute
Respiratory rate 28 breaths/minute
Temperature 37 .9 °C
Men ingitis
Anti-NM DA receptor encephal itis
Ra bies
m
se
As
Mania
Dr
Men ingitis
Anti-NM DA receptor encephalitis
Rabies
Mania
-
""""
Anti-NM DA receptor encephalitis is a para neoplastic syndrome which presents with
prominent psychiatric features
Anti-NM DA receptor encephal itis is a para neoplastic syndrome which presents with
prominent psychiatric features. In this case, it is likely caused by an ovarian tumour.
Meningitis does not usually present with prominent psychiatric features
Rabies can present with psychiatric sympto ms, but it usually presents with hypersalivation
of hydrophobia which is not the feature here.
Japanese encephalitis is less likely with no clea r travel history given and do es not usually
present with such prominent psychiatric sym ptoms.
The patient presents with sym ptoms of psychosis but no suggestion of mood disturbance
hence man ia is unlikely. Given the finding of an ovarian tumou r and abno rmality in her
vital signs, an organic illness needs to be ruled out before psychiatric illness can be
s em
diagnosed.
As
I •• I •• I
Dr
Tmnr()\fP J
Which one o f the following is least associated with the development of cho rea?
Haemoch romatosis
Ataxic te langiectasia
Carbon monoxide poison ing
SLE
m
se
As
Dr
Haemochromatosis eD
Ataxic telant ectasia tiD
Carbon monoxide poisoning GD
SLE flD
m
se
Huntington's d isease CD
As
Dr
A 40-year-old man presents with a progressive deterioration in vision over the past 2
weeks. On examination, there is ophthalmoplegia, his gait is noticeably ataxic and there is
a generalised loss of the deep tendon reflexes. He returned from Turkey two weeks ago
where he describes having a simple viral illness involving a sore throat and fever that
lasted for aroun d 1 week and resolved shortly before his return home. He drank more
alcohol than normal during the holiday, having around 3 glasses of wi ne each night. What
is the cause of his poor vision?
Acute mot or axonal neuropathy
Chronic inflammatory demyelinating polyneuropathy
Alcoholic polyneuropathy
m
se
As
Miller-Fisher variant
Dr
Acute motor axonal neuropathy
Alcoholic polyneuropathy
Miller-Fisher variant
Miller-Fisher variant is a type of Guillain- Barre syndrome that st arts by affecti ng the
cranial nerves and therefore manifest s with eye signs. Both Guillain-Barre syndrome and
Miller-Fisher tend to be preceded by an infection, classically Campylobacter jejuni.
Ophthalmoplegia, areflexia and ataxia (of which the question has all three) are the major
features of Miller-Fisher.
m
This alcohol consumption is a distract or as the question st ates he drank much more than
se
usual th is week and alcoholic polyneuropathy only comes from a ch ronic, heavy alcohol
As
history.
Dr
A 62-year-o ld man is referred to the neuro logy cl inic with worsening symptoms over the
past few months. The neuro logist suspects the patient has progressive sup ranuclea r palsy.
Which one o f the followin g featu res is least li kely to be seen in this patient?
Poor response to L-dopa
Impairment of horizonta l gaze
Fa lls
Cogn itive im pa irment
m
se
As
Slurring of speech
Dr
Poo r res ponse t o L-dopa
Impairment of horizontal gaze
Falls
Cognitive impairment
-
""""
Slurring of speech
Progressive supranuclear pa lsy: parkinsonis m, impairment of vertical gaze

Impairment o f vertical gaze is seen in p rogressive supranu clear palsy. Horizontal gaze
m
se
impairment is sometim es seen later as t he disease p rogresses, b ut would b e atypi cal in a
As
newly diagn osed patient.
Dr
You are working on the stroke wa rd. A 69-year-o ld lady has come in followin g a sudden
onset of dizziness and visua l disturbances which started yesterday morning. She initially
thought she was j ust dehydrated however later rea lised she was unable to read her own
shopping list. On the wa rd round the consu ltant examines her and finds she is indeed
unable to read. She is however, able to w rite. When she w rites a sentence it makes perfect
sense, although she is again unable to read it out. She ha s no problems with her speech,
and is able to converse completely normally. She has no motor foca l neurological deficit.
The consu ltant asks you where the lesion is likely to be?
Corpus callosum
Wernicke's area
Right (non-dominant) parietal lobe
Left frontal lobe
m
se
As
Broca's area
Dr
I Corpus callosum
Wernicke's a rea
r :ght (non-dominant) parietal lobe

-
~
Left frontal lobe
Broca's area
The scena rio he re is a lexia (ina bility to read), without agraphia (ina bility to write). This
occurs because of an infarction of the left posterior cerebral artery which perfuses the
splenium of the corpus callosum and left visual (occipital) cortex. Althoug h it is a rare
condition, it is one of the disconnect syndromes associated with lesions of the corpus
callosum.
Because the left visual co rtex is damaged by the stroke, only the right visua l co rtex can
process information. However because there has been an infa rction in the corpus
callosum information cannot be tra nsmitted from the right hem isphere to the left
hemisphere. Therefore it is not able to reach the Wernicke's an d Broca's areas in the left
(do minant) hemisphere.
Speech is unaffected as Broca's a rea re ma ins inta ct and can transmit information to the
prima ry moto r cortex. The ability to write is likewise unaffected as the Wernicke's and
Broca's areas can still transm it information to the prima ry motor cortex.
There are many d isco nnect syndromes from les ions o f the corpus callosum, the eponym
em
for this one being 'Dejerine syn drome'.

s
As
Dr
A 78-yea r-old gentleman presents to the memory clinic accompan ied by his wife. He is
p leasantly confused . His wife reports he is sti ll coping at home fai rly independently,
although she does have to re mind him of things more frequently. He has a known
diagnosis of Alzheime r's d isease and was sta rted on donepezil and successfully up-
titrated to the maxi mum the rapeutic d ose. Cognitive testing revea ls his min i mental test
score to be 21/30. Six months previously his score was 24/30.
Stop donepezil
Add in memantine
Switch to rivastig mine
Continue donepezil
m
se
As
Add in olanzapine
Dr
I Sto g d onepezil fD
Add in memantine eD
Swit ch to rivastigmine CD
I Continue donepezil CD
Add in olanzapi ne m
NICE gui delines d o not support the use of memantine in mild dementia
Despite evid ence of a sma ll cog nitive d ecline, this gent leman still has 'mild' dement ia as
ref lected by his MMSE and t he fact he is coping at home. He has no evidence of
significant b ehavioural or psych olog ical sym ptom s. As such, continuing donep ezil (which
he is to lerating) would b e the most ap propriate answer. A cogn it ive decline d esp it e
init iat ion of d onep ezil would be expected due t o the progressive natu re o f t he disease.
There is no evidence in th is case to su pport switching to an alt ernative
acetylcholinesterase inhibit or (e.g. rivastigmine) u nless there is another reason to do so
(e.g. rivastigmine comes in a patch form for those unable t o swallow). NICE does not
recommend stopping acetylcholinesterase inhibitors on t he basis of disease severity
m
se
alone. Memant ine is only recom mended in mod erate and severe alzheimer's disease.
As
There is no role for an anti-psychotic in t his case.
Dr
A 23 -yea r-o ld man with a histo ry o f migraine p resents fo r review. His hea daches a re now
occurring a bout o nce a week. He describes unilateral, thro bbin g headaches that may last
over 24 hou rs. Neu ro log ical exam in atio n is unremarka ble. Oth er than a histo ry o f asthma
he is fit a nd well. What is the most su itab le thera py to red uce the freq uency o f mig raine
attacks?
Propra nolo l
Zolmitriptan
Topiramate
Amitriptyline
m
se
As
Pizotife n
Dr
Propranolol flD
Zolmitriptan f!D
P ,piramate G3
Amitriptyline fD
Pizotifen m
Mig raine
• acute: triptan + NSAID or tripta n + pa racetamol
• p rophylaxis: top iramate o r proprano lol
m
se
Pizotifen is used less commonly nowadays due to s ide-effects such as weight ga in.
As
Proprano lo l should be avoided in asthmatics.
Dr
A 45-yea r-old lady presents with a 2-month history of leh-hand weakness. She has no
past med ical history. On examination, there is a mild weakness of the leh upper and lower
li mbs with a right s ided facial weakness which spares the forehea d. Where is the lesion?
Right cerebrum
Leh cerebrum
Right pons
Leh pons
m
se
As
Cervical spinal cord
Dr
Right cerebrum &':)
Left cerebru m fD
Right pons CID
Left pT s (D
Cervica l spinal cord fD
This is a fairly challenging localisatio n question but is perhaps not as difficult as it first
seems if you work th rough the possibilities a nd e limi nate options as you go.
A right cereb ral les io n would give left upper a nd lower li mb weakness. It would al so ca use
a left sided facial wea kness
A left cerebral lesion would g ive right upper a nd lower li mb weakness with right facial
weakness
A cervical spina l co rd lesion wou ld not cause a facial weakness
We are left with the pons. The pons is above the leve l of decussation of the corticospin al
tracts so a pontine lesion wou ld cause a contralatera l li mb weakness. Based o n th is
information a lone you can conclude that optio n 3 must be the correct a nswe r without
needing to understand why it has caused an ipsilate ral facial weakness
The facial motor nucleus is located in the po ns a nd supplies the ipsilatera l facial muscles
s em
The d iffere nce between an upper an d lower motor neuron CN7 les io n is not discussed
As
he re but is worth learn ing

Dr
Which one of t he followin g stat ement s regarding restless legs syndrome is incorrect?
M ovements may be seen during sleep
May be second ary t o uraemia
Affect s app roximately 5% of the general population
Family history is found in up to 50% of patients
m
se
As
It is three t imes as common in fema les
Dr
Movements may b e seen during sleep
May be second ary to uraemia
Affects a r p roximately 5% o f the genera l pop ulation
Family history is found in up to 50% of patients
It is three ti mes as common in females
m
se
Males and females are thou ght to be eq ua lly affected, with only one study showin g a
As
s lig htly increased incide nce in fema les
Dr
A 29-year-old female with progressive dementia and myoclonus is seen in the memory
clinic. On examination, the patient has marked myoclonus w ith impairment of the
concentration and memory aspect s of the Addenbrooke's t est. An MRI reveals a 'hockey
stick sign'. A few weeks lat er the patient develops akinetic mutism and paresis of vertica l
upgaze. What is the likely diagnosis given the clinical and radiological findings?
Variant Creutzf eldt-Jakob disease
Lewy body dementia
Wilson's disease
m
se
As
Dr
I Variant Creutzfe ldt-Jakob disease
Lewy body d ementia
Wilson 's disease
This is a case of va riant Creutzfe ldt-Ja kob d isease (vCJD). The typical presentation is that
of a you nger patient with progressive dementia (less rapid the sporadic CJD) with
myo clonus and, in the later sta ges, mutism a nd ve rtica l upgaze pa lsy (found in 50%). An
MRI brai n reveals a chara cteristic 'hockey stick sign' where the pulvinar regio n a nd
d o rso med ia l tha lamus a re hyperintense o n T2-we ighted imaging (or pulvinar s ign whe re
the p ulvinar reg ion is hyperinte nse o nly). CSF pro te in for 14-3-3 and p eriod ic sharp wave
com plexes o n the EEG a re more commonly seen in s pora dic CJD.
Wilson 's disease often has extrapyra midal s igns with othe r featu res such as live r di sea se
and Kayser-Fleische r rings. Prog ressive supra nucl ear pa lsy would p resent with a
d owngaze ve rtical g aze pa lsy mo re com mon ly and Lewy bo dy d e mentia would have more
m
Parkinson ian features. The re is no o bvious family history o f Huntingto n's he re and there
se
would be caudate atrophy on the MRI.
As
Dr
Yo u are a sked to see a 21-year-ol d woma n o n the med ical take who presents with a 2-
d ay history of blu rred vision a nd pain in her right eye which worse ned after her morni ng
bath. She had simi la r symptoms 6 months a go a ffecting her right eye but these resolved
spontaneously a nd she did not seek medical attention. Exa mination revea ls a central
scotoma and impaired colour vision o n Ishiha ra p lates in the right eye . Exa mi nation is
otherwise unremarkab le. A contrast M RI brain shows T2 enhancement of the right optic
nerve but no other abnormalities. l umbar pu ncture d e monstrates olig oclonal bands in
the cerebrosp inal flu id (CSF). Her mother has mu ltip le scle rosis (MS) a nd she is
understand ab ly a nxious to discuss her diagnosis and treatment o ptions. Which of the
following is the most ap pro priate act ion?
Sta rt Beta-interferon
Reassure her she d oes not have MS a nd discharg e
Give steroids a nd a rrang e MRI whole s pine
Perform visua l evoked pote ntials
m
se
As
Give steroids a nd a rrang e repeat MRI b rain as a neurology outpatient
Dr
Start Beta-interferon
Rea ssu re her she d oes not have MS a nd d ischarg e
I Give stero ids and a rrange MRI whole spine
Perfo rm visual evo ked pote ntia ls
Give steroid s and a rrang e repeat MRI b rain as a neurolo gy outpatient
Multiple sclerosis diagnosis that requires d e mye linating les ions that a re sepa rated
in space a nd time
The d iagnosis of multiple scle rosis requ ires the id enti fication of demyelinating lesions that
a re sepa rated in s pace and ti me . The question is trying to lure you into making a
diagnosis of MS but pay attention to the d etails and don't be fooled - o n the evidence
provided you cannot d emonstrate that lesions are separated in BOTH space and time and
so you can 't d iagnose MS.
She curre ntly has o ptic neuritis affecting the right eye . This is sup ported by the MRI bra in
showing a d emye linating lesion of the right optic nerve. From her history it's like ly she has
had a p revious ep isode of right-sided optic neuritis. So she has d isease sepa rated in time
but so far not space. Olig oclona l bands in the CSF help supp ort a d iagnosis of MS b ut
a ren't diagnostic and still d on't show dissemination in space. For this she would need to
have a contrast-enhanced MRI sp ine. This cou ld show o ld p laques/ active demyelination;
that wou ld con firm disease d issem inated in time AND space and so allow a d iagnosis of
MS.
Givi ng ste roid s to treat her o ptic neuritis can shorten the duration of the attack and
improve recove ry so it's app ro priate to start them.
1 - Beta-interferon is used in certain MS patients who meet sp ecific crite ria. It reduces the
frequency of attacks. It is ina ppro priate to start in this scenario as you are not even a ble
to confirm a d iagnosis of MS
2 - You cannot exclude MS with the information available a nd so it wo uld be wrong (and
frankly neg ligent) to reassu re a nd discha rge her (on the basis of probability it's very likely
that she has/will d evelop MS in the future b ut again on the limited information you have
avai lable you can't ma ke that dia g nosis).
3 - This is the best o ption. By doing a n MRI spine you can d etermine if there are lesions
separated in space and time. Ste ro ids wou ld treat her cu rrent o ptic neuritis
4 . Visual evoked potentials are used in investigatin g MS but wouldn't add anything in this
scena rio. You a lready know she has o ptic neuritis and the MRI bra in has shown a
d emye linating lesion.
s em
5 - Giving steroids would help her cu rrent o ptic neuritis but simply re p eating the MRI
As
b rain at a later d ate is ina ppro p riate

Dr
A 76-yea r-old woman is diag nosed with Alzheimer's disease. Which one of the following
cou ld be a contraindication to the p rescription o f donepezil?
History of dep ression
Sick sinus syndrome
Concurrent simvastatin therapy
Concu rrent citalopram therapy
m
se
As
Ischaemic hea rt disease
Dr
History of dep ression
Sick sinus syndrome
Cof current simvastatin therapy
Concurrent citalopram therapy
m
se
As
Donepezil may cause b radycardia and atrioventricular node block.
Dr
A 45-yea r-old male presents to the acute medical take with a three day history of
progressive bilateral leg weakness. Which of the following constellation of signs on
examination is the most consistent with a diagnosis of Guillain-Barre Syndrome?
Bradycardia with lower lim b hyporeflexia and flaccid paralysis
Tachycardia with lower li mb hyporeflexia and spastic pa ralysis
Bradycardia with lower lim b hyperreflexia and spastic pa ralysis
Tachycardia with lower li mb hyporeflexia and flaccid para lysis
m
se
As
Tachycardia with lower li mb hyperreflexia and flaccid pa ralysis
Dr
Bradycardia with lower limb hyporeflexia and flaccid para lysis
Tachycardia with lower li mb hyporeflexia and spastic pa ralysis
Bra ycardia with lowe r limb hyperreflexia and spastic pa ralysis
Tachycardia with lower lim b hyporeflexia and flaccid pa ralysis
Tachycardia with lower li mb hyperreflexia and flaccid pa ralysis
Absent or depressed deep tendon reflexes are classical findings in Guillain-Barre

Syndrome (GBS). Hyperreflexia is seen in a GBS variant known as Bickerstaff's encephalitis.
The paralysis in GBS is flaccid.
Autonomic symptoms are common in GBS. The most frequently encountered are
m
se
tachycardia and urinary retention. Although autonomic dysfunction may manifest as
As
hypertension, hypotension, bradycardia, or ileus, these are not as com monly seen.
Dr
You are examining a patient who complains of doub le vis ion. Whilst looking forward the
patient's right eye turns downwards and outwards. On attempting to look to the patient's
left the patient is unable to a ddu ct the right eye and dou ble vision wo rsens. On looking
right the angle of the squ int is less. What is the most li kely underlying prob lem?
Left 6th ne rve palsy
Right 3rd nerve pa lsy
m
se
As
Dr
Left 3rd nerve palsy «JD
Left 6th nerve palsy fD
I Right 3rd nerve palsy ED

Right 4th nerve palsy GD
m
se
Right 6th nerve palsy «JD
As
Dr
A patient is given ondansetron for chemothe rapy related nausea. What is the most li kely
s id e-effect?
Constipation
Dry mouth
Inso mnia
Visua l disturbance
m
se
As
Pruritus
Dr
I Constipation ED
Dry mouth fi!D
In so nia m
Visual distu rbance fl!D
Pru ritus
•
m
se
As
Whilst a ll the above may occu r constipation is most common
Dr
A 19-yea r-old presents as she wou ld like to start a combined oral contraceptive pill.
During the history she states that in the past she has had migraine with aura. She asks
why the combined oral contraceptive pill is contraindicated. What is the most ap propriate
response?
Theoretica l risk of ischaem ic stroke
Significantly increa sed risk of ischaemic stroke
Increased frequency o f migra ines
Mig raine is an inde pendent risk factor for venous throm boembo lism
m
se
As
Increased severity o f mig raines
Dr
Theoretica l ris k o f ischaem ic stroke
~nificantly increased risk of ischaemic stro ke

Increased freq uency o f migra ines
Mig raine is a n ind ep endent risk facto r fo r venous thromboembo lism
m
se
Increased seve rity o f mig ra ines
As
Dr
A 29-yea r-old fema le has just g iven birth a baby boy who we ig hs 3.1kg . The baby
unfortunately d evelo ps bleed ing via the umb il icus, mucous membranes, gastrointestinal
tract. The mo ther has a past medical histo ry of ep ilepsy.
What anti-e pileptic is most likely implicated?
Sodium valp roate
Carbamaze pine
La motrig ine
Levetira cetam
m
se
As
Phenytoin
Dr
Sodium valproate CD
Carbamazepi ne fED
l amotrig ine .
(D
m
..
Levetiracetam
Phenytoin
Phenytoin induces vitam in K metabolism, which can cause a relative vitamin K

d eficiency, creating the potential for hea morrhagic disease o f the newborn
Phe nytoin induces vitam in K metabol is m, which ca n cause a relative vita mi n K deficiency,
creating the potential fo r hemorrhagic disease of the newborn. The most common sites of
bleeding are the umbil icus, mucous membranes, gastrointestinal tract, and
venepunctures.
Sodium valproate causes a 20-fo ld increase in neural tube defects.
Carbamazepi ne also increases the risk of neu ral tube defects.
m
se
Recent studies have shown that lamotrigine and leveti racetam do not significantly As
increase risk of b irth d efects during pregnancy.
Dr
A 35-year-old gentleman presents to general practice with neck swelling. He denies any
other lumps and has no B symptoms. He has no sig nifica nt past medical history and is on
no medications.
On examination, you note a S.Scm smooth and regular swelling in the anterior cervical
lymph node chain. There is no other neck, groin, o r axillary lymphadenopathy. There is no
he patosplenomegaly. Blood tests are all unremarkable.
He is thereafter referred for an ultrasound guided biopsy which reveals the presence of
abnormal follicles with atrophic and hyalinized germina l centres su rrou nded by prominent
mantle zo nes containing small lymphocytes. What is the most li kely underlying condition?
Cat scratch f eve r
Myeloma
Hodgkins lym phoma
Unicentric Castleman's disease
m
se
As
HIV lympha denitis
Dr
Cat scratch feve r
Myeloma
Hodg kins lymp homa
Unicentric Castleman's d isease
HIV lympha denitis

-
~
Unicentric Castleman 's d isease is a lympho proliferative d isorder associated in a subset of

cases with HIV a nd HHV-8. Patient's with unicentric Castleman's disease tend to be
asympto matic and lymphad enopathy is constrained to one lymph node grou p.The most
common sites o f the disease be ing the chest (24 p ercent), neck (20 p ercent), a bdomen (18
percent), and retro peritoneum (14 percent). Biopsy of the lymph node com mo nly shows
regressed g e rminal centres su rro unded by prominent mantle zones.
Here, there is no contact histo ry with cats to suggest cat scratch feve r. The re is no histo ry
of HIV a lthough multiple sites of lympha denopathy cou ld be caused by this infectious
m
disease. Myeloma would include mention of a pa rap rote inaemia with plasma cells present
se
on the bio psy with evidence of o rgan invo lve ment. This biopsy resu lt is not consistent
As
with Ho dgkin 's lympho ma and the re a re no B sympto ms.
Dr
A 70 yea r old man has decompressive surgery for d egenerative cervical myelopathy.
Three years later he presents with neck pain and hand paraesthesias. Wh ich one of the
following management strategies is recommended?
Tria l of neuropathic analgesia and cervica l nerve root injections
Investigate with nerve cond uction studies and EMG in the first instance
Urgent AP/Iateral cervical spine radiogra phs as an M RI scan is contraindicated
Urgent re fe rra l to sp ina l su rgery or neurosurgery
m
se
As
Refer to physiotherapy services
Dr
Trial of neuropathic analgesia and cervical nerve root injectio ns (D
Investigate with ne rve co nd uction stu dies a nd EMG in the first insta nce (D
Urgent AP/ Iateral cervical spine radiog raphs as a n M RI sca n is contraindicated GJ
I Urgent referral to sp ina l surgery or neurosurge ry fZ!D

Refer to p hys iothe rapy services GJ
Postoperative ly, patients with cervica l myelopathy requ ire o ngoing fo ll ow-up as
patho logy can 'recur' at a djacent spinal leve ls, which we re not treated by the in itial
d eco mpressive surge ry.
Recurrent sym ptoms should be treated with a hig h d egree of susp icio n. Althoug h
periphera l neuropathy can o ccur in any patient, this shou ld not b e the diagnosis that is
the most stro ngly susp ected a s delays in d iagnos is a nd treatme nt of DCM a ffect
o utco mes. Therefo re, B is false.
All patients with recurrent symptoms s houl d be evalu ated urgently by specialist sp ina l
services (A an d E, false). Axial sp ine imag ing is necessary and a MRI scan is first li ne . In
patients unable to to have a MRI, CT o r CT mye logra m may be cons id ered. AP and la tera l
radiog rap hs are of limited use whe n myelo pathy is susp ected (C, fa lse).
References
1. Kong L, Cao J, Wan g L, She n Y. Prevale nce of a djacent segment disease following
ce rvica l sp in e surge ry: A PRISMA-com pliant systematic review a nd meta -analys is.
em
s
Medicine (Baltimo re). 2016 Ju1;95(27):e4171.

As
Dr
A 71-year-old man is admitted to the Emergency Department. His fa mily report t hat since
yesterday he has been very 'clumsy' and unsteady on his feet. This morning he started to
complain of numbness down his left side. On examination you notice t hat he has a right-
sided Horner's syndrome and horizonta l nystagmus. Examination of the periphera l
nervous system confirms t he sensory loss on the leh side. Where is the lesion most likely
to be?
Lateral sinus th rombosis
Posterior ce rebral artery
m
se
As
Dr
Late ral sinus th rom bosis .
(D
Posterior cereb ra l artery CD
I Posterior inferior cerebellar artery eD

Middle cereb ra l artery fi!D
-
m
se
GD
As
Anterior inferior cerebe llar artery
Dr
A 76-yea r-old ma n prese nts to the Emergency Department, th is is his 5th attend a nce in 2
months. His past medica l histo ry includes hyperte nsio n, hypercholesterolae mia an d
chronic alcoh ol use. Yo u have neve r seen him a nd p rio r to e nte ring the cubicle the
registrar tel ls you to give his usual trea tment of fluids, Pab rinex a nd d ischa rge back home.
You ma nag e to take a minimal history from the patient b ut he denies fa ll ing o r a histo ry
o f head trauma. You exa mine him as best you ca n. He has an ataxic gait, ho rizontal
nysta g mus and dysmetria.
What is an important cause o f his sympto ms not to be missed?
Alcohol withdrawal
Extradural haemo rrhage
Subdural hae mo rrhage
Vestibular neuronitis
m
se
As
Cerebellar stroke
Dr
Cerebellar stroke pat ients can present like they are 'drunk'
Patients w ith ce rebellar st rokes can p resent like t he are drunk and those with alcoho l
misuse this diagnosis can be missed.
Alcoho l withdrawa l can range f ro m mild, mode rat e and severe/delirium t remens
d epending on the symptoms. Mild to moderate withdrawa l may start as early as 4 to 6
hours after the last drink, and pea k at 24 to 36 hours. Severe w ithdrawal symptoms occu r
after 24 hours and usually peak at d ay 2. Delirium tremens generally occu rs after 3 days of
abstinence or d ecreased drinking.
Vestibular neuronitis is characterised by acut e, spont aneous, and p rolonged vertigo,

com mon ly after a viral infection. Hearing loss and t innitus are not feat ures but may b e
p resent in labyrinth itis.
Extradural and subdural haemorrhage may be p resent. Extradural haemorrhages usually

p resent w ith with a history of t rauma, like a b low t o the pt erion impacting on t he middle
meningeal artery. Subdural haemorrhag es are seen in pat ients wit h ch ron ic alcohol int ake
s em
and the elderly and may present w ith a reduced GCS or conf usion, particu larly if t hey are
As
on anticoagu lants.
Dr
A 45-year-old female with a past medical history of asthma is diagnosed as having
essential tremor. What is the most suitable management?
Am itriptyline
Propranolol
Sodium valproate
Carbamazepine
m
se
As
Primidone
Dr
Am itriptyline «D
Propranolol f!D
podium valproate CD
Carbamazepi ne GD
I Primidone CD
Essential tremor is an AD condition that is made worse when arms are outstretched,
ma de better by alcohol and propranolol
m
se
Propranolol is generally considered first -line in essential but given the history of asthma
As
primidone should be used
Dr
A 19-year-old woman presents to her General Practitioner with a bilateral sensorineural
hearing loss. An MRI brain is requested and it reveals what are like ly to be bilateral
vest ibular schwannoma s.
What neurocut aneous syndrome is the pat ient very likely to have?
Sturge Weber syndrome
Von Hippel Lin dau syndrome
Tuberous scleros is
m
se
As
Dr
Sturge Weber syndrome
Von Hip pel Lin dau syndrome
Tuberous sclerosis
Neu rofibromatosis type 1
Neuro fibro matosis type 2 is associated with bilatera l vestibula r schwa nnomas
Neurofibromatosis type 2 is a rare neurocutaneous syndrome. A classical feature includes

bilateral vestibu lar schwannomas (previously known as acoustic neu romas), which present
as a sensorineu ral hea ring loss. Patients may have multiple schwannomas, meningiomas
and ep endym o mas o f the b rai n or spine . Other findings includ e retinal ha martomas,
cata racts, Cafe Au Lait markings and peripheral nerve tumours.
Neurofibromatosis type 1, a lso known as vo n Recklinghausen disease, d oes not typically

feature b ilateral vestibular schwan nomas. The typica l features a re Ca fe au La it spots,
axillary freckling, Lisch nodules, neurofibromas and o ptic nerve gliomas.
Von Hipp el Lin dau syndrome is a co ndition featu ring visceral cysts and benign tumours in
any system, includ ing the brain. It is not associated with b ilateral vestibular schwan nomas.
Tub erous sclerosis is a rare genetic disorder due to mutation o f either the TSC1 or TSC2
genes. Its features are mu ltiple central nervous system hamartomas (tubers),
su bep endymal giant cell astrocytomas of the b rain, kidneys ang iomyolipomas, cardiac
rhabdomyomas, facial angiofibromas, Shagreen patches an d retinal astrocytic
hamartomas.
Sturge Weber syndrome characterised by a 'port-wine sta in' of the forehead, lea rni ng
em
disab ilities, seizures and glaucoma.

s
As
Dr
'' •• tt Discuss (1) Improve

A 24 -yea r-old lady presents with a two-week history o f fro nta l hea dache associated with
blurred vision and nausea. She has a histo ry of asthma and acne. She uses a sa lbutamol
inhaler as needed, a topica l retino id and is ha lfway throug h a three-month course of
d oxycycline. On exa mination, she has no neu ro log ica l d eficits b ut is noted to have
b ilateral gross papill oed ema. He r body mass index is 26kg/m 2 . ACT scan shows no
hydrocephalus o r mass lesions.
Whi ch of the fo llowing is the most like ly cause of he r symptoms?
Migraine
Retino id use
Venous sinus throm bos is
Subarachno id haemo rrhage
m
se
As
Tetra cycline use
Dr
Mig raine
Retinoid use
-
~
Venous sinus throm bosis
Su barachno id haemorrhage
Tetracycline use
This patient has symptoms and signs consistent with idiopathic intracranial hypertension.
This cond ition is known to b e associated with tetracycline use.
Explanation for othe r options:

• 1. The find ing of bilateral pap illoed ema is not consistent with a history of migra ines.
• 2. Retinoids a re not associated with raised intracranial hypertension.
• 3. Venous sinus thrombosis is a possible cause of these symptoms but wou ld usua lly
have some focal neurologica l si gns, and the history of tetracycl ine use makes
idiopathic intracranial hypertens ion more like ly.
• 4. Suba rachnoid hae morrha ge ten ds to present with a sudden onset 'thunderclap
m
se
headache' rathe r than this patient's more gradua l symptoms.
As
Dr
A patient is refe rred due to the d evelopment of a third nerve pa lsy associated with a
headache. On exam inatio n meningism is present. Which one of the following diagnoses
needs to be urgently excluded?
Weber's syndrome
Internal ca rotid a rtery aneurysm
Multip le sclerosis
Posterio r communicating a rtery aneurysm
m
se
As
Anterior communicating a rtery aneurysm
Dr
Weber's syndrome
Internal ca rotid artery aneurysm
Multiple sclerosis
Posterior co mmunicating artery aneurysm
Anterior communicating artery aneurysm
Painful third nerve palsy = posterior commu nicating artery aneurysm

m
se
Given th e combination of a headache and third nerve palsy it is important to exclude a
As
posterior com municating artery aneurysm
Dr
A 28-year-old woman w it h a history o f systemic lupus erythematosus (SLE) p resents w ith
j erky, irregular movement s w hich seem to move from one limb to an other. Her symptoms
are continuous and t here are no other neurological features such as impairement of
consciousness. Where is t he neurological lesion most likely to be?
Cerebellum
Temporal lobe
Hippocampus
Tha lamus
m
se
As
Caudate nucleus
Dr
Cerebell um CD
Temporal lobe f.D
Hippocf mpus fliD
fD
..
Thalamus
[ Caudate nu cleus
Cho rea is caused by d a mage to the basa l ganglia, in pa rticular the Cau date nu cleus
m
se
These sym ptoms are consistent with chorea, which may have a number of causes
As
includi ng SLE. Tempo ra l lobe epilepsy would not ca use continuous symptoms.
Dr
An 86-year-old man with Lewy body dementia is presents to memory cli nic w ith his wife.
His wife reports that his hallucinations have worsened, and he is becoming more
confused. Despit e the b est effo rts of his carers, he remains agitat ed. His wife feels
threatened by him at times.
Which medication must b e avoided?
Donepezil
Lorazepam
Memantine
Olanza pine
m
se
As
Clonazepam
Dr
Donepezil GD
Lo razepam C!D
Mema ntine C!D
Olanzapine ED
Clo nazepam .
(D
Antipsychotics a re associated with a s ign ificant increase in mortality in d ementia

patients
In a ll d e mentia patients, a ntipsychotics should be avoide d if poss ible d ue to the increase

in mortality, pa rticularly from ca rdiovascu la r causes. Lewy body d e mentia is a spe cial case
howeve r: these patients a re p articularly sensitive to neu ro leptic medication. In a dd ition to
the increase in mo rta lity, neu ro le ptic medication will wo rsen moto r sympto ms, and p ut
the patient at an especially high risk of neu role ptic malig nant syndro me.
m
Acetylcho li neste rase in hibito rs such as d onepezil a re recommended by NICE in l ewy body
se
d e mentia. Me mantine is also recommende d if acetylcho lin este rase in hibitors a re not
As
to le rated. Benzodiazepines may be used with cautio n.
Dr
A 55-yea r-old ma le presented following a co llapse. In his initia l workup, he is found to
have postural hypotension desp ite being on no anti-hypertensives. He was recently
diagnosed with idiopathi c Parkinso n's disease and was started o n Levod opa three months
ago, but has noticed no substantia l change from using it. He also confides that he has
been having pro blems with impotence and has sta rted us ing a catheter due to frequent
ep isod es of u rinary retention. What is the most likely diagnos is?
Multi-system atrophy
Normal progressio n o f id iopathic Parki nson 's d isea se
Normal p ressure hyd rocep halus
Progressive s upranuclear palsy
m
se
As
Corticobasa l syndrome
Dr
Multi- system atrophy
Normal progression o f idiopathic Parki nson 's disease
Corticobasal syndrome
The correct answer is multi-system atrophy due to classical hist ory of p oo r response to
levodopa, impot ence, urinary retention and age group.
The classical triad of idiopathic Parkinson's disease is rigidity, a resting tremor and
bradykinesia (slowness of movement), collectively known as parkinsonism. Other features
can include a shuffling gait, mask-like face, micrographia (small handwriting) an d
dementia.
Normal pressure hydrocephalus is characterised by progressive menta l impairment and

dementia, difficu lty walking and impaired bladder control. The gait disturbance is often
the most noticeable sym ptom, it can resemble a parkinsonian gait but unlike Parkinson's
there is no rig idity or tremo r.
Progressive supranuclear palsy st arts with patients having impaired balance and therefore
being prone to many falls. On examination, they have a vertica l gaze palsy. It has a
symm etrica l onset and is poorly responsive t o levodopa, unlike Parkinson's disease.
Corticobasal syndrome begins as a movement disorder, with a unilateral absence of

movements and muscle rigidity w ith a tremor. It is a progressive neurological disorder
em
that can also affect cognition.

s
As
Dr
Which one o f the following featu res is most likely to be seen following facial nerve
paralysis?
Hyperacusis
Hyperlacrimat ion
Hyperest hesia
Hypera lgesia
m
se
Hypersalivation
As
Dr
I Hyperacusis CD
Hyperlacrimation GD
Hyperesthesia CD
IHy~eralgesia CD
Hypersalivation GD
m
se
Hyperacusis results from para lysis of the stapedius muscle. Overflow of tears may occur
As
but hyperlacrimation does not.
Dr
A 35-year-old man with a history o f migraines has b een admitted to the medical ta ke w ith
a right-sided hemiparesis. On closer questioning, there is a family history o f stroke and
migraines. A CT brain reveals multiple hypodensities within the basal ganglia and
t emporal lobes, out of keeping for his age. A diagnosis o f CADASI L is suspect ed. What is
the pathophysiology of th is condition?
NOTCH3 mutation
NOD2/CARD15 mutation
FXN mutatio n
GLA mut ati on
m
se
As
SCNSa mutation
Dr
NOTCH3 mutation
NOD2/CARD15 mutation
FXN mutatio n
GLA mutation
-
~
SCN5a mutation
CADASIL (also known as cerebral autosomal d om inant arteriopathy with subcortical

infarcts and leukoencephalopathy) is the most common cause of hereditary cerebral
small-vessel disease and vascular cogn itive impairment in young adults. It is, as implied by
the name, an autosomal dominant condition caused by a NOTCH3 mutation on
chromosome 19. Cha racteristically, this presents wit h a migraine with aura, and a fa mily
history of such, which can ultimately lead to stroke-like features and is a recognised
important cause of stroke in t he young. Brain imaging w ill reveal multiple subcortica l
white matter lesions, particularly in the anterior temporal lobes and basa l ganglia, out of
keeping with the patient 's age.
NOD2/CARD15 mutations are associated with Crohn 's, FXN mutations are associated with
m
se
Fried reich's ataxia and GLA mutations w ith Fabry disease. SCNSa mutations are associated
As
with Brugada Syndrome. Dr
A 25 year-old man present s w ith worsening bilateral sensorin eural deafness. A t rial o f
steroid therapy by his GP had b een unsuccessful. He has an M RI scan which d emonstrat es
b ilateral lesions at t he ce reb elloponti ne angles. He recalls t hat his father had some form
o f brain tumou rs, but can't remember what. His fat her also has hearing impairment.
Which o f t he follow ing chromosomes is likely to have a d efect on genetic ana lysis?
16
17
m
se
As
22
Dr
3 CD
16 CfD
17 f.ID
X CfD
22 CD
This man has neurofibromatosis type 2, ind icated by the b ilateral acoustic neuromas. This
is autosomal dominant and is an inherited d efect in chromosome 22.
Neu rofibromatosis type 1 is due to a mutation in chromosome 17, von-H ippel Lindau is
m
se
inherited via chromosome 3 an d tu berous sclerosis is often associated with a mutation in
As
chromosome 16 (as is polycystic kidney disease type 1).
Dr
A 23-year-old man with difficu lt to control epilepsy is reviewed in cl inic, fou r months after
a change in his antiepileptic medication. He has remained seizure free but has gained 5
kg in weight since last reviewed. Wh ich one of the following antiepileptic drugs is most
associat ed w ith weight gain?
Ethosuximide
Sodium valproate
Levetiracetam
Carbamazepine
m
se
As
Lamotrigine
Dr
Ethosuximide m
Sodium valp roate CD
Leve1 racetam .
(D
Carbamazepine f!D
Lamotrig ine f!D
m
se
Sodium valp roate may cause weight g a in
As
Dr
A 31-yea r-old female with prog ressive leg weakness has nerve conduction stud ies for
suspected Guilla in-Ba rre syndro me. Which one of the followi ng findings wo uld be most
consistent with this diagnosis?
Reduced conduction velocity
Extended series o f re petitive discharges lasting up to 30 seconds
Increased co nd uct io n ve locity
Dimi nis hed resp onse to re petitive stimulation
m
se
As
Reduced wave am p litude
Dr
Reduced conduction velocity
Extended series o f repetitive d ischarges lasting up to 30 seconds
Increased conduction velocity
Diminished response to repetitive stimu lation
Reduced wave am p litud e
m
se
Slowing of the ne rve conduction velocity usually ind icates there is damage to the myelin
As
sheath, as in Guillain-Barre syndro me
Dr
A 67 -year-old woman comes for review with her husband. Her husband comp lains that
she is constantly getting up from bed at night and pacing around the bedroom. She
complains of 'antsy' legs and a 'horrible, creeping sensation'. Her symptoms generally
come on in th e evening and are only relieved by moving round. Given the likely diagnosis,
what is the most appropriat e treatment?
Ropinirole
Carbamazepine
Am itriptyline
Citalopram
m
se
As
Quinine
Dr
Ropinirole CID
Carbamazepine G.D
Am itriptyline flD
Citalopram f!D
Quinine f!D
Restless leg syndrome - management includ es d opamine agonists such as
m
se
ropinirole
As
Dr
A 23-year-old man is admitted following the sudden onset of an occip ita l headache. On
exam ination GCS is 15/15, neu ro logica l exam ination is unrema rkable but neck stiffness is
noted. A suba rachno id haemo rrhage is suspected but the CT scan is normal. At what time
s hould a lumba r puncture be done to exclude the diagnosis?
Immed iately
2 hours post-headache
m
se
As
Dr
Immediately
12 hours post-head ache

-
"""'
24 hot s post-headache
To detect a subarachno id haemorrhage the LP shou ld be done at least 12 hou rs

after the start of the headache
A lumba r puncture shou ld not be do ne until 12 hours after the onset of the headache to
allow time for xathochromia to develop.
SIGN guid elines state the following:
Subarachnoid blood degrades rapidly. Performing CT brain imaging as soon as possible

maximises the chance of accurate diagnosis. Even timely CT brain imaging may not pick up
subarachnoid blood, so lumbar puncture is also required. Lumbar puncture should be
delayed til/12 hours after headache onset.
em
If the patient was acute ly unwell o r had a n altered GCS then discussion with neurosurgery
s
As
may be appropriate rather than waiting 12 hou rs.

Dr
A 5 -yea r-o ld boy is referred by his GP to the neuro logy clinic with abnorma l movements.
His mother noticed that for the last year, the boy is starting to fa ll over mo re and more
frequently. He has also been having increasing ly slurred speech. These have been getting
p rog ressive ly worse. He has had recurrent chest infectio ns in his child hood.
Friedreich's ataxia
Infantile -onset s pinocerebellar ataxia
Di-George syndrome
Cerebral palsy
m
se
As
Dr
Friedreich's ataxia
Infantile-onset spinocerebellar ataxia
Di-George syndrome
Cerebral palsy
Ataxic telangiectasia is characterised by cerebe llar ataxia and telangiectasia, onset is

in ch ildhood
Ataxic telangiectasia is characterised by cerebe llar ataxia and telangiectasia, onset is in

child hood. Immune deficiency is a lso a feature, manifesting in frequent chi ldhood
infections.
Fried reich's ataxia and Infantile-o nset spinocerebellar ataxia do not present with
immu nodeficiency.
Cerebral palsy does not p resent with ataxia.
m
se
Di-George syndrome is a cause of im mune deficiency but does not usually cause ataxia.
As
Dr
A 47 -year-old man presents to the Emergency Department with a three day history of
severe headache associated with vom iting. There is no past medical history o f note. On
examination blood pressure is 98/ 62 mmHg, pulse is 108 bpm and temperature is 37.0°C.
There is mild neck stiffness and a partial third nerve palsy of the left eye. Blood rests
reveal:
Hb 14 .8 g/dl
Pit 373 * 109/1

8
WBC 13.6 109/1
132 mmol/ 1
5. 2 mmolfl
Urea 4 .2 mmol/1
9 pmol/1
Free T4
(range 10-22)
Cavernous sinus th rombosis
Meningitis
Pituitary apoplexy
em
s
Lateral sinus thrombosis

As
Dr
m
se
The hypotension, electrolytes and low free T4 point towards hypopituitarism. Clinically,
As
pitu itary apoplexy can mimic a subarachnoid haemorrhage
Dr
Which of the following drugs is least likely to cause peripheral neuropathy?
Am iodarone
Vincristine
Trimethoprim
Isoniazid
m
se
As
Nitrofurant oin
Dr
Amiodarone CD
Vincristine CD
Trimethoprim ED
Isoniazid CD
Nitrofurantoin CD
m
se
As
Trimethoprim is not listed in the BNF as causing peripheral neuropathy
Dr
In patie nts with Gu illa in-Barre synd ro me, re spirato ry function should be monitored with:
Oxygen satu ratio ns
PEFR
Flow vo lume loop
Arte rial b lood gases
m
se
As
Fo rced vital capacity
Dr
Oxygen saturations CD
PEFR GD
Flow volume loop GD
Arterial blood gases CD
Forced vital capacity CD
m
se
FVC is used to monitor respirato ry funct ion in Guillain-Barre syndrome
As
Dr
A 35-yea r-old woma n is seen in the emerg ency d epartm ent with right-sid ed facia l
wea kness. She first noticed the weakness yeste rday mo rn ing b ut did not th ink it was
anything serio us a nd so did not seek med ica l attention. She has been b rou ght in to day by
he r frie nd who is concerned that the wea kne ss has b ecome worse ove rnight . Her
observatio ns are unrema rkab le. Cranial nerve exam reveals unilatera l wea kness of the
facial muscles in the distribution of the VII nerve affect ing the e ntire right side of the face.
She has no other foca l neurology in the face, arms or leg s and the skin is inta ct with no
lesi ons. Blood s done on a rriva l are normal.
Give n the unde rlying d iagnosis what is the most appropriate management o f this patient?
CT head
Asp irin
Prednisolo ne
Aciclovir
m
se
As
Prednisolo ne + Aciclovir
Dr
CT head
Aspirin
-
. .wr
Prednisolone
Aciclovir
Predniso lone + Aciclovir
Treatment of Bell's Palsy is with p rednisolone because it increases the likelihood of

com plete recovery
This patient has Bell's Palsy. Th is is a cli nical diagnosis of exclusion and in the absence of
sympto ms/signs t hat are atypical for Bell's Palsy, neuroimaging is not indicated.
Obviously, upper motor neuron (UMN) facial nerve weakness (with forehead spa ring)
raises co ncern about t he possibility of a stroke and would deman d neuroima ging to
exclude t his. However, in t he context of an isolated lower motor neurone facial nerve
weakness, wit h typical features of Bell's Palsy this is not necessary at this stage.
The treat ment o f cho ice for Bell's Palsy is prednisolone (lmg/kg) for 10 days and this
m
se
should be started within 72 hours of symptom onset. Prednisolone has been shown to
increase the likelihood of complete recovery. As
Dr
A 24-year-old man is seen in the ' First Seizure' clinic. He has been referred by the loca l t he
Emergency Department fo llowing a sing le episode of a witnessed seizure. Which one of
the following factors wou ld be least relevant when deciding whether to start anti-ep ileptic
drugs after a single seizu re?
Brain imaging shows a structural abnormality
The patient has a neurologica l deficit
The EEG shows unequivocal epileptic activity
The patient is less than 45 years old
m
se
As
The patient considers the risk o f having a fu rther seizu re unacceptable
Dr
Brain ima ging shows a structural abnorma lity
The patient has a neu rological deficit
The EEG shows unequivocal epilepti c activity
I The patient is less than 45 yea rs old
m
se
As
The patient considers the risk of having a furthe r seizu re unacceptable
Dr
A 72-yea r-old man presents to the Emergency Department. Whilst walking back from a
friends house he slipped on some ice and fell backwards, landing on his right arm and
banging his head on the kerb in the process. His past medical history includes atrial
fibrillation for wh ich he takes bisoprolol and warfarin. A routine INR taken four days ago
was 2.2. There are no signs of any external injury to his right arm or scalp. What is the
most appropriate course of actio n with relation to his head inj ury?
Arrange a CT head scan to be performed within 8 hours
Discharge with standard head injury advice
Adm it fo r 24 hou rs of observation
Adm it fo r 8 hours of observation
m
se
As
Discharge with standard head inju ry advice + advise he stops warfarin fo r 5 days
Dr
I Arrange a CT head scan to be performed within 8 hours fJD
Discharge with standard head inju ry advice 0

Ad mit for 24 hou rs of observation 4!D
Admit for 8 hou rs of observation 0
Discharge with standard head inju ry advice + advise he stops warfarin fo r 5 days CD
m
se
Patients who've had a head injury and are on warfarin need to have a CT scan, regard less
As
of whether they have risk factors for an intracran ial inj ury.
Dr
An 18-year-old girl with a known Chiari 1 malformation presents to her General
Practitioner with loss of sensation in both o f her arms and forearms, and on the back of
her neck. On t esting, she specifically ca n't feel pain and temperature but ca n detect fine
touch, proprioception and vibrati on.
Which of the following abnormalities has this patient most likely have?
Syringomyelia
Hydrocephalus
Brain st em compressio n
Cerebellar compression
m
se
As
Dr
Syringomyelia
Hydrocep ha lus
Bra in stem com press ion
Cere be lla r compression

-
~
Periphe ral neu ropathy
Chiari malformations are often associated with syringomyelia due to d isturb ed

cerebrospinal fluid flow at the foramen magnum
Chia ri 1 ma lfo rmatio n is a condition cha racte rised by hern iation o f the cere be llar tonsils
throug h the fo ra me n magnum. It causes sympto ms by compressing the bra in stem,
cerebe llum and by distu rbing the flow o f cere brosp ina l fluid (CSF). Disturb ed CSF flow
either causes hydrocepha lus (uncommon) o r syringo myelia (common; -50%).
Syringomyelia is a di lata tio n of a CSF space within the spinal cord. It occu rs within the
cervical a nd thoracic seg ments a nd causes compressio n o f the s pinotha lam ic tracts
m
d ecussating in the a nte rio r white com missu re . This resu lts in dissociative loss of sensatio n
se
o f pain, tem pera tu re and non -discriminative touch. There is classica lly a 'cap e -li ke '
As
distribution of this sensory loss. Dr
A 27 -yea r-old man present s t o t he Emergency Department wit h 2 d ay history o f severe
headache and pyrexia (38.2°C). ACT scan is reported as follows:
CT: Bra in
Petechial haemorrhages in the temporal and inferior frontal lobes. No mass effect . Brain parenchyma
otherwise normal
Brain abscess
M en ing oco ccal m en ingitis
Cerebral m alaria
Herp es simplex encep halitis
m
se
As
New variant CJD
Dr
m
se
CT head showing tempora l lobe changes - think herpes simplex encephalitis
As
Dr
Which one o f the following infections is most st rong ly associated with the development
o f Guillain-Barre syndrome
Shigella
Salmonella
E. coli H7:0157
Herpes simplex
m
se
As
Dr
Shigella
Salmonella
I E. col:
Herpes simplex
H7:0157
-
~
m
se
Campylobacter jejuni is strongly associated with the development o f Guillain -Barre
As
syndrome
Dr
You review a 62-yea r-old man three days after he had been adm itted with an acute
corona ry synd rome. His past medica l history includes myasthenia gravis fo r which he
takes long -term predn isolone. Since adm iss ion his symptoms of myasthenia have become
ma rkedly worse. In pa rticular you notice bilatera l ptosis and slu rring of speech. Which o f
the following recently started medications is most likely to be responsible?
Clopidog rel
Atorvastatin
Ram ipril
Aspirin
m
se
As
Bisoprolo l
Dr
Clopidogrel fl':D
Atorvastatin GD
Ramipril «D
Aspirin .
(D
Bisopro lo l ED
m
se
As
Beta- blockers such as b isop rolo l a re common precipitants o f myasthen ic crises.
Dr
A 10-year-old is referred to neurology due t o episodes her GP feels are epileptiform. Her
mother reports t hat she appears t o j ust 'stop', sometimes even in mid conversation, for
several seconds at random t imes during t he d ay. Durin g t hese episodes she can be
unresponsive t o quest ioning and has no recollection of t hem.
Which o f these drugs is cont raindicated in this condition?
Ethosuximide
Sodium valp roate
Lamotrigine
Carbamazepi ne
m
se
As
Clonazepa m
Dr
Ethosuximide CD
Sodium valp roate GD
Lamotrig ine .
(D
Carbamazepine G3
Clonazepa m CD
Carbamazepine is contra ind icated in a bsence se izu res

These are absence seizures. Ethosuximide is the gold sta ndard treatment a nd valp roate,
la mo trigine and clonazepam can all be useful.
m
se
Carbamazepi ne is contraind icated and can worsen absence se izures (alo ng with
As
p henytoin, vig abatrin and gabapentin).
Dr
A 59-year-old man with no significant past medica l history is admitt ed to hospital
following an ischaemic stroke. He presented outside of the thrombolysis w indow and is
treated w ith aspirin for the first few days. His blood pressure is 130/80 mmHg, fasting
glucose is 5.6 mmol/1and fasting cholesterol is 3.9 mmol/1. He makes a good recovery
and has rega ined nearly all of his previous functions upon discharge. Following recent
NICE guidelines, which o f the following medications should he be takin g upon discharge
(i.e. aher 14 days)?
Aspirin + statin
Aspirin + dipyridamole + st atin + ramipril
Clopidog rei + st ati n
Aspirin + dipyridamole
m
se
As
Aspirin + dipyridamole + st atin
Dr
Asp irin + statin (D
Asp irin + dipyridamole + st atin + ramipril m.

I Clopidogrel + statin 6D
Asp irin + dipyridamole
•
m
se
Asp irin + dipyridamole + st atin «D
As
Dr
A 73-year-old male presents with progressively worsening gait and urinary urg ency. He is
diagnosed with degenerative cervical myelopathy. Which ONE of the following is true
regarding this condition?
Smoking is not a risk factor in isolation
Asians ca n have a different underlying aetiology than caucasians
Bowel and bladders sympto ms are rare and should prom pt consideration of cauda
equina syndrome
Most patients present with a classic triad of neck pain, finger paraesthesias and
weak legs
m
se
As
Fam ily history is of limited value
Dr
Smoking is not a risk factor in isolation
Asians can have a different underlying aetiology t han caucasians
Bowel and bladders symptoms are rare and should p rom pt consid eration of
cauda equina sy1drome
Most patients present with a classic triad of neck pain, finger paraesthesias and
weak legs
Family history is of limited value
Asian popu lat ions have a higher rate of ossification of the posterior long itudinal ligament
(OPLL), which can result in myelopathy.
Degenerative cervical myelopat hy (DCM) has a number of risk factors, wh ich include
smoking due t o its effects on the intervertebral discs (A, false), genetics (option E, fa lse)
and occupat ion - those exposing pat ients to high axial load ing [1].
The present ation of DCM is very variable (opt ion D, false). Early sym ptoms are often
subtle and ca n vary in severity day to day, making the disease difficu lt to detect init ially.
However as a p rogressive condition, wo rsen ing, deteriorat ing or new symptoms should
be a warning sign.
DCM sympto ms can include any combination of [1]:

Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple t asks such as holding a
fork or doing up their shirt buttons, arm or leg weakness/st iffness leading to impaired
gait and imbalance
Loss of sensory f unction causing numbness
Loss of autonom ic function (u rinary or faeca l incont inence and/or impotence) -these can
occur and do not necessarily suggest cauda equina syndrom e in the absence of o t her
hallmarks of t hat condition
The most commo n sympto ms at p resentat ion of DCM are unknown, but in one series 50%
o f patients were init ially in co rrectly diagnosed and so met imes treat ed for carpal tunne l
syndrome [2].
References
1. Baron EM, You ng WF. Cervical spondylot ic myelopathy: a brief review of its
pat hophysiology, clinical cou rse, and diagnosis. Neurosu rgery. 2007 Jan;60(1 Supp1
1):535-41.
2. Behrbalk E, Sa lame K, Reg ev GJ, Keynan 0, Boszczyk B, Lidar Z. Delayed diagnosis of
cervical spondylot ic myelopathy by primary care physicians. Neurosu rg Focus. 2013
s em
Jui;35(1):El.
As
Dr
A 50-yea r-old man develops chronic, severe pain after sustaining a brachial plexus inju ry
as a result of motorbike accident. He has had no benefit fro m paracetamol or ibuprofen.
He has had a trial of amitriptyline which was not successful. Following recent NICE
guidelines, what is the most app ropriate medication to consider?
Sertraline
Topical lidocaine
Carbamazepi ne
Pregabalin
m
se
As
Buprenorphine
Dr
Sertraline
•
Topical lid oca ine
Carbamazepine «ED
•
Pregabalin &D
m
se
•
As
Buprenorphine
Dr
A 73-yea r-o ld woman presents with episodic confusion a nd headaches for the past week.
She has a history of alcoho l excess and a backg rou nd o f atria l fibrillation a nd type 2
diabetes mellitus. Her daug hte r reports that s he has been having frequent spells o f
confusion over the past few days. Last yea r she was assessed for freq uent falls. Her
current medications include bisoprolo l, metformin and warfarin. Neurologica l examination
is unremarkable a nd her blood sugar is 6.7 mmol/1. What is the most likely diagnosis?
Korsakoff's syndrome
m
se
As
Subdural haematoma
Dr
Korsakoff's syndrom e (!D
Wernicke's encephalopathy CD
Extradura l haematoma .
(D
Subarachnoid haemorrhage m
I Subdural haematoma 6D
Fluctuating confus ion/consciousness? - subdural haemato ma

Th is patient has a number o f risk facto rs fo r a subdu ra l haematom a including o ld age,
m
se
alcoho lism and anticoagu lation. Korsakoff's synd rome and Wernicke's encephalopathy do
As
not usually cause headaches.
Dr
A 67 -yea r-o ld ma n is reviewed in the neu rology cl inic due to concerns a bout increasing
clumsin ess. Exam inatio n reveals an ataxic ga it a nd increased up per limb tone with cog -
wheel rig idity. Blood p ressure is 135/ 80 lyin g a nd 95/ 70 sta ndi ng. What is the most li ke ly
diagn osis?
Moto r neuron d isease
Progressive supranuclea r pa lsy
Pa rkinson 's disea se
Multip le sclerosis
m
se
As
Dr
Moto r neuron d isease
Progressive supranuclear pa lsy
Parkinson's disease
Multip le scleros is
m
se
Whilst postural hypotens ion may b e seen in Pa rkinson's disease the ataxic gait point
As
towa rds a d iagnosis of multip le system atrophy.
Dr
The following drugs co mmonly exacerbate myasthen ia gravis, except:
Methotrexate
Genta micin
Beta-blockers
Quinidine
m
se
As
Penicilla mine
Dr
Methotrexate GD
Gentamicin CD
Beta- blockers tiD.
Quinidine fi!D
m
se
Penicillamine CD
As
Dr
A 24-yea r-old woman with Charcot- Ma rie-Tooth d isease (type 1) asks how like ly it is that
any future ch ildren will have the di sease. What is the most accu rate answer?
Three times as li kely as background population
25%
Between 5 - 10%
Same as background po pulation
m
se
As
50%
Dr
Three times as likely as background population
25%
Between 5 - 10%
Same as background population

-
. .wr
50%
m
se
As
Charcot - Marie-Tooth disease (hereditary sensorimot or neuropat hy type I) is an autosomal
d om inant condition and t herefore 50% of children will b e affected
Dr
A 50-yea r-old man p resents to the e me rgency d e partment with a one-hour history of
right-side d weakness and facial droop, which has now entirely resolved . He has a past
med ical history of mig raines with aura, which started a round 8 yea rs ago, a nd low mood .
He had a simila rly brief e pisode o f sud den dizziness and slurred speech six months ago
but did not seek medica l attention. His father had sim ilar expe riences in his 50s b ut d ied
in a roa d traffic accident a ged 60.
The patient's CT hea d is norma l. He has an MRI head which shows a number of
hyperintense lesions. What is the most like ly cause for his sympto ms?
Ea rly o nset Alzheimer's disea se
CADASIL
Variant Creutzfe ldt-Jacob disease
m
se
As
Atypical migraine
Dr
Early onset Alzheimer's disease a
I CADASIL
.,
Hunting ton's disease fiiD
Variant Creutzfeldt-Jacob disease CD
Atypical migraine GD
CADASIL is a ra re cause of multiple cerebra l infarctions

The correct answer is CADASIL - cerebral aut osomal dominant arteriopat hy w ith
subcortical infarcts and leukoencep halopathy. This is a g enet ic co ndition due to a
mutation in t he NOCTH3 gene. It usually presents with t he onset o f migraines in mid dle
age, followed by recurrent TIAs and strokes, and resulting in neuro -cog nitive decline,
psychiatric p roblems and d ementia. MRI often shows multiple widesp rea d hyper-intense
lesions in t he wh ite matt er, basa l ganglia, t halamus and pons.
m
se
CADASIL foundat ion:
As
https:/ /www.cad asi lfoundation.org/what.ht ml
Dr
You review a 25-year-old man w ho is complaining of leg weakness. Other than a bout of
diarrhoea three weeks ago he has been feeling fit and well and has no significant medical
history. On examination you note reduced power in his legs, normal sensation and
reduced knee and ankle reflexes. His pulse is 78/ min and blood pressure is 122/ 84 mmHg
(standing), 100/ 64 mmHg (sitting). What is the most likely diagnosis?
Botulism food poisoning
Guillain-Barre syn drome
Cauda equina syndrom e
Myasthenia gravis
m
se
As
Transverse myelitis
Dr
Botulism food poisoning
Cauda equina syndrome

-
~
m
Myasthenia gravis
se
As
Transverse myelitis
Dr
A 64-year-old female with a history of rheumatoid arthrit is presents with increased
difficu lty in walking. On examination th ere is weakness o f ankle d orsiflexion and o f t he
ext ensor hallucis longus associated w it h loss of sensation on t he lateral aspect of the
lower leg. What is t he most likely diagnosis?
Tibial nerve palsy
Obturator nerve palsy
Common peroneal nerve palsy
Late ral cutaneous nerve palsy
m
se
As
Pu dend al nerve pa lsy
Dr
Tibial nerve pa lsy f!D
Obturator nerve palsy CD
I Common peroneal nerve palsy GD

Late ral cutaneous nerve palsy CfD
m
se
m
As
Pu dendal nerve pa lsy
Dr
A 34-yea r-old woman who p resents with confus ion, headache a nd fever is admitted to
the Emergen cy Depa rtment. Shortly after a dmiss ion she has a seizure. A MRI sca n is
pe rfo rmed which shows patchy haemorrhagic chang es in the tempo ral lobe. Given the
like ly diagnosis, what is the treatme nt of cho ice?
Supportive treatment + intravenous cefotaxime
Supportive treatment + intravenous a ciclovir
Supportive treatment + intravenous am photericin B
Supportive treatment a lone
m
se
As
Supportive treatment + intravenous immuno glo buli n
Dr
Supportive treatment + int ravenous cefotaxime
Supportive treatment + intravenous aciclovir
Supportive treatment + intravenous amphot ericin B
Supportive treatment alone
m
se
As
Supportive treatment + int ravenous immunoglobu lin ~
Dr
A 45-year-old man presents with dizziness and right-sided hearing loss. Which one of the
following tests would most likely indicate an acoustic neuroma?
Jerky nystagmus
Left homonymous hemianopia
Tongue deviated to the left
Fa sciculation of the tongue
m
se
Absent cornea l reflex
As
Dr
m
Loss of co rnea l ref lex -think acoustic neuro ma
se
As
Dr
A 45-year-old woman who works in a children's nursery presents due to 'weakness' in her
right foot. This has develo ped over the past couple of days. She is otherwise well and
reports no other symptoms.
On examination, you note a high-st epping gait on th e right side. Weakness of the right
foot dorsiflexors is noted. All reflexes in the lower limb are normal and no fasci culations
are noted. Hip abduction strength is normal.
Admit fo r CT head and lumbar puncture
Urgent referra l to neurology
Advice to avoid leg crossing, squatting or kneeling and review in 4 weeks
Advise the patient to increase their vitamin D consumption
m
se
As
Arra nge nerve conduction studies
Dr
Adm it fo r CT head and lumba r punctu re
Urgent referra l to neu ro lo gy

-
~
Advice to avoid leg cross ing, squatting or kneeling and review in 4 weeks
Ai:Jvise the patient to increase their vitam in D consumptio n
Arra nge nerve conduction stud ie s
Leg cross ing, squatting o r kneeli ng may cause a foot drop second a ry to a co mm on
peroneal neuropathy
This patie nt has foot drop seco ndary to a common pe ro nea l ne rve lesio n. This may have
been precipitated by kneeling and squatting in her job at the nursery.
m
se
In the a bsence of othe r find ings, conservative management with advice is approp riate
As
initially.
Dr
A 71-yea r-old woman is presecribed o ndan setron to help tre at nausea which ha s not
respond ed to e ither metoclopram id e o r cycl izine. What is the mechan is m of actio n o f
onda nsetron?
5-HT3 antagonist
5-HT2 a ntagonist
NKl receptor antag on ist
m
se
As
Antihistami ne
Dr
I 5-HT3 antagonist
5-HT2 antagon ist

fD
(D
Dopamine antagonist
~Kl receptor antago nist

•
•
Antih istami ne
•
m
se
As
Exa mples of do pami ne a ntagonists incl ude metoclo pram ide and dom peridone.
Dr
A 32-year-old woman visited her GP two weeks ago compla in ing of thick g reen nasa l
secretions, a fever a nd facial pain. There is tenderness on pa lpation of the maxillary and
fronta l s inuses. The patient was reassured that she as suffering from acute sinusitis which
s hould resolve itself in 2-3 weeks without antibiotic therapy.
She now has a frontal headache with nausea. She is also having increasing difficulty lifting
her right arm and leg. She presents herself to the emergency depa rtment with these new
symptoms, whilst in the depa rtment, she has a seizure.
Which complication o f acute sinusitis has s he developed?
Cerebral stroke
Meningitis
Cerebral abscess
Cavernous sinus thrombosis
m
se
As
Intracran ial bleed
Dr
Cere bral stroke
Men ingitis
I Cerebral abscess
Cavernous sinus th rombosis
Intracran ial bleed
Sinusitis + foca l neurology and fever - ?brain abscess

A co mmon cause o f a b rain a bscess is ascend ing infection fro m middle ear of from facial
s in uses. Appropriate safety netting is necessa ry in primary care to ensure prompt
treatment o f complications in sin usitis . Cavernous sinus thrombosis is a nother impo rtant
m
se
complication in sinusitis but usua lly presents with unilatera l facia l oedema, photophobia,
As
p roptosis and pa lsies o f the cranial nerves which pass through it (Ill, IV, V, VI).
Dr
A 30-year-old lady w ith no past medica l history presents t o the emerg ency department
with a 2-day history of pins and needles in the lower limbs and progressive walki ng
difficu lties. She o ffers a hist ory of a diarrhoeal illness 1 week ago. On examination, there is
a loss of pinprick sensation in the lower limbs fro m mid-thigh distally and in the upper
limbs from MCPj oint s distally. The re is a bilateral w eakness of ankle dorsiflexion to 3/ 5
and knee flexion and extension is weak t o 4/ 5 bilatera lly. Power in upper and lower limbs
is o th erwise normal. Knee and ankle deep t endon reflexes are absent. What is the most
likely diagnosis?
Multiple sclerosis
Guillain -Barre syndrome
Functional neurological syndrome
m
se
As
Botulism
Dr
Multiple sclerosis
F~ nctional neurologica l syndrome

-
~
Botulism
The correct answer is Guillain-Barre syndrome
Functional neurological syndrome can be discount ed due to the presence of hard

neuro logica l signs
MS can be excluded due to the presence of low er motor neuron signs (i.e. areflexia) and
absence of upper mot or neuron signs
Chronic inflammatory demyelinating polyneuropathy (ClOP) is the chronic form of

Guillain-barre syndro me (a lso known as acut e inflammatory demyelinating
polyneuropathy). Guillain-barre syndrome reaches its nadir within three to four weeks,
whereas ClOP is defined by progression for longer than 8 weeks.
m
se
The diarrhoeal illness may be relevant. Prior Campylobacter infection con fers a p oorer
prognosis As
Dr
Which one o f the followin g is least associated with the development o f chorea?
SLE
Wi lson's disease
Pregnancy
m
se
As
Infective endoca rditis
Dr
Ataxic telangiectasia GD
SLE f!D
Wilson 's disease fD
Pregnancy GD
Infective endoca rditis CD
m
se
Chorea can be a very ra re manifestation o f infective endoca rditis, following embolisation
As
to the basa l ganglia . It is however the least like ly of the a bove five o ptio ns
Dr
Which one o f the followi ng haematolog ical disorders is most associated with gingival
hyperp lasia?
Myelof ibrosis
Polycythaem ia ru bra vera
Haemophilia A
m
se
As
Dr
M yelof ibrosis
Polycythaemia rubra vera
Haemophilia A
m
se
Gin gival hyperplasia: phenytoin, ci clos porin, calcium cha nnel blockers and A ML
As
Dr
An 80-year-old man is investigated for progressive cogn itive impairment. Which one of
the following features is most suggestive of Lewy body dementia?
Disinhibition
Em otional lability
Sym ptoms worsen w ith neuroleptics
m
se
As
Paucity o f extrapyra midal signs
Dr
Disinhibition .
CD
Emotional lability CD
I Symptoms worsen with neuroleptics GD

Urinary incontinence fD
m
se
CD
As
Paucity of extrapyra midal signs
Dr
A 58-year-old female present s to general practice com plaining o f w eakness in her legs.
She reports increasing difficu lty climbing st airs and getting up from sitting positions.
On taking a hist ory, you not e she ha s no significant past medical history but has smoked
fo r most o f her adult life.
On examination, you not e a waddling gait, reduced strength in proximal muscles of all
limbs and reduced t endon reflexes. there is no wasting, fasciculations, sensory
abnormalities or ocular sympt oms. On repetitive movements, her weakness appears t o
initially improve.
Given the likely diagnosis, the presence of which of the following antibodies in th e blood
wou ld be diagnostic?
ACh receptor antibodies
Anti-Mi-2 antibodies
Antinuclear antibody
Rheumat oid fact or
m
se
As
Voltage-gat ed calcium-channel antibodies
Dr
ACh recept or antibodies
Ant i-Mi-2 antibo dies
~ntinuclear ant ibody

-
.....,
Rheumatoid fact or
I Voltage-gated calcium-channel antibodies
Lam bert-Eaton Syndrome or Myasthen ia Gravis? Weakness in Lambert Eaton

improves after exercise, unlike Myasthenia Gravis; which worsens after exercise
ACh recept or ant ibodies are associated w it h Myasthenia Gravis (M G). MG can present
wit h isolated proximal muscle w eakness, however, more commonly p resents wit h o cular
sympto ms i.e. ptosis. MG is charact erized by increased fatig ability w it h exercise, unlike t his
patient w hose weakness init ially improves w it h exercise.
Ant i-Mi-2 antibo dies are associated with d ermat omyos it is. Another different ial fo r
p roximal muscle weakness, b ut usually also p resents w it h systemic upset and rash.
Ant inuclear ant ibody is used in t he diagnosis o f various aut oimmune conditions, in
particular, systemic lupus erythema w hich would present different ly.
Rheumat oid fact or (RF) is used as a marker of inflammatory an d aut oimmune activity. RF
is com monly used alongside other t ests to aid t he diagnosis of rheumat oid arthritis.
Rheumat oid fact or has no role in t he diagn osis of Lambert- Eaton Myasthenic Syndrome
(LEM S). This patient has no j oint sym ptoms, which makes t he diagnosis o f rheumatoid
disease less like ly.
Voltag e-g at ed calcium -channel ant ibodies are sug gestive of Lambert-Eaton Myasthenic
Syndrome (LEMS). LEMS is characterized by weakness, particularly of the p roximal
muscl es, which improves (initially) w it h exercise. This condition g enerally present s in later
life, unlike MG w hich has peaks in t he 3rd and 6th d ecades. LEM S is often associated wit h
s em
an u nd erlying malignancy, most commonly small cell lung cancer. This pat ients smoking
As
histo ry gives anot her clue in favou r o f t his diagnosis.

Dr
A 41-yea r-old female p resents with double vision and difficult walki ng for the last 1 week.
She says she has been fa ll ing a lot the past week and has doub le visions when looking left
or right. She had a cold 4 weeks ago. On exam ination, one notes a wide based gait
(ataxia), areflexia in the lower limbs and ophthalmoplegia in all directions. There were no
other neurologica l deficits o r systemic symptoms such as weight loss noted. Blood tests
which included an auto immune screen were positive fo r Anti-GQlb antibodies. What is
Meningoencephalitis
Cerebral venous sinus thrombosis
Miller Fisher syndrome
Vasculitis
m
se
As
Para neo plastic synd ro me
Dr
Men ingoencephalitis
Cerebral venous sinus thrombosis
Vasculitis
-
~
Para neoplastic synd rome
Miller-Fisher syndrome is a variant of Guilla in-Ba rre syndrome. Anti-GQl b antibod ies are
present in 90% of patients with Mille r-Fischer syndro me . Ataxia, a reflexia and
ophthalmopleg ia a re characteristic of Mill er- Fisher synd ro me . Anti-GQ l b a ntibodies are
not p resent in the other fou r options. Miller- Fisher syndro me normal presents a s
descendi ng para lysis as opposed to ascending pa ralys is.
Meningoencephalitis normally p resents with more system ic symptoms such as headache,

fever, photophobia, seizu res and reduced co nsciousness in severe cases. It doesn't
present with areflexia o r a taxia normally.
In para neo plastic syndro me you wou ld expect sympto ms o f malig nancy such as weig ht
loss o r a ny ongoing systemic symptoms which the patient doesn't have .
m
se
In vascu litis, you wou ld expect the patient to have a vascu litic rash which is not noted in
As
this case.
Dr
A 14-yea r-old male is noted to have optic atrophy on fu ndoscopy. Neu rological exam
reveals dysarthric speech and nystag mus. Knee and ankle jerks a re absent but there is an
extensor plantar response. What is the likely d ia gnosis?
Leber's optic atrophy
Fried re ich's ataxia
Subacute combined degeneration of the cord
m
se
As
Multip le scle rosis
Dr
Leber's optic atrophy
Ataxic te la ngiectasia
-
~
Friedreich's ataxia
Subacute combined degene ration of the cord
Multip le sclerosis
m
se
As
Multip le scle rosis wou ld be unli kely at this age
Dr
A 44-year-old man p resents t o his GP co mplaining of weakness i n his hands and leg s and
numbness in his feet. He first noticed some p ro blems w ith walking in his late teens and
reports t hat he's always been "clumsy" and will often trip over. He is otherwise well and
t akes no regular medications. On examination, he has a hi gh -ste pping g ait w ith wasting
of t he lower legs and high arches. Power is reduced in all limbs and ref lexes are difficu lt to
elicit. The re is a reduction in sensation which is more pronounced dista lly. Coordination is
int act.
Duchenne muscular dystrophy
Cervica l spondylotic myelopathy
Subacute co mbined d egeneration o f the cord
m
se
As
Charcot-Marie-Tooth disease
Dr
Duchenne muscular dystrophy
Cervica l spondylotic myelopathy
Subacut e combined d egeneration of the cord
Charcot-Marie-Tooth disease can affect both motor and senso ry peripheral nerves
Charcot- Marie-Tooth disease is a hereditary sensory and motor p eripheral neuropathy.

UMN signs are not present in these patient s. Patient s can present with low er motor
neurone signs in all limbs and reduced sensation (more pronounced distally).
Duchenne muscular dystrophy is an inherited myopathy. It is caused by progressive

d egeneration and weakness of specif ic muscle groups. Most patients lose t he ability to
wa lk by 12 years o f age and require ventilatory su pport by the age o f 25. Sensation is
intact in these patients.
Cervical spondylosis is the term used for osteoarthritis of the sp ine and can result in
compressio n of the spinal co rd. This is more likely to result in LMN signs at t he level of
the compression (ie. upper limb if the lesion is below CS) with UM N sign s below (in the
lower limb). Patients usually complain of neck pain and stiffness.
Guillain-Barre syndrome (GBS) is an inflammatory p eripheral sensory and motor

neuropathy. It typically presents over the cou rse o f days to weeks, not yea rs. There is
ohen a recent bacterial or viral infect ion in the history.
Patients with subacute co mbined d egeneration of the cord (SCDC) classically have an
ataxic gait (due t o degeneration o f t he d orsal columns) and mixed UMN and LMN signs
em
(due t o degeneration o f lateral motor tract s and p eripheral nerves). The hist ory wil l
s
typically be subacute, occu rring over months rather than decad es. Patient s with SCDC
As
ohen notice sensory symptoms before weakness.

Dr
A 65-yea r-old ma le is admitted with a leh si ded facial droop. He states that he r noticed it
when he wo ke up this mo rning. He has no past medical histo ry a nd takes no regular
med icines. On examination he has a leh s ided facial droop which s pares the forehead
muscles.
Blood tests a re as follows:
Hb 145 g/ 1 Na• 136 mmol/ 1
Plat elet s 489 * 109/ 1 K• 3.9 mmol/1
WBC 9.2 * 109/ 1 urea 6 .2 mmol/1
Neuts 6.4 * 109/ 1 Creatinine 42 IJmol/1
Lymphs 2.2 * 109/ 1 CRP 10 mg/1
Glucose 11.5 mmol/ 1
What is the most likely cause?
Bell' s pa lsy
Acoustic neuroma
Stroke
Sarcoid osis
m
se
As
Diabetes mellitus
Dr
Bell's palsy 6D
Acoustic neuroma m
Stroke ED
Sarcoid osis m
Diab et es mellit us (D
'
In facial nerve pa lsy, upper mot or neuron lesions spa re t he upper face (i.e. forehead)
When assessing facial nerve palsy, it is extremely important to est ablish if it is an up per
motor neurone weakness or lower mo tor neurone weakness. The region of the facial
nerve nuclei responsible for forehead muscles is innervated bilateral from t he upp er
motor neurones of the co rticob ulbar tracts. Therefore lesions of th e u pper mot or
neurones will spare th e forehead (as t he facial nerve nuclei will still receive input from t he
contralat eral t racts). In contrast, lesions of t he t he lower motor neurones will affect all the
facial nerve muscles.
Th is patient has sparing of th e forehead muscles maki ng stro ke t he only plausible

explanation. All th e ot her opt ions cause a low er motor neurone pattern of weakness.
The blood results suggest a diagnosis of diabetes. Indeed, diabet es can cause m
se
mononeuritis multip lex, however this wou ld b e exp ected t o cause a lower mot or neurone
As
facial nerve weakness. Diab et es mellitus itself is a strong risk factor for stroke.
Dr
A 72-year-old gentleman with a hist ory of hypertension an d stroke presents to the
emergen cy department accompanied by his w ife. His w ife rep orted him waking at ?am
conf used. Rep etit ive questioning was a p rom inent feature. He was observed t o be
rub b ing his hands t o gether duri ng the event. He was ab le to recognise his w ife and
correctly reported his address and d ate o f birth t o paramedics. The event lasted
approximately 10 minutes. On arrival to the emergency department he a Glasgow Coma
Scale score of 13 (E3 M6 V4). A full neurological examination was otherwise normal. What
is the most likely diagnosis?
Epilepsy
Transient psychog enic amnesia
Brain tumour
m
se
As
Dr
I Ep ilepsy
Transient psychogen ic amnesia
( frain tumour
Transient ischaem ic a ttack
The gentleman in th is scena rio presents with an e pisod e of transient amnesia. The key to
this question is d istinguishin g between transient globa l amnesia an d trans ient e pileptic
amnesia.
Transient global amnes ia is a clin ical syndrome of uncerta in aetiology, characterised by a

discrete episode lasting for a few hours (always less than 24 hou rs) of anterograde
amnesia, retrog rade amnesia, re petitive question ing with an absence of other cognitive or
neurological impairments.
Diagnostic criteria (in ad dition to the above features) are as follows; re liab le witness to
e p isod e, an absence o f head trauma or loss of consciousness at the onset, p reserved
personal id entity and absence of ep ileptic features.
Epilepsy can present with discreet e pisodes o f amnesia. This syndrome is called transient
e p ileptic amnesia. Featu res that suggest epilepsy are; shorter duration (should be less
than 1 hour), mu ltiple attacks, onset on waking from sleep and accompanying ep ileptic
features - e.g. motor automatism, stereotyped behaviours, limb shaking.
The correct answer is epilepsy rather than transient global amnesia due to the presence of
motor automatism (rubbing hands together) and the short duration of the event. The
em
previous stroke may be the und e rlying cause of his seizure. The mildly reduced score on
s
As
the Glasgow Coma Scale may indicate a post -ictal state.

Dr
Each one of the following is associated with ataxic telangiectas ia, except:
Telangiectasia
Cerebella r ataxia
Autosomal dom inant inhe ritance
Recu rrent chest infections
m
se
As
Increased risk of ma lignancy
Dr
Telangiectasia CD
Cere be lla r ataxia CD
ED
..
Autosomal dominant inhe ritance
Recurrent chest infections
m
se
As
Increased risk of malignancy GD
Dr
A 35-yea r-old man p resents to the Emergency Department (ED) with confusion and
feel ing hot. He has a histo ry of schizophre nia and was recently started on rispe ridone. He
d oes not smoke o r drink alcoho l. On exam ination, he had wid esp read muscle rig idity and
was disoriented to time. His vita l s igns were heart rate 120/min, b lood pressu re 150/ 92
mmHg, respiratory rate 20/min and tem perature 37.9°C.
Investigations show myo globinuria and ra ised creatine kinase.
In ad d ition to supportive treatments and sympto m control, which of the fo ll owing

med ications is indicated ?
Sodium bicarbo nate
Flumazenil
Cyproheptad ine
Propra nolol
m
se
As
Dantrolene
Dr
Sodium b icarbo nate fD
Flumazenil m
Cypro rye ptadine CD
Propra no lo l m
Dantrolene GD
Treatment of neu roleptic mal ignant syndrome - dantrolene

Important for me l ess im;>crtc.nt
This patient has classical featu res of th e neu ro leptic mal ignant syndrome which presents
with feve r, muscle rig idity, e ncephalopathy, myoglobinuria, unstab le vita l s igns a nd raised
creatin e ki nase. It is a ra re b ut serious s ide effect of antipsychotic drugs. In severe cases, it
is treated with dantro lene which acts as an antagonist at the ryanodine receptors
d ecreasing the free intracellular ca lci um concentration.
Other answers:
• Sodium bicarbonate is used in TCA toxicity
• Flumazenil is ra re ly used in the management of b enzodiazepine toxicity
• Cyproheptadine is used in severe sero to nin syndrome
• Propranolol d oes not have any ro le as an antidote in serotonin synd rome. Beta
blockers can mask tachyca rdia which is used to monito r the effectiveness of em
treatment.
s
As
Dr
Which one of the following is least associated with Miller-Fisher syndrome?
Anti-GQlb antibodies
Areflexia
Ataxia
Postu ral hypotension
m
se
As
Ophthalmoplegia
Dr
Anti-GQl b antibodies f!D
Areflexia f!D
Ataxia CD
p ostu ral hypotension e!D
Op hthalmoplegia f!D
m
se
Po stural hypotension due to auton om ic involvement is not a feature of Miller Fisher
As
syndrome, but may b e seen in Guillain -Barre syndrome
Dr
A 72-year-old woman wit h a past history of t reated hypertension p resents to t he
Emergency Department. Yesterday she had a 2 hour episode where she cou ldn't f ind the
right wo rd when speaking. This has never happened before and there were no associated
featu res. Neurolog ical examination is unremarkable and blood pressu re was 150/100
m mHg. Her only current medicatio n is am lod ipine. What is t he most approp riate
management?
Aspirin 300mg immediat ely + specialist review w ithin 2 weeks
Specialist review within 2 weeks
Asp irin 300mg immediat ely + specialist review w ithin 24 hours
Asp irin 75mg + outpatient CT brain
m
se
As
Specialist review within 24 hours
Dr
Asp irin 300m g immediat ely + speciali st review w it hin 2 weeks
Spec:ialist review with in 2 weeks

I
Asp irin 300m g immediat ely + specialist revij l w it hin 24 hours
Asp irin 75mg + outpat ient CT b rain
Specialist review with in 24 ho urs
This patients age, blood pressure and duration of sym ptoms wou ld p ut her in a higher
risk categ o ry. Current guidelines advocate specialist review wit hin 24 hours.
If a pat ient's symptoms have not fully resolved t hen asp irin should be w ithheld unt il an
m
se
haemohorragic stroke has been excluded. As t his is a transient ischaemic attack
As
(sym ptoms last less than 24 hours) aspirin sho uld be given as soon as possible.
Dr
A 34-year-old female presents due to a number of 'fu nny-dos'. She d escribes a sensat ion
that her su rrounding s are unreal, 'like a dream'. Following t his she has been told that she
st arts to smack her lips, alt houg h she has no recollection of doing t his. What is t he most
likely diagnosis?
Myoclonic seizu re
Focal t o bilat eral seizu re
m
se
As
Absence seizure
Dr
Myoclonic seizu re
Focal to bilateral seizu re
Absence seizure
m
se
With focal aware seizures there is no disturbance of consciousness or awareness. Lip
As
smacking is an example of an automatism - an automatic, repetit ive act
Dr
A 78-yea r-o ld fe ma le has been d iagnosed with mild to moderate dementia. Wh ich of the
following is an effect of choli nesterase in hibito rs?
Imp rove ment in physical function
Imp rove ment in activities o f d aily living
Longer time befo re ente ring residentia l care
Imp roved mortality
m
se
As
Minim ize the p rog ression o f d e mentia
Dr
Improvement in physical function
Improvement in activities of daily living
Longer time befo re entering residential care
Improved mortality
Minimize the progression of dementia
Patients with Alzheimer disease have reduced production of choline acetyl transferase,
leading to a decrease in acetylcholine synthesis and impaired cortica l cholinergic
functioning.
The only role for cholinesterase inhibitors is t o improve some cogn itive function and
m
se
improvement in activities of daily living. There is no role for cholinest erase inhibitors in
As
advanced Alzheimer's disease.
Dr
You review a 47 -year-old man in cli nic. He has been referred with difficult to control
hypertension despite taking a combination of lisinopril, indapamide and amlodipine.
Whilst examining the patient you note over 15 large cafe-au-lait spot s on his trunk. Some
axillary freckling is also present. His blood pressure (despit e medication) is 170/ 94 mmHg
and pulse 90/ min.
Routine bloods are ordered:
Hb 15.2 g/dl
Plat elet s 20 1 * 109/ 1
WBC 5.2 * 109/ 1
Na• 14 1 mmol/ 1
K• 4 .3 mmolfl
Urea 6.1 mmolfl
Urine dipstick is normal. Which one of the following investigations is most likely to be
diagnostic?
MRI brai n
24 hr urinary cortisol
Glucose tolerance test with growth hormone measurements
Renal arteriography
em
24 hr urinary collection of catecholamines

s
As
Dr
MRI brain
R r urinary cortisol
Glu cose tolerance test with growth hormone meas urements
Renal a rteriography
124 hr urinary collection of catecholamines

Patients with neurofib rom atosis may d eve lop hype rtension for three main reasons:
• coexista nt essential hypertens ion
• p haechrom ocytoma
• renal vascular stenosis seconda ry to fibromuscu lar dysplasia
m
se
The no rmal renal function in this patient points away from a d iagnosis of renal vascular
As
disease. Phaechromocyto ma the refore needs to be excluded first.
Dr
A 9-year-old boy is referred to a p ediatric neu rologist for a headache that has b een
persistent for the past two months. The mother had initia lly thought that the boy was
having a head ache b ecause of school stress b ut recently the boy has been increasingly
involved in accid ents while riding his bicycle. The boy says that he could not see his other
friend s when they rod e the ir bi cycle next to him. The boy was born via a Caesarean
section and had a normal deve lo pment so fa r and is doing wel l at school. After a
tho rough exa mination, the doctor finds that the b oy also has a visual defect cha ra cterized
by an inability to perceive the two tempo ral visual fields. If this boy und ergoes surgery fo r
his con dition, which part of this ch ild's hypothalamus woul d be a ffected causing weight
g ain a fte r su rgery?
Supraoptic nucleus of the hypotha lamus
Posterior hypothalamus
Anterior hypothalam us
Ventromedial area of the hypothalamus
m
se
As
Pa raventricular nucleus of the hypothalamus
Dr
Su praoptic nucleus of the hypotha lamus
Posterior hypothalamus
-
Anterior hypothalamus
I Ventromedial area of the hypothalamus
Paraventricular nucleus of the hypothalamus

-
~
This child presented with the signs and symptoms of a cranio pharyngioma. This is a
common brain tumor in child ren and often mimics pitu itary a denoma due to the presence
of a b item poral hemianopia in this g roup of patients. Craniopharyng ioma is derived from
the Rathke's pouch and it often invades the pituitary and hypotha la mus. The
ventromedial a rea of the thalamus is o ften involved.
1: This area of the hypotha lamus along with the paraventricular nucleus of the
hypothalamus is responsible for the synthesis of antidiuretic hormone and oxytocin,
which a re transported to the poste rior hypothala mus for storage and re lease.
2: The posterior hypothalamus is respons ible fo r heat g eneration to maintain co re body
temperature.
3: The anterior hypotha la mus is res ponsible for heat dissipation to cool down the body to
prevent a rise in tem pe rature which would be d etrimental to body's internal environm ent.
4: The ventromed ia l area of the hypothalamus is often invaded by craniopharyngiomas.
This area of the tha lamus controls the satiety center and it is removed du ring surgery, the
patient can have uninhibited hunge r leading to significant weight gain.
5: This area of the hypotha lamus along with the supraoptic nucleus of the hypothala mus
is responsible for the synthesis of antidiu retic hormone an d oxytocin, which a re
em
transported to the posterior hypotha lamus for storage and release.

s
As
Dr
A 76 yea r-old ma n is brought in to the Emergency Department with confusion, a
temperature o f 39.9 degrees Celsius and rig idity. From a recent clinic letter you see he
lives a lone at home and depends on help from his dau ghter, who has recently had a
prolonged stay in hospita l for append icitis. Upon her d ischarge she went to see him,
found him unwell and calle d 999. She had called him and he had been well the day
before. He has a background o f hypertension and Parkinson's disease for which he takes
ra mipril. a mlodipine and 'a Pa rkinson's ta blet' which he does not have with him. His chest
x- ray and u rine dip a re clear and he is unable to give a history. ACT bra in shows no acute
abnormality.
What is the most a pp ropriate intervention?
Broad s pectrum antibiotics
Neu rosurgical referra l
Bromocriptine
Intravenous aciclovir
m
se
As
Cyproheptad in e
Dr
Broad s pectrum antibi otics
Neurosu rgical refe rra l
Bromocriptine
Intrave nous aciclovir
Cyprohe ptadine
The presentation is characteristic of neuro le ptic malignant syndrome, but without a

history of neu ro leptic drug use. In a patient with Parkinson's disease, this ra ises the
q uestion o f Pa rkinsonian mal ignant syndrome- a s imila r clinical picture triggered by
a brupt withdrawal from anti pa rkinsonian medicatio n. In this case, the patient is
d e pendent on his daughter b rin ging in his prescriptions and has run out during her stay
in hos pital - hence why he does not have the a nti-Parkinsonian medication with him.
Althou gh the exact pathogenes is of malig nant synd rome is not understood, re initiation of
Parkinson 's the ra py is curative.
Piperacillin and tazobactam therapy wou ld cover a p ossible sepsis, but is not a typica l
treatment fo r a potential centra l ne rvo us system infectio n and therefore wou ld be the
inco rrect choice even if se psis was the unde rlying cause o f this pati ent's symptoms.
Neurosu rg ica l refe rral is clea rly inap propriate with out any clear o perative treatment.
Intravenous aciclovir is the treatment fo r herpes simp lex encephal itis, which is a
differential in this case. It is mad e less likely on ly by a lack of any p rodromal illness.
m
se
Cyproheptadine would be a treatment o ption in seroton in syndrome, but this man is not
As
on any serotonergic drugs an d has no reason to have taken any, ma king this less li kely.
Dr
A 44-year-old male is seen in Neurology cli nic aher presenting with a su bacute history of
a headache. His headache seems to be worse on recumbency and cough ing/ sneezing.
On examination, upper and lower limbs are normal with int act cranial nerves. On closer
examination of t he oropharynx, t here is evidence of palatal myoclonus. ACT scan
confirms a space occupying lesion. Where is the lesion likely located?
Temporal lobe
Olivary nucleus
Pariet al lobe
Occipital lobe
m
se
As
Frontal lobe
Dr
Temporal lobe CD
I Olivary nucleu s CD
Parietal lobe CD
Occipital lobe CD
Frontal lobe GD
Palatal myoclonus is a specific featu re o f hypertrophic olivary degeneration. This is caused

by a lesi on in the triangle of Guilla in and Mollaret (triangle linking the inferior olivary
nucleus, red nucleu s and the contralateral dentate nucleus). An MRI brain is the gold
standard imaging for this lesion.
m
se
As
The other answers are not a part of the triangle of Mollaret.
Dr
A 26-year-old male is admitt ed with sud den onset pain and wea kness in both leg s just
after eating at a Chinese restau rant.
He has no significant past medica l histo ry. He works on a construct ion site an d on careful
quest ioning admits using coca ine several times a week.
Exa mination of the cranial nerves and upper limbs is normal. In t he lower limbs his
reflexes are p resent only w ith reinforcement and the p lantar response is ambiguous.
There is an ascending pattern of weakness. There is no impairment of light touch
sensation or of p roprioception.
ACT hea d scan is reported as normal, as is MRI imaging of the spine done 24 hou rs after
admission normal. He has a mildly ra ised CRP and a screen for ant i-GMl antibodies is
negative.
Which o f the follow ing is the most likely diagnosis?
Prolapsed lumbar disc
Bacillary dyse ntery
Conversion disorder
m
Anterior spi nal artery syndrome
se
As
Dr
Prolapsed lumbar disc CD
Bacillary dysent ery fD
Conversion disorder CD
I Anterior spinal artery syndrome &D

Guillain-Barre syndrome GD
Bilateral spastic paresis and loss o f pain and temperature sensat ion - anterior spin al
artery occlusi on
Sud den onset weakness points to a vascular cause of neurological impairment. Co caine
and o ther drugs can cause vasospasm w hich in t his case ap pears to have affected his
anterior sp inal artery. Recall t hat during t he initial p hase of a neurovascular insult, there
may be an element of spinal sho ck which d ampens the tendon reflexes.
m
se
As
GBS has a much more sub -acute on set. Bacillary dysentery would not p resent like this.
Dr
A 23 -year-o ld man is admitted to th e e mergency department fo llowing a stabbing
incident. He has mu ltiple lacerations to his flank and lower back which have been caused
by a knife. Ah er being stab ilized he complains of his right leg 'feeling funny.'
You perform a full neurological examination which reveals the following:

• weakness in extension and flexion o f the rig ht knee
• loss of proprioception a nd vibration below mid thig h in the right leg
• loss of pa in sensatio n below the mid thigh in leh leg
Given the likely diagnosis, which of the fo llowing best describes the trauma?
Lace ration to right sciatic nerve
Hem isection o f ante rio r section of spinal cord
Right -sided late ral hem isection o f sp inal co rd
Left-s ided latera l hemisection of sp ina l co rd
m
se
As
Posterio r d isk p rolapse
Dr
Lace ration to right sciatic nerve
Hem isection of anterior section of spinal cord
I Right-s ided latera l hemisection of sp ina l co rd
Left-sided lateral hemisection of sp ina l cord
Posterior d isk prolapse
Brown-Seq ua rd syndrome is a resu lt of latera l he misection o f the s pinal cord

The patient has Brown -Sequard synd rome, which is a latera l hemisection o f spina l cord. It
causes same sided weakness and p roprioception/vibration loss a nd loss o f
pa in/te mperature on the opposite s ide to the hemisection. Th is is because the pathway
for pai n/tempe rature sensatio n decussates at the leve l of the nerve root.
Damage to the sciatic nerve would produce unilatera l sympto ms. Anterio r hem isection is
ra re and unlikely g iven the mechanism of injury. It wou ld also produce a d iffe rent
m
se
distribution of neu ro logica l symptoms. A left-s id ed he misection wou ld cause ips ilateral
As
weakness. A posterior d isk prolapse is a lso unlikely g iven the mechanism of trauma.
Dr
A 40-year-o ld man undergoes a tempo ral lobectomy after the discovery of a bra in
tumou r. Which one o f the following consequences would be least likely to develo p?
Prosopagnosia
Astereognosis
Wernicke's aphasia
Superior homonymous quadra ntanopia
m
se
As
Aud ito ry agnosia
Dr
Prosopagnosia (D
I Astereognosis CD
Wernicke's aphasia GD
Superior homonymous quadrantano pia GD
Auditory agnosia CD
m
se
Parieta l lobe lesions may cause astereognos is
As
Dr
A 25 -year-o ld male is broug ht to the emergency department after being struck on the
s ide o f the head with a bott le in a nightclub. Accord ing to one o f his accompanying
friends, he was knocked unconscious initially but then regained consciousness. An
ambulance was ca lled after the patient lost co nsciousness again. The a d mission CT head
scan shows a n intracran ia l haemorrhage.
What is the most li kely intracranial haemorrhage based on the history?
Contusion
Concussion
m
se
Diffuse axona l injury
As
Dr
~ntusion
Concussion
Diffuse axona l injury
Patients with an intracran ia l extradura l haematoma may experience a lucid interva l

in which they briefly regain consciousness after the injury before p rogress ing into a
coma
An extrad ura l haematoma is typically caused by blu nt-force, low-impact traumatic head
injury. Patients may rega in consciousness in itially followin g the injury but progressively
s lip into a coma as the haematoma continues to expand.
An acute subdura l haematoma is typica lly caused by high- impact injuries (such as a road
traffic accident or severe fall) and is often accompan ied with diffuse injuries (such as
diffuse axona l injury). Patients are either comatose from the outset and do not have the
classica l lucid interva l that is seen in patients with extradural haematomas.
Contusions are a common consequence of traumatic head injury. Over the two to three
days following a head inj ury, contusions can expand and swell (caused by oedema). This
effect is termed 'blossoming'. This is a slower p rocess than the neu rolog ical deterio ration
seen in extradural haematoma, which is typica lly minutes to hours.
Diffuse axona l injury is associated with acceleration and deceleration forces (such as those
em
imposed by a road traffic accident). Coma is of immed iate onset and recovery typically
s
As
takes weeks to months.

Dr
A 59-yea r-old man p resents with recu rrent attacks of vertigo and dizziness. These attacks
a re often precipitated by a change in head position and typically last around half a
minute. Examination of the cranial nerves and ears is unremarkab le. His b lood pressu re is
120/78 mmHg sittin g an d 116/ 76 mmHg standing. Given the li kely unde rlying d isord er,
what is the most appro priate next step to help confirm the dia gnosis?
Epley manoeuvre
Tilt ta ble test
24 hour ECG mo nitoring
MRI o f the cereb ellopo ntine ang le
m
se
As
Dix-Hallpike ma noeuvre
Dr
Epley manoeuvre
p4
Tilt table test
hour ECG monitoring

-
...wr
MRI of the cerebellopontine angle
Dix-Hallpike manoeuvre
This patient has classical symptoms of benign paroxysmal positional vertigo. A positive
Dix-Hallpike manoeuvre is an appropriate next step and would help support the
diagnosis.
m
se
As
The change in blood pressure on st anding is not significant.
Dr
Which one o f t he followin g featu res is most associated with frontal lobe lesions?
Wernicke's aphasia
Gerstmann's syndrome
Perseveration
Cortical blindness
m
se
As
Superior homonymous quadrantanopi a
Dr
Wernicke's aphasia f!D
Gerstmann's syndrome GD
I Perseveration GD
Cortica l blindness m
Su perior homonymous quadrantanopia CD
m
se
Frontal lobe lesions may cause perseveration
As
Dr
A 61-yea r-o ld wo man with a histo ry o f metastatic breast cancer complains of nausea
fo llowing a chemothera py infusion. You elect to prescribe ondansetro n. What is the most
impo rtant site of actio n of this drug?
Effe rent b ra nch of the vagal nerve
Substantia nigra
Gastric mucosa
Hypotha la mus
m
se
As
Medulla oblo nga ta
Dr
Efferent b ranch of the vagal nerve GD
Substantia nigra
Gastric mucosa
-
m
Hypothalamus fD
m
se
I eD
As
Medulla o blongata
I
Dr
A 50-year-old gentleman present s to clinic with a 20-year hist ory of bilat eral upper limb
tremo r. He has no past medical history. On examination, he has a bilat eral symmetrical
upper limb postural tremor w ith no rest or intention tremor. His father had a similar
tremo r. He has noticed improvement with alcohol. It has become more severe in the past
2 years and he would like treatment. What is the best first line therapy?
L-DOPA
Deep brain stimulation
Primidone
Propranolol
m
se
As
Botulinum t oxin
Dr
L-DOPA CD
Deep brain stim ulation
Primidone tiD
•
I Propranolol fiD
~
Botulinum t oxin
•
This is a chronic tremo r which is co nf ined to the upper limbs, does not occu r at rest,
responds to alcohol and is associated with a positive family history. The diagnosis is
Essential t remor.
L-DOPA is a treatment for Parkinson's disease and has no role here.
m
se
As
Answers 2-5 are all treatments for essential tremor. Propranolol is the f irst line t reatment.
Dr
A 72-yea r-old man who is being treated for Parkin son's disease is reviewed. Which one o f
the following featu res shou ld prompt you to consider an a lternative d iagnosis?
Micrographia
Impaired olfactio n
REM sleep behaviour d isorder
Diplopia
m
se
As
Psychosis
Dr
Micrographia
Impa ired olfactio n
REM s eep behaviour disorder
Dip lopia
Psychosis
m
se
Dip lopia is not common in Parkinson's disease and may suggest an alternative cause of
As
pa rkinsonism such as p rogressive su pranuclea r palsy
Dr
A 49-year-old man is prescribed p rocyclidine for Parkinson's disease. What is the
mechanism of action?
Anti muscarinic
Dopamin e recepto r agonist
Decarboxylase inhibitor
Dopamin e recepto r antagonist
m
se
As
Monoamine Oxidase- B inhibitor
Dr
Anti muscarinic 6D
Dopamine recepto r agonist CD
Decarboxylase inhibitor CD
Dopamine recepto r antagonist m
Monoamine Oxidase-B inhibitor GD
m
se
Procyclidine - anti muscarinic
As
Dr
A 27 -year-old man present s w ith a history of fits consist ent w ith tonic-clonic seizu res.
What is the most suitable first -line treatment?
Gabapentin
Lamotrigine
Sodium valproate
Carbamazepine
m
se
As
Phenytoin
Dr
Gabapentin m
La motrigine m
I Sodium valproate GD.
Carbamazepine CD
Phenytoin CD
Epilepsy medication: first- line

• generalised seizure: sodium valproate
m
• focal seizu re: ca rbamazepine
se
As
Dr
A 68-year-old fema le patient presents to the memory clinic, accompanied by her fam ily,
with a 6 months history of rapid ly declining cog nitive function. Her fa mily reports that her
short-term memory has significantly deteriorated during the period. There is a lso
increasing emotional labi lity and change in personal ity. They a lso noticed freq uent jerking
movement of the arms. On exam ination, there is significant dysphasia, agnosia and
apraxia. Myoclonus was observed but the rest o f the neu rologica l examinations a re
unrema rkable. There is significant cogn itive and fu nctiona l impairment. Her past medica l
history of unremarkable . There is a fa mi ly h istory of Alzheimer's disease.
Alzheimer's dementia
Creutzfeld t-Ja kob Disease
Corticobasal d egeneration
m
se
As
Vascular dementia
Dr
Alzhe imer's dementia
Progressir e supranuclear palsy
Creutzfeld t-Jakob Disease
Corticobasa l d egeneration
Vascular dementia
Creutzfeld t-Jakob disease is characterised by rap id onset d e mentia and myoclonus

Creutzfeld t-Jakob disease is one of the p rion diseases cha racte rised by the rap id o nset o f
d ementia and myoclonus. The je rking move ments in the a rms a re myoclonus.
The onset is too rapid fo r Alzheimer's deme ntia a nd the presence of myo clon us raises the
suspicion o f CJD.
Progressive supranuclea r pa lsy does not usua lly present with myoclonus. It is li ke ly to
present with parki nsonis m a nd/o r cere bellar signs.
Cortico basa l d egene ration is likely to present with pa rkinsonism.
m
se
As
The re is no me ntio n of any vascula r risk factors hence this is not as like ly.
Dr
A 69-year-old man is diagnosed as having Parkinson's disease. Which one of the
following psychiatric problems is most likely to occu r in th is patient?
Tics
Psychosis
Mania
Dementia
m
se
As
Depression
Dr
Tics
Psychosis
•
CD
Mania m
Dementia f1D
I Dep ress ion ED
Parkinson's disease - most common psychiatric problem is d epression

m
se
Whilst dementia is common in pat ients with Parkinson's disease dep ression is known to
As
exist in around 40%
Dr
A 60-year-old man is diagnosed w ith Bell's palsy. What is the current evidenced base
approach to the management of this cond ition?
Ref er for urgent surgical decompression
Aciclovir
No treatment
Aciclovir + prednisolone
m
se
As
Prednisolone
Dr
Ref er fo r urgent surg ical decompression
Aciclovir
No t reat ment
Aciclovir + p rednisolone
-
~
m
se
Prednisolone
As
Dr
A 34-year-old man is reviewed in the neurology cl inic. He has been esta blished on sodium
valproate for primary generalised epilepsy. Despite now taking a therapeutic dose he
continues to have seizures and is troubled by weight gain since st arting sodium valproate.
He asks to stop his current medicati on an d try a different drug. Which one o f the
following drugs would be the most appropriate second-line treatment?
Lamotrigine
Ethosuximide
Pregabalin
Gabapentin
m
se
Tiagabine
As
Dr
Lamotrigine .
GD
Ethosuximide fD
Pregabalin m
fa abapentin m
~
Tiagabine m
Monotherapy with another drug shoul d be attempted before comb ination therapy is
m
se
started. Caution should be exercised when combining sodium valproat e and lamotrigine
As
as serious skin rashes such as Steven-Johnson 's syndrome may be provoked
Dr
A 42-yea r-old gentleman is seen in General Practi ce with dou ble vis ion, weakness and a
dry mouth .
He has a known histo ry of type 1 d ia betes, hypothyroi dism and smal l ce ll lun g cancer.
On examinatio n, you note a b ilateral ptos is and p roxima l muscle weakness in the upp er
limbs with a bse nt reflexes. With susta ined isometric contracti on of the upper limbs, you
note an improve ment in the weakness. He also has weakness o f neck flexion and eye lid
elevation after sustained upgaze.
What is the likely autoantibody a ssociated with this condition?
Anti-Musk antibody
Anti-m itochondrial antibody
Anti-voltag e -gated calcium channel antibody
Anti-Jo l antibody
m
se
As
Anti-Mi2 antibody
Dr
Anti-Musk antibody
Anti-mitochondrial antibody
I Anti-voltag e-gated calcium channel antibody
Anti-Jo l antibody
Anti-Mi2 antibody
This is a case of La mbert-Eato n myasthenic syndrome which is characterised by a

potentiation effect whereby increased act ivity enhances muscle power. The voltage-gated
calcium channel antibody is present in 85-95% of patients.
m
se
Anti-Musk is associated with myasthenia gravis patients, anti-Jol and anti-Mi2 with
As
inflammatory myositis, and anti-mitochondrial anti body with prima ry bilia ry cirrhosis.
Dr
A 68-yea r-old woman presents with a two mo nth history o f electric shock like pains o n
the right sid e of her face . She d escribes having a round 10 -20 ep isodes a day which, each
lasting for a round 30 -60 seconds. A recent d e nta l check was normal. Neu rolog ical
exam ination is unrema rkab le . What is the most su itable first-line mana gement?
Am itriptyline
Sodium valp roate
Carbamazepine
Atenolo l
m
se
Zolmitriptan
As
Dr
Am itriptyline ED.
Sodium valproate CD
Carb amazepine eD
Atenolol CD
Zolmitriptan m.
m
se
Trigeminal neuralgia - carbamazepine is first-line
As
Dr
A 67 -year-old man p resents to his GP with numbness in his feet and recurrent falls over
the past mont h. He describes difficulty walking. His GP recently started him on folate for a
macrocytic anaemia. He takes no o ther regular medications. He does not drink alcohol.
On examination, he has an ataxic gait and Romberg 's test is posit ive. Examination of his
lower limbs demonstrates an increase in to ne and bilateral wea kness. He has absent ankle
and knee jerks with upgoing p lantars. Li ght touch and vibration sense is reduced
b ilaterally.
What is the most likely cause of his symptoms?
Amyotrophic lateral sclerosis
Guillain - Barre syndrome
Subacute combined degeneration of the cord
Myasthenia gravis
m
se
As
Dr
I 1. I
Amyotrophic ateral scleros1s
.
GD
Guillain-Barre syndrome CD
I Subacute combined degeneration of the cord fZD

Myasthenia gravis

•
CD
Always replace vitamin B12 b efo re folate - giving folate to a patient deficient in B12
can p recipitate su bacute com bined d egeneration of the cord
Subacut e co mbined d egenerat ion o f t he cord involves d egenerat ion of t he p osterior and
lateral colu mns of t he sp inal cord, often due to vita min B12 d eficiency.
• Damage to t he posterior colu mns - loss o f proprio ception, light touch and vib ration
sense (sensory at axia and a p ositive Ro mberg's t est).
• Damage to lat eral columns - spastic weakness and upgoing p lantars (UM N signs).
• Damage to peripheral nerves - absent ankle and knee j erks (LM N signs).
When t here is a mix o f UMN and LMN signs in a pat ient, always consider SCDC.
Replacing folat e wit hout vitam in B12 (hinted at in t his case) ca n p recipitat e subacut e
com bined d eg eneration o f t he co rd in a pat ient who is vitamin B12 def icient. Always
ensure vitamin 812 levels are checked (and replenished) before giving folate for a
macrocytic anaemia.
Amyo t rop hic lateral scleros is is a subtype o f mot or neurone disease. This may present
wit h mixed UMN and LMN signs but no associated sensory d ef icit s.
Guillain-Barre syndrome is an inflamm atory peripheral neuropathy so w ill not p resent

wit h UMN signs. There is not hing in the hist ory to sugg est a recent bacterial or viral
infection.
Myasthenia gravis is an aut oimmune disease affecting t he neuromuscular junction so

will not present w ith UMN signs or sensory loss.
em
Charcot -Marie-Tooth disease is a heredita ry sensory and motor peripheral neuropathy.

s
UMN signs are not present in t hese pat ients. However, patients can present with LMN
As
signs in all limbs and reduced sensation (more pronounced dist ally).
Dr
A 65 -year-old lady presents to cl inic w ith a 6-month hist ory of walking difficu lty. She
o ffers a more recent hist ory of uri nary urgency. Exa mination reveals a short, shu ffling gait,
mild bilat eral, postural upp er limb tremor, and extensor plantar response. She scored
20/ 30 on an MMSE. What is the most likely diagnosis?
Idiopathic parkinson 's disease
Parkinson 's disease with dementia
m
se
As
Vascular dementia
Dr
Id iopathic parkinson's d isease CD
Dementia with Lewy bod ies «!D
Parkinso n's disease with dementia GD
I Normal p ressure hyd rocep halus CD

Vascular dementia CD
Th is case conforms to the classical triad of NPH .
In idiopathic Parkinson's di sease, you wou ld expect to see a unilate ral upper lim b onset
Dementia with Lewy bod ies and Parkinson's disease with dementia both p resent with
m
se
cognitive impairment and parkinson ism. In the former, the cogn itive impa irment precedes
As
the motor manifestations or occurs within 1 year of the onset of moto r manifestations
Dr
A 56-yea r-o ld woman presents with facia l asymmetry. Whilst brushing he r teeth this
morn ing she noted that the rig ht ha nd corner of her mouth was d rooping . She is
g e nera lly well but noted some pa in behi nd he r right ea r yesterday and says he r rig ht eye
is beco ming dry. On exam ination s he has a com plete pa ra lys is of the facia l nerve o n the
rig ht s id e, extendi ng fro m the fo rehea d to the mouth. Ea r, nose and throat exa mination is
normal. Clinica l exam ination o f the pe rip he ral nervous system is normal. What is the most
li kely diagnosis?
Ramsey-H unt syndrome
Bell' s pa lsy
Stroke
Multiple sclerosis
m
se
As
Pa rotid tumou r
Dr
Ramsey-Hunt syndrome @D
Bell's pa lsy (D
Stroke m
Multiple sclerosis
Parotid tu mou r
•
CD
The pa in around the ea r ra ises the possib ility of Ramsey- Hu nt syndrome but th is is
m
se
actually quite common in Bell's pa lsy - so me stud ies suggest it is seen in 50% of patients.
As
The normal ea r exam also goes aga inst this diagnosis.
Dr
Which o f the following is least recogn ised as a cause of macrog lossia?
Amyloi dosis
Tu rner's syndrome
Duchenne muscular dystrop hy
Acromeg aly
m
se
As
Hurler syndrome
Dr
Amyloidosis GD
I Turne r's syndrome ED

Duchenne muscular dystrophy ED
r:~omegaly m
m
se
GD
As
Hurler syndrome
Dr
A 65-yea r-old gentleman p resents with prog ressive dementia and b ehavioura l
a bnormalities. On closer q uestioning, he seems to have deficits in concentration, memory
a nd judgement d ifficu lties. The re is a fam ily history of psychosis . During the consu ltation,
you notice the patient's ga it is ataxic with a nota ble j erk of his left hand and genera l
hypokines ia . There is also nystagmus d uring horizonta l gaze. Rom berg's and Dix-Ha llpike
tests are neg ative . What is the most li ke ly diagnosis?
Vascular deme ntia
Lewy body d ementia
Sp ora dic Creutzfeld t-Jakob disease
Alzhe imer's d isease
m
se
As
Frontote mpora l d ementia
Dr
Vascular dementia CD
Lewy body d ementia fD
I Spora dic Creutzfeld t-Jakob disease CD

Alzheimer's disea se CD
Frontote mporal d ementia ED
The clue here is the 'notable jerk' fo und o n examination co nsistent with myoclo nus. Two
ca rdinal features of s pora dic Creutzfeld t-Jakob disease (sCJ D) are rapidly progressive
mental d eterioration and myo clonus (usually provo ked by sta rtle). Extrapyra midal a nd
cerebellar features occu r in two-thirds of cases. The question hints at a fam ilial link which
is p resent in 10-15% of cases, or a g eneral fam ily history of psychos is (OR 9.9) has been
shown to be associated with the d isease.
Lewy body d ementia, Alzheimer's disea se, and vascu lar d ementia would not a ccou nt fo r
the myo clonus nor the cerebellar features. Fro ntotempo ral dementia tends to present
m
with a history of disinhibition, apathy, loss of sympathy/empathy, compulsive behaviours
se
and hyperorality.
As
Dr
A 25 -year-old female with a hist ory of bilat eral vitreous haemorrhage is referred due t o
progressive ataxia. What is the likely diagnosis?
Neurofibromatosis type I
Neurofibromatosis type II
Tuberose sclerosis
Von Hippei-Lin dau syndrome
m
se
As
Sarcoidosis
Dr
Neurofibromatosis type I
Neurofibromatosis type II
Tuberose sclerosis
Von Hippei-Lindau syndrome
Sarcoidosis
-
~
m
Retinal an d cerebellar haemangiomas are key features of Von Hippei- Lindau syndrome.
se
Retinal haemangiomas are b ilateral in 25% of patients and may lead to vitreous
As
haemorrhage
Dr
A 65 -year-old man is referred to t he neurology out patient clinic due to a resting tremor
o f his right hand. A diagnosis o f Parkinson's disease is made. He is ot herwise well and is
not cu rrently disa bled by his symptoms. What is the most ap propriat e treat ment?
Amantadine
No t reatment
New generation dopamine receptor agonist e.g. ropinirole
Conventional dopamine receptor agonist e.g. bromocriptine
m
se
As
Ant imuscarinics
Dr
Amantadine
No treatment
~w generat ion dopamine receptor agonist e.g. ropinirole

Conventional dopamine receptor agonist e.g. bromocriptine
Antimuscarinics
m
se
Following t he NICE 2017 guidelines, it is now recommended to use a dopamine recept or
As
agonist for motor symptoms that are not affecti ng a patient's quality of life.
Dr
Which one of the following is least recognised as causing idiopathic intracranial
hypertension?
Tetracycline
Ciclosporin
Prednisolone
m
se
As
Vita min A
Dr
Ora l cL ceptive pill CD
Tetracycline GD
I Ciclosporin ED
Predniso lone tiD.
m
se
As
Vita min A f1D
Dr
A 64-year-old man wit h a history o f Parkinson's disea se is reviewed in cli nic and a
d ecision has been mad e to start him on ca bergoline. Which one o f t he following adverse
effects is most strongly associated w it h t his drug?
Optic neurit is
Transient rise in liver function tests
Pulmonary f ibrosis
Renal fa ilure
m
se
As
Thro mbo cytopenia
Dr
Optic neuritis
Transient rise in liver function tests

-
~
Pulmonary fibrosis
Renal failure
m
se
As
Th rombocytopenia
Dr
Which one of the following is least likely to cause a raised prot ein level in the
cerebrospinal fluid?
Fungal meningitis
Frein's syndrome
m
se
As
Dr
~illain-Barre syn~rome
Fungal meningitis
-
Froin's syndrome
m
se
As
Dr
A 27 -year-o ld woman is reviewed d ue to sudden loss of vision in her left eye. She is
known to have severe rheumato id arthritis and is treated cu rrently with me thotrexate,
inflixima b a nd predniso lo ne. She has in the past a lso used su lfasa lazine a nd
hydroxychlo roquine. Fo r the past 6 weeks she has developed troublesome headaches.
Examination d emonstrates bilateral papilloedema. Which one of the following is most
li kely to be responsible for this p resentation?
Chloroqu ine retinopathy
Prednisolone
Infliximab
Methotrexate
m
se
As
Keratoconjunctivitis s icca
Dr
Chloroqu ine retinopathy
Predniso lone
Infliximab
Methotrexate
Ke ratoconjunctivitis sicca
-~
m
se
This patient has d eve loped intracran ia l hyperte nsion probably seco nd ary to pred nisolone.
As
Patients may lose si ght su dd enly if the optic nerve becomes co mpressed
Dr
You are a CTl in Acut e Medicine coveri ng a g eneral medical ward at night. You are asked
t o see a 60-year-old patient with kn own myast hen ia gravis who is complaining o f
increased b reathlessness and fatigue. Wh ich of the following ant ibiot ics is most likely t o
be responsible for a myast henic crisis?
Met ronidazole
Doxycycline
Gentamicin
Clarit hromycin
m
se
As
Amoxicillin
Dr
Metronidazole .
(D
Doxycycli~ e GD
Gentamicin CiD
Clarithromycin fD
Amoxicilli n fD
Th is question asks which antib iotic is the most li ke ly cause of a n exacerbation. Although
macrolides, tetracycli nes, an d metronidazole a re occasionally a ssociated with
exacerbation in myasthenic patients, they a re usually well to le rated in this population.
Am inog lycosi des, includ ing gentam icin, a re relatively contraindicated in myasthenia as
they a re mo re common ly associated with exacerbations. The mechanism is thought to b e
competitive inhibition of the re lease of acetylcho li ne at the presyna ptic membrane o f the
m
neuromuscular junction.
se
As
Amoxicilli n is generally considered to be safe in myasthenia gravis.
Dr
A 65 -year-old man with a history o f Parkinson's disease is referred to the respiratory clinic
with shortness o f breath. He has never smoked. Spirometry is performed:
Percentage
pred icted
FEVl 71%
FVC 74%
Which one o f the following drugs is most likely to b e responsible?
Levodopa
Entacapone
Ropinirole
Selegiline
m
se
As
Pergolide
Dr
Levodopa fi!D
Entacapone f!D
Ropinirole f.D
Selegiline GD
I Pergolide ED
m
se
This p atient has developed pulmonary fibrosis (explaining the restrictive picture o n
As
spirometry) secondary to p ergolide therapy
Dr
Which one of the following is most associated with downbeat nystagmus?
Arnold-Chiari malformation
Pseudobulbar palsy
Jugular foramen syndrome
Acoustic neuro ma
m
se
As
Cerebellar vermis lesions
Dr
Arnold-Chiari malformation
Pseudobulbar palsy
Jugular foramen syndrome

-
Acoustic neuroma
m
se
As
Cerebellar vermis lesions
Dr
A 35-year-old female is admitted to hospital w ith hypovolaemic shock. CT abdomen
reveals a haemorrhagic lesion in the right kidney. Following surgery and biopsy this is
shown to be an angiomyolipoma. What is the most likely underlying diagnosis?
Neurofibromatosis
Budd-C hiari syndrome
Heredit ary haemorrhagic telangiectasia
m
se
As
Tuberous sclerosis
Dr
Neurofibromatosis
Budd-Chiari syndrome
Heredit ary haemorrhagic tel angiectasia
Tu berous sclerosis
Around 1 in 10 people w ho are diagnosed with a renal angiomyolipoma have underlying

tuberous scleros is. Conversely, most patients w ith tuberous sclerosis w ill have several
m
renal angiomyolipomata affecting both kidneys.
se
As
The other cond itions are not linked with renal angiomyo lipomat a.
Dr
Which of the following statements is most accurate reg a rd ing the usefu lness of cervical
spine radiog raphs (X- rays) in the assessment of degenerative cervica l myelopathy (DCM)?
Cervica l spine radiog raphs should be obta ined in all patients suspected of having
DCM
Where DCM is suspected, AP (anteroposterior), latera l and obliqu e cervical spine

radiographs shou ld be re quested
Cervica l spine radiog raphs are a useful first line investigation where a diag nosis o f
DCM is suspected
Cervica l spine radiog raphs have a low sens itivity but high specificity fo r DCM
m
se
As
Cervica l spine radiog raphs cannot diagn ose DCM
Dr
Cervical spine radiogra phs should be obt ained in all patients suspect ed of having m
DCM
Where DCM is susp ected, AP (anteroposterior), lateral and o blique cervical sp ine «D
radiograp hs should be requested
Cervical spine radiog rap hs are a useful f irst line investigation where a diagnosis
o f DCM is susp ected
Cerviaal spine radiog raphs have a low sens it ivity but high sp ecif icity for DCM
-~
Cervical spine radiogra phs cannot diagnose DCM
Radiograp hs are of limit ed value where a diagnosis of degenerative cervical myelopathy is

-
~
sus pect ed [1) as t hey cannot visualise the soft tissue, such as the sp inal cord.
Sp ine radiog raphs have a high sensitivity, b ut limited specificity to diagnose most spinal
conditions. Ob lique spine radiog rap hs are usually request ed in t he lumbar sp ine region t o
p ick up d efect s in the pars int erarticularis. They have no value in setting of DCM.
The finding of spondylosis is com mon in spi nal x-rays of adults over 40 [2). It s absence
d oes not exclude neural compression.
Deg enerat ive Ce rvical Myelopat hy [DCM) is sp inal cord comp ression due t o d egenerat ive
changes of t he su rrounding sp inal struct u res; e.g. from disc herniation, ligament
hypertro phy o r calcification, o r ost eophytes. Therefo re in o rder t o visualise t hese
st ructures, a MRI is gold standard and first line.
Agai n the presence of such d egenerative chang es is co mmon on MRI; i n one st udy, 57%
of patient s old er t han 64 years of age had disc b ulgin g, thoug h only 26% had spinal cord
com press ion [3). Therefo re a diagnosis of DCM requ ires t he fi nding o f MRI com pression
in concert w it h app ro priate signs and symptoms.
Ref erences
1. Nou ri A, Tetreault L, Singh A, Karadimas SK, Fehlings MG. Degenerative Cervica l
Myelopathy: Epid emiology, Genet ics, and Pathogenesis. Spine (Ph ila Pa 1976). 2015 Ju n
15;40(12):E675-93.
2. Baron EM, You ng WF. Cervical spondylotic myelopathy: a brief review of its
pathophysiolo gy, clinical cou rse, and diagnosis. Neurosurg ery. 2007 Jan;60(1 Supp1
1):S35 -41.
3. Teresi LM, Lufki n RB, Reicher MA, Moffit BJ, Vinuela FV, Wi lson GM, Bent so n JR,
Hanafee WN : Asympto matic d egenerative disk disease and spondylosis of the cervica l
em
spine: M R imaging. Radiology 164:8388, 1987.

s
As
Dr
A 75-year old gentleman presents with a short history of neck pa in, pa raesthesia in his
finger tips and p rogressive leg weakness. Following a MRI scan of his spine, he is
diagnosed with degenerative cervical myelopathy due to a C4/ 5 d isc prolapse. Which o f
the following is the most appropriate management?
Cervica l decompressive su rgery
Cervica l nerve root injection
Analgesia and referra l to physiotherapy
Analgesia and review in 4 weeks tim e
m
se
As
Analgesia, a ha rd cervical collar and review in 4 weeks
Dr
I Cervical decompress ive surgery
Cervica l nerve root injectio n

-
~
Ana lgesia a nd refe rra l to physiothe rapy
( lnalgesia a nd review in 4 weeks tim e
Ana lgesia, a ha rd ce rvical collar and review in 4 weeks
All patie nts with d eg ene rative ce rvica l myelo pathy s ho uld be urgently re ferred fo r
assessment by specialist sp ina l services (neurosurge ry o r o rtho paedic sp ina l su rge ry). This
is d ue to the impo rta nce of ea rly treatment. The timing o f surge ry is important, as a ny
existing sp ina l co rd da mag e ca n be pe rmane nt. Early treatment (within 6 months of
diag nosis) o ffe rs the best cha nce o f a full recove ry but a t present, most patie nts a re
presenting too late. In one study, patients ave rag ed ove r 5 app ointments b efo re
diag nosis, re presenting > 2 yea rs [1].
Cu rre ntly, d ecompress ive su rgery is the o nly effective treatme nt. It ha s been shown to
prevent disease p rogress ion. Close o bse rvatio n is a n option fo r mild stab le di sea se, but
anything pro gressive o r mo re seve re requires surge ry to preve nt furth er d ete rioratio n.
Phys iothe rapy s hou ld o nly b e initiated by s pecia list services, as manipulatio n ca n cause
mo re sp ina l co rd damag e.
Pro mpt diag nosis and o nward re fe rral a re the refo re key to ensu ring g ood outcome fo r
you r patients. There a re national initiatives to ra ise aware ness of the condition to try and
improve refe rra l times (www.mye lopathy.o rg). All of the othe r listed o ptio ns in this
q uestion d o not contro l the patie nts pri ma ry pathology.
References:
1. Behrbalk E, Sa la me K, Reg ev GJ, et al. Delayed dia gnosis o f cervica l s po ndylotic
mye lo pathy by prima ry ca re p hysicians. Neurosurg Focus 2013;35:El.
em
d o i:10.3171/2013.3.FOCUS1374
s
As
Dr
A 76-yea r-old man is reviewed in the Elde rly Med icin e clinic. He is concerned a bout his
increasing fo rgetfulness over the past six months. His daughter notes he has generally
'slowed down' and strugg les to follow conversations. Over th e past month he has noted
increasingly frequent e pisodes o f urina ry incontinence. He has also had one e pisode of
faecal incontinence in the p ast week. On examination he is noted to have brisk reflexes
a nd a sho rt, shuffling g a it. No cere b ella r signs are noted . What is the most li kely
diagnosis?
Pa rkinson 's disea se
Urina ry tract infection
m
se
As
Pick's disease
Dr
Parkinson's di sease
-
~
Normal p ressure hydrocep halus
Urinary tract infection
Pick's disease
Urinary incontinence + gait abnormality + dementia = normal pressure

hydrocephalus
m
se
The presence of dementia and absence of cerebellar signs point away from a diagnosis of
As
mult iple system atrophy
Dr
A 54-yea r-old ma n is a d mitted to the Emergency De partment with a left hemiplegia. His
sympto ms started around 5 hou rs ago and he has ha d no headache, visual distu rbance o r
loss of consciousness. On examination a d e nse left he miplegia is noted. Blood pressure is
120/78 mmHg, GCS is 15/ 15 and pupils a re equal a nd reactive to light. An urgent CT scan
is performed sho rtly after his a rriva l. This d e mo nstrates no a bnormality. What is the most
appropriate initial ma nag e me nt?
Enoxapa rin
Alteplase
Dexamethasone
Warfarin
m
se
As
Asp irin
Dr
Enoxaparin CD
Alteplase GD
Dexamethasone m
Warfarin CD
Asp irin f.D
Stroke thrombo lysis - only consid er if less than 4.5 hours and haemorrhage
exclu ded
m
se
This patient has had an ischaemic stroke. He is however out side the t hrombolytic window
As
and should therefore be t reated with aspirin
Dr
A 67 -year-old male attends the Emergency department with su dden onset dizziness and
vomiting, which has been present for the past 2 hours. He has a background of
hypertension and hypercholesterolaemia for wh ich he takes ramipril an d simvastatin.
Examination reveals vertical nyst agmus and difficu lty standing without support. What is
the most appropriate next step in this patient's management?
Prochlorperazine 12.5 mg IM
Arra nge immediate admission for thrombolysis
Urgent CT head
Sumatriptan 50 mg PO
m
se
As
Perform the Epley manoeuvre
Dr
Pro chlo rpe razine 12.5 mg IM
Arra nge immediate adm ission for thrombo lys is
Urgent CT head
Sumatriptan SO mg PO
Perfo rm the Epley manoeuvre
This history is sugg estive of a cereb ellar stroke. Circulatio n to the cere bell um is impaired
d ue to a lesio n o f th e sup erio r ce re bellar a rte ry, anterio r infe rio r cere bella r artery or the
poste rio r inferio r cere be lla r artery (a lso known as late ral med ullary syndrome). Th e first
step would be dete rmine any evide nce o f cere bella r haemorrhage, which wou ld
contra in dicate throm bo lysis. MRI will be better a ble to visualise cere be lla r infa rct io n.
Cere be llar stroke may present in a s imilar fashion to vestibula r neu ritis. Clinically, ve rtical
nystag mus is sugg estive of a central cause o f vertigo . Additio nally, patients usually ca nnot
stand without suppo rt, eve n with the eyes op en, whereas a pati ent with acute vestibula r
neu ritis is usually ab le to d o so.
Benig n pa roxysma l pos itional ve rtigo (BPPV) is a ve ry com mon cause of ve rtigo in o ld er
people. It is characterised by severe, brief paro xysms o f rotational vertigo provoked by
pos itional changes. In contrast to this case, vertigo usually lasts a few seconds to a minute
(typica lly less than 30 second s).
Mig raine is a a nothe r com mo n cause of ve rti go, howeve r give n this patient's age a nd
s em
ca rdiovascu la r risk facto rs, stroke is more likely and the impo rtant diagnosis not to miss.
As
Dr
An 80-year-old man presents to the Emergency Department reporting that he awoke th is
morning with dizziness a nd vom iting. On fu rther questioning, you establish that he has a
sensation of the room spinning a round him, which is worse when he moves his head
quickly, although persists with his head still, and that he vomits when these symptoms a re
at their most severe. He is unsteady on his feet and staggers when you try to walk him
around his bed. He has no other symptoms or signs. He has a past med ical history of
hypertension, high cho lesterol, type n dia betes which is diet contro lled, and osteoarthritis.
Which of the following dia gnoses is it most important to exclude?
Posterio r circulation stroke
Benign pa roxysmal pos itional vertigo
Men ingo-encepha litis
m
se
As
Vi ral labyrinthitis
Dr
I Posterior circulation stroke
Benig n paroxysmal positional vertigo
Men ingo-encepha litis
Viral la byrinthitis
Posterio r circulation stroke must a lways be considered as a differential in a patient

p resenting with acute vertigo
A centra l cause o f vertigo must a lways be considered. Centra l causes include posterio r
circulation stroke, acoustic neu roma and othe r benign and ma lignant brain tumours, and
mu ltip le sclerosis. Stroke is the most urgent d iagnos is to make, and the most li kely in this
patient with card iovascu lar risk facto rs.
A posterio r circu lation stroke affects the bra in tissue su pplied by the vertebral. basila r or
posterio r cerebra l arte ries -which includes the brainstem, cerebell um, tha lamus, midbra in,
and pa rts of the tempo ra l and occipita l cortex. Posterio r circulation strokes account fo r
20 -25% of ischaemic strokes in the UK but a re more d ifficu lt to diagnose than anterio r
circulation strokes. Symptoms can include dizziness, vomiting, double vision, dysarthria,
dysphag ia, ataxia, li mb weakness and visua l field defects.
BMJ Clinica l Review - posterio r circu lation stroke

s em
http://www.bmj.com/content/348/bmj.g3175
As
Dr
I . I _ I _ __ I_
A 42-yea r-old woman fall s off her horse and susta ins a head injury. ACT scan on
admission to the Emergency Department demonstrates a sku ll fracture and an associated
extra-du ral haematoma overlying the left pa rieta l lobe. She has a Glasgow coma score of
12; E3 V4 MS, on a rriva l with no apparent neu ro logica l deficits . At the time both pu pils a re
4mm in diameter with intact pu pillary light responses. She deterio rates within an hou r to
a Glasgow coma sco re of 8; E2 V2 M4. Her left pupil is now fixed at 7mm and her right
pupil is 3mm and reacts to light. Add itionally, her left eye is deviated inferiorly and away
from the midline.
What is the most likely pathology respons ible for her clinica l findings?
Trans-tentoria l herniation
Cerebel lar tons illar he rniation
Posterior co mm unicating artery aneu rysm
Frontal eye field injury
m
se
As
Optic nerve compression
Dr
Trans-tentorial herniation
Cerebellar t ons illar herniat ion
Posterior commu nicating artery aneurysm
Frontal eye field injury
Optic nerve comp ression
Ra ised ICP can cause a third nerve palsy due to herniation

The com bination of a fixed and dilated pupil with an eye d eviat ed inferiorly and laterally
('dow n and out') is indicative of a t hird nerve pa lsy. In t he co ntext of a d ecreasing
conscious level and an int racranial ma ss (the haematoma) t his is in dicat ive of a t ran s-
t ent orial, or uncal, herniation.
Cerebellar to nsillar herniat ion affects t he medulla ob longata and is o ften a terminal event
in an unconscious patient resulting in asystolic ca rdio -resp iratory arrest. Although a
classica l cause o f a third nerve palsy, a p ost erior co mmuni cating artery aneurysm is not
the most likely cause here given the history o f t rauma and an int racranial mass. Frontal
m
eye f ield inj u ry would cause a f unctional ocular paralysis and t he eye wou ld tend to t he
se
neut ral pos it ion in a st ate of redu ced conscious ness. Optic nerve compression wou ld not As
cause deviation o f t he eye.
Dr
A 17-year-old man is referred to dermatology. He has around 10 hyperp igmented
ma cules on his torso which vary in size from 1.5-5 em in size. His GP also noted some
freckles in the groin region. He is also currently under orthopaedic review due to a
worsen ing scoliosis o f t he spine. His fat her suffered f rom similar problems before having
a fatal myocardial infarction two years ago. Which chromosome is most likely to have a
gene d efect?
Chromosome 4
Chromosome 11
Chromosome 16
Chromosome 17
m
se
As
Chromosome 22
Dr
Chromosome 4 fi!D
Chromosome 11 GD
Chromosome 16 f!D
~romosome 17 CD
Chromosome 22 GD
Neurofibromatosis type 1- chromosome 17

This patient meet s t he diagnostic criteria for NF1.
One o f ou r regist ered users sent t he follow ing mnemonic to us:
m
se
• NF1: chromosome 17 - as neurof ibromat osis has 17 charact ers
As
• NF2: chromosome 22 - all the 2's
Dr
A 20-year-old man presents with recent episodes of severe, stabbing pa in in the right eye.
These episodes typica lly occur once a day and last around 30 minutes. His wife reports
him pacing around and shouting with the pain. She also reports that his right eye a p pears
red and that he has clear nasal discharge during the episodes.
Given the likely diagnosis, which one of the following should you advise the patient to
avoid to help prevent further episodes?
Opio id medications includin g codeine
Stress
Alcohol
Sun light
m
se
As
Excessive exercise
Dr
Opioid medications includin g codeine
Stress
Alcohol
-
~
Sunlight
Excessive exercise
- """'
Alcoho l is a common trigge r fo r cluster headaches

m
se
As
This is a typical history of cluster headaches, including the age and gender of the patient.
Dr
A 63-year-old man is prescribed ropinirole for Parkinson's disease. What is the
mechanism of action?
MAO-B inhibitor
Anti muscarinic
Dopamine receptor agonist
Dopamine recepto r antagonist
m
se
As
Dr
MAO-B inhibitor
Anti muscarinic
Dopamine recepto r agonist
-
"""'
m
se
Ropinirole - dopamine receptor agonist
As
Dr
Which of the following is least associated with Parkinson ism?
Chlorpromazine
Progressive supranuclea r palsy
Lead poison ing
m
se
As
Wilson 's disease
Dr
Chlorpromazine
Dementia pugilis ca
-
..wr
Lead poisoning
m
se
As
W ilson's disease
Dr
A 61-year-old man with a chronic cough and gradual weight loss presents to the cl inic
with gradually worsening proxima l myopathy over the past few weeks. A hilar mass has
been identified on chest x-ray and he is awaiting referra l to the respiratory oncology
clinic. Neurological testing confirms weakness which is improved by rei nforcement and
movement repetition.
Which of the follow ing autoantibodies is most likely to be found?
Anti-AChR
Anti-H u
Anti-Ri
Anti-Yo
m
se
As
Anti-VGCC
Dr
Anti-ACh R flD.
Anti-Hu CD
Ant Ri m
Anti-Yo m
Anti-VGCC ED
The most li kely diag nosis is Lam be rt-Eato n syndrome, re lated to antibod ies directed
aga inst vo ltage-g ated calcium channels, resulting in proximal myo pathy. A key difference
from myasthen ia g ravis is that muscle power increases with re inforceme nt. There is a
stro ng associatio n with unde rlyin g bronchial ca rcinoma and sympto ms often improve
when the und e rlying tumou r is treated .
Anti-AChR antibodies a re associated with the d eve lo pment o f myasthenia gravis. Anti-H u
m
a ntibod ies a re associated with pa ra neoplastic e nce phalomye litis, also associated with
se
As
bro nch ia l ca rcinoma . Anti- Ri a ntibodies a re associated with ocular o psoclonus. Anti-Yo
a ntibod ies a re associated with pa ra neoplastic cerebella r degene ration.
Dr
A 20-year-old male patient p resents to the GP su rgery with a 2-year history of upper back
pain, shoulder and arm weakness. On inspection, you notice that he has an asym metric
smile. On fu rther examination, there is ma rked weakness and wasting of the right facial
muscles, right tra pezius, de ltoid and biceps muscles. There is also winging of the right
scapu la. There is some weakness and wasting of the same muscle g roups on the left s ide
but to a much lesser extent. A type of muscular dystro phy is suspected.
What is the inheritance pattern of this condition?
Autosomal dominant
Autosomal recessive
X- li nked recessive
X- li nked dominant
m
se
As
Id iopathic
Dr
Autosomal dominant 8!.D
Autosomal recessive tiD.
X- li nked recessive ED
X- li nked dominant CfD
Idiopathic CD
Facioscapu lohumera l muscular d ystrophy is an austosomal dominent d iso rder

This patient p resents with the classic app earance of facioscapulohumeral muscu la r
dystrophy, which is an autosomal dominant d isorder. There is typically an asymmetric
pattern.
m
The other inheritance patterns a re not ap plicable to this condition.
se
As
This condition is not idio pathic.
Dr
A 54 yea r-old woman presents with severe heada che after a collapse while at a wedding
reception. She had been dancing when she abruptly fell to the ground. On exam ination
she is neurolog ically intact, but clearly find s it difficu lt to concentrate a nd is in some
discomfort due to her head ache. She is afebrile and denies chest pa in. She reports that
she had about 3 glasses o f wine ton ight and she normally drinks 10 -12 un its weekly. Her
husband reports that she was unconscious for a bout o ne minute and was drowsy and
confused on waking.
ECG Normal sinus rhythm
What is the most a p propriate ma nagement from the options below?
Urgent CT brain
Referra l to first-fit clinic
Intravenous ceftriaxone and aciclovir
Referra l for outpatient ambulatory ECG monitoring
m
se
Discharge with alcoho l cessation advice
As
Dr
I Urgent CT brain
-
.,....,
Referral to first-fit clinic
Intravenous ceftriaxone and aciclovir

- '""""
I Rt erra l for outpatient ambulatory ECG monitoring
Discharge w ith alcohol cessat ion advice
This patient has collapsed in the community w ith onset of severe headache. Although
-
'""""
seizure and cardiogenic syncope enter the different ial, it is vital to exclude subarachnoid
haemorrhage as a cause. Referral for f irst -f it clin ic or outpatient ECG monitoring risk
discharging a patient with an intracerebral bleed and are inappropriate. The normal ECG
and absence of chest pain also make a cardiogenic cause less likely. Discharging the
patient w ith alcoho l cessation advice in the context of a safe level of alcoho l consumption
is also incorrect.
IV ceftriaxone and aciclovir would be treatment fo r meningitis/encephalitis. This is an
m
se
important differential in severe headache but does not typically cause a collapse with
As
sudden-onset headache.
Dr
A 78-year-old man is referred to neurology outpatients. For the p ast six months he has
been troubled with memory impairment, hallucinations and a resting tremor. On walki ng
int o the cl inic room he is not ed to have a festinating gait and an expressionless face. He
scores 12 I 30 on the mini-mental stat e examination (MMSE). Given the likely diagnos is,
which one of the followi ng test s is most likely to confirm the diagnosis?
Serum co pper levels
Cerebral angiography
MRI head
SPECT scan
m
se
As
PET scan
Dr
Serum copper levels m
Cerebral angiography m
MRI head tiD
I SPECT scan eD
PET scan CD
~
m
se
This patient has Lewy body dementia. The findi ngs on conventiona l imaging such as MRI
As
are generally no n-specific.
Dr
A 19-yea r-old man is ad mitted following a genera lised seizu re . No past history is availab le
as the man is cu rrently in a postictal state. On exa minatio n it is noted that he has three
patches o f hypop igme nted ski n and fibromata unde r two of his finger nails. What is the
most li kely diagnosis?
Neurofibro mato sis
Lennox-Gastaut Syndrome
Multip le e ndocrine neoplasia type 1
Birt- Hogg - Dube synd rome
m
se
As
Tub ero us sclerosis
Dr
Neurofibromatosis QD
Lennox-Gastaut Syndrome CD
I 1 ultiple endocrine neoplasia type 1
Birt-Hogg-Dube syndrome
-
CD
Tu berous sclerosis CD
Th is man has a neurocutaneous syndrome which raises the possibility of
m
se
neurofibromatosis or tuberous sclerosis. Given the areas of hypopigmentation and
As
subungual fibromas the most likely diagnosis is tuberous sclerosis
Dr
A 29-year-old female presents complaining of double vision and unsteadiness. She has no
past medical history of note. On examination she has limited movement o f her eyes in all
directions. Pupils are 3 mm, equal and reactive to light. Examinat ion o f the periphera l
nervous system is normal other than reduced ref lexes and the p lantars are down going.
Some past- pointing is also noted . What is t he most likely diagnosis?
Multiple sclerosis
Conversion disorder
m
se
As
Friedreich's ataxia
Dr
Multiple sclerosis f!D
Conversion disorder fD
I Miller Fisher syndrome ED

Ataxic telangiectasia CD
Miller Fisher syndrome - areflexia, at axia, op hthalmop legia

m
se
As
Th is patient has Miller Fisher syndrome, a variant of Guillain -Barre syndrome
Dr
A 39-year-old femal e who presents with a 3-month history of acute attacks of loss of
vision and weakness in the lower limbs is diagnosed with neuromyelitis optica. When
making a diagnosis of neuromyelitis optica, wh ich of the following is a possible
distinguishing feature from multiple sclerosis?
Memory loss
Optic neuritis
Acute myelitis
NMO-IgG seropositive
m
se
As
Brain CT not meeting criteria for Multiple sclerosis at disease onset
Dr
Memory loss
Optic neurit is
Acute myeliti s
NMO-IgG seropositive
Brain CT not meeting criteria for Multiple scleros is at disease onset
Mult iple sclerosis (MS) can present with memory loss, opt ic neuritis, acute myelitis but is
not N MO-IgG seropositive. Brain MRI not meeting criteria fo r Multiple sclerosis at disease
onset is a distinguishing factor from neuromyelit is optica b ut not Brain CT.
Neuromyelitis opt ica which is also known as Devic's disease is an autoimmune di sord er in
which immune syst em cells and ant ibodies attack t he optic nerves and t he spinal cord.
The pat hophysiolo gy is still how ever completely unclear. The diagnosis of neuromyeliti s
o pt ica is d et ermin ed as follows:
Absolute criteria:
• Optic neuritis
• Acute myelitis
Supportive criteria:
• Brain M RI not meeting criteria for MS at disease onset

• Sp inal cord MRI with contiguous T2 -weighted signal abnormality extendin g over
three or more verteb ral segments
• NMO-IgG seroposit ive st at us (The NMO-IgG t est checks t he existence of antibodies
against the aquapori n 4 antigen.)
em
Compa red to mult ip le sclerosis, t he acut e ep isodes are not und erst ood t o be t riggered by
s
As
the immune system's T cells, but rather by antibodies called NMO-IgG.

Dr
A 63-year-old man is prescribed selegiline for Parkinson's disease. What is the mechanism
of action?
Dopamine receptor agonist
Monoamine Oxidase-B inhibitor
Anti muscarinic
m
se
As
Catechoi-0-Methyl Transferase inhibitor
Dr
Dopamine receptor antagonist m
Dopamine recepto r agon ist f!D
r : : noamine Oxidase-B inhibitor GD
Anti muscarinic CD
Catechoi-0-Methyl Transferase inhibitor CD
m
se
Selegiline - MAO-B inhibito r
As
Dr
A 34-yea r-old ma le rugby player presents to the GP surgery with a 5-d ay history o f
sud den onset seve re pa in in the right shou ld er and up per arm, which has now su bsided
but fo llowed by a 1-day history of weakness in the shoulde r. On examination, there is
reduced powe r in the de ltoid muscle. There is a full range of passive movement of the
shoulder joint. The rest of the neuro logica l exam ination is norma l.
Shou ld e r joint dislo catio n
Osteoarthriti s
Adh esive ca psulitis
Bra chial neu ritis
m
se
As
Cervical arte ry dissection
Dr
Shoulder joint dislocation
Osteoarthritis
Adhesive capsulitis
Brachial neuritis
Cervica l artery dissectio n
Brachial neuritis is characterized by acute onset unilate ra l severe pa in fo llowed by

shoulder and scapular weakness several days late r
Bra chial neu ritis is cha racterized by a cute onset o f uni lateral severe pa in followed by
shoulder and scapu la r wea kness seve ral days late r.
The clinica l information rules out dislocation.
The patient is too young to have significant osteoarthritis a nd the p resentation is too
acute to be osteoa rthritis. Osteoarthritis wou ld also p resent with joint pain on passive
movement which is not the case here.
m
se
Cervical artery d issection is a cause of stroke. It wou ld present with uppe r moto r neu rone As
Dr
s igns and pain is not such a prominent co m ponent.
Each one of the following is associated with Friedreich's ataxia, except:
Increased risk of d eep ve in thrombosis
Optic atrop hy
Card iomyo pathy
Nystagmus
m
se
As
High -arched pa late
Dr
I Increased risk of d eep vein throm bosi J
Optic atro phy
I Cardiomyopathy
Nystagmus
m
se
As
High-arched palate
Dr
A 39-yea r-old lady admitted complaining of severe hea dache and floppy li mbs. She says
she has some blu rry vis ion
She is well known to the card iology firm due to her post p artum card iomyopathy Previous
investigations for fo r blu rry vision were inconclusive with no particular diagnosis reached.
On exam ination she has 5/ 5 powe r and sensation but tires easily. There is an upgoing left
plantar. The patient has a body mass ind ex of 41 kg/ m 2. Her ECG shows normal sinus
rhythm.
Resu lts from a lu mb ar punctu re are as follows:
White Cells 2 cells/ L
Red Cells 3 cells/ L
Glucose 75% of plasma level
Xanthochromia negative
Opening pressure 36 em H 20
The on ca ll radiolog ist has authorised this rep ort:
CT Head No acute intracranial bleed . Skull base intact . Chronic changes to right hemisphere
Whi ch is the next most a ppro priate investigation?
Ultra so und d opp ler scan of the carotids
Autoimmu ne screen
CT arterial ang io gram
Echo c.a rdiog ram

em
s
MRI brai n with veno gram

As
Dr
Ultrasound dopp ler scan of the carotids
Autoimmune screen
Ia a rte ria) ang iogra m
I
Echocardiogram
-
~
MRI b rai n with venogram

I
The re are features sug gestive of idio pathic intracranial hypertensio n (e.g., raised opening
pressure. However, the upgoing p lantar and curious CT head report must make you
suspicious of a ce rebrovascu lar event, such as an infa rct ion or even an intracran ial s inus
thrombosis. In this situation MRI im ag ing of the hea d wou ld b e the best test to rule out
these d ifferentials. Remember that a CT head is not perfectly sens itive for acute ischaemia,
and its use in the acute scenario is to rule out a haemorrhagic stroke
The other tests may b e useful later when once the p rima ry pathology (in this case, an
m
se
acute stroke) has been established. CT angiogra phy would only be of use if you suspected
As
a carotid or vertebral d issection - there is little in the history to support this.
Dr
Which one of the following drugs is used in the management of multiple sclerosis?
Beta-interferon
Gamma-interferon
Infliximab
Rituximab
m
se
As
Alpha-interferon
Dr
I Beta-interferon
Gamma-interferon
CD
mt
Infliximab CD
I Ritul(imab fD
m
se
As
Alpha- interferon CD
Dr
A 23-yea r-old ma n p resents with a 4 d ay history of an itchy and sore right ear. He has
recently returned from hol iday in Spai n. On exam ination the rig ht ear canal is inflam ed
but no d ebris is seen. The tympanic membrane is clea rly visible and is unremarkable.
What is the most a pp ropriate ma nagement?
To pical corticostero id + ami noglycos ide
To pica l corticostero id
Refer to ENT
To pical corticostero id + clotrimazo le
m
se
As
Oral flu cloxacillin
Dr
Topical corticosteroid + aminog lycoside
-
~
Topical corticosteroid
Refer to ENT
-
~
Topical corticosteroid + clotrimazole
Oral flucloxacillin
This patient has otitis externa, which commonly develops after swimming on holiday. The
m
se
first line management is either a topical antibiotic or a combined topical antibiotic and
As
steroid.
Dr
Which one o f the following cond it ions is least recognised as a cause of a sevent h nerve
pa lsy?
Acoustic neuroma
Herp es zoster
HN
Syst emic lupus erythematosus
m
se
Diabet es mellit us
As
Dr
Acoustic neuroma
Herpes zoste r
HIV

-
-
m
se
As
Diabetes mellitus ~
Dr
A 49-year-old man presents t o the Emergency Department complaining of visual
disturbance. Examination reveals a right incong ruous homonymous hemianopia. Where is
the lesion most likely to be?
Left optic tract
Left optic radiation
Right optic tract
Right optic radiation
m
se
As
Optic chiasm
Dr
A 49-year-old man presents to the Emergency Department complain ing of visual
disturbance. Examination reveals a right incongruous homonymous hemianopia. Where is
the lesion most likely to be?
I Left optic tract ED

Left optic rad iation fD
Right optic tract f!D
Right optic radiation .
(D
m
se
m
As
Optic chiasm
Dr
An 18-year-old male g ives a history of early morning jerking movements of his arm. After
a night of heavy drinki ng and sleep deprivation, he has a generalised tonic-clonic seizure
a t Sam. An EEG revea ls general ised spike and wave discharges. What is the most
appropriate choice o f anti-epileptic?
Carbamazepine
Ethosuximide
Sodium valp roate
Gabapentin
m
se
As
Phenytoin
Dr
Carbamazepine GD
Ethosuximide m
Sodium valproate fiD
t abapentin fD
Phenytoin CD
Juvenile myoclonic epilepsy (the diagnosis here), is a common form of idiopathic

generalised epilepsy, representing 10% of all patient s with epilepsy. This disorder typically
first manifests itself between the ages of 10 and 18 with brief episodes of involuntary
muscle twitching occurring early in the morning. Most patients also have generalised
m
se
seizures th at affect the enti re brain and others have absence seizures. The most effective
As
medicatio n for this disorder is sodium valproate.
Dr
Which one of the following antibodies are associated with painful sensory neuropathy in
patients with small cell lung cancer?
Anti-Ri
Anti-GAD
Anti-Ro
Anti-Hu
m
se
As
Anti-Yo
Dr
Anti-Ri t!D
Anti-GAD CD
Anti-Ro «D
Anti-Hu ED
m
se
As
Anti-Yo GD
Dr
A 52-year-old man is reviewed in the neurology cl inic. He has been referred due to the
development of difficu ltly in finding the right words whilst speaking. His comprehension
of normal co nversation has however remained normal. Where is the likely lesion?
Anterior t emporal lobe
Posterior te mporal lobe
Pariet al lobe
Lateral part of frontal lobe (inferior fronta l gyrus)
m
se
As
Medial part of frontal lobe (cingulat e gyrus)
Dr
Anterior t emporal lobe
Posterior te mporal lob e
Parietal lobe
Lateral pa rt of f ront al lobe (inferior fronta l g yrus)
Medial part of frontal lobe (cingulat e gyrus)
m
se
This man has expressive ap has ia due to a lesion in Broca 's area, located on t he post erior
As
aspect o f t he f ront al lobe, in the inf erior fronta l gyrus
Dr
A 45-year-old fema le is diagnosed w it h a glioma in t he parietal lob e after being
investigated fo r new onset se izu res. Which one of t he following features is she most likely
t o develop?
Visual agnosia
Auditory agnosia
Acalcu lia
Inability t o generate a list
m
se
As
Expressive (Broca's) aphasia
Dr
Visua l agnosia
Aud itory agnosia
Acalcu lia
Inability to generate a list

-
.......,
m
se
Pariet al lobe lesions may cause aca lcu lia
As
Dr
A 44-year-old man was admitted to the medical unit with vomiting, drowsiness and
headache. On examinatio n he was febrile, squinting to bright light s and had severe pain
when extending his knee when his hip was lifted off the bed. He was started on IV
cefotaxime and IV dexamethasone and underwent a lumbar puncture.
What is the most common long-term complicatio n of this cond ition?
Encephalitis
Hydrocephalus
Sensorineural hearing loss
Seizures
m
se
As
Cerebral abscess
Dr
Encephalit is
Hydrocephalus
Sensorineural hearing loss
Seizures
Cerebral abscess
Sensorineural hearing loss is t he most common complication fol lowing meningitis
m
se
As
The correct answer is sensorineu ral hearing loss.
Dr
A 61 yea r-o ld man presents to the resp iratory cli nic with a 2- month history o f progressive
weakness and shortness o f breath. He find s it difficult to sta nd fro m sitting, and struggles
climbing sta irs. He is a n ex-smoke r with chro nic o bstructive pu lmonary disease (COPD).
He had a recent exacerbation one month ago for which he was treated by the GP with a
cou rse of ora l p red nisolone, du ring which time his wea kness transiently improved. On
exam ination you note a left -sided mono pho nic wheeze and reduced b reath sou nd s at the
left lung base. Blood tests and a chest x-ray a re req uested.
Hb 145 g/ L
wee 10.9 109/ 1
Na+ 138 mmoi/ L
K+ 4.3 mmoi/L
Urea 6 .8 mmoi/L
Creatinine 93 mmoi/L
Calcium 2.62 mmoi/L
Phosphate 1.44 mmoi/ L
Chest x-ray Hyperexpanded lungs, left lower lobe collapse, bulky left hilum
What is the most li kely cause of this patie nt's weakness?
Myasthe nia gravis
Stero id -induced myopathy
Lam bert -Eaton myasthe nic syndrome
Hypercalcaemia
em
s
Moto r neurone disease

As
Dr
Myast henia gravis f!D
Stero id -induced myopathy fD
I Lambert-Eaton myasthen ic syndrome GD

Hypercalcaemia D
Moto r neurone disease m
This man has a s ma ll-cell lung cancer (SCLC} and associated Lambert-Eaton myasthenic
syndrome - a well -recognised pa raneoplastic manifestation of SCLC. This classically
effects the proxi ma l muscles, especially in the legs, causing difficulty in standin g from a
seated pos ition and cl imbing sta irs. In contrast to myasthenia gravis, eye invo lvement is
uncommon. Treatment with stero ids is often helpful, wh ich exp la ins his trans ient
symptomatic improvement du ring treatment for his COPD exacerbation.
Stero id myopathy d oes not fit as the symptoms started well before his course of
p rednisolone. Although the patient is mildly hypercalcaem ic this would not be su fficient
to produce his p resenting symptoms, although it does reinforce the sus picion of lung
m
malignancy. Moto r neuro ne disease wou ld be unlikely in this context and wou ld not
se
improve with stero ids. Myasthenia gravis cou ld produce these symptoms, but in the
As
context of a new lung mass is a less viab le dia g nos is. Dr
A 41-yea r-old man presents with a two week history of head aches a round the left s ide of
his face associated with watery eyes. He describes having about two episodes a d ay each
lasting a round 30 minutes. On examinatio n he has a red left eye and a pa rtial left ptosis.
There is no past medical history of note o ther than migraines as a ch ild . What is the likely
diagnosis?
Atypical migraine
Cluster hea dache
Trigeminal neuralgia
Acute ang le closu re glaucoma
m
se
As
Dr
Atypical migraine
Cluster hea dache
Trig eminal neuralgia
Acut e angle closu re glaucoma
m
se
Episodic eye pain, lacrimation, nasal stuffiness occurring daily - cluster head ache
As
Dr
A 33-yea r-old motorcyclist was brought into the emergency department by am bu lance
following a traffic accident. On presentation, he was haemodynamically stable .
Neu rological examination revea led a para lysis o f all intrins ic muscles of th e right hand.
There is also a loss of sensation in the med ia l aspect of the right hand and fo rea rm.
Klum p ke's para lysis
Median nerve d a mage
Carpal tunnel syndro me
Erb's palsy
m
se
As
Acute intracranial haemorrhage
Dr
Klum pke's para lysis: T1 nerve root damage
This patient has pa ralys is of a ll intrinsic hand muscles which points towards C8 -T1 nerve
root damage i.e. Klumpke's pa ralysis.
Median nerve damage usually leads to weakness of the thenar mu scles.
Carpal tu nnel syndrome usually causes median nerve pathology and d oes not a ffect the
o ther intrinsic ha nd muscles.
m
se
Erb's pa lsy is damage to the CS-6 nerve root. It usually p resents with loss o f sensation in
As
the arm and paralysis o f the deltoid, biceps, and b rachia lis muscles
Dr
In the treatment of migra ine, sumatriptan is an example of a :
Beta-blocker
Alpha -blocker and a partial 5-HT2 agonist
Specific 5-HTl agonist
5-HT2 antagon ist
m
se
As
Tricyclic antidepressant
Dr
Beta-blocker m
Alpha-blocker and a pa rtial 5-HT2 agonist m
I Specific 5-HTl agonist CD
5-HT2 antagonist fD
Tricyclic antidepressant CD
Migraine
• acute: triptan + NSAID or triptan + paracetamol
m
se
• prophylaxis: topiramate or propranolol
As
Dr
You are working on the neurology ward. A 32-year-old woma n with two young child ren
has just been dia gnosed with a chronic neurologica l disease after p resenting with acute
dou ble vision. Two years a go she had an episode of acute vertigo which she put down to
labyrinthitis. She has had an MRI scan of her brain and spine. She wants to know what
sort of d isease course she should expect. Which of the following patterns is most li kely for
the first several years of the disease?
Symptoms affecting peripheral nervous system first, and central nervous system
later
Occasional flares of new symptoms in different areas of the body with va riable
recovery in between
A slow and gradual accumulation of symptoms over the next 20 yea rs
Symptoms gradual ly ascending up her body starting with foot drop
m
se
As
Rapid accumu lation of new symptoms initia lly but slowing after around 10 yea rs
Dr
Sym toms affecting p eriphera l ne rvo us system first, a nd central nervous system G)
late
Occasional flares of new symptoms in different a reas of the b ody with variab le
recovery in between
A s low an d g radua l accu mu latio n o f symptoms over the next 20 yea rs
Sym ptoms g radua lly ascend ing up he r body sta rting with fo ot d ro p
Rapid a ccumulation of new symptoms initia lly but slowing a fter a rou nd 10 years
The most com mon pattern fo r progress ion of mu ltiple sclerosis is relapsing-
remitting
The correct a nswer is 2. This wo man is li ke ly to have multiple sclerosis (MS). She ha s
distinct lesions in diffe rent a reas of her b rain and s pine, which have deve lo ped at different
times.
The re a re fou r disease patterns in MS (clinica lly isolated syndro me, re la psing -re mitting
MS, prima ry progress ive MS, and seconda ry pro gressive MS). The most like ly disease
cou rse is re lapsing a nd remitting - the occasiona l o nset of new symptoms with com plete
o r partia l recovery in between e pisod es a nd the g ra dual a ccumulation of di sa bility.
NICE: multiple sclerosis

em
https://www.nice.o rg .uk/g uid ance/ CG186/ chapter/l -Recom mend ations#providing-

s
info rmation -and -su ppo rt

As
Dr
A 31-yea r-old man attends his a p pointment with a n oncolo gist aher be ing referred by his
fam ily physician. The man re p orted feeling nauseous and having a persistent hea dache
fo r th e past month. The pain was not relieved by the regula r ove r-the-counte r p ainkille r.
The patient confirms that he has a significant family history of cancer and this is why he
has b een referred to see the o ncolog ist.
Aher chro mosome analysis which revealed an ab norma lity re lated to the chromosome 3 p,
the patient is exp la ined that his con dition will put him at hig he r risk of develop ing seve ral
tu mors, which cou ld be both b enign a nd malignant. The o ncologist tells the patient that
this conditi on can be passed on to future g enerations and that the p atient's children have
a fih y-percent chance of develo pin g the condition, given his spouse d oes not ca rry the
mutation as well. The patient is happy to know that he will not need a screenin g flexible
sigmoidosco py.
Which o f the fo llowing diseases is the patient at the highest ris k of d eveloping due to his
unde rlying cond ition?
Lung carcino ma
Clear-cell re nal ca rci noma
Prosta te ca rcinoma
Brea st carcinoma
m
se
As
Osteoge nic sa rco ma
Dr
Lung ca rcinom a GD
I Clear-cell renal carcinoma CiD

Prostate ca rcinoma CD
Breast carcinoma CD
Ost eogenic sa rcoma fiD
Von Hippei- Lin dau syndrome is associat ed with t he d evelop ment o f clear-cell ren al
cell ca rcinoma
Th is patient present ed with a persistent headache and feeling nauseous, in th e sett ing of
a p ositive family h istory o f cancer. Th is has p ro mpt ed the fa mily p hysician t o make a
referral t o an oncolog ist for further investigations. An abnormality relat ed to the
ch ro moso me 3p, w hich carries t he VHL gene, indicat es t hat th is man might be su ffering
from Von Hip pei-Li ndau (VHL) syndrome. This is an au tosomal dominant condition wh ich
increases t he risk of develop ing several cancers. Clear-cell rena l carcinoma is one o f t he
t u mors w hich patient with VH L syndrome are at an increased risk of suffering from,
although t he most co mmon t u mors are hemangiomas. None of th e ot her cancers
ment ioned below are associat ed with VHL although they may occu r in a person with VH L.
(First Aid 2017, p49 5).
1: Lung ca rcinoma is one of t he maj or causes of d eat h worldwide. The disease is mainly
due to smoking but ca n also occu r in non-smokers due to environ mental p ollutants.
Symptoms includ e p ersistent cough, hemoptysis, and loss o f weight. Chest X-ray is an
important first- line invest igati on in pati ents sus pect ed of having lung cancer.
3: Prostat e ca rcinoma is one of t he most co mmon cance rs in men. Pati ents usually present
with lowe r u rinary t ract sym pt oms such as f requency, p oo r flow or noct uria amongst
o th ers. While these symptoms are oh en due t o b enign prost atic hypert rophy, it is
important to investigate th ese patient s to ru le out a prost at e malignancy.
4: Breast ca rcinoma is one of th e most com mon cancers in women. It can be non -invasive
o r invasive. Invasive ductal carcin oma is t he most common o f all breast cancers.
Treatment ra nge from wide- marg in excision to mast ectomy, and may also include
radioth erapy and chemoth erapy.
5: Osteog enic sa rcoma, also known as osteosarcoma, is one o f t he most prevalent bone
t u mors of malignant origin. The disease usually occu rs into t hose under 20 years and
em
above 65 years o f age. Anat omica lly, it d evelops in the metaphyses of th e long bones,
s
As
typica lly around t he knee. A charact eristic X-ray app earance is that o f th e Codman
triangle.
Dr
A 59-year-old man present s w ith a severe pain deep w ithin his right ear. He feels dizzy
and reports t hat t he room 'is spinning'. Clin ica l examination shows a partial facial nerve
pa lsy on the right sid e and vesicu lar lesions on t he anterior two -thirds o f his tongue.
Meniere's disease
Herp es zoste r ophtha lmicus
Acoustic neuro ma
m
se
As
Trig eminal neuralgia
Dr
Men ie re's disease
Herpes zoste r ophtha lmicus
Acou stic neuroma
m
se
Whil st vesicula r lesio ns a re mo re classically seen in the externa l auditory ca na l and p inna
As
they may also be seen on the anterior 2/ 3rd s o f the tongue and the soh pa late .
Dr
Which one of the following stat ement s regarding the stopping of anti-epileptic drugs
(AED) is most correct?
Can be considered if seizure free for > 5 years, with AEDs being stopped over 2-3
months
months
Can be considered if seizure free fo r > 1 year, with AEDs being stopped over 2-3
months
months
m
Can be considered if seizure free fo r> 1 year, with AEDs being stopped over 8-12
se
As
months
Dr
Can b e considered if seizure f ree fo r > 5 years, w ith AEDs being stopped over 2- «t£)
3 months
Can b e considered if seizure f ree fo r > 2 years, w ith AEDs being stopped over 2- CD
3 months
Can be considered if seizure f ree fo r > 1 year, with AEDs being stopped over 2-3 (D
months
Can be considered if seizure f ree fo r > 5 years, w ith AEDs being stopped over 8- «<iD
12 months
Can be considered if seizure f ree fo r> 1 year, with AEDs being stopped over 8-12 CD
months
m
se
The above reflects 2004 NICE guidelines and should be done under the guid ance of a
As
special ist. Benzodiazep ines should be withdrawn over a longer period.
Dr
A 54-y ea r-old m an p resents concerned about leg weakness. On exa mination he is noted
t o have increased tone in bot h legs, b risk ref lexes and weakness in bot h lower limbs.
Examination of his upper limbs is normal. Which one of the fo llowing is least likely to
produce these sym pt oms?
HIV
Amylo idosis
Heredit ary spastic parapleg ia
Multiple sclerosis
m
se
As
Parasagittal meningio ma
Dr
HIV
Amyl oidosis~
Hereditary spastic pa ra plegia
-
~
Mu ltiple sclerosis
Parasagittal me ning ioma
m
se
As
Amyloidos is is the least li ke ly o f the a bove options to resu lt in a spastic pa rapa resis
Dr
Each of the following features are seen in myotonic dystrophy, except:
Mild mental impairment
Round face
Frontal balding
Myotonia
m
se
As
Cataracts
Dr
GD
..
Mild menta l impairment
I Round face
Frontal bald ing CD
~;otonia m
Cataracts GD
Dystro phia myotonica - DMl

• d ista l weakness initi ally
• autosomal d ominant
• d iabetes
m
• dysarthria
se
As
Dr
A 29-year-old man with myotonic dystrophy has an electroca rdiogra m. Which one of the
following findings is most likely to be present?
Wide QRS complex
Atrial fibrillation
Voltage criteria for left ventricular hypertrophy
Right axis deviation
m
se
As
Prolonged PR interva l
Dr
Wide QRS complex
I Atrial fibrillation
Voltage criteria for left ventricular hypertrophy
Right axis deviation
I Prolonged PR inte rval

I
m
se
As
A prolonged PR interval is seen in arou nd 20-40% o f patient s
Dr
A 40-year-o ld woman presents with recu rrent episode o f vertigo associated with a feeling
or 'fu ll ness' and 'pressure' in her ea rs. She thinks her hea ring is worse during the attacks.
Clin ical exam ination is unremarkable. What is the most like ly d iagnosis?
Men iere's disease
Benign paroxysmal pos itional vertigo
Acoustic neuroma
Cholesteatoma
m
se
As
Somatisatio n
Dr
Meniere's disease fD
Benign paroxysma l positional vertigo CD
Acoustic neu ro ma f.D
Cholesteatoma m
m
se
•
As
Somatisation
Dr
A 63-year-old man who is known to have small cell lung ca rcinoma presents with
gradually worsening muscle weakness. This initially affected his legs but is now spreading
to the arms. He also complains of a dry mouth and erectile dysfunction. Neurologica l
examination show bilateral leg and arm weakness associated with hyporeflexia.
Antibodies to which one of the following are most likely to be responsible for these
findings?
RNA-binding protein Nova-1
NMDA-receptors
Muscarinic acetylcholine receptors
m
se
As
Voltage gated calcium channels
Dr
RNA-b inding protein Nova-1 m
N M DA -receptors fD
I
Muscari nic acetylcholine receptors

CD
m
I
se
Voltage gated calcium channels CD
As
Dr
A 35-yea r-o ld man with a histo ry o f schizo phrenia is brought to the Eme rgency
Department by worried friend s due to d rowsiness. On exa mination he is genera lly rig id . A
diagn osis of neuro le ptic ma lignant syndro me is susp ected . Each one o f the fo ll owing is a
feat ure of neu ro leptic malignant syndrome, except:
Renal fa ilure
Pyrexia
Elevated crea tine kinase
Usua lly occurs a fter prol onged treatment
m
se
As
Tachycardia
Dr
Renal fa ilure GD
Pyrexia
Elevated creatine kinase

•m
I Usually occurs after prolonged treatment fZ!D
Tachycardia CD
m
se
Neu roleptic mal ignant syndrome is typically seen in patients who have just commenced
As
treatment. Rena l fa il ure may occur secondary to rhabdo myolysis
Dr
A 51-year-old man with a history o f schizophrenia is reviewed. He has developed
parkinsonism secondary to his antipsychotic medication. Which one of the fo llowing
drugs is most useful in the management of tremor?
Apomorphine
Cabergoline
Selegiline
Amantadine
m
se
As
Benzhexol
Dr
Ap omorphine C!D
Cabergoline tED
Selegiline CD
Amantadini GD
Benzhexol CD
m
se
Benzhexol is now more common ly referred to as trihexyphenidyl. It is now mainly used for
As
drug-induced parkinsonism rather than idiopathic Parkinson's disease
Dr
A 57 -yea r-old woman presents with an 8 wee k h istory of interm ittent dizziness. These
episodes typically occu r when she suddenly moves her head and are characterised by the
sensation that the room is 'spinning'. Most attacks last around one minute before
dissipating. Neurological examination is un rema rkable. What is the most likely diagnosis?
Benign pa roxysmal positional vertigo
Meniere disease
Crescendo transient ischaemic attacks
Multip le sclerosis
m
se
As
Vira l labyrinthitis
Dr
I Benign paroxysmal pos itional vertigo
Meniere disea se
Cresce ndo transient ischaemic attacks
lt ltiple sclerosis
Viral labyrinthitis
Vi ral labyrinthitis typically causes constant sympto ms of a shorter du ratio n. Pa tients with
m
se
Me niere d isease usually have a ssociated hea ring loss and tinnitus. Also, the verti go
As
a ssociated with Me niere disease typica lly lasts mu ch lo nger.
Dr
A 45 -year-o ld male with a history of a lco ho lic live r d isease presents with in creasing
confusion. On assessment, he is noted to be obtunded with a Glasgow coma scale o f 14
out of 15, has a wide -based ga it and nystag mus. There is no history o r s ig ns of recent
trauma.
What is the most specific find ing on b ra in MRI fo r this patient's cond ition?
Left-sided subdu ral haematoma
Genera lised cerebral atrophy
Hydrocep halus
Enhancement of the mam illary bodies
m
se
As
Right-sided cerebellar infa rct ion
Dr
Left-sided subd ura l haematoma
Generalised cerebra l atrophy
Hydrocep ha lus
Enhancement of the mamillary bodies

-
"""'
Right-sid ed cere bellar infa rction
This patient is suffering from Wernicke's encephalopathy as indicated by the history of

-
""""
alcoholic liver disease with co nfusion, ataxia and ophthalmopleg ia. The MRI findi ng of
enha ncement of the mam illa ry bodies d ue to petechial haemo rrha ges is specific for
Wernicke's encephalopathy, although sensitivity is on ly 50%.
Exp lanation for othe r options:

• 1. A spontaneous subdural haematoma is a com mon cause of neu rological
deterioration in alcoho lic patients but this patient's signs are more suggestive of
Wernicke's rathe r than a localising bra in lesion.
• 2. This wou ld like ly a lso be present but wou ld not account for the acute
p resentation.
• 3. There is nothing in the history to suggest a cause of hydrocephalus.
m
se
• 5. This wou ld cause ataxia and nystagmus but wou ld be more like ly to p resent with
latera lizing signs and would not be associated with acute confusion. As
Dr
A 44-year-old woman presents with a three month hist ory of worsening involuntary
movements of t he head. These are worse when she is stressed and improved by alcohol.
They are not present when she is sleep. There are no other neuro logica l symptoms of
note and neurolog ical examination is unremarkable other than spotaneous movements of
the head which are worse when she looks to either side. Her father had a similar
complaint but never sought medical att ention. What is the most likely diagnosis?
Parkinson 's disease
Cerebellar tremor
Multip le sclerosis
m
se
As
Essential tremor
Dr
r r kinson's di sease
Cerebellar tremor
Multiple sclerosis
Essentia l tremor
Essential tremor is the most common cause of titubation (head tremor). Whi lst the
majority of patients will complain of hand tremor titu bation may occu r in isolation. The
m
se
tremor is characteristic as it is worse on movement and du ring stress and re lieved by
As
alcohol and sleep. The fa mily history is a lso a pointer.
Dr
A 5-year-old boy is diagnosed as having absence seizures. What is the chance he will be
seizure free by the age of 16-years-old?
5-10%
20 -25%
40 -45%
65-70%
m
se
As
90-95%
Dr
5-10% fD
20 -25% GD
40 -45% GD
65-70% (D.
90-95% ED
m
se
Ab sence seizu res - good p rognosis: 90-95% become seizu re free in adolescence
As
Dr
A 54-year-old man w ith smal l cel l lung cancer complains of muscle weakness. Each one o f
t he following are feat u res of Lambert-Eaton syndrome, except:
Proximal muscles more commonly affected
Hyporef lexia
Dry mouth
Repeated muscle contract ions lead to d ecreased muscle streng th
m
se
As
Impotence
Dr
Proxima l muscles mo re commonly affected
Hyporeflexia
Dry mouth
Repeated muscle contractions lead to d ecreased muscle streng th
Impote ce
m
se
In myasthenia gravis re peated muscle contractions lea d to reduced muscle stre ngth. The
As
o pposite is howeve r classically seen in the re lated disorde r La mbert- Eaton syndrome
Dr
Which one of the following is least likely to produce a lymphocytosis in the cerebrospinal
fluid?
Viral encephalitis
Partially treated bact erial meningitis
m
se
As
Behcet's syndrome
Dr
Systemic lupus erythematous GD
I Guillain-Barre syndrome fD
Viral encephalit is GD
Partially treated l:lact erial meningitis CD
m
se
As
Behcet's syndro me «ED
Dr
A 38-yea r-old woma n comes for review. Six months ago she fractured her leh wrist whilst
s ki ing. The fracture was treated using a cast and repeat x- rays showed that the bone had
hea led well. Unfortunately for the past few weeks s he has been pla gued with ongoing
'sho oti ng pain s' in he r leh hand associated with swe lling . On exami nation the leh ha nd is
extremely tender to even lig ht to uch. Her leh ha nd is also slightly swollen compared to
the right. What is the most likely dia gnosis?
Depression
Conversion disorder
Com plex regional pain syndrome
Uln ar nerve injury
m
se
As
Osteomyelitis
Dr
Depression
Conversion disord er
•m
Comp lex regional p ain syndrome GD
Ulnar nerve injury f!D
m
se
Ost eomyeliti s «ED
As
Dr
A 65 -year-old female is admitted with a right hemiparesis. Examination reveals she is in
atrial fibrillation. CT confirms an ischaemic stroke and aspirin 300mg is com menced. If the
patient is well and develops no new problems at what point should wa rfarin be started?
After 14 days
Immediately
After 7 days
Following a repeat CT at 28 days to exclude secondary haemorrhage
m
se
As
Following a repeat CT at 14 days to exclude secondary haemorrhage
Dr
After 14 days
Immed iate ly
-
~
After 7 d ays
J 1uowing a repeat CT at 28 d ays to excl ude secondary haemorrhage

- ~
Following a repeat CT at 14 d ays to exclude secondary haemorrhage

-
~
The 2004 RCP guideli nes recommend that anticoagu lation shou ld be commenced 14 days
m
se
after an ischaemic stroke. Earl ier anticoagulation may exacerbate any secondary
As
haemorrhage
Dr
A 27 year old male w ith p olycystic kidney di sease presents with su dd en onset head ache
and collapse. On admission t o emergency d epartment his blood pressure 190/ 105 mmHg,
t achycardic with a Glasg ow Coma Score of 7/ 15. He is intubated and t ransferred for a CT
scan. The sca n reveals a subarach noid haemorrhage. He is t ransferred t o the crit ical ca re
unit for monitori ng. Which medi cation shou ld be prescribed to reduce the chance o f any
acute co mplications?
Labetal ol
Mannitol
Ram ipril
Furosemide
m
se
As
Nimodipine
Dr
Labeta lol (D.
Mannitol CD
( 1mipril CD
Furosem ide m
Nimodipine ED
Nimodipine is used to prevent vasospasm in aneurysmal su barachn oid

haemorrhages
Patients presenting f ollowing su b arachn oid haemorrhage may su ffer f rom cerebral
vasospasm. Vasospasm occu rs in app roximately 30% o f pat ient s. In t he sub pop ulation
that t his occu rs in, it may result in further ischemia due to a reduction in distal b lood flow.
All patients are prescribed a calciu m channel blocke r to prophylactically prevent t his from
occurring.
In these patients we do not want to decrease the blood p ressure acutely, t his is because a
higher blood p ressure may be requ ired t o drive t he same cerebral p erfusion pressure.
m
se
Guidelines on t he management o f Subarachnoid Haemorrhag e
As
http:/ I stro ke.ahaj ou rna Is.org/ content/40/ 3/ 994. fuII
Dr
A 54-yea r-o ld male patient has been brought in by am bulance aher falling down the
stairs. He complains of im med iate onset of back pa in and rig ht leg weakness fo llowing
the fall. On examination, there is weakness of all muscle groups o f right hip and leg. There
is loss of proprioception and vibration sense in the distribution of Ll -SS of the right hip
and lower limb. There is loss of pain and temperature sensation in the distribution o f Ll-
SS of the leh hip and lowe r lim b.
What is the diagnosis?
Anterior cord syndrome
Central cord synd rome
Posterio r cord syndrome
Brown-Sequa rd syndrome
m
se
As
Cauda-equina syndrome
Dr
Anterior co rd syndrome
Central cord synd rome
Poste rio r cord syndrome
Brown-Sequa rd syndrome
Cauda-equina syndrome
Brown-Seq ua rd syndrome: ipsi late ra l weakness, loss o f proprioception and vibration

sensation, contra late ra l loss o f pain and temperature sensation
Brown-Sequa rd syndrome: ipsilatera l weakness, loss of p roprioception and vibratio n

sensation, contralate ral loss of pain and temperature sensation.
Central cord syndrome usually p resents with bilatera l motor weakness.
Anterior co rd syndrome usually affects motor funct ion, pain and temperature sensation.
Proprioception is usually spared.
Posterior cord syndrome usually affects prop rioception.
m
se
As
Cauda-equina syndrome usua lly causes bladder/bowel dysfunction and saddle
Dr
anaesthesia.
A 22-year-old man complain s o f hearing problems. You perform an examination of his
auditory system including Rinne's and Weber's t est:
Left ear: bone conduction > air conduction

Ri nne's test :
Right ear : air conduction > bone conduction
Weber 's test: Lateralises to the left side
What do these test s imply?
Normal hearing
Right conductive deafness
Left sensorineural deafness
m
se
As
Right sensorineural deafness
Dr
Normal hearing
Right c~ctive deafness

-
~
Left sensorineural d ea fness
m
se
As
Right sensori neural d ea fness
Dr
A 61-yea r-o ld fe ma le with a long-sta nding history of type 2 dia betes mell itus,
hypertension and hypercho leste ro le mia d evelo ped a sudd e n o nset wea kness o f her rig ht
lowe r leg while p re paring breakfast. Her son b rought her to the emerge ncy de partme nt
whe re she to ld the attending doctor that she had a s imila r ep isod e two d ays ago b ut
resolved a fte r 1 ho ur. She can s peak we ll and fully unde rsta nd what the doctor tells he r.
On exam ination, the d octor finds that the patient also ha d d ecreased touch sensation o n
he r rig ht leg. A no n-contrast co mputed tomog rap hy (CT) sca n is unremarka ble but a
repeat CT sca n a fte r 12 hou rs showed an a rea o f hypo -attenuation in a reg io n of the
bra in. Which o f the fo llowing a rte ries o f the cereb ra l circulatio n is the most like ly to b e
occluded in this patie nt?
Po sterio r ce reb ra l artery
Anterior ce reb ra l a rte ry
Midd le ce reb ra l artery
Basilar a rte ry
m
se
As
Po sterio r inferior cere bellar arte ry
Dr
Posterio r ce reb ral a rte ry
I Anterior cerebral artery
Midd le ce reb ral a rtery
I Basllar a rtery
Posterior inferio r cereb ellar arte ry
Contra lateral hem ipares is and sensory loss with the lower extremity being more
affected than the upp er- anterio r cere bral artery
The most like ly diagnosis in this patient is a stroke given the long histo ry o f d ia betes,
hypertension, and hyperc holeste rolemia wh ich a re all risk factors fo r a n ischemic stro ke .
The re is also a likely episode of a trans ient ischemic attack in this patient, which is an
ep isod e o f stroke- like sympto ms resolving in less than 24 hou rs. There a re no ris k factors
fo r a hemorrhagic stroke in this patient, such as the use of warfarin o r a blood clo tting
disorder. An ische mic stroke is usually only seen on CT at the earliest afte r 6 hours
fo llowing an ischemic episode and this exp la ins why the CT scan was unremarkable at the
time of ad mission. However, 12 hours later the bra in tissue swells and this pro duces an
a rea of hypo-attenuation vis ible on CT scan.
1: An ische mic stro ke d ue to an o bstruction of the posterior cere bral a rtery would resu lt in
a contra lateral hem ianopia with macular spa ring. This is because the poste rior cere bral
artery sup plies blood to occipital lo be which is respons ible for visual processing. However,
the reg ion receiving info rmation from the macu la a lso has a d ual blood supply from the
d eep branches of the mid d le cerebra l a rtery.
2: The anterio r cere b ra l artery su pplies the moto r an d sensory co rtices p refe ra bly on t he
med ia l side of the ce reb ral hemis phe re and results in sympto ms in the lower limbs.
3 : The middle cereb ra l artery su pp lies t he motor a nd sensory cortices bu t would be more
like ly to affect the reg ion su p plyi ng the up per limbs than the lowe r limbs. The face can
a lso be affected when the mid dle cerebra l artery is occluded resulting in a uni late ra l
droo p. In ad dition, the language centers can be affected if the stroke occu rs on the
d om inant side of the b ra in o r hemineglect can hap pen if the stroke occurs on the non-
d om inant side.
4 : An Ischem ic stroke of the a reas su pplied by the basilar a rtery can result in more severe
neu ro logical impairment such as locked -in syndro me o r qua dripleg ia . This is b ecause of
the extreme ly im portant areas of t he b rainstem such as the pons, med ulla, a nd midbra in
which receive b lood from the basilar artery.
em
5: An occlusion of the posterior infe rior cere bellar a rtery would have pro duced swa llowing
s
As
im pairment, hoa rseness o f the voice as we ll as a loss of the gag reflex.

Dr
A 76-year-old man is admitt ed w ith a rig ht hemiparesis. He first noticed weakness on his
right side around six hours ago. ACT scan shows an ischaemic stroke and asp irin 300mg
is commenced . terms of further management in the acute phase, w hich one of the
following values should not be corrected?
BP 210/110
Blood glucose 11.2 mmol/1
Oxygen saturation 93%
Temp 38.3°C
m
se
As
Blood glucose 3.5 mmol/1
Dr
BP 210/110 63
Blood glucose 11.2 mmol/1 ED
Oxygel saturation 93% f.ID
Temp 38.3°( CD
Blood glucose 3.5 mmol/1 .
(D
Hypertension shoul d not be treated in the init ial p eriod follow ing a stroke
El evated blood pressure shou ld not be t reat ed in the acute phase follow ing a st roke
m
unless complications develop. Other physiological paramet ers should be kept within
se
normal limits - an aggressive approach w ith respect to t his has been shown to improve
As
outcome
Dr
Which one o f t he followin g is least recognised as an adverse effect of phenyto in use?
Megaloblastic anaemia
Alopecia
Osteoma lacia
m
se
As
Coa rsening of facial features
Dr
Megaloblastic anaemia
•
•
I Alopecia ED
Osteomalacia GD
Coa rsening of facial features GD
m
se
As
Phenytoin is associated with hirsut ism, rather tha n alopecia
Dr
A 67 -year-old male undergoes investigations for bilateral pa raesthesia in the radial
aspects of both hands, over t he thumbs and f irst fingers. He also has paraesthesia in the
lateral aspects of both forearms and lower limb spasticity. Blood t ests reveal a HBAlc of
46 mmol/mol. He undergoes nerve co nduction stu dies and EMG with evidence of
denervation. Which ONE of the following diagnoses is most likely?
Bilateral carpal t unnel syndrome
Degenerative cervical myelopathy
Multiple sclerosis
Syringomyelia
m
se
As
Diabetic neuropathy
Dr
Bilatera l carpal tunnel syndrome
Degenerative cervica l myelopathy
Multiple sclerosis
Syringomyelia
Diabetic neuropathy
-
"'""
This patients twitches a re p robably fibrillations, a sign of lower motor neu ron dysfunction.
This is confirmed on the neurophysiology report, with evi dence of denervation. His
symptoms a re predom inantly in the C6 dermatome distribution bilaterally. Although
med ian nerve comp ression at the elbow bilate rally could in theo ry p roduce his sympto ms,
it wou ld be less like ly to explain his symptoms given his age. He is li kely to have
d egenerative cervical myelopathy. This cond ition is associated with a delay in diagnosis,
estimated to be > 2 years in some studies [1].
Patients with d egenerative cervica l mye lopathy can present with a number of proble ms
[2]:
• Pain/ stiffness: affecting the neck, upper and/or lower limbs. Lhermittes s ign is a
s harp pa in ra diating d own the spine on flexion of the neck, which is class ica lly
associated with multiple sclerosis, though it can occur in cervical myelopathy.
• Loss o f function: Clumsiness (e.g. cant do s hirt buttons, ho ld cup}, leg weakness
lead ing to impaired gait, imbalance and fa lls.
• Sphincter disturbance: th is can range from frequency and urgency to incontinence.
Neurologi cal exa mination can revea l lower motor neuron s igns at the leve l of the lesion
and upper motor neuron s ig ns b elow. Note that neu rolog ical signs can be subtle and a
high degree of susp icion is needed [2].
The other answers in this question a re unlikely fo r the following reasons:

• A: bilateral carpa l tun nel syn drom e wou ld not cause forearm symptoms. Ca rpal
tunnel syndrom e results from med ian nerve compression at the wrist and resu lts in
a lower motor neuron picture, with thena r muscle wasting and weakness of the
LOAF muscles (lateral lumbricals, opponens poll icis, abductor poll icis b revis and
flexor pol icis brevis). Tinels test and Phalens test can be positive.
• C: mu ltiple sclerosis (MS) is rare in this age group. MS predominantly affects woman
(3 -4 tim es common) and usually p resents befo re the age o f 45. It can have a
va riab le p resentation, affecting both the sensory and/or motor systems.
Inflammatory changes are often present at multiple sites, which can cause
symptoms at mo re than one s ite; a dissociated sensory loss, that is numbness at
different and unlinked sites, is a hallmark of MS. Often patients will recall previou s
e p isod es o f o dd neu rologica l d eficits, which resolved.
• D: Syringomyelia refers to the develop ment of a syrinx in the spina l cord. It presents
with a central cord syndrome, with p redominantly upper li mb signs. It is a re latively
uncommon condition.
• E: His HBAlc is not with in the diagnostic range of d iab etes mellitus. Diabetes
mell itus can cause a peripheral neuropathy presenting in a glove and stocking
distribution, as we ll as neu ropathy of periphera l nerves - mononeuritis mu ltiplex.
References:
1. Behrbalk E, Sa lame K, Regev GJ, Keynan 0, Boszczyk B, Lidar Z. Delayed diagnosis of
cervical spondylotic myelopathy by p rimary care physicians. Neurosurg Focus. 2013
Jul;35(l):El.
2. Ba ron EM, Young WF. Cervical spondylotic myelo pathy: a brief review of its
pathop hysio logy, clinical course, and d iagnosis. Neu rosu rgery. 2007 Jan;60(1 Suppl
m
se
1):S35-41.
As
Dr
A 21-year-old female is seen in the first seizu re clinic in the outpatient department. Both
the EEG and MRI bra in are normal. A decision is made not to start her on anti-epileptic
medication. What restrictions on driving should she be informed about?
No restrictions but inform DVLA
No restrictions, no need to inform DVLA if not on medication
Cannot drive for 1 month from date of seizure
Cannot drive for 6 months from dat e of seizu re
m
se
As
Cannot drive for 1 year from date of seizure
Dr
No rest rict ions b ut inform DVLA C!D
No rest rict ions, no need to inform DVLA if not on medication CD
Cannot drive for 1 month from dat e o f seizu re CfD
I Cannot drive for 6 months f rom date o f seizu re CD
Cannot drive for 1 year from date o f seizu re GD
m
se
Patients cannot drive for 6 months following a seizure
As
Dr
Which one o f t he followin g is least recognised as a cause o f autonomic neuropathy
New variant CJD
Diabet es
Parkinson 's
m
se
As
HIV
Dr
Guillain-Barre syndrome fD
I New variant CJD fD.

Diabetes f.D
Parkinson's .
CD
m
se
HN (D
As
Dr
A 32-year-old woman is broug ht into the emergency department by ambulance with
following an episode in of vertigo, diplopia and dysarthria, aher w hich she became
drowsy and responsive to pain only. Her symptoms came on over ten minutes an d lasted
for approximately one hour. Her initial symptoms have now fu lly resolved, but she feels
nauseous. Neurological examination is unremarkable. She has a past medical history of
migraine. She ta kes the progesterone-only contraceptive pill, but no other medications.
Simple partial seizure
Complex partial seizu re
Migraine with brainstem aura
m
se
As
Multiple sclerosis
Dr
Simple partial seizure
Complex partial se izure
r :graine with b ra instem aura
Multip le sclerosis
Stroke and TIA are associated with sud den-onset 'negative' sym ptoms, migraine is
more commonly associated w ith 'posit ive' symptoms
Migraine is common, with a prevalence of approximat ely 10% of the p opulation.

Therefore, even ra re presentation o f migraine may occu r more com monly than co mmon
p resentations of rarer cond itions. This is migraine w ith b rainst em aura (basilar-type
migraine, or Bickersta ff's Syndro me). The gradual onset over ten minutes, and step -wise
p rogression of symptoms point more towards migraine than an ischaemic event. A
remind er that it is possible for migrain e aura to occur w ithout th e su bsequent headache,
m
se
as in this case. New-onset seizures wou ld b e less likely than an atypica l presentation of
As
known migraine. Multiple sclerosis wou ld not p resent like t his.
Dr
A 56-year-old wo man comes fo r review. Around 4 weeks ago she had a blistering rash
under her right breast which ext ended around to the back. A diagnos is of shingles was
made. Unfortu nately since that time she has been exp eriencing severe 'shooting' pains.
The skin is also very t ender to touch. Neither p aracetamol nor ibuprofen have helped her
sympt oms. What is the most appropriat e next step in management?
Lidocaine pat ch
Trama dol
Amitriptyline
Carbamazepi ne
m
se
As
Diclofenac
Dr
Lidocaine patch CD
Trama dol .
(D
Amitriptyline CD
Carbamazepine ED
Diclofenac CD
~
m
se
This lady has developed postherpetic neu ralgia. NICE recommend using amitriptyline,
As
duloxetine, gabapentin or pregabalin first-line.
Dr
A 45-year-old woman presents complaining of visual disturbance. Exam inatio n reveals a
left congruous homonymous hemianopia. Where is the lesion most likely to be?
Optic chiasm
Left occipital cortex
Right optic tract
Right occipital cortex
m
se
As
Left optic tract
Dr
Optic chiasm m
Left occipital cortex CD
Right optic tract ED
I Right occipital cortex
Left optic tract

CD
.
(D
Visua l field defects:

• left ho monymous hemiano pia means visual field defect to the left, i.e. lesion
• ho monymous quad rantanopias: PITS (Parietal-Inferior, Temporal-Su perior)
• incongruous defects = optic tract lesion; congruous defects= optic radiation
m
se
As
Dr
A 33-year-old man is seen in the Emergency Department w ith a fa ll. He is a known
alcoholic and drank a bottle of vodka and 2 cans of cider in the last 24 hours. He is started
on a chlordiazepoxide reducing reg imen by the junior doctor. He is post-taken by the
medica l consu ltant who examines him requests that he is urgently started on Pabrinex as
he has features consist ent with Wern icke's encephalopathy.
Which of the following is a feature of Wernicke's encephalopathy?
Dysarthria
Retrograde amnesia
Ophthalmoplegia
Confabulation
m
se
As
Tremor
Dr
Dysarthria .
(D
Retrograde amnesia CD
Ophthalmoplegia mt
Confabulation tD
Trem or fD
Confusion, ataxia, nystagmus + ophthalmoplegia are features of Wernicke's

encephalopathy
A useful mnemonic to remember the features of We rnicke's encephalopathy is CAN

OPEN
Confusion
A taxia
Nystagmus
Ophthamoplegia
PEripheral
Neuropathy
Retrograde amnesia and confabulation are features of Ko rsakoff's psychosis

m
se
As
Dysarthria and tremor are multifactorial sympto m of neurological/systemic disease

Dr
A 61-year-old wo man presents with bilateral tinnitus. She reports no change i n her
hearing or other ear-related sympt oms. Ear and cranial nerve examination is
unremarkable. Which medication is she most likely to have recently st arted?
Ciprofloxacin
Nifedipine
Repaglinide
Quinine
m
se
As
Bendroflumethiazide
Dr
Ciprofloxacin GD
Nifedipine .
(D
Repaglin ide .
(D
I Quinine CD
m
se
QD
As
Bendroflumethiazide
Dr
A 58 yea r old gentleman p resents with left sided paraesthesias affect ing his thumb and
first finger. He complains of g rip wea kness and d ropping objects unintentionally. On
exam ination, there is wasting over the thena r em inence. Wh ich of the following signs
wou ld suggest a diag nosis other tha n carpa l tunnel syndrome?
Positive Hoffmans s ign
Thenar muscle wasting
Unilatera l weakness o f pincer grip
Positive Pha lens test
m
se
As
Positive Ti nnels test
Dr
I Positive Hoffmans sign CD
Thenar muscle wasting GD
Unilateral weakness o f pincer grip fD
Positive Pha lens test CD
Positive Ti nnels test CD
A positive Hoffmans s ign is a s ig n of upper motor neu ron dysfunction and points to a
disease of the central nervous system - in this case fro m the histo ry degenerative cervica l
myelopathy [DCM] affecting the cervica l spina l cord is most likely. To elicit it, the examiner
should flick th e patients distal phalanx (usually of the middle finger) to cause momentary
flexion. A positive sign is exaggerated flexion o f the thumb.
DCM is often missed initially and there is a delay in the diagnosis of th is condition by >2
years in so me stud ies [1]. Th is is a p roblem as delayed treatment limits recovery. It is most
commo nly misd iagnosed as carpal tunnel syndrome and in one study, 43% of patients
who underwent su rgery for degenerative cervica l myelopathy, had been initia lly
diagn osed with carpal tunnel synd rome [1]. DCM is therefore an important d ifferentia l in
patients suspected to have Carpal Tunnel Syndrome [CTS].
CTS is a disease o f the periphera l nervous system, resu lting from median nerve
compression at the wrist in sid e the carpal tunnel. It there fo re a ffects only the aspects of
the hand innervated by the median nerve:
• Sensation; Thumb I Index I Mid dle Finger. Th is typically manifests as inte rmittent
pain o r pa rasthesiae.
• Motor; LOAF Muscles(lateral lumbrica ls, opponens pollicis, abducto r pollicis b revis
and flexor po licis brevis). Motor s igns are less co mmon ly seen with presentations of
CTS, but wasting of the thenar em inence may be present.
Tine ls test and Phalens test ca n be positive, but not always. Both tests aim to increase the
pressure within the carpal tunnel, to try to exacerbate symptoms; Tinels test via tapping
on it and Pha lens test by sustained full flexion o f the wrist.
In focal centra l nervous system di sord e rs, like DCM, examination features a re known to
have low sensitivity but hig h specificity [2]. As a disease of the cervical spina l cord, DCM
can affect the sensory, moto r and autonom ic nervous systems fro m the neck downwards.
Motor signs will be upper moto r neu ron signs such as increased toned, hyper-reflexia and
pyram ida l weakness. Note that the neu ro log ica l s igns of DCM are often subtle initially
and easily missed, but as a progressive condition they a re likely to get worse [3].
Therefore detecting early DCM can be challeng ing . A high ind ex o f suspicion, along side a
comprehensive neu rologica l exam ination and monitoring for progression is req ui red.
References:
1. Behrbalk E, Sa lame K, Regev GJ, Keynan 0, Boszczyk B, l idar Z. Delayed diagnosis of
cervica l spondylotic mye lopathy by primary care physicians. Neurosurg Focus. 2013
Ju l;35(l):El.
2. Nicholl DJ, Appleton JP. Clinical neu rology: why this still matters in the 21st century.
Journa l of Neuro logy, Neu rosurgery & Psych iatry 2015;86:229 -33.
3 . Ba ron EM, Young WF. Cervical spondylotic mye lopathy: a brief review of its
pathop hysio logy, clinical cou rse, and d iagnosis. Neu rosurg ery. 2007 Jan;60(1 Suppl
em
1):535-41.
s
As
Dr
A 33-year-old man presents complaining of visual disturbance. Examination reveals a
bitemporal hemianopia with predominately the upper quadrants being affected. What is
the most likely lesion?
Craniopharyngioma
Brainstem lesion
Pituita ry macroadenoma
Frontal lobe lesion
m
se
As
Dr
Craniopharyngioma
Brainstem lesion
Pituitary macroadenoma
Frontal lobe lesion
Right o ccipital lesion
Bitemporal hemianopia
• lesion o f optic ch ias m
• upper quadrant d efect > lower quadrant defect = inferior chiasm aI
com press ion, co mmonly a pitu itary t umour
• lower quadrant d efect > u pper quadrant defect = superior ch ias ma)
com press ion, co mmonly a craniop haryngioma
m
se
An upp er quadrant defect implies inferior ch iasma! co mpression maki ng a p itu itary
As
macroadenoma the most likely diagn osis
Dr
A 34-year-old fema le with a history of p rimary genera lised epilepsy asks for a dvice in the
neurology clinic as she plans to start a fam ily. She currently ta kes sodium va lproate as
monotherapy. What a dvice should be given rega rdi ng the prevention of neural tube
defects?
Folic acid 400 meg per day once pregnancy has been confirmed
Folic acid 1 mg per day once pregnancy has been co nfirmed
Folic acid 5 mg per day starting now
Folic acid 10 mg per day starting now
m
se
As
Folic acid 400 meg per day starting now
Dr
Folic acid 400 meg per day once preg nancy has been confirmed CD
Folic acid 1 mg per day once pregnancy has been co nfirmed CD
Folic acid 5 mg per day starting now GD
Folic acid 10 mg per day starting now CD
Folic acid 400 meg per day starting now GD
m
se
Ep ile psy + p reg nancy = Smg fol ic acid
As
Dr
You see a 23-year-old man who complains of sudden unavoidable urges to sleep. When
these occur, he can collapse on the spot and immediately lose consciousness. This can be
brought on by strong emotions such as fea r or laughter.
Which of the follow ing neuropeptides is low in this condition?
GABA
Orexin
Cryptochrome
Melatonin
m
se
As
Leptin
Dr
GABA tD
I Orexin ED
Cryptoch rome fD
Melaton in fiD.
Leptin f!D
Narco lepsy is associated with low o rexin (hypocretin) leve ls

This conditio n is narcolepsy. It is characte rised by d aytime somnolence a nd dys regu latio n
o f sleep. 70% also have cata plexy - a cond itio n in which sudd e n emotions can trigger
colla ps ing e pisod es. It is theorised this is due to the d estruction o f neu rons that pro duce
o rexin (hypocreti n), which p ro motes wakefulness.
Cryptochrome is also invo lved in sleep - mostly in how lig ht in fluences the sleep cycle.
m
Melatonin is a ho rmo ne released by the p in eal gland that lead s to th e feeling o f
se
s leep in ess. Le ptin is a neu rop eptide most associate d with regu lating the sensation of
As
hunger.
Dr
A 31-year-old fema le with a history of epilepsy consults you following an uneventful
pregnancy. Which one of the following drugs would it be safe to continue during brea st
feeding?
Phenytoin
Carbamazepine
Lamotrigine
Sodium valproat e
m
se
As
All of the above
Dr
Brea st feedi ng is a ccepta b le with nea rly a ll a nti -ep ile ptic drugs
m
se
The BNF states 'b rea st-feed ing is acceptable with all antiepi leptic drugs, taken in norma l
As
doses, with the poss ible exception of ba rb iturates'
Dr
Which one of the followin g is least characteristic of Wernicke's encephalopathy?
Ataxia
Confusion
Ophthalmoplegia
Confabu lation
m
se
As
Nystag mus
Dr
Ataxia
- •
Confusion
Ophthalmoplegia
•
tiD
I Confabulation GD
Nystagmus D.
m
se
An inability to acqu ire new memories and confabulation suggest s th e development of
As
Ko rsakoff's syndrome
Dr
A 28-year-old woman is brought by Emergency ambulance to the hospital. She is
accompanied by her husband who tells you that his w ife has suffered a progressive f lu
like illness over t he past few days. Over the past 24hrs she has begun to develop short
term memory problems, been behaving oddly, and has now developed worsen ing
drowsiness and disorientation. On examinati on her Glasgow Coma Scale is 13. You
confirm confused, ra mbling speech. She has neck stiffness, fundoscopy is unremarkable.
Investigations
Hb 130 g/ 1 Na• 134 mmol/ 1
Platelet s 182 * 109/1 K• 4. 7 mmol/1
WBC 9 .2 * 109/ 1 Urea 5.9 mmoljl
Neut s 2.8 * 109/ 1 Creatinine 92 IJffiOI/1
Lymphs 5.8 * 109/ 1 CRP 61 mg/1
Eosin 0.4 * 109/ 1
Which of t he following is t he most likely u nderlying diagnosis?
Herp es encephalit is
Severe influenza
Measles encephalitis
em
s
As
Dr
Herpes encephalitis
Meningocoacal meningitis
Severe influenza
Measles encep halit is
-
'"""'
The progressive confusion seen here with memory loss, lymphocytosis and a mod erate
elevation of CRP, fol lowing a f lu like illness, fits well wit h a dia gnosis of herpes
encephalit is. MRI b rain is the investigat ion of choice initially, which should demonstrate
t emporal lobe changes, although often CT only is available out of hou rs. CSF
lymphocytosis is seen, there is a mild elevatio n in prot ein and glucose is either normal or
slightly decreased. IV acyclovir is the intervention of choice.
Meningococcal meningitis isn't suggested because of t he peripheral blood lymphocytosis,

and the lack of featu res of meningococcal bacteraemia such as a skin rash. Measles
encephalit is is associated w ith a subacute p resentation of gradual memory loss, and
tuberculous meningitis seems less like ly given we are provided with no history of
m
se
respirato ry symptoms, or possible TB exposure. Severe in fluenza with encephalitis is a
As
possible differential, although a predilect ion for memory loss would be unusual. Dr
Which one o f the following dopamine receptor agonists used in the management o f
Parkinson's disease is least associated with pulmonary, retroperitoneal and perica rdia I
fibrosis?
Pergo lide
Lisuride
Bromocriptine
Cabergoline
m
se
As
Ropinirole
Dr
Pergolide GD
Lisuride GD
Bromocriptine tiD
Cabergoline «tiD
m
se
I Ropinirole eD
As
I
Dr
A 63-year-old female is reviewed in the ra pid access t ra nsient ischaemic attack clinic. For
the past t hree weeks she has been having episodes of transient loss of vision in the right
eye. Carotid ultrasound revea ls a 48% stenosis of her right carotid artery and an ECG
shows sinus rhythm. She was started on aspirin 300mg od by her own GP after the first
episode. What is the most appropriate management of th is patient?
Warfarin
Clopidog rel
Carotid endarte recto my
Dipyridamole
m
se
As
Asp irin and dipyridamole
Dr
Warfa rin
Clopidogrel
Carotid endarte rectomy
Dipyridamole
Aspirin and dipyridamole
Anti plat elets

• TIA: clopidogrel
• ischaemic stroke: clop idogrel
Carotid artery endarterectomy is recommend if the patient has suffered a stroke or TIA in
the caroti d t erritory and is not severely disabled. It should only be considered if the
carotid stenosis is greater than 70% or 50%, depending on the reporting criteria used -
please see below.
NICE Clinica l Knowledge Summaries stat e the following:
Antiplatelet therapy is initiated by secondary care on diagnosis of ischaemic stroke or TIA

without paroxysmal or permanent atrial fibrillation for long -term vascular prevention:
• The standard treatment is clopidogrel 75mg daily (licenced for use in ischaemic stroke,
off-label use in TIA).
• Modified-release dipyridamole 200 mg twice daily may be used if both c/opidogrel
and aspirin are contraindicated or cannot be tolerated.
• Aspirin 75mg daily may be used if both clopidogrel and modified-release
dipyridamole are contraindicated or cannot be tolerated.
• Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily may be
used if c/opidogrel cannot be tolerated.
em
The 2012 Roya l College of Physicians National clinica l guidelines for stroke now
s
recommend using dopidogrel following a TIA. This brin gs it in line with cu rrent stroke
As
guidance.
Dr
A 25-year-old female patient presents to the GP surgery with hearing loss. She reports
that her hearing has been gradually declining to the point that it is now affecting her
work as a secretary. She also complains o f ringing in the left ear at times but denies pa in
or discha rge from e ither ear. Her mother a lso has hea ring loss at a young age but she's
not su re what the cause was. You perform the following tests:
Weber test not local ising to either side
Right ear left ear
Rinne test bone conduction >air conduction bone conduction > air conduction
Otitis media with effusion
Otosclerosis
Cerumen impactio n
Cholesteatoma
m
se
As
Stickler syndrome Dr
Otitis media with effusio n
Otosclerosis
Ceru l impaction
Cholesteatoma
Stickle r syndro me
-
~
Otosclerosis is c ha racterised by conductive hea ring loss, tinn itus a nd p ositive fam ily
histo ry
The Weber and Rinn e test s howed a b ilate ra l conductive hea rin g loss. This, in
comb inatio n with th e history of ti nnitus and positive fam ily history, po ints towa rd s
o tosclerosis as the li kely diagnosis.
Otitis media with effusion can a lso cause cond uct ive hea ring loss but typica lly there is a
histo ry of otitis media a nd more common in child ren.
Cerumen impactio n can cause conductive hearing loss, however, given the positive fam ily
histo ry, otosclerosis is more like ly.
Cholesteatoma can cause conductive hearing loss but it d oes not fit with the bilate ra l
hea ring loss with a positive fam ily histo ry.
em
Stickle r syndrome is a cause of senso rineu ra l heari ng loss.

s
As
I •• I •• I -
Dr
n ic::rr rc::c:: f 1' I Tmnrri\fP I

A 70-year-old man who presented with repetitive large involuntary movements of right
his lower limb and right upper limb has been diagnosed with hemiba llismus. This affects
which part of the brain?
Medial thalamus and mamm illary bodies of the hypotha lamus
Subthalamic nucleus of the basal gang lia
Amygda la
Substantia nigra of the basal gang lia
m
se
As
Striatum (caudate nucleus) of the basal gang lia
Dr
I
Medial thalamus and mamm illary bodies of the hypothalamus
Subthalamic nucleus of the basal gang lia

-
~
Amygda la
Substantia nigra of the basal ganglia
Striatum (caud ate nucleus) of the basa l ganglia

-
~
Subtha la mic nucleus of the basa l g ang lia lesions may ca use hemiballism
Hem ibal lism is a type of chorea which is caused by a decreased activity in the subthalamic
nucleus of the basal gang lia in most cases.
The other a reas of the bra in are associated with other conditions. Wernicke and Korsakoff
syndrome localises to the medial thalamus and mamm illa ry bodies of the hypothalamus.
Huntington chorea is loca lised to the striatum (caudate nucleus) o f the basa l ganglia.
Pa rkinson 's disease is caused by disease o f the substantia nig ra o f the basa l gang lia.
m
se
Kluve r-Bucy syndrome is caused by damage both temporal lobes includ ing the amygda la.
As
Dr
A 19-yea r-o ld ma n is diag nosed as having myo clo nic seizures. What is the most
a ppro priate first-line a ntiep ile ptic?
Sodium valp roate
Ca rbamazepi ne
Topiramate
Clonazepa m
m
se
As
Etho suximid e
Dr
I Sodium valproate GD
Carbamazepine GD
Topiramate m
I Clonazepa m .
(D
Ethosuximid e fD
m
se
M yoclonic seizu res - sod iu m va lproat e
As
Dr
A 47-year-old man with a known hist ory of schizophrenia is admitted t o the Emergency
Department due to confusion. A bottle of procycl idine tablet s are found in his pocket. On
examination the t emperature is 38.1°( with a blood pressure of 155/ 100 mmHg.
Neurological examination reveals a GCS of 13/15 but assessment of his peripheral
nervous system is difficult due t o generalised increased muscle t one. What is the most
likely diagnosis?
Procyclidine overdose
Catatonic schizophrenia
Clozapine induced agranulocytosis
m
se
As
Quetiapine induced rhabdomyolysis
Dr
Procyclidine overdose
-
~
Catatonic schizophrenia
Clozapine induced agranulocytosis
m
se
As
Quetiapine induced rhabdomyolysis
Dr
Which one o f the following is least associated with myot onic dystrophy?
Dysphagia
Diabet es mellitus
Testicular atrophy
m
se
As
Learn ing difficu lties
Dr
Dysphagia mt
I Aortic regurgitation CD
Diabetes mellitus GD
Testicular atrophy fD
Learning difficu lties GD

• distal weakness initially
• autosomal dominant
• diabetes
• dysarthria
m
se
As
Dr
You are a foundation doctor working in general practice. You review a forty-year-old
woman complaining of d izziness. Symptoms are worse when rolling over in bed and are
associated with nausea. She has never had any previous episodes, does not complain of
aural fullness and does not have nystagmus.
What could be done to confirm the d iagnosis?
Audiogram
Rinne and weber tests
Otoscopy
Dix- Hallpike manoeuvre
Epley manoeuvre
m
se
As
Submit answer
Dr
Audiogram
Rinne and weber tests
Otoscopy
Epley manoeuvre
Dix- Hallpike test: rapidly lower a patient to the supine positionwith an extended
neck. A posit ive test recreates the symptoms of benign paroxysmal positional
vertigo
Importa nt fo r me l ess important
This patient likely has a case of Benign paroxysmal positional vertigo. Dix-Hallpike test
helps to confirm the diagnosis whereas the Epley manoeuvre can be used as a non
medical treatment.
If Meniere's disease was suspected then an audiog ram would be appropriate. However
this patient appears to have simple vert igo. Meniere's disease would likely present with
recurrent episodes of vertigo/ tinnitus and hearing loss. There may be an associated
feeling of aural fullness.
Rinne and weber tests would identify any hearing loss. Although useful this test would not
confirm the diagnosis of benign paroxysmal positional vertigo.
Otoscopy would identify any outer or midd le ear infection. This can be associated with
labyrinthitis however labyrinthitis is likely to cause nystagmus in addition to vert igo and
nausea.
[.. I•• tt Discuss Improve ]
Next question )
Benign paroxysma l posit iona l vertigo (BPPV) is one of the most common causes of
vertigo encountered. It is characterised by the sudden onset of d izziness and vert igo
triggered by changes in head position. The average age of onset is 55 years and it is less
common in younger patients.
Feat ures
• vertigo triggered by change in head posit ion (e.g. rolling over in bed or gazing
upwards)
• may be associated with nausea
• each episode typically lasts 10-20 seconds
• P()? i tiy~.l? i X.: Ij (l l l pi~.~... l!l<lr1.()~Ljyr~
BPPV has a good prognosis and usua lly resolves spontaneously after a few weeks to
months. Symptomatic relief may be gained by:
• ~P I E!Y '!'CII'l()E! IJ.Y~E! (successful in around 80% of cases)
• teaching the patient exercises they can do themselves at home, termed vestibular
rehabilitation, for example Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

m
se
Around ha lf of people with BPPV will have a recurrence of symptoms 3- 5 years after their
As
diagnosis
Dr
A 64-year-o ld woman present s to her genera l practitioner with dizziness. When she rolls
over in bed in the morning, she experiences sudden onset dizziness associated with
nausea, which spontaneously resolves after around 20 seconds if she keeps her head still.
After these episodes, t he patient feels light-headed and unbalanced for several hou rs. She
has suffered recurrent otit is media in the past and her family history is signifi cant for
otosclerosis.
What is the most important immediate investigation?
Audiometry
CT head
Epley manoeuvre
MRI head
m
se
As
Submit answer
Dr
Aud iometry CD
CT head CD
I Dix-Hallpike manoeuvre
Epley manoeuvre
C!B
GB
MRI head CD
BPPV
• Dix-Hallpike manoeuvre is d iagnostic
• Epley manoeuvre is for treatment
This is a typical history of benign paroxysma l positional vertigo (BPPV), which is

diagnosed by perform ing Dix-Ha llpike manoeuvre, which recreates the symptoms. The
Epley manoeuvre is a t herapeutic procedure that successfully resolves symptoms in ~80%
of cases.
The recurrent otitis med ia and fam ily history of otosclerosis are distractors.
Aud iometry would be a usefu l investigation in Meniere's disease, as there is sensorineural

hea ring loss in this cond ition. ACT head would be useful in the d iagnosis of otosclerosis,
whilst an MRI scan of the head is the gold standard investigation for diagnosis of acoustic
neuroma.
[ .. Ia• tt Discuss Improve ]
Benign paroxysma l posit iona l vert igo (BPPV) is one of the most common causes of
vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo
triggered by changes in head position. The average age of onset is 55 years and it is less
common in younger patient s.
Features
• vertigo triggered by change in head posit ion (e.g. rolling over in bed or gazing
upwards)
• may be associated with nausea
• each episode typically lasts 10-20 seconds
• positive Dix-Hallpike manoeuvre
BPPV has a good prognosis and usua lly resolves spontaneously after a few weeks to
months. Symptomatic relief may be gained by:
• Epley manoeuvre (successful in around 80% of cases)
• teaching t he patient exercises they can do themselves at home, termed vestibular
rehabilitation, for example Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahisti ne) but it tends to be of limited value.
m
se
Around ha lf of people with BPPV will have a recurrence of symptoms 3-5 years after their
As
diagnosis
Dr
A 67 -yea r-old ma le patient p resents to the ophthalmo logy emergency department with
sudden onset pa inless loss of vision in the right eye. He describes it as having a dense
shadow over the vision, prog ressing from perip hery to the centre. He has no past medical
history of note.
Retina l d etach ment
Vitreous haemorrhage
Central reti nal a rtery occlusion
Centra l reti nal vein occlusion
m
se
As
Ischaemic optic neu ropathy
Dr
Retinal d etachment
Vitreous Jaemorrhage
Central retinal a rtery occlusion
Centra l retinal vein occlusion
Ischaem ic optic neuropathy
Retina l d etach ment is a cause of sudden painless loss of vis io n. It is characterised by

a dense shadow starting pe riphera lly and p rogress ing centrally
Retinal detachment is a cause of sudden pa inless loss of vision. It is chara cterised by a

dense shadow starting peripherally a nd progressing centrally.
Vitreous ha emorrhage usually presents with dark spots.
Central retinal artery occlusio n and central retina l vein occlusion does not usually present
with p rogress ing dense shadow.
m
se
As
Th is man's lack o f ischaemic risk factors makes ischaemic optic neuropathy less likely. Dr
During routine follow-up at ren al cl inic a man is not ed t o have co rpuscular pigmentation
of the left retina. Which one of the following conditions is associated with retinitis
pigment osa?
Autosomal dominant polycystic kidney disease
Tuberous sclerosis
Alpert's syndrome
m
se
As
Medullary sponge kidney
Dr
Autosomal dominant polycystic kidney disease
Tuberous sr :osis
I
Alpert's syndrome
-
~
m
se
As
Medullary s ponge kidney
Dr
A 34-yea r-old female patient is brou ght into the emergency depa rtment by he r husband .
Husba nd reports that she has been confused in the la st 3 days. She has a long-stand ing
history of seve re psorias is but no other past med ica l history. Basic observations a re all
within no rmal range and aCT head is unremarkable. A fu ndoscopy revea ls bilatera l
pap illoedema.
What is the likely cause?
Encepha litis
Brain abscess
Primary b rain tumou r
Vita min A toxicity
m
se
As
Hydrocep halus
Dr
Encephalitis (f.D
~ain abscess CD
Primary brain tumour (iD
I Vitamin A toxicity
Hydrocephalus
eD
(f.D
Vita min A toxicity is a rare cause of papilloedema

Vita min A toxicity is a rare cause of pap illoedema. In this case, she is likely to have been
taki ng retinoids for psorias is.
Encephalitis does not usually present with pa pilloedema.
m
se
As
Brain abscess, brain tu mou r and hydrocephalus are al l less like ly with a normal CT head.
Dr
Which one o f the followin g statements rega rd ing macular degeneration is true?
Drusen a re characteristic of wet macu la r degene ratio n
Photodyna mic therapy is useful in dry macula r degene ration
Asian ethnicity is a risk facto r
Male sex is a risk facto r
m
se
As
Wet macular degene ratio n ca rries the worst prognos is
Dr
Drusen a re characteristic of wet macula r degeneration
Photodyna mic therapy is usefu l in dry macula r degeneration
Asian ethnicity is a risk facto r

-
.....,
Male sex is a risk factor
-
.....,
m
se
As
Wet macu la r degene ration carries the wo rst prognosis
Dr
Each one of the following is a cause of a mydriatic pupil, except:
Third nerve palsy
Atro pine
Holmes-Adie pupil
Argyii-Robertson pupil
m
se
As
Traumatic iridoplegia
Dr
Th ird nerve palsy GD
Atropine f!D
Holmes-Adie pupil GD
I Argyii-Robertson pupil eD
Traumatic iridoplegia CD
Argyii-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in

neurosyphilis and is often said to be the prostitut e's pupil - accommodates but doesn't
react. Another mnemonic used for the Argyii-Robertson Pupil (ARP) is Accommodation
Reflex Present (ARP) but Pupillary Reflex Absent (PRA)
Features
• small, irregular pupils
• no res ponse to light but there is a response to accommodate
Causes
• diabetes mellitus
m
se
• syphilis
As
Dr
A 74-year-old man presents t o ophthalmology clin ic aher seeing his optician. They have
noticed raised intra-ocular pressure and decreased p eripheral vision. His past medica l
history includes asthma and typ e 2 diabetes mellitus. What is the most appropriate
treatment given the likely diagnosis?
Latanoprost
Pilocarpine
Timolol
Dorzolam ide
m
se
As
Brimonidine
Dr
I Latanoprost CD
Pilocarpine fD
Timolol «ED
Dorzolamide flD
Brimonidine CD
m
se
As
A prostaglan din analogue should be used first-line in patients with a history of asthma.
Dr
A 34-yea r-o ld female presents with fatig ue a nd frequent headaches. On examinatio n of
he r eyes, you notice an abnorma lity du ring the swingin g light test. As the light is moved
from the leh to the rig ht eye both pupils appear to dilate. The pupillary res ponse to
accom modation is norma l bilate ral ly. Fundoscopy is a lso no rma l bilaterally. Her past
me d ical history includes type one d iabetes and hypertension. What is the most likely
explanation for this patients' s igns?
Ra ised intracran ia l pressure
Diabetic eye disease
Ho lmes-Ad ie's pupil on the right
Marcus-Gunn Pupil (relative afferent p upillary d efect) on the rig ht
m
se
As
Argyll Robertson pupil on the right
Dr
Raised intracranial pressure
Diabetic eye disease
Holmes-Adie's pupil on the right
Marcus-Gunn Pupil (relative afferent pupillary defect) on the right
Argyll Robertson pupil on the right
Marcus Gunn pupil (relative afferent pupillary defect) is diagnosed during the swinging
-
~
light t est. If there is damage to the afferent pathway (retina or optic nerve) of one eye, the
pupil of that affect ed eye will abnormally dilate when a light is shone int o it. This is
because the consensual pupillary relaxation response from the healthy eye will dominate.
Marcus Gunn pupil can be found in patients with multiple sclerosis. Therefore, given the
history, this should be ruled out in this patient.
The hist ory and examination findings in the question are not typical of raised intracranial
pressure. Ra ised intracranial pressure may present with symptoms such as a headache,
vomiting, bilat eral blurred vision and seizures. Patients with i ncreased intracranial
pressure often have bilateral papilloedema on fundoscopy.
Althou gh the hist ory states the f emale is diabetic, there are typically normal pupillary light
responses in patients with diabetic eye disease. Furthermore, with diabetic eye disease,
you would expect t o see some abnormality on fundoscopy.
Holmes-Aide's pupil is a dilated pupil which poorly (if at all) react s to direct light,
however, slowly reacts to accommodation. This does not correlate to the history.
The inf ormation given in the question above does not suggest Argyll Robertson pupil.
This is characterised by a constricted pupil that does not res pond to light but resp onds t o
em
accommodation. It is usually bilateral and is often associat ed with neurosyphilis.

s
As
Dr
Which one o f the following is least a ssociated with the development o f o ptic atrophy?
Longstanding papilloedema
Multiple sclerosis
Glaucoma
m
se
As
Retinitis pigmentosa
Dr
Longstanding papilloedema
L..
Multiple sclerosis
Glaucoma
m
se
As
Dr
Which one of the following causes of Horn er's syndro me is due to a lesion in the post-
ganglionic part of the nerve supply?
Interna l carotid aneurysm
Stroke
Syringomyelia
Pancoast's tumour
m
se
As
Thyroidectomy
Dr
Internal carotid aneurysm
Stroke
Syringomyelia
Pancoast's tumou
Thyroidectomy
Horner's syndrome - anhydrosis determines site of lesion:

• head, arm, t runk = central lesion: stro ke, syring omyelia
• just face = pre- ganglionic lesion: Pancoast's, cervical rib
m
• absent = post-gan glion ic lesion: carotid artery
se
As
Dr
A 45-yea r-old man presents to the Emergency Department following the sudden onset of
pain in the right side of his face whilst ham mering a nail into the wall. The pain is
described as severe and constant. On examination he has a mild right ptosis and small
right pupil. What is the most likely diagnosis?
Glaucoma
Carotid artery dissection
Syringo myelia
m
se
Migraine
As
Dr
Glaucoma
Carotid artery dissection
Syringomyelia
Migraine
This patient has Horner's syndrome caused by a carotid artery dissection. This may be
m
se
caused by relatively benign trauma to the neck such as hyperextension whilst doing DIY.
As
Cluste r headache would be a differential diagnosis
Dr
A 19-yea r-old male presents to the emergency depa rtment with a 1-day histo ry of
redness aroun d the left eye a ssociated with p uffiness of the eye and pa in on eye
movement. Overnight he repo rts feeling feve rish. His vision is restricted d ue to an inability
to o pen the eye. On exam ination, there is oed ema su rroundi ng upper and lower eye lids
with e rythema a nd p ro ptos is. The eye itse lf app ears normal with normal p upil reflexes but
pa in o n eye movements. There is mi ld ly raised intraocula r pressu re. He is normally fit a nd
wel l but has recently been takin g intranasal corticosteroid fo r sin usitis.
Refer for u rgent (within 1 week) ophthalmolo gy appo intm ent
Adm it fo r intrave nous a ntibiotics
Refer for emerg e ncy (with in 24 hours) o phthalmology appointment
Discha rge home with o ra l a ntibiotics
m
se
As
Discha rge home with top ica l a ntibiotics
Dr
Refer fo r urgent (within 1 week) ophtha lmology appointment
Admit fo r intravenous antibiotics
Refer fo r e mergency (within 24 hours) ophthalmology appointment

-
.....,
Discharge ho me with ora l antibiotics
Discharge home with topical antibiotics
Patients with orbita l cellulitis requi re adm ission to hospita l for IV antibiotics due to
the ris k of cavernous sinus throm bosis and intracranial sp read
The correct answer here is to adm it for intravenous antib iotics. This patient has orbita l
cellu litis which is a medica l eme rgency due to risk o r optic nerve damage, cavernous sinus
thrombosis and intracrania l sp read. The system ic upset and pa in on eye movements a re
clues po intin g towards o rb ital as opposed to perio rb ital cellulitis. As the condition
p rog resses patient can develop proptosis, relative afferent pupillary defect and ra ised
intraocu la r pressu re. There may a lso be globe disp lacement with res istance to
retropu ls ion. Recent sinus infection or sinusitis is a risk factor for orbita l cellulitis and
points towa rds the d iagnosis. In some hosp itals, su ita ble patients may be ambulated with
intravenous antibiotics as an a lternative to admission.
Referring to an urg ent (within 1 week) ophthalmology appointment wou ld not be

appropriate a s this is a medi cal emergency.
Referring fo r an emergency (same day) ophtha lmo logy appointment would be more
appropriate tha n referring for an appointment within 1 week as it highlights the urgency
o f the situ ation, however, this patient should be ad mitted under the general medica l ta ke
for intravenous antibiotics and s hould not be left without treatment for a period up to 24
hou rs. As such an out patient appo intment is not appropriate.
Discha rging home with o ral antibiotics may be appropriate if periorbital cellulitis was
suspected. The inability to open the eye, pa in on eye movements a nd history of fever
point towards orbita l cell ulitis a s opposed to periorbital cellu litis and so admission is
requ ired.
em
Topical antibiotics cou ld be used in conjunctivitis but would not be appropriate in this
s
As
case.
Dr
Which one o f the following is not a featu re o f backg round d iabetic retino pathy?
Microaneurysms
Blot haemorrhages
Cotton wool spots
Seen in both type 1 and type 2 diabetes mellitus
m
se
As
Ha rd exudates
Dr
Microaneurysms (D
Blot haemorrhages (D
I Cotton wool spots

I ED
Seen in both type 1 and type 2 d iabetes mellitus tiD
Ha rd exudates tD
m
se
As
Cotton wool spots a re seen in pre-prolife rative retinopathy
Dr
An 84-yea r-old man presents with loss of vision in his left eye s ince the morn ing . He is
otherwise asymptomatic a nd of note has had no associated eye pain o r headaches. His
past med ica l history includes ischaemic hea rt disease but he is otherwise well. On
exam ination he has no vision in his left eye. The left pupil responds poorly to light but the
consensual light reaction is normal. Fu ndoscopy revea ls a red spot over a pa le and
opa que retina. What is the most likely dia gnosis?
Vitreous haemorrhag e
Retinal d etachment
Ischaem ic optic neuropathy
Centra l retinal vein occlus ion
m
se
Central retinal a rtery occlus io n
As
Dr
Vitreous haemorrhage CD
Retinal detachment CD
Ischaemic optic neu ropathy GD
Central reti nal vein occlusion CD
m
se
Central retinal artery occlusion GD
As
Dr
Which one o f the following is associated with het erochromia in congenital disease?
Holmes-Adie pupil
Third nerve palsy
Sixth nerve palsy
Argyii -Robertson pupil
m
se
As
Horner's syndrome
Dr
Holmes-Adie pupil ED
Th ird nerve palsy
Sixth nerve palsy

•m
Argyii-Robertson pupil fD
m
se
CD
As
Horner's syndrome
Dr
A 67 -year-old wo man present s fo r review. She has recently been diagnosed w ith dry age-
relat ed macular degeneration. Which one o f the following is the strongest risk factor for
developing this condition?
Hypertension
Poor diet
Smoking
Diabet es mellitus
m
se
As
Alcohol excess
Dr
Hypertension
•
Poor diet
Smoking
•
GD
Diabetes mellitus f!D
Alcohol excess D
Macular d egeneration - smoking is risk factor

Having a balanced diet, with plenty o f f resh fruits and veget ables may also slow the
m
se
p rogression o f macu lar d egeneration. There is still ongoin g research looking at t he ro le of
As
su pp lementary ant ioxidants
Dr
A 62-yea r-old man p resents with sudd en visual loss in his right eye. He is otherwise
asym ptomatic. Which o ne of the fo llowing conditions is least li kely to be responsible?
Ischaemic optic neuropathy
Occlus ion of the central retinal ve in
Occlusion of the central retinal arte ry
O ptic neuritis
m
se
As
Dr
Occlusion of the central retinal ve in
Occlusion of the central retinal artery
Optic neuritis
Vitreous haemo rrhage
Whilst optic neuritis can p resent with su dden loss, in this 62-year-o ld man it is the least
m
se
likely option. Typically there is a unilate ral d ecrease in visual acuity ove r hours or days.
As
The re may be poo r d iscrim ination of colou rs and eye pain on movement
Dr
A 65-year-old man with a known history of Paget's d isease is noted to have irregu lar d a rk
red lines radiating from the optic nerve. What is the like ly diagnosis?
Retinitis pi gmentosa
Optic neu ritis
Ang ioi d reti nal streaks
Choroidoretinitis
m
se
As
Malig na nt hypertension
Dr
Retinitis pigmentosa «!D
Optic neuritis
•
I Angioid retinal streaks GD
Choroidoretinitis CD
alignant hypertension CD
m
se
This is a typical descriptio n of angioid retinal streaks which a re associated with Pa get's
As
disease
Dr
A 40-yea r-old man p resents with bilateral d ry, gritty eyes. A d iagnosis o f blep haritis is
considered. Wh ich one of the following is least likely to be associated with b lepharitis?
Meibomian g land dysfunction
Seborrhoeic de rmatitis
Sta p hylococcal infection
Acne rosacea
m
se
As
Vira l upper respiratory tract infection
Dr
Meibomian gland dysfunction
Staphylococcal infection
r- ----,
Acne rosacea
m
se
Vira l upper respiratory tract infection
As
Dr
A 71-yea r-old man presents with a burning sensation arou nd his right eye. On
examination an erythematous blistering rash can be seen in the right trigemina l
distribution. What is the most li kely diagnosis?
Ramsay Hu nt syndrome
Cluster headache
Fungal keratitis
Herpes zoster ophtha lmicus
m
se
As
Dr
Ramsay Hunt syndrome «D
Clust er headache m
· ungal kerat itis
Herp es zoster ophthalm icus fD

-
m
se
m
As
Dr
A 35-year-old man presents with visual problems. He has had very poor vision in the dark
for a long time but is now worried as he is developing 'tunnel vision'. He states his
grandfather had a similar problem and was registered blind in his SO's. What is the most
likely diagnosis?
Leber's congenital amau rosis
Vitellifo rm macu lar dystrophy
Central serous retinopathy
Primary open angle glaucoma
m
se
As
Dr
Leber's congenital amaurosis
Vitelliform macular dystrophy
Central serous retinopathy
m
se
Retinitis pigmentosa - night blindness + tunnel vision
As
Dr
A 65-year-old man with a history of primary open-angle glaucoma presents with sudden
painless loss of vision in his right eye. On exa mination of the right eye the optic disc is
swollen with multiple flame-shaped and blot haemorrhages. What is the most likely
diagnosis?
Diabetic retino pathy
Vitreous haem orrhage
Occlusion of centra l retina l vein
m
se
As
Occlusion of centra l retina l artery
Dr
Diabetic retinopathy
Ischaemic optic neuropathy
~elusion of central retinal vein

-
~
Occlusion of central retinal artery

-
~
Centra l reti nal vein occlus ion - su dden painless loss of vision, severe retinal
m
haemorrhages o n f undoscopy
se
Important for me l ess 'mocrtc.nt
As
Dr
A 63-yea r-old man presents to his GP complaining of pain in his right eye. On
examination the sclera is red and the pupil is dilated with a hazy cornea. What is the most
li kely diagnosis?
Scleritis
Conjunctivitis
Acute angle closu re glaucoma
Anterior uveitis
m
se
As
Subco njunctival haemorrhage
Dr
Scleritis
Conjunctivitis
-
~
Acute angle closure g laucoma
Anterior uveitis
Subconjunctival haemorrhage
Red eye - glauco ma or uveitis?

• glaucoma: severe pain, haloes, 'semi-dilated' pupil
m
• uveitis: sma ll, fixed oval pupil, ciliary flush
se
As
Dr
A 67 -yea r-o ld man who is known to have raised intraocu la r pressu re is p rescribed
d o rzola mid e eye d rops. What is the mechanism o f action of this drug?
Prosta glandin a nalogue
Alpha2-a drenocepto r ag o nist
Carbonic anhydrase inh ibito r
Musca rinic recepto r ag on ist
m
se
As
Beta -b locke r
Dr
Prostaglandin a na logue
Alpha2-ad renoceptor agonist
Carbonic anhydrase inhi bito r
Muscarinic receptor agonist

-
........
m
se
Beta - blocker
As
Dr
A 39-yea r-old woman with a history of rheu mato id arthritis presents with a two day
histo ry of a red right eye. There is no itch or pain. Pupils are 3mm, equal and reactive to
light. Visual acu ity is 6/ 5 in both eyes. What is the most likely diagnosis?
Keratoconj unct ivitis sicca
Scleritis
Glau coma
Episcleritis
m
se
As
Anterior uveitis
Dr
Keratoconjunctivitis sicca GD
Scleritis CD
Episcleritis
•.,
Anterior uveitis CD
m
se
Sclerit is is painful, episcleritis is not painful
As
Dr
An 80-year-old woman present s w ith 'funny spots' affecti ng her vision. Over the past
week she has noticed a number o f fla shes and floaters in the visual field of the right eye.
Retinal detachment
Posterior vitreou s det achment
Optic neuritis
Depression
m
se
As
Dr
Retinal detachment
Posterior vitreous detachment
Optic neu ritis
Depression
Posterio r vitreous detachment is thought to occur in up to 50-75% of the population over
m
se
65 years and is the most likely diag nosis here. Such patients are norma lly reviewed by an
As
ophthalmologist to assess the risk of progressing to retina l detachment.
Dr
Which one o f t he following is t he most common o cu lar manifestat ion of rh eumatoid
arthritis?
Sclerit is
Episclerit is
Keratoconjunctivitis sicca
Corneal ulceration
m
se
As
Keratitis
Dr
Scleritis
Episcleritis
E rnea l ulceratio n
-
~
Keratitis
m
se
Keratoconjunctivitis sicca is characterised by dry, burning and gritty eyes caused by
As
decreased tear produ ction
Dr
A 15-year-old boy presents to the GP surgery with some skin changes o f the neck. The
mother reports that she first noticed a small a rea o f skin changes 3 mo nths ago. Initia lly,
she d idn't think too much about it but recently noticed that it has been getting bigger
and more o bvious, now invo lving the skin covering almost ha lf o f the rig ht side of the
neck. On exam ination, there is a large a rea of Small. yellow papules of 1-5 mm in
diameter in a reticu lar pattern and coa lescing at p la ces into plaques. The skin has a
·plu cked -chicken' appearance. The boy reports no p ro blem with his vision.
What wou ld you be the like ly findin g on fundoscopy?
Ang io id retinal streaks
Lisch nodules
Cotton wool spots
Neovascu la risation
m
se
As
Bone spicu les
Dr
Angioid retinal streaks
Lisch nodules
Cotton wool spots

-
~
Neovascularisation
Bone spicules
Angioi d reti nal streaks are a feature of pseudoxanthoma elasticum

Ang io id streaks are s mall breaks in Bruch's me mbrane, an elastic tissue containing
membrane of the retina. It is a featu re of pseudoxanthoma elasticum. The earl iest sign in
pseudoxanthoma elasticum is the skin changes. This patient likely has pseudoxanthoma
elasticum.
Lisch nodu les are features of neu rofibromatosis.
Cotton wool spots and neovascula risation are both features of diab etic retinopathy.
m
se
As
Bone spicu les a re seen in retinitis pi gm entosa. Dr
A 54-yea r-old woman presents with a persistent watery left eye for the past 4 days. On
examination there is erythema and swelling o f the inner canthus of the left eye. What is
the most li kely diagnosis?
Blepharitis
Meibomian cyst
Dacryocystitis
m
se
As
Pinguecula
Dr
Blepharitis CD
r:~ute ang le closu re glaucoma CD
Meibomian cyst CD
I Dacryocystitis .,
m
se
As
Pinguecula m
Dr
A 53-yea r-o ld ma le who p resents to the emergency depa rtment with a painful red eye. He
has vo mited once since the pa in sta rted . He re po rts seeing haloes a round lights.
His immed iate ma na ge ment inclu des latanoprost and piloca rpine, a nd he requires an
urg ent o phtha lmo lo gy re fe rra l.
What is the mode of the actio n of piloca rpine?
Musca rinic recepto r ag on ist
Musca rinic recepto r antagonist
Nicotinic recepto r ag onist
Nicotinic receptor a nta gonist
m
se
As
Adrenerg ic rece pto r ag onist
Dr
Muscarinic receptor agonist
Muscarinic receptor antagonist
~otinic receptor agonist

Nicotinic receptor antagonist
Ad renergic receptor agonist

-
~
Pilocarpi ne is a muscarinic receptor agonist

Pi loca rpine is a muscarinic receptor agonist - it increases uveoscleral outflow by

constricting the pupil.
Examples of muscarinic receptor antagonists include atropine and hyoscine (scopolam ine)
- t hese are not used in the management of glaucoma.
Nicotinic receptor agonist s include nicotine and acetylcholine, therefore th is answer is

incorrect.
Nicotinic receptor antagonists include succinylcho line, atracurium, vecuronium and

bupropion.
m
se
As
Adrenergic recepto r agonists include norep inephrine and epinephrine.

Dr
A 72-year-old woman present s with a vesicular rash around her leh eye. The leh eye is red
and there is a degree of pho tophobia. A presumptive diagnosis o f herpes zoster
ophthalmicus is mad e and an urgent referral to ophthalmology is made.
What treatment is she most likely to be given?
Topical aciclovir + topical chloramphenicol
Topical aciclovir + topical corticosteroids
Oral prednisolone + top ica l aciclovir
Topical aciclovir
m
se
As
Oral aciclovir
Dr
Topical aciclovir +topical chloramphenicol
popical acr lovir + topical corticosteroids
Oral p rednisolone + top ical aciclovir
Topical aciclovir
Oral aciclovir
m
se
There is no role for topical antivirals if systemic therapy is given. Topical corticoste roids
As
are so metimes given to treat seco ndary inf lammation.
Dr
A 71-yea r-old ma n who has recently been d ia gnosed with ma cular degeneration asks fo r
a dvice regard ing a ntioxidant dietary s upplements. Which one o f the following may
contra indicate the p rescription of such su pp lements?
Current smoker
Pernicious an aemia
Treated hyperte nsion
History of de p ression
m
se
As
Previous episodes o f tendonitis
Dr
I Current smoker
Pernicious anae mia
Treated hyperte nsion

-
~
I History of dep ression
Previous episodes of tendonitis
m
se
Beta-carotene has been found to increase the risk of lu ng cancer and hence antioxidant
As
dietary supplements a re not recommended for smokers.
Dr
A 47 -yea r-old female with a history of rheumatoid arthritis presents with a painful and red
left eye. Visual acuity is normal. Fundosco py is also unremarkable. What is the most likely
diagnosis?
Scleritis
Episcleritis
Glau coma
Anterior uveitis
m
se
As
Keratoconj unctivitis sicca
Dr
Scleritis
Episcleritis
Glaucoma
Anterion uveitis
Scleritis is painful, episcleritis is not painful

A key way to discriminate between scleritis and episcleritis is the presence of pain.
m
se
Keratoconjunctivitis sicca is usually bilateral and associated more with dryness, burning
As
and itch
Dr
A 24-yea r-old man presents to the emergency department complaining o f left eye pain.
He has not been able to wea r his contact lenses for the past 24 hou rs due to the pa in. He
describes the pain as severe and wonders whether he has 'got something stuck in his eye'.
On exam ination there is diffuse hyperaemia of the left eye. The left cornea appea rs hazy
and pupillary reaction is normal. Visual acuity is redu ced on the left s ide and a degree o f
photophobia is noted. A hypopyon is also seen. What is the most likely d iagnosis?
Acute angle closure glaucoma
Viral conjunctivitis
Keratitis
Ep iscleritis
m
se
As
Anterio r uveitis
Dr
Acute angle closure glaucoma
Viral conjunctivitis
Keratitis
Episcleritis
Anterior uveitis
-
~
m
se
Whilst a hypopyon ca n of cou rse be seen in ante rior uveitis the combination of a norm al
As
pupillary reaction and cont act lens use make a diagnosis of keratitis more likely.
Dr
A 71-yea r-o ld female with dry age-re lated macular degeneration is reviewed .
Unfortunately her eyesight has d eteriorated ove r the past s ix months. She has never
smoked and is taking antioxidant su pplements. What is the most appropriate next step?
Retinal transplant
Intravitreal ra nibizumab
Exp la in no other med ical therapies currently available
Photodyna mic therapy
m
se
As
Photocoagulation
Dr
Retinal transplant CD
Intravitreal ran ibizumab QD
I Explain no other medical therapies currently available GD

Photodynamic thera py GD
m
se
As
Photocoagulati on GD
Dr
Which one o f the following is least recogn ised a s a cause of tunnel vision?
Papilloed ema
Choroidoretinitis
Ang io id retinal streaks
Glaucoma
m
se
As
Dr
Papilloedema
Choroidoretinitis
Angioid retinal streaks
Glaucoma
m
se
As
Dr
Which one o f the following causes o f Horn er's syndro me is due to a cent ral lesion?
Cavernous sinus throm bosis
Syring omyelia
Pancoast's tumour
m
se
As
Cervica l rib
Dr
Cavernous sinus throm bosis

-~
Syringomyelia
Pancoast 's tu mour
Cervica I rib
-
........
Horner's syndrome - anhydros is determines site of lesion:

• head, arm, t runk = central lesion: stro ke, syringomyelia
• just face = pre- ganglionic lesion: Pancoast's, cervical rib
m
• absent = post-gan glionic lesion: ca rotid arte ry
se
As
Dr
A 24 -yea r-old man who has a fa mily history of retinitis pigmentosa is reviewed in the
ophthalmo logy cl inic. He reports worsening vision over the past few months. Du ring
fundoscopy, which of the following findings with most support a dia gnos is of retinitis
pigmentosa?
Pigmented scrambled egg appearance concentrated a round the macula
Central irregu la r pigmentation with bu ll's eye macu lopathy
Black bone spicule-shaped p igmentation in the peripheral retina
Drusen with haemorrhagic atrophic changes concentrated at the periphe ry of the

retina
m
se
As
Pigmented choro idal neovascularisation throughout the retina
Dr
Pigmented scrambled egg appearance concentrated a round the macu la
Central irregu la r p igmentation with b ull's eye macu lopathy

-
~
Black bone sp icule-s haped p igmentation in the peri phe ral retina
Dr~sen with haemorrhagic atrophic changes concentrated at the periphe ry of the G3

retma
m
se
As
Pigmented choroidal neovascularisation throug hout the retina
Dr
A 65-yea r-old woman presents to the Eme rgency Department with visua l pro blems. She
has rheumato id a rthritis, depressio n and takes medication to contro l her blood pressure.
Over the past few d ays she has been getting troub lesome headaches and blurred visio n
but to day has noted a ma rke d re d uction in vision in the right eye. On exa mination her
right eye is red, has a sluggish p upil and a co rrected visua l a cuity 6/ 30. Her medicatio n
has recently been changed. Wh ich one o f the fo llowing drugs is most likely to have
p recip itated this event?
Methotrexate
Doxazos in
Amitriptyline
Atenolo l
m
se
As
Bend ro flumethiazid e
Dr
Methotrexate fi!D
Doxazosin (D.
I Amitriptyline tiD
Atenolol «D
m
se
Drugs which may precipitate acut e glaucoma include anticholinerg ics and tricyclic
As
antidepressants
Dr
A 64 -yea r-old woma n with type 2 diabetes mell itus presents as she has started to b ump
into things since the mornin g. Over the previous two days she ha d noticed some 'floating
spots in her eyes'. Exa mination reveals she has no vis ion in her right eye. The red reflex on
the rig ht side is difficult to e licit and you are u nable to visualise the retina o n the right
sid e during fu nd oscopy. Exa mination of the left fundus revea ls changes consistent with
p re-prolife rative dia betic retino pathy. What is the most likely diag nosis?
Occlus ion of central retina l vein
Proliferative retino pathy
Cata ract
m
se
Retina l d etachment
As
Dr
Occlusion of central retina l vein
Prolt,rative retinopathy
Cataract
Retinal detachment
The history of d iabetes, complete loss of vision in the affected eye and inability to
m
se
visua lise the retina poi nt towa rds a diagnosis of vitreous hae mo rrhage. Please see th e
As
table below for help in d ifferentiating retina l detachment from vitreous haemorrhage.
Dr
Each one of the following predisposes to cataract formation, except:
Down's syndrome
Hypercalcaem ia
Diabetes mellitus
Long -term steroid use
m
se
As
Uveitis
Dr
Down's syndrome GD
Hypercalcaemia CD
Diabetes mellitus CD
Long-term steroid use m
Uveitis ED
m
se
Hypocalcaemia is a cause of cataracts
As
Dr
An 80-year-old ma le p resents to the Neu rology clinic with d ou ble vision and unsteadiness
whilst wa lking . He has a past medica l histo ry of hype rtension, hype rcholeste rolaemia a nd
type 2 diabetes.
On exam ination, you notice a rig ht partia l ptosis a nd miosis. The patient a lso has notable
right facial loss of pain a nd temperature sensation with left sided truncal sensory loss
contra late ra l to the face.
In the clinic, a praclo nidine eye dro ps are ad ded to the a ffected eye, which causes a
dilatatio n, whilst in the o p posite eye, a pupil constriction occurs. Afte r the eye dro ps have
been elim inated from the body, 1% hyd roxyam phetami ne eye drops are the n instilled.
One hour after instillation, both p upils dilate.
What neuro ne o rder is like ly affected in the sympathetic pathway?
First order
Second o rder
Third o rder
Fourth o rde r
m
se
Fifth ord er As
Dr
I First order ED
Second ord er CD
Th ird ord er CD
I Fourth o rd e r .
(D
Fifth o rder
•
The answer is the first orde r neurone.
Apraclonidine eye drops a re initially used to confirm a Horner's pupil. Apraclonidi ne

stimulates both a lpha-1 and alpha-2 recepto rs. When added to the a ffected eye, it causes
pupil dilation by > 2mm beca use of the relative supersensitivity of th is pupil to a lpha-1
receptor a ctivity. In a normal pupil, howeve r, it causes constriction d ue to the more potent
activity at the alpha -2 receptor which trigg ers reuptake of norad renaline in the synaptic
cleft.
Hydroxya mpheta mi ne is then used to distingu ish between first/second o r third order
neurones. In other words, it will d istingu ish either a lesion in the brainstem, cervical co rd,
chest or neck and one a ffecting above the superior cervical gang lion at the carotid
bifurcation. In a no rm al pu pil o r a first/second order Horner's, the pupil will dilate
secondary to increa sed levels o f noradrenaline released from the post-synaptic neu rones.
m
In a third order neu rone, th is will not occur. se
As
There is no fourth or fifth order neu rone.

Dr
A 25-yea r-old woman presents with a one-day history of a pa infu l and red left eye. She
describes how her eye is continually streaming tea rs. On examination she exhibits a
degree of photop hobia in the affected eye and application of fluorescein demonstrates a
dendritic pattern of stain ing . Visua l acu ity is 6/ 6 in both eyes. What is the most
Topica l ste roid
Perform a lumbar puncture
Treat with subcutaneous sumatriptan
Topica l aciclovir
m
se
As
Topical chlo ram phenicol
Dr
Topical steroid G'D
Perform a lumba r puncture CD
Treat with subcutaneous sumatriptan fD
I Topical aciclovir ED.

Topical chloramphenicol G'D
This patient has a dendritic corneal ulcer. Topical aciclovir and ophthalmology review is
m
se
required. Giving a topical steroid in this situation could be disastrous as it may worsen the
As
infection.
Dr
Which one of the following is not a risk factor for pri mary open -an gle glaucoma?
Diabetes mellitus
Family history
Hypertension
Afro -Caribbean ethnicity
m
se
As
Hypermetropia
Dr
Diabetes mell itus
Family history
Hypertension
Afro-Caribbean e hnicity
Hypermetropia
Acute angle closure glaucoma is associated with hypermetropia, where as primary
m
se
open-angle glaucoma is associated with myopia
As
Dr
A 34-year-old woman presents comp la ining of headaches. Exa mination of her pu pils
using a light shone alternately in each eye reveals that when the light is shone in the right
eye both pu pils constrict but when the light source im mediately moves to the left eye
both eyes appear to dilate.
Right optic neu ritis
Left s ided Horner's synd rome
Cra niopha ryngio ma
Left o ptic neu ritis
m
se
As
Right Holmes-Adie pupil
Dr
Right optic neuritis
Left sided Horner's syndrome
Craniopharyngioma
Left optic neuritis
Right Holmes-Adie pupil

-
~
This is the 'swinging light test' and reveals a relative afferent pupillary defect. As there is a
defect in the afferent nerve on the left side the pupils constrict less than normal, giving
the impression of dilation.
Given her age, multiple scleros is causing optic neuritis is the like ly underlying diagnosis.
m
se
Optic neuritis typica lly causes a dull ache in the region of the eye which is agg ravated by
As
movement
Dr
Which one o f the fo llowin g statements rega rd ing the Ho lmes -Adie p upil is incorrect?
May be associated with absent a nkle/knee reflexes
Bilate ral in 80% o f ca ses
It is a benign conditio n
Slowly reactive to accommodatio n but ve ry poo rly (if at all) to light
m
se
As
Ca uses a dilated pupil
Dr
May be associated with absent a nkle/knee reflexes
~teral in 80% of ca ses

-
"""
It is a be nig n cond ition
Slowly reactive to accommodation but very poorly (if at a ll) to light
Causes a dilated pupil
m
se
As
The Holmes-Adie pupil is un ilateral, rather than b ilateral, in 80% o f patients
Dr
A 71-yea r-old man presents with severe pain around his right eye and vomiting. On
examination the right eye is red and decreased visual acuity is noted. Which one of the
following options is the most appropriate initia l treatment?
Topica l pilocarpine+ o ral pred nisol one
Topica l pilocarpine+ topi cal stero ids
Topica l ste roids
Topical pilocarpine+ intravenous acetazo lam ide
m
se
As
Topica l stero ids + intravenous acetazolamide
Dr
Topical pilocarpin e+ o ra l prednisolone
Topical pilocarp in e+ topical stero ids
Tol ica l ste ro ids
Topical pilocarpine + intravenous acetazolam ide
Topical ste ro ids + intrave nous acetazolam id e
m
se
Treatment of acute glaucoma - acetazolam ide + p ilocarpine
As
Dr
Which one of the following best d escribes the action of lat anoprost in the management
of primary open -ang le g laucoma?
Carb onic anhydrase inhibit or
Reduces aqueous production + increases outflow
Opens up drainage pores
Increases uveoscleral outf low
m
se
As
Reduces aqueous production
Dr
Carbon ic anhydrase inh ib ito r
Reduces aqueous production + increases outflow
0 17ens up drainage pores
Increases uveoscleral outflow
m
se
As
Reduces aqueous production
Dr
A 65-yea r-o ld man with a 16 yea r history o f type 2 diab etes mell itus presents co mpla ining
o f poor eye s ight a nd blu rred vis ion. Visua l acu ity measu red using a Snellen chart is
reduced to 6/ 12 in the right eye and 6/ 18 in the left eye. Fundosco py reveals a num ber of
ye llow deposits in the left eye consistent with d rusen formatio n. Simila r changes b ut to a
lesser exte nt a re seen in the right eye. What is the most likely dia g nosis?
Wet a ge-related ma cular deg e neration
Pre-p ro liferative d iab etic retinopathy
Chronic open ang le g lau coma
Prol iferative diabeti c reti nopathy
m
se
As
Dry age-re lated macu lar d eg eneration
Dr
Wet age- re lated macular degeneration (fD
Pre-prol iferative d iabetic retinopathy GD

l crronic open angle glaucoma CD
Proliferative diabetic retino pathy CD
Dry age-related macu lar degeneration CD
m
se
Drusen = Dry macular degeneration
As
Dr
A 49-yea r-o ld ma le patient p rese nts with acute o nset loss o f vision in the rig ht eye
p reced ed by a 2-ho ur history of progress ively e nla rg ing da rk s pots in his vision. He has
type -1 diabetes mellitus fo r over 15 yea rs and has been poorly co ntro lle d.
What is the most li kely diag nosis
Ocula r mig raine
Ischaem ic optic neu ropathy
m
se
As
Retina l artery occlusio n
Dr
Ocular mig raine
Retinal detachment ED
•
I Vitreous haemo rrhage ED
Ischaemic optic neuropathy CD
Retinal artery occlusion CD
Vitreous haemorrhage is a cause of sudden painless loss o f vision in the context of

diabetic retinopathy
Vitreous haemorrhage is a cause of sudden painless loss of vision in the context o f

diabetic retinopathy. It usually p resents with dark spots (scotoma) in the vision initially.
This man is likely to have diabetic retinopathy.
Ocular mig raine does not usually cause visual loss.
Retinal detachment usually p resents with dense shadow over vis ion p rogressing centrally.
Even thoug h th is man has ischaem ic risk factors, ischaem ic optic neuropathy does not
m
se
usually present with dark s pots.
As
Retinal artery occlusion does not usually present with dark spots.
Dr
A 71-yea r-old with a history of type 2 diabetes mellitus and hypertension presents due to
the sensation of light flashes in his right eye. These symptoms have been present for the
past 2 days and seem to occur more at the perip heral part of vision. There is no redness
o r pain in the affected eye. Corrected visua l acuity is measured as 6/ 9 in both eyes. What
is the most li kely diagnosis?
Change in shape of eye seconda ry to va riations in b lood su gar
Vitreous d etachment
Norma l phe nom eno n in d ia betic retino pathy
m
se
As
Norma l phe nom eno n in healthy eyes
Dr
Change in shape of eye seconda ry to va riations in blo od su gar
Vitreous d etach ment
Norma l p he nom eno n in d ia betic retino pathy
Norma l phe nom e no n in healthy eyes

-
........
Flashes and floate rs - vitreous/retina l d etachment

m
se
Flashes and floate rs are symptoms o f vitreous detachment. The patient is at risk of reti na l
As
d etachment and s hould be referred u rgently to a n op htha lmo lo gist
Dr
Which one o f t he followin g is least associated wit h the development o f opt ic at rophy?
Tobacco
Methanol
Lead
m
se
As
Zinc def iciency
Dr
Tobacco
Methanol
Lead
-
~
m
se
As
Zinc deficiency
Dr
A 54-year-old man with type 2 diabetes mellitus is found on annual review to have new
vessel fo rmation at the optic disc. Visual acuity in both eyes is not affected (6/9). Blood
pressure islSS/ 84 mmHg.
HbA lc 68 mmol/ mol (8 .4%)
What is the most important intervention in this patient?
Follow-up ophthalmoscopy in 3 months
Add aspirin
Blood pressure control
Tight glycaemic control
m
se
As
Laser therapy
Dr
Follow-up o phthalmoscopy in 3 months
Add asp irin
Blood pressure control
Tight glycae mic control
Laser therapy
m
se
This patie nt has pro life rative diab etic retinopathy and urgent re ferral to an
As
o phthalmo logist for pa nreti na l p hotocoagulation is ind icated
Dr
A 70-yea r-old man is investigated for blurred vision. Fundoscopy reveals drusen, retinal
epithelial and macu lar neovascularisation. A dia gnosis of age related macular
degeneration is sus pected. What is the most appropriate next investigation?
Vitreous fluid sampling
MRI orbits
Ocular tonometry
Fluorescein angiography
m
se
As
Kinetic perimetry
Dr
Vitreous fluid sampling f.D
I MRII orbits f.D

Ocular tonometry GD.
I Fluorescein angiography CD
m
se
Kinetic perimetry CD.
As
Dr
An 83-year-old female presented to her GP with com plet e loss of vision in her right eye
which occurred suddenly. The episode lasted for 10 minutes and she denies any pain in
her eye. Her past medica l history includes hypercholesterolaemia, diet controlled, and
hypertension for which she takes amlodipine.
Eye examination and fundoscopy are normal. Her blood pressure is 145/ 80 mmH g.
What medication are you going to give first?
Aspirin 300mg
Aspirin 75mg
Simvastatin 20mg
Apixaban Smg BD
m
se
As
Enoxaparin 40mg
Dr
-1Asp irin 300m g (D
Asp irin 75mg CfD
Simvastatin 20mg CD
Ap ixaban Smg BD CD
Enoxaparin 40mg .
(D
Monocular trans ient painless loss of vision (amaurosis fugax) shou ld be treated as a
TIA
Sud den painless loss of vision with a normal f undoscopy examination is an amaurosis
fugax and thus treated as a transient ischaem ic attack (TIA). NICE guidance st ates that
300mg of aspirin should b e given immediately and admission if ABCD2 score >3 or
crescen do TIA. otherwise an immediate TIA clinic referral is required.
Option 2 is the correct medication but incorrect d ose.
Option 3 is likely to be added later but aspirin is the first i nit ial plan.
m
se
Ap ixaban is usually given for ca rdiovascular disease and enoxaparin 40mg is the d ose As
given for d eep vein throm bosis prophylaxis w ith normal rena l f unction.
Dr
A 78-yea r-old gentleman p resents to the e mergency depa rtment compla ining of a seve re
headache. His only medical cond ition is hypertensio n, fo r which he take Ra mipril 10 mg
a nd Amlodipine 10 mg. As pa rt o f the full work up fund oscopy is perfo rmed, with the
fo llowing results bilate rally: Scattered cotton wool spots, tortuous vessels throughout, and
AV nip ping .
What stage of hype rte nsive re tinopathy according the Keith -Wagener classification does
this p atient have?
Stage 1
Stage 2
Stage 3
Stage 4
m
se
As
No retinopathy present
Dr
Stage 1 CD
Stage 2 fiD
Stage 3 ED.
Stage 4 f!D
No retinopathy p resent CD
Fundoscopy revea ls end o rgan d a mage in hypertensio n

This describes stage 3 hypertensive retinopathy, as there are featu res of stages 1 to 3
d escribed.
m
se
As
Hypertensive and d iabetic retinopathy a re both common fina ls questions.
Dr
A 67 -year-old man p resents as he has d eveloped a painful blistering rash around his right
eye. On examination a vesicular rash covering the right trigeminal nerve dermatome is
seen. Currently he has no eye symptoms or signs. Wh ich one of the following is most
likely to p redict future eye involvement?
Presence of the rash on the tip of his nose
Smoking hist ory
Increasing age
m
Previous courses of corticoste roids
se
As
Presence of the rash in the ear canal
Dr
I Presence of the rash on the tip of his nose
Smoking history
Increasing age
IPrevi~us cou rses of corticosteroids
Presence of the rash in the ear canal

-
~
m
se
As
This is Hutchinson's s ign which is strongly p redictive for ocular invo lvement.
Dr
A 68-year-old man with a history of type 2 dia betes mellitus presents with worsening eye
s ight. Mydriatic drops a re appl ied and fundoscopy reveals p re -prolife rative d ia betic
retino pathy. A referra l to ophtha lmology is made. Later in the eve ning wh ilst driving
home he develops pain in his left eye associated with d ecreased visua l acu ity. What is the
most li ke ly diagnosis?
Keratiti s secondary to mydriatic drops
Prolife rative diabeti c retinopathy
Centra l retinal a rtery occlusio n
m
se
As
Vitreous haemo rrhage
Dr
Keratitis secondary to mydriatic drops
Proliferative diabetic retinopathy
Acute ang le closure g laucoma
Central retinal artery occlusion
m
se
M ydriatic drops are a known p recip ita nt o f acute angle closure glaucoma. This scena rio is
As
more common in exams t han clinical practice.
Dr
Which one o f the following featu res is not cha ract erist ic o f optic neurit is?
Eye pain worse on movement
Relative afferent pupillary defect
Poor discrimination o f colours, 'red d esaturation'
Sud den onset o f visual loss
m
se
As
Cent ral scotoma
Dr
Eye pain worse on movement «ED
I Relative afferent pupillary defect CD

Poor discrimination of colours, 'red d esaturation' «ED
I Sudden onset of visual loss CiD

Central scotoma GD
m
se
Visua l loss typically occurs ove r days rat her t han hours. Sudden visua l loss due to optic
As
neuritis is very unusual.
Dr
A 64-yea r-old wo man presents with b ilate ra l so re eyelids. She a lso complai ns o f her eyes
being dry a ll the time. On exam inati on her eye lid margi ns are erythematous at the
margins but a re not swollen. Of the give n options, what is the most appropriate in itial
management?
Topical chloramp hen icol + mechanical removal o f lid d ebris
Hot compresses + topi cal stero ids
Topical chlo ramphen icol +topica l steroids
Hot comp resses + mecha nical removal of lid d e bris
m
se
As
Topica l chlo ramp hen icol + hot compresses
Dr
Topical chloramphenicol + mechanical removal of lid debris
Hot comp resses + topical steroids
Topical chloramphenicol +topical steroids
Hot compresses + mec hanical removal of lid debris

-
~
Topical chloramphenicol + hot compresses
m
se
As
Artificial tears may also be given for sym ptom relief of blepharitis
Dr
Which one of t he followin g is associated with the Holmes-Adie pupil?
Decreased ankle ref lexes
Pupillary constriction
Pt os is in 10-20% of cases
An increased of d eveloping mult iple sclerosis
m
se
As
Neurosyphilis
Dr
Decreased ankle ref lexes
Pup illary constrict ion
Ptosis in 10-20% of cases
An increased o f d eveloping multiple sclerosis

- """
Neurosyphilis
-
~
m
se
Holmes AD!e = Dilated pupil, fema les, absent leg reflexes
As
Dr
Rachel is a 45-year-old who has routine bloods for a health check. Blood tests show the
following:
Na• 125 mmol/ 1
K• 4.3 mmol/1
Urea 5.3 mmolfl
She takes the fol lowing medications: sertraline, carbimazole, am lodipine, metformin,
aspirin. Which of he r medications is likely to be the cause of her hyponatraemia?
Aspirin
Metformin
Am lodipi ne
Carbimazole
m
se
As
Sertraline
Dr
Asp irin m
I Me!fo rmin CD
Amlodipi ne D.
Carbimazole GD
~raline ED
SSRls are associat ed with hyponatraemia

Out o f the list above sertraline is the medication known to cause hyponatraemia.
Other co mmon drug causes o f low sodium include: ch lorpropramide, carbamazepine,
m
se
selective serotonin reuptake inhibitor (SSRI) antidepressants, tricycl ic antidepressant s,
As
lithium, MDMA/ecstasy, tramadol, haloperidol, vincristine, desmopressin, fluphenazin e.
Dr
Which one of the followin g interventions is most likely to be beneficia l in a patient with
schizophrenia?
Counselling
Supportive psychotherapy
Social skill s training
Adherence therapy
m
se
As
Dr
Counselling m
Supportive psychothe rapy 6D
Social skill s training f!D
Adherence therapy GD
m
I
se
Cognitive behavioura l therapy CD
As
Dr
A 32-year-old woman is brought to the Emergency depa rtment by the police. She was
found p reaching outs ide the local supermarket, telling people that she is god's discip le
and has been sent to prevent them from wasting money. It transpires that she has also
spent up to her li mit on her bank ca rd . She began treatment with fluoxetine some 3
weeks ago for reactive dep ression after sp litting from her husba nd. A li mited p hysical
examination due to poor compliance is unremarkable, as is a routine b lood screen.
Psychotic depression
Munchausen's syndrome
Schizophrenia
Vi ral encephalitis
m
se
As
Mania
Dr
Psychotic depression QD
Schizophrenia
•
CD
Vi ral e ncephalitis fD
I Man ia
I
ED
Key features here includ e clear evid ence o f delusions of g randeu r, cou pled with starting
treatment for fluoxetine so me 3 weeks ago. Taken together these factors suggest possible
mania. it is most like ly to b e re lated to selective serotonin reuptake inhibitor prescription
for her d e pression.
Psychotic depression is unl ikely given there are no del usions related to ill ness, loss of self-
worth o r other featu res usual ly exp ected. Sch izophrenia is also un li kely given the absence
o f featu res such as au ditory hallucinations or delusions of reference. Rather than being
m
associated with agitation and hyperactivity, drowsiness and memory loss are more
se
common featu res of viral encephalitis. The proximity to fluoxetine p rescription, and the
As
fact features of her illness fit so well with mania, make Munchausen's syndrome unlikely.
Dr
A 24-year-old female is reviewed following a course of cognitive behaviour therapy for
bulimia. She feels there has been no improvement in her cond ition and is int erested in
trying pharmacologica l treatment s. Which one of the following is most suitable?
Low-dose citalopram
Low-dose fluoxetine
Low-dose amitriptyline
High-dose amitriptyline
m
se
As
High-dose fluoxetine
Dr
Low-dose citalopram CD
Low-dose fluoxetine .
ED
Low-dose amitriptyline GD
High-dose amitriptyline m
m
I
se
High-dose fluoxetine flD
As
Dr
A 23-yea r-old man asks to be referred to a plastic su rgeon. From his records you can see
he has been treated fo r anxiety and dep ression with fluoxetine p reviously and has been
o ff wo rk with back pa in for the past three months. He is concerned that his ea rs are too
big in p roportion to his face. He repo rts that he now seld om leaves the house because of
this. On exam ination his ea rs appear to b e within norma l li mits. What is the most
appropriate d escription o f this b ehaviour?
Hypochondriasis
Generalised anxiety disorder
Somatisatio n
Malingering
m
se
As
Dysmorphophobia
Dr
I Hypochondriasis
Somatisation
Ma lingeri ng
-
. ..wl'
m
se
Dysmorphophobia
As
Dr
A 34-year-old male comes to clin ic for an asthma review. He tells you he has recently
been diagnosed with a pe rsonality d isorder. The diagnosis came about after he was
referred by his boss to occupational hea lth fo r being overly sensitive and getting angry
when colleagues told him how to do his job. He feels his diagnosis is unjustified and is al l
a set up as his boss, who used to be a good friend, knows he is better at his job than him.
What diagnosis is he most like ly to have received?
Schizoid perso na lity diso rder
Narciss istic persona lity disorder
Paranoid personality disorder
Bo rderline persona lity diso rder
m
se
As
Avoidant personality d isord e r
Dr
Schizoid perso nality disorder tiD
Narcissistic p ersonality disorder ED
e:D.
r Paranoid persona lity disorder
Borde rline perso nal ity diso rder GD

Avoidant pe rsonality d isorder CD
Paranoid persona lity disorde r may be diagnosed in patients who are o ve rly sensitive
and can be unfo rg iving if insulted, question loya lty of those a round them and a re
reluctant to confide in others
The correct answer is paranoid perso nality disorder. Patients with pa rano id personal ity
diso rder are ove r sensitive, u nforgiving and p erce ive feedback as attacks on their
cha racte r. They can be preoccup ied with conspiracy theo ries and tend to question the
loyalty of others. Based on the patients' description, this is the most likely diagnosis.
Option 2 is incorrect. Patients with sch izoid p ersonality disorder tend to have a lack o f
interest in sexual interactions are cold and lack close frien dships preferring to spend time
alone. They are also indiffe rent to praise making this unl ikely to be the correct answer.
Na rcissistic personal ity disorder is not the correct answer. These patients have a
heig htened impression o f self-im portance and entitle ment often believing they have
unlimited abilities to succeed, beco me powerful or look beautiful. Add itionally, they lack
empathy and will hap pily take a dvanta ge of others to ach ieve their own need.
Bo rderline perso nal ity diso rder is also incorrect. Th is is characterised by emotiona l
instab ility, im pulsive behaviour, feelings o f emptiness and recurrent attempts at self-harm.
Patients often fea r abandonment as opposed to the question ing loyalty o f those around
them.
Patients with avoid ant personal ity d isorder tend to avoid social contact/relationships due
to fear o f b eing criticised, rejected or e mbarrassed as o pposed to bei ng unforgiving,
making this less likely the co rrect answer.
em
Further informatio n on personal ity diso rder can be found in the lCD 10 guide -
s
As
http:/I a p ps.who. int/ cia ssificatio ns/icd 10/ browse/20 16/en#/ F66
Dr
The risk of developing schizophren ia if one monozygotic twin is affected is approximately:
10%
20%
50%
75%
m
se
As
>95%
Dr
10% .
(D
20% GD
50% CD
75% CD
m
se
.
As
>95% (D
Dr
A 65-yea r-old female with a histo ry of ischaemic heart disea se is noted to be d epressed
following a recent myocardial infarcti on. What woul d be the most a pp ropriate
antidep ressant to start?
Pa roxetine
Imipramin e
Fl upentixol
Venlafaxin e
m
se
As
Sertra line
Dr
Paroxetine CD
Imipramin e m
Flupent ixol (iD
Venlafaxine CD
Sertraline CD
Sertraline is t he SSRI o f choice post myocardial infarction

m
se
Sertraline is the p referred antidepressant follow ing a myocardial i nfarct ion as there is
As
more evid ence for its saf e use in t his situat ion t han other antid epressants
Dr
Which one of the following statements regarding post-partum menta l health p roblems is
NOT true?
Post-nata l d epression is seen in around 2-3% of women
Pue rperal psychosis has a recu rrence rate of around 20%
Baby-blues are seen in the majority of women
Post-nata l d epression usually develops within the first month
m
se
As
Sertraline ca n be used whilst mothers are breast feed ing
Dr
Post-natal d epression is seen in around 2-3% of women ED
Puerperal psychosis has a recurrence rate of around 20% CD
Baby-blues are seen in the majority of women CD
Post-natal depression usually develops with in the first month flD
Sertraline ca n be used whilst mothers are breast feed ing flD
m
Post-natal d epression is seen in around 10% of women
se
As
Dr
You a reviewing a 24-year-old man w ho complains of auditory hallucinations. These have
become increasingly common and are now happening on a daily basis. Which one of the
following factors in his history is the strongest risk factor for psychotic disorders?
Indian subcontinent ethnicity
Having a parent with schizophrenia
A history o f long-term cannabis use
A history o f being sexually abused when younger
m
se
As
Working in the performing arts
Dr
Indian subcontinent ethnicity
Having a parent with schizophrenia
A history o f long -term ca nnabis use
A history o f being sexually abused when younger
Working in the performing arts

-
. .wr
m
se
Family history is the strongest risk facto r for psychoti c disorders
As
Important for me l ess 'mocrtant
Dr
A 54-yea r-old ma n p resents with a variety of physical symptoms that have been p resent
for the past 9 years. Numerous investigations and review by a variety of specia lties have
indicated no o rgan ic basis for his sympto ms. This is an example of:
Munchausen's syndrom e
Hypochondria I diso rde r
Dissociative d iso rder
Somatisation d isorde r
m
se
As
Dr
~pochondrial diso rder

Dissociative diso rder
I Somatisation diso rder
Unexplained symptoms
• Som atisation = Symptoms
• hypoChondria = Cancer
Somatisation diso rder is the correct answer as t he patient is concerned about p ersist ent,
m
unexplained sympt oms rather t han an underlying diagnosis such as cancer
se
(hypochondria! disorder). Munchausen 's syndrome describes t he intentional pro duction
As
o f symptoms, for example self poisonin g
Dr
A 31-year-old woman who gave b irth two weeks ago presents for review with her
husband. He is worried by her mood as she now seems depressed and is interacting
poorly with the ba by. He describes her mood three days ago being much different, when
she was ta lking in a rapid and incoherent fashion about the future. The mother denies any
hallucinations but states that her child has been brought into a 'very bad world'. What is
the most appropriate ma nagement?
Start fluoxetine
Reassurance + review by health visitor
Start lithiu m
m
se
As
Arrange urgent admission
Dr
Start fluoxetine
I
Reassurance + review by hea lth visitor
Cognitive b r avioural therapy

-
~
Start lith ium
Arrange urgent admission
The mother may be suffering from puerpera l psychosis and needs urgent adm ission to
allow psychiatric evaluation.
Whilst there is not a full comp lement of psychotic features there a re a number of po inte rs
towards s ignificant menta l hea lth p rob lems:
• poor interaction with the baby: this is very unusual, including in women with
postnata l depression
• 'talking in an incoherent fashion about the futu re'
• stating that the ba by 'has been broug ht into a very bad world' is odd and somewhat
worrymg
m
se
As
For these reasons, the mother should have an urgent psych iatric evaluation. Dr
A 64-yea r-old woman presents as she is feeling down and sleeping poorly. After speaking
to the patient and using a validated symptom measu re you decide she has moderate
depression. She has a past history of ischaemic hea rt d isease and currently takes aspirin,
ra mipril and simvastatin. What is the most appropriate course of action?
Stop aspirin, start sertraline
Start venlafaxine
Start sertraline + lansoprazole
Stop aspirin, start clop idrog rel + sertraline
m
se
As
Start sertraline
Dr
Stop aspirin, start sertraline
Sta rt ven lafaxine
Start sertraline + lansoprazole
Stop aspirin, start clop idrogrel + sertra line
Start sertraline
-
~
SSRI + NSAID = Gl bleed ing ris k - g ive a PPI

There is an increased incidence of gastro intestina l bleed ing when aspirin I NSA!Ds are
comb ined with selective seroto nin reuptake in hibito rs. This patient shou ld there fo re a lso
be offered a proton pum p inh ibito r such as la nsoprazo le . It wou ld be inappropriate to
stop aspirin in a patient with a history of ischaem ic heart d isease.
m
se
Note the use of sertra lin e in this patient, the first-choice SSRI in patients with a history of
As
cardiovascu la r disease.
Dr
A 42-yea r-old woman presents for review. Her husband reports that she has had an
argument with their son which resulted in hi m leaving home. Since this happened she has
not b een able to speak. Clinica l exam ination of her throat and chest is un remarkable.
Which one o f the followin g terms best describes this p resentation?
Aprosodia
Schizophasia
Expressive a phasia
Akinetic mutism
m
se
As
Psychogenic aphon ia
Dr
Ap rosodia m
Schizophasia CD
Expressive a phasia f.D
Ak. . I .
1net1c myt1sm GD
Psychogenic aphon ia CD
m
se
Psychogenic apho nia is consid e red to be a fo rm of conve rsion diso rde r. Please see the
As
li nk fo r mo re d etails.
Dr
You a re reviewing a 24-year-old PhD student who presents with feeli ng on edge all of the
time. He feels that nothing specific makes him feel worse. He cannot relax and as a result
is not sleeping too well, but his appetite is good . He te lls you that his mood is okay. You
have reviewed him for several weeks with the same symptoms and despite referral to self-
help sessions he has made no imp rove ment.
Given the likely diagnosis, which pharmaco logica l option is most like ly to be indicated?
Beta blocker
Prega balin
Benzodiazep ine
Atypical antipsychotic
m
se
As
Selective serotonin reupta ke inhibitor (SSRI)
Dr
Beta blocker
(1regabalin
Benzodiazepine
Atypical antipsychotic
Selective serotonin reupta ke inhibitor (SSRI)
SSRis are the first -l ine pharmacolog ical therapy for generalised anxiety disorder
This scenario most likely represents generalised anxiety disorder. NICE recommend
pharmacological therapy if low-intensity psychological interventions have been
m
unsuccessful. Sertraline if reco mm ended first-line, and if contraindicated or not tolerated
se
As
then any other SSRI or se rotonin noradrenaline reuptake inhibito r (SNRI). Pregabalin is
indicat ed but only if these treatment s have failed.
Dr
An 84-year-old female has been an inpatient in a psychiatric ward for the past 6 months
with a fixed belief that her insides are rotting as she is deceased.
This type o f delusion is know n as which o f the following?
Cotard delusion
Othello delusion
De Clerambault syndrome
Ekbom syndrome
m
se
As
Capgras delusion
Dr
I Cotard delusion
Othello delusion
eD
.
(D
De Clerambault syndrome .
(D
Ekbom syndrome GD
Capgras delusion GD
Othello syndrom e is a delusional belief that a patients partner is committing infidelity

despite no evidence o f this. It can often result in violence and controlling behaviou r.
De Clerambault syndrome (otherwise known as erot omania), is where a patient b elieves

that a person of a higher social or professional standing is in love with them. Often this
presents w ith people who believe celebrities are in love with them.
Ekbom syndrome is also known as delusional pa rasit osis and is the belief that they are
inf ected w ith parasites or have 'bugs' under their skin. This can vary from the classic
psychosis sym ptoms in narcotic use where the user can 'see' bugs crawling under their
skin or can b e a patient who b elieves that they are infested w ith snakes.
m
se
As
Capgras delusion is the b elief that friends or family members have been replaced by an
identical looking imposter.
Dr
A 45-yea r-old man who takes chlorpromazine fo r schizophrenia presents with severe
restlessness. What s ide-effect o f antipsychotic medication is this an exam ple of?
Akathisia
Acute dysto nia
Ta rdive dyski nesia
m
se
As
Pa rkinsonism
Dr
Akathisia
Acute dystonia
-
"""
Ta rdive dyski nesia
Parkinson ism
m
se
Ant i psychot ics may cause akathisia (severe restlessness)
As
Dr
Hyperarousal GD.
Emotional numbing fD
Nightmares CD
Loss o f inhibitions CD
m
se
Avoidance m
As
Dr
A 34-year-old man co nfides in you that he experienced childhood sexual abuse. Which
one of the following features is not a characteristic featu re of post-traumatic stress
disorder?
Hyperarousal
Emotional numbing
Nightma res
Loss of inhibitions
m
se
As
Avoidance
Dr
A 18-yea r-old s printer who is cu rrently pre paring for a nationa l ath letics meeting asks to
see the team doctor due to an unusual sensation in his legs. He describes a numb
sensation b elow his knee. On exam ination the patient there is apparent sensory loss
below the right knee in a non-dermatoma l distribution. The team doctor suspects a non-
organic cause of his symptoms. This is an example o f a:
Hypochondria I disorder
Somatisatio n d isorder
Malingering
m
se
As
Dr
HypochondriaI disorder
Somatisation disordy
Malingering
Conversion disorder - typ ically involves loss o f mot or or senso ry function. May be
m
se
caused by stress
As
Dr
A 14-yea r-old boy is brou ght for review. He is normal ly fit a nd well and hasn't seen a
d octor for over five years. His mother has been increa singly conce rned about his
behaviou r in the pa st few weeks. She d escribes him staying up late at night, talking
quickly an d be ing ve ry irritab le. Ye sterday he to ld his mother he was planning to 'ta ke-
over' the school assembly a nd give 'constructive criticism' to his tea chers in fro nt o f the
o ther pu pils. He feels many of his tea chers a re 'underp erform ing ' a nd need to b e
'retaught' the ir subjects by him. He ad mits to trying ca nnabis o nce around six months a go
and has drank alcoho l 'a few tim es' in the past yea r, the last time be ing two weeks a go .
Prio r to his d ete rioration a few weeks ag o his mother d escribes him as a hap py, we ll -
a djusted, sociable young ma n. Which o ne of the following is the most like ly d iagnos is?
Hypo man ia
Cannabis- ind uced psychosis
Mania
Alcoholic hall ucinos is
m
se
As
Asperger's syndrome
Dr
Hypomania
Cannab is-ind uced psychosis
r : nia
Alcoholic hall ucinosis
Asperger's syndrome
m
se
Cannnabis and alcohol re lated problems are very unlikely given how long ago he used
As
those substances. The delusions of grandeu r im p ly this is mania rather than hypomania.
Dr
A 24-year-old male is admitted to the Emergency Department complaining o f severe
abdominal pain. On examination he is sh ivering and rolling around the trolley. He has
previously been investigated for abdominal pain and no cause has been foun d. He st at es
that unless he is given morphine fo r the pain he will kill himself. This is an example of:
Conversion disorder
Malingeri ng
m
se
As
Dr
Hypocho ndria I disorder m
Conversion d isorder CD
I Ma lingeri ng flD
Munchausen's syndrom e tiD
Somatisatio n d iso rder CD
Lying o r exa gge rating for financi al gain is malinge ring, for exam ple someone who
fakes whiplash a fte r a road traffic a ccid e nt fo r an insurance paym ent
m
This is difficu lt as the patient may well be a n opiate abuser who is withd rawing. However,
se
given the above options the most appropriate te rm to use is malingering as the patient is
As
reporting symptoms with the deliberate intention of getting morph in e
Dr
A 34-year-old fema le has been suffering from depression for the past 3-years and is
managed with sertraline and psychological interventions. During her most recent
admission to the psychiatric intensive care unit, one of the nurses has noticed that she has
been in a fa irly fixed p osition for the past few hours and has not moved much. The patient
does not appear agitat ed.
Which o f the follow ing would be an appropriate first -line treatment for the patient?
Quetiapine
Olanzapine
Risp eridone
ECT
m
se
As
Haloperidol
Dr
Quetiapine tiD
Olanzapine flD
Risperidone GD
~ CiD
Haloperidol GD
NICE suggest ECT is indicated for catatonic patients

The most appropriate treatment option in the list above is ECT (electroconvulsive
thera py).
It wou ld a lso be appropriate to adm inister a 2nd or 3rd generation anti-d epressant such
as fluoxetine or citalopra m.
m
se
Anti-psychotics (such as olanzapine, quetiapine, risperidone, and halo perido l) are on ly
As
indicated as an adj unct med ication in some patients. It is not first -li ne for catatonia.
Dr
A 23-year-old man presents as he is concerned about a number of recent episodes
related to s leep. He finds when he wakes up and less often when he is fa lling asleep he is
'paralysed' and unable to move. This sometimes associated with what the patient
describes as 'hallucinations' such as seeing another person in the room. He is becoming
increasing ly anxious about these recent episodes. What is the most likely dia gnosis?
Frontal lobe epilepsy
Genera lised anxiety disorder
Sleep pa ra lysis
Night terro rs
m
se
As
Acute schizophrenia
Dr
Front al lobe ep ilepsy m
Ge eralised anxiety disorder (D
Sleep paralys is GD
Night terro rs GD
m
se
fD
As
Acute schizophrenia
Dr
A patient reports feeling unwell after suddenly stopping pa roxetine. Which one o f the
following symptoms is most consistent with selective serotonin reu ptake inhi bitor
discontinuation synd rome?
Diarrhoea
Myoclonic je rks
Hallucinations
m
se
As
Seizures
Dr
Postu ral hypotension CD
I Diarrhoea CD
Myoclonic jerks f!D
Ha llucinatio ns GD
Seizu res fiD
Gastro intestinal side-effects such as dia rrhoea are seen in SSRI d iscontinuation
syndrome
m
se
Selective sero tonin reupta ke inhibitor discontinuatio n synd rome ca n p resent with a wid e
As
variety of sympto ms includ ing diarrhoea, vom iting a nd a bdom inal pa in.
Dr
A 93-yea r-old female patient on the ward is brought to you r attention by the nu rses. They
a re concerned s he is expe riencing visual hallucinations. She was ad mitted fo llowing a
d ecline in mobility that was thou ght to be secondary to a u rinary tract infection (UTI). She
has imp roved clinically an d biochemically during he r time on the ward and she is awa iting
a increase package of care b efo re discha rge.
Yo u review the patient who tel ls you she ea rlier saw very s mall chi ldren running across the
end of the b ed . She rep orts she reg ula rly sees s imilar images at home and has d one so
fo r many years. She has a backgro u nd of hypertension, d epression and age-related
macula r deg eneration. What is the most appro p riate step in this patient's management?
Reassure the patient
Urgent psychiatric eva luation
Consider trea tment fa ilure o f her UTI
Prescri be 40mg o f chlordiazepoxide
m
se
As
Consider co mm e ncing an antid e pressa nt
Dr
Reassure the patient
Urgent psychiatric evaluation
Consider t reatment failure o f her UTI
Pre crib e 40mg o f chlordiazepoxide
Consider co mm encing an antid epressa nt
This most likely rep resent s Charles Bonnet syndrome. Reassurance is usually t he best
treatment, helping peop le t o understand and come to terms with their hallucinations. It is
m
importance to ensure there is not an alternative cause e.g. infection, psychosis, dement ia
se
(pa rticu larly Lewy body dementia), intoxication, metabolic abnormalities, foca l
As
neuro logical illness.
Dr
A 25-yea r-old man d emand s aCT scan of his abdo men in cli nic. He states it is 'obvious'
he ha s cancer despite previous negative investigations. This is an exa mple of a:
Hypochondria I diso rde r
m
se
As
Dr
Dr
As
sem
Yo u review a patient who has been taking citalopram fo r the past two years to treat
d epression. He has felt well now fo r the past year an d you agree a p la n to stop the
antidep ressant. How should the citalop ram be sto pped?
Can be stopped immediately
Withdraw gradu ally ove r the next 3 days
Withdraw gradu ally over the next we ek
Withdraw gradu ally ove r the next 2 weeks
m
se
As
Withdraw gradu ally ove r the next 4 we eks
Dr
Can be stop ped immediately CD
Withdraw g radua lly ove r the next 3 days
•
I l ithdraw g radu ally ove r the next week
Withdraw g radu ally over the next 2 wee ks CD

•
I Withdraw gradually over the next 4 weeks GD
When sto pping a SSRI the d ose shou ld be g radually reduced over a 4 week period
m
se
As
This not necessa ry with fluoxetine due to its lon ge r half-life.
Dr
A 54-yea r-old man with a history of d e press ion presents for review. He was started on
fluoxetine eight weeks ago a nd is now requesting to stop his med ica tion as he feels so
well. What shou ld be recommended reg arding his treatment?
It should be stopped stra ig ht away
It should be continued for at lea st a nother 6 weeks
It should be continued for at lea st a nother 3 month s
m
se
As
It should be continued for at lea st a nother 12 months
Dr
A 54-yea r-old ma n with a history of d e pression presents for review. He was started on
fluoxetine e ight weeks a go a nd is now requesting to stop his med ica tion as he feels so
well. What shou ld be recommended reg arding his treatment?
It should be stopped stra ig ht away
~should be continued for at lea st a nother 6 wee ks

I It s hould be continued fo r at least anoth er 6 month s
It sh ould be continued for at lea st a nother 12 months
Antid e pressants shou ld be continued for at least 6 months a fter remission o f

symptoms to d ecrease risk of re lapse
m
se
This greatly reduces the risk of re la pse. Patie nts should be rea ssured that a ntidep ressants
As
are not ad d ictive.
Dr
You are considering prescribing a selective serotonin reuptake inhibitor for a patient with
depression. Which class of drug is most likely to interact w ith a selective serotonin
reuptake inhibitor?
Beta- blocker
Thiazolidinediones
Tetracycline
Statin
m
se
As
Triptan
Dr
Beta-blocker CD
Thiazolidined iones .
(D
Tetracycline fD
--
Statin GD
Triptan ED
m
se
Triptans should be avo ided in patients ta king a SSRI
As
Dr
Victoria has recently been diagnosed with ago raphob ia and the psychiatrist plans to start
med ical treatment. Wh ich is the first line med ication used fo r ago raphob ia?
Fluoxetine
Sertraline
Citalopram
Mirtazapine
m
se
Venlafaxine
As
Dr
Fluoxetine .,
Sertraline ED
Citalopram f!D
Mirtaza pine f!D
Venlafaxine GD
Agoraphobia is usua lly managed with sertraline

m
se
Agoraphobia is usually managed with sertraline. The other antidepressants may be used
As
as second-lin e therapy depending on the patient's specific symptoms.
Dr
A 45-year-old man is admitt ed due to haematemesis. He reports drinking 120 units of
alcohol a week. When is the peak incidence of seizu res following alcohol w ithdrawal?
2 hours
6 hours
12 hours
24 hours
m
se
As
36 hours
Dr
2 hours m
6 hours CD
12 hours tiD
24 hours tiD
I 36 hours CD
Alcohol withdrawal
• sympto ms: 6-12 hours
• seizures: 36 hours
m
• delirium tremens: 72 hours
se
As
Dr
A 29-yea r-o ld fireman presents fo llowing a recent tra umatic in cident whe re a child d ied in
a house fire. He describes recu rrent nig htmares and flashbacks which have been present
fo r the past 3 mo nths. A diagnosis o f post-tra umatic stress disorde r is suspected . What is
the most a pp ro priate first-li ne treatme nt?
Arra nge a CT head to exclud e a n o rgan ic ca use
Cogn itive b ehavio ura l therapy o r eye movement d esens itisation an d repro cessing
thera py
Cogn itive b ehavio ura l therapy o r g rad ed exposure the rapy
Cogn itive b ehavio ura l therapy o r psychodyna mic the ra py
m
se
As
Watchful wa iting
Dr
Arrange a CT head to exclude an organ ic cause
I
Cognitive behavioural therapy or eye movement desensitisation and
reprocessing therapy
Cognitive behavioural therapy or graded exposure therapy
Cognitive behavioural therapy or psychodynamic therapy
m
se
Watchful waiting
As
Dr
A 62-yea r-old man is b rought to the d octors by his daug hter. Fou r weeks ago his wife
died fro m metastatic breast cancer. He rep orts being tea rful eve ry d ay but his d aug hter is
concerned b ecause he is constantly 'picking fights' with her o ve r mino r matters and issues
re lating to their family past. The d aughte r a lso reports that he has on occasion d escribed
hearing his wife ta lking to him and on one occas ion he pre pared a meal fo r he r.
Desp ite this he has sta rted g o ing walking a ga in with friends and says that he is
d ete rm ined to get 'back o n track'.
Atypical g rief reaction
Dep ression without psychotic featu res
Delusional diso rder
Dep ression with psychotic features
m
se
As
Normal grief reaction
Dr
Atypical grief reaction GD
Depress ion without p sychotic featu res m
Delusio nal diso rde r m
De pression with psychotic features f!D
m
se
eD
As
Normal grief reaction
Dr
A 24-yea r-old ma n is bro ught to the Emergency Depa rtment by his b rother who is
concerned a bout his odd behaviour. Over the past two weeks he has started to tell his
brother that he can hear peop le ta lking ab out him o n the radio. He denies any a ud itory
hall ucinations. Duri ng the consultatio n he scores 10/10 on the mini- mental state
exami natio n. When a sked to explain the meaning of the statement 'people in glass
houses s houldn't throw stones' he replies 'yo u may break the glass'. What is this an
example o f?
Depress ion
Autistic thinking
Concrete thinking
Delusional disorder
m
se
As
Acute mania
Dr
Depression CD
Autistic thinking CD
I Concrete thinking CD
Delusional diso rder fD
Acute mania tiD
This is an example of concrete thinking where a patient cannot use abstraction to

understand the meaning of a sentence. It is more common in schizophrenia. Literal
m
se
thinking is of cou rse a feature of autism but this wou ld not explain his delusional
As
perception and is unli kely to present in a sub-acute fashion at this age
Dr
Which one o f the followin g selective serotonin reuptake inhibito rs ha s the highest
incidence of d iscontinuation symptoms?
Paroxetine
Citalopra m
Escita lo pram
Fluoxetine
m
se
As
Sertra line
Dr
I Paroxetine ED
Citalopram GD
Escita lopram m
Fluoxetine flD
Sertraline GD
m
se
Paroxetine - higher incidence of discont inuation sympto ms
As
Dr
Carol is a 57-year-ol d lady who is und e r a section 3 at a an in patient psychiatric hosp ital.
She has stop ped eating o r drinking as she believes s he is dead and does not require food
anymore. Which synd ro me is characterised by a perso n bel ieving they are d ead o r non -
existent?
Cota rd syndrom e
Capgras syndrome
Couvade syndrom e
De Clera mbault's syndrom e
m
se
As
Othel lo syndrom e
Dr
Cota rd syndrome
Capg ras syndrome
Couvade syndrome
De Cleram bault's syndrome

-
"""'
Ot hello syndrome
-
"""'
Cota rd syndrome is characterised by a pe rson believing they are dead or non-
existe nt
Cotard syndrome is characterised by a pe rson believing they are dead o r non -existent. It
te nd s to be re lated to d epression.
Capgras syndrome is characte rised by a perso n bel ieving their friend o r relative ha d been
replaced by an exact d ou ble.
Couvade syndrome is also known as 'sympathetic pregnancy'. It affects fathe rs,

pa rticu la rly du ring the first and third trimesters of p regnancy, who suffer the somatic
features o f pregnancy.
De Cleram ba ult's syndrome is cha racterised by a person be lieving that anothe r individual
(often a cele brity) is deep ly in love with them. It typica lly affects females.
s em
Othe llo syndrome is when the patie nt believes their partner is cheating o n them. They
As
may be th reaten ing or stalk their pa rtner. This seems to affect males mo re than females.
Dr
A 36-yea r-old patient presents with nausea, headaches and palpitations. He has ha d
multiple p revious ad missions with such sym ptoms over the past 2 years, each time no
organic cause was fou nd . What kind of disorder is th is likely to represent?
Hypochondria I diso rder
Somatisation d isorder
m
se
As
Dr
Hypot ondria l diso rder
Somatisation diso rder
Conversion disorder
Dissociative d isorder
Unexplained symptoms
• Somatisation = Symptoms
m
• hypoC hondria = Ca ncer
se
As
Dr
A 60-yea r-old male is admitted to the in-patient psych iatric unit last night. On reviewing
him this morning, he is a poor historian, answering most questions minimally and stating
he d oes not need to be here as he is deceased, and hosp ita ls shou ld b e fo r living patients.
What is the na me o f this delu sional d isorder and which condition is it most commonly
associated with?
De Cleram bault's syndrom e and Major Dep ressive Disorde r
Cota rd syndrome an d Major Dep ressive Disorder
Othello syndrom e and Pa ranoid Schizoph renia
Capgras d e lusion and Dementia
m
se
As
Charles d e Bonnet syndro me and Bipola r Disorde r
Dr
De Clerambault's syndrome and Major Dep ressive Disorder
Cotard syndrome an d Majo r Dep ressive Diso rder
Othe llo syndrom e and Pa ranoid Schizop hren ia
Capg ras d elusion and Dementia
Charles d e Bonnet syndrome and Bipolar Disorder
Cotard syndro me is associated with severe d e pressio n

This patient is presenting with Cota rd's syndrome, a ra re subtype of nihilistic delusions, in
m
se
which they believe they or pa rt o f them is d ead o r does not exist. This is seen most
As
commo nly in severe depression, but is al so associated with schizophrenia.
Dr
A 58-yea r-old lady presents to her GP concerned her pa rtner is bei ng unfaithful. She
appea rs ve ry distressed by this yet a fter further questioni ng does not appear to have any
evidence to support her claims, yet she is convinced she is rig ht. What might this concern
be a symptom of?
Capgras' delusion
Grandiose d elus ion
d e Clerambault's synd ro me
Othel lo 's syndrome
m
se
As
Charles Bonnet syndrome
Dr
Capgras' delusion
Grandiose delusion
d e Clerambault's syndrome
Othello's syndrome
De Clerambault's syndrome also called erotomania is a delusiona l belief that someone
m
se
else is in love with the patient. Charles Bonnet syndrome is t he experience of complex
As
visual hallucinations in patients w ith partial or severe b lindness.
Dr
A 21-yea r-old fema le is adm itted to the acute med ical unit after a paracetamol overdose.
She later adm its to multiple episodes of impu ls ive self-harm and ove rdoses. She repo rts
that her recent overdose was triggered by a fight with her dad and concerns that he will
no longer want to see her. She describes long -stand ing feelings of emptiness and does
not like the way she looks.
What is the most likely underlying personality disorder?
Narcissistic persona lity disorder
Paranoid persona lity disorder
Bo rderline personal ity disorder
Dependant personality disorder
m
se
As
Avoidant personality d isord er
Dr
~rcissi stic p ersonal ity disorder
Para no id perso na lity disorder
Borde rline personal ity disorder

-
......,
Dependant persona lity disorder
Avo idant personality d isord er

-
......,
Bo rde rline perso nal ity diso rder is associated with impulsivity, feelings o f em ptiness,
fea r of aba ndonment a nd unstab le se lf image
The correct a nswer is borde rline persona lity disorde r. Patie nts with persona lity disorde r
have di stu rbances in behaviou r and personality that resu lt in considera ble pe rsonal a nd
social distress across a ll areas of life. Bo rderline o r emotiona lly unstab le pe rso na lity
disorde r is cha racterised by e motiona l in sta bility, impulsive b ehaviour and inte nse but
unsta ble re lationships with othe rs. Patients ofte n fea r a bando nment of those close to
them a nd may ido lise these peo ple. As in the patient describ ed, they ofte n have feelings
of emptiness, poo r self-image and recurrent attempts at self-ha rm. The re is an association
between the develop ment o f borde rli ne pe rsonality d isord e r and history of trau ma o r
a buse in child hood.
Narcissistic p ersona lity disorder is incorrect. These patients have a n ove r exaggerated
sense of self-i mpo rtance, lack empathy and tend to have a sense of entitle me nt.
Optio n 2 is incorrect. Pa rano id personality disorde r presents in patie nts who are re luctant
to confide in othe rs. They o ften questio n the loyalty o f friend s a nd family and can be
unfo rgiving. They ca n see hidden meanin g in things o r a re concerned about co nspiracy
theories.
Patie nts with d e pendent persona lity diso rde r strug gle to make eve ryday life d ecis io ns a nd
require reassurance and sup port fro m othe rs. They cope best when in a relationship and
fea r b eing alone. Wh ilst the re are features in the stem o f the patient id o lising he r father
the re is no evide nce of d e pendent persona lity disorde r.
Optio n 5 is a lso incorrect. Avo ida nt pe rsona lity d isorde r is characterised by avoi dance of
social contact/re lationships due to fear of be ing criticised, rejected o r embarrassed.
Patie nts view themselves as inferio r to othe rs a nd so are not keen to be invo lved unless
they a re certain of being li ked.
em
Further info rmatio n on persona lity diso rde r can be fo und in the lCD 10 g u id e -
s
As
http:/ I a pps.who.int/ cia ss ificatio ns/icd 10/ browse/ 20 16/ en#/ F66
Dr
A 34-yea r-old ex-soldie r with a histo ry of post-traumatic stress disorder returns fo r
review. He has ha d a course of eye movement d esensitisatio n a nd reprocessing therapy
which was not he lpful and is reluctant to try cogn itive b ehavioural therapy. Of the options
listed, which medication may be usefu l in such patients?
Fluoxetine
Citalop ram
Mirtazapine
Topiramate
m
se
As
Buprop ion
Dr
Fl uoxetine ED
Citalopra m CD
I Mirtazapine CD
Topiramate
•m
m
se
Bup ropion
As
Dr
An 88-year-old woman is brought to her GP by her daughter b ecause of new memory
problems. She did not want to attend as she is worried about her memory and does not
want to be diagnosed w ith dementia. She scores 12 out of 30 on a mini-mental st ate
exam.
Her memory is globally impaired with failure to retain new information as well as failure
to remember important events from her life. Her daughter reports this has been the case
for the past two months and she was previously fine and had no cognitive concerns. Her
daught er also reports she is struggling w ith sleep and her appetite has reduced
significantly in this time although the patient does not th ink this is the case.
What is the most likely cause of her memory impairment?
Alzheimer's disease
Chronic small vessel ischaemia
Lewy body disease
Acute delirium
m
se
As
Depression
Dr
Alzheimer's disease
Chronic small vessel ischaemia
Lewy body disease
Acute d elirium
-
~
Dep ress ion
Severe depression can mimic dementia but gives a pattern of global memory loss
rather than short-term memory loss - this is ca lled pseudodementia
It can ohen be difficu lt t o ascertain t he cause o f memory impairment off a single

encounter but t here are three main causes to consid er:
• A d ementia process.
• An acute d eliriu m.
• Depress ion (also called pseud odement ia).
The key features here which indicate it is not a dementia p rocess are t he short length of
time (less t han six mont hs) and global memory loss. The b iolog ical sympt oms o f p oo r
sleep and loss of ap pet ite as well as worry about memory would also not fit with a
d ementia process. You wou ld expect an early stage d ement ia patient to remember
significant life events which occurred many years earlier as the first memory issues that
occur are usually related t o loss of sho rt-term memory and inability t o remember new
things.
Depress ion ca n produce a d ement ia-like pictu re in a very short t ime p erio d in the elderly
em
and for th is reason it is so met imes known as pseud o -d ement ia.

s
As
Dr
A 65 -year-o ld male with a background of chronic alcoho l excess and previous Wernicke's
encepha lopathy is adm itted to the acute medical take with behavioural d isturbance. He
has not consumed alcoho l in the past 2 yea rs.
Which of the following phenomena is he likely to display on fu rther assessment?
Confabu lation
Dysthymia
Hydrophobia
Lilliputia ns
m
se
As
Perseveration
Dr
I Confabulation QD
Dysthymia m '
Hydrophobia m
Lilliputians CD
Perseveration CD
Confa bulation in a patient with ch ron ic alcoholism p oints towards Korsa koff's
syndrome
Ko rsakoff's is cha ract erised by confa bulation and amnesia, typically occurring in alcoholics
secondary to chronic vitamin Bl (thiamine) deficiency. Dysthymia ref ers t o mild
depression; hydrophobia is a feature of rabies; Iiiiiputians may be observed in delirium
m
se
tremens; perseveration is repetitive speech patterns, commonly seen after traumatic brain
As
injury.
Dr
A 21-yea r-old female patient is be ing investigated for a personality disorder. She is fo und
to be low in self-esteem and fearful of criticism o r rejection, particula rly in socia l
s ituations. She reports struggling to make friend s at wo rk despite bein g d esperate to be
liked. She feels that her colleagues a re much better at he r job than her. She beco mes very
a nxious eve ry d ay o n the way to wo rk as she worries she will make a fool of herself. As a
result, she struggles to hold d own a job often moving jobs regu la rly. She has had the
same expe rience with re lationsh ips out of wo rk as she d oes not feel good enough for
a nyo ne.
Dependa nt persona lity disorder
Pa ranoid persona lity disorder
Bo rde rline perso nal ity disorder
Histrionic personal ity disorder
m
se
As
Avoidant pe rso nality d isord e r
Dr
Patients with avoid ant personal ity d isorder a re fearfu l o f criticism, b eing unliked,
rejection and ridicule
The correct answer here is 5 -avo idant personality disorder. Patients with personality
diso rder have disturbances in b ehavio ur and p ersona lity that result in consi dera ble
pe rsonal and socia l distress across a ll a reas of life. As in the stem, patients with avo idant
pe rsonal ity diso rder tend to avo id social contact/re lationships d ue to fea r of b eing
c riticised, rejected o r em ba rrassed. They view themselves as inferio r to others and so are
not keen to b e invo lved u nless they are certa in of be ing liked . They sometimes have an
o ve rwhe lm ing sense of tension o r app rehension.
Patients with d e pendent pe rsonal ity diso rder strug gle to make eve ryday life d ecis ions a nd
require reassurance and sup port fro m others. They ten d to lack in itiative and feel they are
unab le to look aher themselves. They cop e best when in a relationsh ip and fear being
a lone. As such this not the co rrect answe r.
Paranoid persona lity disorde r presents in patients who a re reluctant to confide in others.
They ohen question the loya lty of friend s and fa mily a nd can be unforg iving. They can see
hi dde n meaning in things o r a re concerned a bout consp iracies. The re is no evid ence o f
pa ra no id p ersonality disorder in this stem.
Bo rde rline persona lity diso rde r is cha racterized by emotional insta bility, impulsive
behaviour and intense but unsta ble re lationships with othe rs. They oh en have feelings of
em ptiness, poor self-image and recu rrent attempts a t self-harm. Aga in making this an
inco rrect answer.
Histrionic persona lity diso rde r is seen in patients who crave being the centre o f attention,
they can be sexua lly inappro priate in behaviou r o r ap pea rance and suggestible. These are
not the featu res described in the stem.
s em
Further info rmation on persona lity diso rde r can be found in the lCD 10 g u ide -
As
http:/I a p ps. who.int/ cIa ss ificatio ns/icd 10/ browse/ 20 16/ en#/ F66
Dr
An e lderly patient in a nursing home is started on quetia pine due to persistent aggressive
behaviour that has not res ponded to no n-pha rmacolog ica l approaches. Which of the
following adve rse effects do anti psychotics increase the risk of in elderly patients?
Atrial fibrillation
Aspiration pneumonia
Stroke
m
se
As
Breast cancer
Dr
m
se
Anti psychotics in the elderly - increased risk of stroke and VTE
As
Dr
A 39-year-old patient is taking phenelzine, a monoamine oxidase inhibitor, for the
treatment o f depression. Which one of the following foods can the patient safely eat?
Bovril
Cheese
Oxo
Eggs
m
se
As
Broad beans
Dr
Bovril CD
Cheese f!D
Oxo CD
I Eg g s CiD
m
se
Broad beans 6D
As
Dr
Which one o f t he followin g is not a recognised feature o f anorexia nervosa?
Hypoka laemia
Low LH
Low FSH
m
se
As
Reduced growth hormone levels
Dr
Hypokalaemia
Low LH
Impaired glucose tolerance

-
...wr
I
Low FSH
Reduced growth hormone levels

-
...wr
Anorexia feat u res

• most t hings low
• G's and C' s ra ised: growth hormone, g lucose, salivary g lands, cortisol.
cholesterol, carotinaemia
m
se
As
Dr
Which one of the following side-effects is more common with atypical than conventional
anti-psychotics?
Akath isia
Weight gain
Galactorrhoea
Parkinsonis m
m
se
As
Ta rdive dyskinesia
Dr
Akathisia CD
I Weight gain
Galactorrhoea
GD
.
(D
Parkinso nism CD
Tard ive dyskinesia tED
m
se
Atypical antipsychotics commonly cause weight gain
As
Dr
A 35-year-old man with a history of schizophrenia is transferred to the Emergency
Department due to an oculogyric crisis. What is the most appropriat e treatment?
Selegiline
Haloperidol
Procyclidine
Bromocriptine
m
se
Cabergoline
As
Dr
Seleg iline CD
Haloperido l GD
Procyclid ine ED.
Bromo criptine GD
Cabergo line f.D
m
se
As
Benztro pine is a lso an a ppropriate treatment
Dr
You a re looking aher a 36-year-old female patient on the wa rd when you become
concerned rega rding her behavior towards you. She has made a numbe r of sexually
inap propriate com ments and on your last review she was wearing sed uct ive underwear.
She is ohen disru ptive o n the wa rd ma ki ng a scene and easily encouraged by other
patients. You r consultant advises you to avo id seeing the patie nt on her own and that he
is aware the patient has a p ersonality disorder.
What is he r most like ly d iagnosis?
Histrionic perso nal ity diso rder
Schizoid personality disorder
Schizotypa l p ersonality disorde r
Antisocial p ersonality disord er
m
se
As
Bo rde rline perso nal ity diso rder
Dr
I Histrionic perso nal ity diso rder CD
Schizo id pe rso nality disorder fD
Schizotypal personality disorder CD
Antisocial personality disorder m
Borde rline pe rso nal ity diso rder GD
Histrionic personal ity diso rder is characterised by inap prop riate sexual
seductiveness, su ggestibil ity and intense re lationsh ips
The correct a nswer is 1 - histrionic personal ity diso rde r. Th is condition is seen in patients
who crave be ing the center of attention, can be sexua lly inappro priate in behavior o r
a ppea ra nce and a re hig hly suggestible. They can d evelo p intense relationships but at
o th er times read more into the intimacy of a re lationship that is actually the re.
Optio n 2 is incorrect. Patients with sch izoid personality disorder tend to have a lack o f
interest in sexual inte ractions making this an unlikely diagnosis based on the patient in
q uestion. They are o ften cold and lack close friendsh ips, pre ferring to spend time alone.
Patients with schizotypal personality disorder can have o dd/ eccentric beliefs o r behavio r.
Simila rly to the patie nt in this q uestio n they can be inapp rop riate howeve r struggle to
make friend s a nd can be paranoid/susp icious making this less likely the correct answe r.
Patients with antisocial personal ity diso rde r o ften fa il to comply to socia l norms in terms
o f lawfu l be havior resulting in mu ltip le a rrests. They a re prone to getting into fig hts due
to aggressiveness and can be d eceitful pa rticularly when seeking materia l ga in. They can
have a d isrega rd fo r safety and lack re morse. This does not d escribe the patient in the
stem.
Optio n 5 is a lso incorrect, borde rline persona lity disorder is cha racterised by emotiona l
instab ility, impulsive behavior, feelings of e mptiness and recurrent attempts at self harm.
s em
Simila rly to histrion ic personality disorder they also have intense relatio nships however
As
these a re o ften unstable.

Dr
A 72-yea r-old man who is having tro uble sleeping is p rescribed temazepa m. What is the
mechanis m of action of te mazepam?
Inhibits the effect of a cetylcholi ne
Enhances the effect o f gam ma-a minobutyric a cid
Inhibits the effe ct gamma-a minobutyric a cid
Inhibits the effect of glutamate
m
se
As
Inhibits the effect of norad re nal ine
Dr
Inhibits the effect of a cetylcholi ne
Enhances the effect of gamma -aminobutyric acid

- ~
Inhibits the effect gamr a-a minobutyric a cid
Inhibits the effe ct of glutamate

-
~
Inhibits the effect of norad re nal ine
m
se
Benzodiazep ines enhance the effect of GABA the ma in inhibitory neurotransmitter
As
Dr
A s lim 22 year-o ld dra ma stu dent presents with weakness and muscle cramps. She has a
past medica l histo ry of reflux and a sthma, for which she takes la nsoprazole 30mg o nce
d aily, inha led salbuta mol PRN, and once-da ily inha led corticosteroid . She re ports feeli ng
stressed lately as she has a lea ding role in a significant stage p rodu ction due to o p en in
o ne week. Her hea rt rate is 87b pm, b lood p ressure 103/ 7lmmHg, respirato ry rate 13/ min.
Her blood results are shown:
pH 7.46
Na+ 137 mmoi/ L
K+ 2.6 mmoi/L
Chloride 93 mmoi/L
Magnesium 0 .61 mmoi/L
What is the most likely cause for her symptoms?
Diuretic ab use
Steroid use
Stress
Bulimia
m
se
As
Gitel ma n Synd ro me
Dr
Diuretic ab use fD
Steroid use m.
Stress CD
Bulimia CD
Gitel ma n Synd rome tiD
This is a hard question reflecting a di fficult real-wo rld cha llenge: differentiating between
causes o f hypochloraemia, which ca n be caused (among st others) by Gitelma n syndrome,
bulim ia a nd diureti c abuse. In haled steroid use an d stress wo uld not be res ponsib le for
such ma rked electrolyte dera ngement. Gitelman syndrome, althou gh fitting, is very rare
and would not be considered the most likely diag nosis. As su ch the two remai ning
options are bulimia and di uretic a buse. The scales a re tipped towards bulimia by the mi ld
metabolic alkalosis and histo ry of gastroesophageal reflux (more p re valent in bulimia)
requiring hig h-do se PPI to control -an unusua l requirement in a yo ung slim patient.
m
se
Other potential signs would be parotid gland swelli ng a nd dental enamel erosion induced
As
by regular vomiti ng. Diuretic ab use tends to g ive a hypo chlo raemic acido sis.
Dr
A 34-year-old man originally from West Africa is seen in January with depression. There is
no past medica l hist ory of not e but he is known to smoke canna bis. He has had similar
episod es for t he past two winters. What is the most likely diagnosis?
Cyclothymic disorder
Atypical dep ression
Seasonal affective disorder
Schizo phrenia
m
se
As
Drug -i nduced d ep ression
Dr
Cyclothymic diso rder
Atypical dep ressio n
Seasonal affective disorder
Schizop hren ia
m
se
As
Drug- indu ced d e pression ~
Dr
You review a 45-year-old man w ith a long hist ory of bipolar diso rder. Accord ing to NICE
and National Patient Safety Ag ency (NPSA) guidelines, how often shoul d lithium levels b e
checked once a stable d ose has been ach ieved?
Every month
Every 2 months
Every 3 months
Every 4 months
m
se
As
Every 6 months
Dr
Every month «D
m.
.,
Every 2 months
I Every 3 months
Every 4 months m
Every 6 months fiD
Lithium levels should b e checked every 3 months once a stable dose has been
m
se
achieved
As
Dr
A 23-yea r-old male presents to his GP two weeks after a road traffic accident concerned
about increased anxiety levels, lethargy and headache. At the time he had a CT brain after
banging his head on the steering wheel, which revea led no abnormality. Six months
following this episode his symptoms have resolved. What did his o rig inal symptoms likely
represent?
Conversion disorder
Post-traumatic stress disorder
m
se
As
Post-concussion syndrome
Dr
Conversion disorder
Post-traumatic stress d iso rder
Genera lised anxiety disorder
Post-concussion syndrome
m
se
In post-traumatic stress disorder the onset of symptoms is usually delayed and it tends to
As
run a p rolonged cou rse
Dr
A 47 -yea r-old a lcoholic has been b rought to the emergency d e partment by his brother.
His brother states that he has b een confused fo r the last few days and has fallen ove r a
few times. On exam ination, he has an unsteady ga it. He cannot remember the first female
p rime minister of the UK o r the journey to the e me rgency d e partment. He claimed he
went to the park yesterday - which his bro the r states are untrue. Considering the cli nica l
p ictu re, what is the most likely diag nosis?
Ko rsakoff's syndro me
Alzhe imer's disease
Acute d e liriu m
m
se
As
Lewy-body d ementia
Dr
Wernicke's encephalopathy CD
I Ko rsakoff's syndrome ED
Alzheimer's d isease CD
Acute delirium CD
~
Lewy-body dementia m
Korsakoff's syndro me is a complication o f We rn icke's e ncep ha lopathy. It's features
include: anterog ra de amnesia, ret rog rade am ne sia, an d co nfabu lation
Wernicke's encephalopathy is characterised by ataxia, ophthalmop leg ia a nd co nfusion.

This patie nt had confusion and an unsteady gait (a sign o f ataxia) . Howeve r, the patient
has symptoms o f Korsakoff's syndrome: anterograde amnesia (unable to form new
memories), retrogra de amnesia (unable to recall past memories) and confabulation
(making up new memories) sug gesting his Wern icke's ence phalopathy has progressed .
m
se
Alzheimer's d isease gene rally affects memory in a stepwise p rogression. Lewy- body
As
d ementia classically has signs o f parkinson is m and a lso hallucinations.
Dr
Which of the following types of tricyclic antidepressant is considered the safest in
overdosage?
Nortriptyline
Imipramine
Dosulepin
Lofepramine
m
se
Clomipramine
As
Dr
Nortriptyline .
f!D
Imipramine GD
Dosulepin .
f!D
Lofepra mine fD
Clom ipra mine CD
m
Lofep ramine - the safest TCA in o verdosage
se
As
Dr
The sister of a 34-year-old man comes to see you in clinic as she is worried her b rother
may have a personality d iso rder. She repo rts her bro ther has a lways had a heightened
opin ion of himsel f and often expresses delusional thoughts regardi ng his potentia l for
success as a banker believing he is capa ble o f making millions. He does not seem
pe rturbed by bring ing others down in the process and appears pleased when he ta lks of
o thers fail ures. She re me mbers he behaved simila rly when they were g rowing up and was
unsympathetic towards her when she had to res it her finals due to ill hea lth.
What pe rsonal ity disorder is she describing?
Antisocial p ersonality disord er
Schizoid pe rsonality diso rder
Schizotypal p ersonality disord er
Bo rde rline pe rsonal ity disorder
m
se
As
Narcissistic p ersona lity disorde r
Dr
Na rcisstic personalities lack empathy, have a sense of e ntitle me nt a nd take
a dvanta ge of others to a chieve their own need
The correct answer is na rcissistic personality disorde r. Whilst her brother may not actua lly
qualify for having a persona lity diso rde r if his behaviour d oes not cause him perso nal
distress o r prevent him functioning socially, many of these featu res are seen in narcissistic
behaviour. These patients have a heig htened impression of self-im portance an d
entitlement often believing they have unli mited abilities to succeed, become powerful or
look beautiful. Additiona lly, they lack em pathy and will hap pily take advanta ge of others
to achieve their own need. ln keeping with many p ersonality disorders his symptoms
appear to have been present since childhood and into adult life.
Patients with antisocia l personal ity disorder also lack empathy or feelings of
guilt/remorse. Simila rly to na rcissistic pe rsonalities they can be d eceitful when wanting to
achieve their own need. However, in contrast to na rcissists they often fail to comply with
rules or laws resu lting in criminal offences and a re p rone to getting into fights. As such
the patient in the stem fits more closely with na rcissistic personal ity disorder.
Patients with schizoid persona lity disorder tend to have a lack o f interest in sexual
interactions a re cold and lack close friends hips preferrin g to spend time alone. They are
also indiffe rent to praise ma king th is un likely to be the correct answer.
Option 3 is incorrect. Patients with schizotypa l persona lity disorder can have
odd/eccentric be liefs or behaviour. They can also struggle to make friend s and can be
pa ranoid/ suspicious as opposed to lacking e mpathy o r having a sense o f entitlement.
Option 5 is also incorrect, borderline p ersonality d isorder is cha racterized by emotional

instab ility, im pu lsive b ehaviour, feelings o f emptiness and recurrent attempts at self-harm.
s em
As
I •• I 'f • Discuss Improve J

Dr
Which cla ss o f drug have the Med ici nes a nd Healthcare products Regu lato ry Ag ency
wa rned may be associated with an increa sed risk of ve nous thromboe mbol ism in elderly
patients?
5HT3 a nta gonists
Third generation cephalo spo rins
Benzo d iazepine s
m
se
As
Atypical antipsychotics
Dr
5HT3 a nta gonists
~ird g ene ration ce phalosporins

Benzo d iazep ine s
I Atypical antipsychotics
m
se
Antipsychotics in the e lderly - increased risk of stroke and VTE
As
Dr
Which one o f the following is least recognised as a potential adverse effect of
electroconvulsive t herapy?
Nausea
Epilepsy
Card iac arrhythmias
Short term memory impairment
m
se
As
Head ache
Dr
Nausea
Ep ilepsy
Cardiac arrhythm ias
Short term memory im pairment
Head ache
m
se
Although electroconvulsive the rapy, by definition, causes a controlled seizure there is no
As
increased ris k o f ep ilepsy in the long -term.
Dr
A 30-year-old man p resents to his doctor as he has been feeling generally 'out of sorts'
for the past few weeks. He is accompanied by his girlfriend who says he has 'not been
himself'. She is worried and feels he may need to see a psychiatrist. There is no history o f
past mental health problems. Wh ich one of the following symptoms would be most
suggest ive of depression?
Palpitations
Nausea before certain situations e.g. getting on a bus
Early morning waki ng
Excessive gambling
m
se
As
Flash-backs to ch ildhood problems
Dr
Palpitations
Nausea before certain situations e.g. getting on a bus
Early morning wakin g
Excessive gambli ng
-
. ..wr
Flas h-backs to childhood p roblems
Early morning wakin g is a classic somatic symptom of dep ression and o ften develops
earlier than general insomnia.
Pa lp itations an d nausea and more common with anxiety. Excessive gambling may suggest
m
e ither a simple g a mbli ng ad diction or be part of a hypoma nic/man ic disorder.
se
As
Flash-backs are common in post-traumatic stress disorder.
Dr
A 16-year-old girl is brought for review by her father. She is ta lented violinist and is due
to start music college in a few weeks time. Her parents are concerned she has had a
stroke as she is reporting weakness on her right side. Neurological examination is
inconsistent and you suspect a non-organic cause for her symptoms. Despite reassu rance
about the normal examination findings the girl remains unable to move her right arm.
What is the most appropriat e term for this behaviour?
Conversion disorder
m
se
0
As
Munchausen's-by-proxy syndrome
Dr
Hypochondria I diso rder
Conversion disorder
Munchausen's-by-proxy syndrome
-
~
Conversion disorder - typical ly involves loss of motor or sensory function. May be

caused by stress
m
se
This is a typical conversion disorder. There may be underlying tension regarding her
As
musical career w hich be manifestin g itself as apparent limb weakness.
Dr
A 39-year-old ma n comes for review. Six months ago he was started on paroxetine for
depression. Around five days ago he stopped taking the med ication as he felt that it was
having no benefit. His on ly past medica l history of note is asthma. For the past two days
he has experienced increased anxiety, sweating, headache and the feeling of a needle like
sensation in his hea d . Du ring the consu ltation he is pacing around the room. What is the
most explanation for his symptoms?
Bipolar disorder
Malingering
Selective serotonin reuptake inhibitor discontinuation synd rome
Migraine
m
se
As
Dr
l si polar disorder
r
Malingering
Selective serotonin reuptake inhibitor discontinuation syndrome
Migraine
-
~
m
se
Paroxetine has a higher incidence of discontinuation symptoms than other selective
As
serotonin reuptake inhibitors.
Dr
A 52-yea r-o ld man is b roug ht into the emergency depa rtment having attem pted to take
his own life. He was found at ho me with empty packets o f paracetamo l by his side . He is
still conscious. A histo ry is taken fro m him to assess hi s risk of furthe r attempts.
Which o f the fo llowing is conside red to be the stro ngest risk factor fo r successful suicid e?
Being a fe male
Being married
Having five ch ildren
Addict io n to op iates
m
se
As
Having never seen a Gene ral Practitio ner
Dr
Being a female
Being married
-
......,
Having five ch ildren
Addiction to opiates
Having never seen a General Practitioner
A male w ith a history of alcohol or drug abuse and deliberate self harm shou ld b e
cons idered t o be at high risk o f suicide
This question requ ires you to reca ll the major risk factors for su icide.
Being a female -This is not the most appropriate answer given the options available. In
fact, being male is one o f the most significant risk factors for suicide.
Being married - This is not the most appropriat e answer given the options available.
Having family support is an important protective facto r for suicide.
Having five ch ildren -This is not the most appropriate answer given the options available.
Having children at home is thought to be a protective factor.
Addict ion to opiates - This is correct. Alco hol or drug misuse is one of the major risk
factors for suicide.
Having never seen a General Practitioner- This is not the most appropriate answer given
em
the options available. Having a chronic mental or physical condition is however a risk
s
As
factor for suicide.

Dr
You are considering prescribing a tricycl ic antidepressa nt for a patient who has not
responded to two different types of selective serotonin reuptake inhibit ors. Which one of
the following tricyclic antidepressants is most dangerous in overd ose?
Dosulepin
Imipramine
Clomipramine
Nortriptyline
m
se
As
Lofepramine
Dr
I Dosulepin CD
Imipramine CD
~omipramine f!D
Nortriptyline GD
Lof epramine «D
m
se
Dosulepin - avoid as dangerous in overdose
As
Dr
A 73 -year-old male pat ient w ho lives alone presents wit h recurrent episodes of pleasant
visua l hallucinations but no clouding o f consciousness or confusion. He t ells you he
knows the hallucinations are not real. He is normally fit and well with the exception of
visua l impairment.
Given t he likely diagnosis, w hat opht halmic cond ition is he most likely to suffer from?
Glaucoma
Diabetic retinopathy
Retinal d etachment
Age- related macular degeneration
m
se
As
Cataract
Dr
Glaucoma
~abetic retino pathy

Age-re lated macu la r degene ration
Cata ract
Age- re lated macu la r degene ration is associated with Charles-Bonnet synd rome
Th is patient has Charles-Bonnet syndrome (CBS) as evidenced by visua l hallucinations

with normal insight on a background of visual impa irment. He also lives alone which
cou ld be another risk factor fo r CBS if this leads to him becoming socia lly iso lated. 11-
lS% of patient with severe visual impairment are thought to have coexisting CBS and
experience recurre nt, pe rsistent or episodic visua l or auditory hallucinations. The most
common ophthalmological condition associated with CBS is age-related macu la r
d egeneration and hence this is the correct answer.
Glaucoma and cataract are the next most common causes of visua l impai rment associated
with CBS. CBS can, however, occur in any ophthalmic condition making 1,2,3 and 5 all
possible but less common causes than age-related macular d egeneration.
m
se
It is important to note that the hall ucinations a re related to fai ling eyes ight and a re not a
As
sign o f an unde rlying psychiatric condition.

Dr
A 25 -year-old man with a history o f schizophrenia is prescribed olanzapine. Which one of
the following adverse effect s is he most likely to experience?
Anorexia
Parkinsonism
Hypertension
Weight gain
m
se
As
Ag ranulocytos is
Dr
Anorexia CD
Parkinsonism CD
Hypertension fD
I Weight gain CD
Agranulocytosis GD
m
se
Weight gain is an ext remely common adverse effect of atyp ical antipsychotics such as
As
olanzapine
Dr
A 26-year-old fema le presents to the Emergency Department feeli ng su icidal after the
breakdown of her relationsh ip two weeks ago. She repo rts being fea rful of being on her
own as he had made all major decisions in the ir relationsh ip as she is not capa ble o f
making co rrect choices. She has tried online dating since her re lationship b roke down but
despite mu ltip le dates has not yet found a new pa rtner.
She advises you she was previously diag nosed with a persona lity disorder. What is the
most li kely diag nosis?
Bo rderline persona lity disorde r
Paranoid personality disorde r
Narcissistic personality diso rder
Dependent persona lity disorde r
m
se
Avoidant pe rsonality d isorder
As
Dr
Borderline persona lity disorder
Paranoid personality disorder

-
~
Narciss istic personality disorder
Dependent personality disorder
Avoidant personality d isorder
Patients with d e penda nt persona lity disorde r requi re excessive reassu rance from
others, seek out re lationships and requ ire others to take respo nsibil ity fo r major life
d ecisions
The correct answer is dependent persona lity disorder. The patient in the question is
struggl ing to cope aher the b reakdown of a relatio nship. Patients with this persona lity
disorder strugg le to make everyday life decisions and require reassurance and support
from o thers. They feel they a re unable to look aher themselves and become fearful when
leh to do so. As in this patient whose relationship only b roke down 2 weeks ago but has
already been on multiple d ates, they cope best when in a relationship and urgently seek
out new relationships if one fails. They will o hen passively comply with the wishes o f
o thers.
Bo rderline personal ity disorder is cha racterised by emotional instability, impulsive

behaviour and intense but unsta ble relationships with others. Patients o hen fear
abandonment but do not seek out excessive reassurance and a re able to make life
decisions making this the incorrect answer.
In contrast to dependent personality d isorder, pa ranoid personality disorder presents in

patients who a re reluctant to confide in others, question the loyalty of friends and family
and ca n be unfo rg iving.
Narcissistic personality diso rder is inco rrect. These patients have an over-exaggerated
sense o f self-importance, lack empathy and tend to have a sense o f entitlement.
Avoidant personality d isorder is different from dependent personality disorder in that

patients avoid social contact/relationsh ips due to fear o f being criticised, rejected or
embarrassed. Patients view themselves as inferio r to others and so a re not keen to be
involved unless they a re certain of being liked.
s em
Further info rmatio n on personal ity disorder can be found in the lCD 10 guide -
As
http:/ I a p ps. who. int/ cia ss ificatio ns/icd 10/ browse/20 16/en#/ F66
Dr
A 82-year-old female who has glaucoma starts to experience visual hallucinations w hich
include seeing goldfish, black boxes and mu d sliding dow n shelves. She is completely
blind in the right eye and on ly partially sighted in the leh eye. What is the most likely
diagn osis?
Schizophrenia
Delirium
Peduncular hallucinosis
m
se
As
Anton's syndrome
Dr
Schizophrenia CD
Delirium CD
I Charles Bonnet syndrome (D.
Peduncular hallucinosis fD
Anton's syndrome CD
In a patient who is partially or fully bli nd and experiencing visual halluci nations, Cha rles
Bonnet syndrome should be considered. Deliriu m and schizophrenia also present with
visual ha ll ucinations, but with the history of bli ndness, Charles Bonnet syndro me is the
more likely diagnos is.
Anton's syndrome is is a rare symptom of brain damage occurring in the occipital lobe
characterised by cortical blindness, but will not accept they are blind despite being to ld
that they are. They don't have visua l hallucinations
m
Peduncular hallucinosis is a rare neu rological disorder that causes vivid visual
se
hallu cinations in dark environments which last for several minutes. They typically occu r
As
after a midbra in stroke. Th is diagnosis is less likely given the history of blindness.
Dr
A wo ma n who gave b irth 5 d ays ago presents for review as she is concerned a bout her
mood. She is having difficulty sleeping and feels generally anxious and tearful. Since
givin g birth she has a lso found herself snapp ing at her husband. This is her first
p regnancy, she is not breast feeding and there is no history of mental health d iso rders in
the past. What is the most app ro priate ma na gement?
Explanation and reassurance
Cogn itive b ehavioura l therapy
Trial of flu oxetine
Trial of cita lopram
m
se
Discuss with psychiatric tea m to consider admission to mother an d baby un it
As
Dr
Exp lanatio n and reassu rance
Cog nitive behavioura l therapy
Tria l of fluoxetine
Tria l of cita lopram
Discuss with psychiatric team to consider admission to mother and baby un it
m
se
This woman has the baby- blues which is seen in around two -thirds of women. Whilst
As
poor s leeping can be a sign o f d epression it is to be expected with a new baby!
Dr
A 68-year-old gentleman is brou ght into hospital by his husband who says he has
reported seeing flashing images of foxes and badgers in their living room. This is
something that is extremely distressing to the patient, and has made him reluctant to
venture into some areas of the house. You wonder if this might be Charles-Bonnet
syndrome.
Which of the follow ing risk factors may pre-dispose this gentleman to Charles -Bo nnet
syndrome?
Caucasian
Peripheral visual impairment
Male gender
Hypertension
m
se
As
Occupational history of working in sewers
Dr
Caucasian
Peripheral visual impairment
Male gender
Hypertension
-
~
Occupational history of working in sewers
Charles-Bonnet syndrome - peripheral visual im pairment is a risk factor

Charles-Bonnet syndrome is characterised by visual hallucinations associated with eye

disease.
Most common visual hallucinations are faces, children and wild animals.
m
se
It occurs in patients of increasing age; equally amongst males and females; and with no
As
known increased risk with fam ily history.
Dr
A 33-yea r-o ld female is b rought to the GP by her co ncerned mother. The patient re ports
that the prime mi nister is secretly in love with her, despite her mother protesting there
has never been any contact between them. Wh ich psychiatric disorder does this fit with?
Couvade syn drom e
Bouffee d e lirante
Fregoli d elusion
Capgras delusion
m
se
As
De Clerambault's syndrom e
Dr
Couvade syndrome GD
Bouffee d e lira nte (iD
Fregoli d elusio n GD
«D
..
Capg ras d elusio n
I De Cleram bault's syndrome
Bouffee d elirante is an a cute psychotic disorde r in which ha ll ucinations, d elusions o r

perceptual disturbances a re o bvious b ut ma rkedly va riab le, changing from d ay to day or
even from hour to hou r.
Fregoli d elusion is the mista ken be lief that some person cu rre ntly present in the d eluded
person's e nviro nment (typically a strang er) is a fam iliar person in disgu ise.
Capgras d elusion is the belief that s ig nificant othe rs have been rep laced by imposto rs,
ro bots o r a liens.
m
Couva de is the common but poorly und erstood phe nomeno n where by the expectant
se
fathe r experie nces somatic sympto ms during the pregna ncy fo r which the re is no
As
recognised physiological basis. Dr
A patient with a history of depression presents for review. Wh ich one of the following
suggests an increased risk of suicide?
Being 25-years-old
History of arm cutting
Being married
Female sex
m
se
As
Having a busy job
Dr
Being 25-years -old CD
~tory of arm cutting fZD
Being married CD
I Female sex fD
Having a busy jo b CD
Whilst a rm cutting may sometimes be characte rised as atte ntion-seeking o r 're leas ing the
m
se
pain' studies s how that any histo ry o f deliberate self harm s ignificantly in creases the risk
As
o f suicid e. Employment is a p rotective facto r
Dr
Which one o f the following is not associat ed with a poor prognosis in schizop hrenia?
Acute onset
Stron g family history
Low !Q
Pre morbid history of social withdrawal
m
se
As
Lack of obvious precipit ant
Dr
I Acute onset
Strong fam ily history
Low !Q
-
~
I Premo rb id history o f social withd rawal
Lack of o bvious p recipita nt
m
se
As
A gradua l, rather than acute, o nset is associated with a p oo r prognosis
Dr
A 27-yea r-o ld wo man is broug ht in by her husband . She has b een refus ing to g o outs ide
fo r the past 3 months, te ll ing he r husband s he is afra id of catching avia n flu. On exp loring
this furthe r she is concerned d ue to the hig h nu mber of mig ratin g birds she can see in her
g a rden. She reports that the presence of her husbands socks on the washing line in the
g a rden alerted her to this. What is the most like ly diagnosis?
Depression
Forma l thought diso rder
Bo rde rline perso na lity disorde r
m
se
As
Acute pa ranoid schizophrenia
Dr
m
se
As
The washing line comment is an example of a delusional percept ion - see be low
Dr
A 46-yea r-old man is seen by an occupation hea lth doctor due to lon g -term sickness
leave. He states chronic lower back pa in p revents him from wo rking but exa mination
findings are inconsistent and the doctor suspects a non-organ ic cause of his symptoms.
This is an example of a:
Conversio n d isorder
Muncha usen's syndro me
Malingering
Hypochondria I disorde r
m
se
As
Somatisation d isorder
Dr
Conversion disorder
Malingeri ng
Somatisation diso rder
Lying or exaggerating for f inanci al gain is malingering, for example someone w ho
m
se
fakes whiplash after a road traffic accident for an insurance payment
As
Dr
Which one of the following featu res is least recognised in long-term lithium use?
Alopecia
Weight gain
Fine tremor
Goitre
m
se
As
Diarrhoea
Dr
Alopecia ED
Weight gain CD
Fine tremor CD
Goitre GD
Diarrhoea QD
m
se
All the above side-effects, with th e exception of alopecia, may be seen in patients taking
As
lithium
Dr
Enid, an 87 -year-ol d lady, is exp eriencing d isturbing visual hallucinations. She sees 'evil'
looking faces on the wa ll s a nd snakes and insects on the floor. She knows that these are
not real. She has no auditory ha llucinations. She is otherwise well. She has a history of
hypertension, d epress ion, hearing loss a nd macular deg eneration. What is the most like ly
cause of her ha llucinations?
Lewy body d ementia
Acute psychos is
m
se
As
Dr
Charles-Bonnet syndrome causes unpleasant visual hallucinat ions in a third of
sufferers
The cause of this lady's visual hallucinations is Charles Bonnet syndrome. Arou nd a third
o f sufferers may experience disturb ing or unpleasant hallucinations.
Lewy body dementia may invo lve visua l hallucinations alongside f luctuating cognitive
impairment, but in the absence o f any current neuropsychiat ric symptoms t his makes t his
a less likely diagnosis.
Acute psychosis tends to involve auditory hallucinations associated with delusions.
Psychotic depression wou ld usually involve severe sympt oms of depression with the
develop ment of psychotic symptoms. m
se
As
Normal p ressure hydrocephalus does not usually involve visual hallucinatio ns.
Dr
Olanzapin e is known to block D2 dopam in e recepto rs. What other type of receptor does
it ma inly act on?
Alpha-adrenoceptors
Acetylcholi ne recepto rs
Serotonin receptors
Dl dopa mine receptors
m
se
As
Hl histam ine receptors
Dr
Alpha-adrenoceptors
Acetylcho li ne receptors
~otonin receptors
Dl dopa mine receptors
Hl histam ine recepto rs
m
se
Olanza pin e, li ke othe r atypical a ntipsychotics, is known to blo ck seroto nin recepto rs
As
(especially the 5-HT2 subtype) as we ll as D2 dopam ine receptors
Dr
A patient you a re looking after is sta rted on imipra min e fo r d e pressio n. Which
comb inatio n of s id e -effects is most likely to be seen in a patie nt taking this class of
a ntid ep ressants?
Dry mouth + urina ry freque ncy
Hypertensi on + sweating
Gastrointestinal bleedin g + dyspepsia
Head ache + myo clonus
m
se
As
Blurred visio n + dry mo uth
Dr
Dry mouth + urina ry frequency
Hypertension + sweating
-
Gastro intestinal b leedin g + dyspepsia
Head ache + myo clonus
Blurred vision + dry mo uth

I
m
se
These anti musca ri nic sid e-effects are more common with im ip ra mine than othe r types of
As
tricyclic antide pressants.
Dr
An 80-year-old ma n p resents with recu rrent episodes of hallucinations. He describes
ohen seeing faces smaller than normal or other objects out of p roportion. He finds these
episodes distressing a lthough he says he knows they're not real. His past med ica l history
includes macular degeneration and an episode of depressio n 20 years ago following the
death of his wife. Neuro logica l examination is unrema rkable. What is the most likely
diagnosis?
Schizophrenia
Charles-Bonnet syndrome
Cerebral tumour
m
se
As
Alzheimer's disease
Dr
Schizop hren ia m
I Charles-Bonnet syndrome .
CD
Psychotic depression CD
Cerebral tumour m
m
se
Alzheimer's disease m
As
~
Dr
A 19-yea r-old wo man presents to the Eme rgency d epartment having taken an overdose
of 40x500m g paraceta mol tab lets and 400 ml of vo dka. She took the ove rdose because
he r b oyfriend is go ing away fo r 2 weeks o n a course and she fears a band on ment. This is
he r 4th attendance with an overdose ove r the past 3 years. She is a lso known to the
police after an ep isode o f reckless driving I road rage. On a rrival in the un it she is tearful
a nd upset, and tells you she did it because he r boyfriend is leaving her. Vital si g ns and
g enera l physica l exam ination a re normal a pa rt from evidence of cutting her a rms. She is
given a ctivated cha rcoal. Which of the followi ng is the most likely diagnosis?
Bipola r disorde r
Anti -social personality disorde r
Borde rline perso na lity disorde r
Endogenous de pressi on
m
se
As
Drug ind uced psychosis
Dr
Bipolar disorder
Anti-socia l pe rso na lity disorder
Bo rde rline perso nal ity diso rder
Endo genous depression
Drug indu ced psychosis

-
~
Borde rline personal ity diso rder is marked out by instab ility in moods, be haviour a nd
re lationsh ips.
Diagnosis is co nfirmed by the presence of at least 5 of the following symptoms;
1) Extreme reactionsincluding panic, de pression, rage, o r fra ntic actionsto a ba ndonment,

whether rea l or perceived
2) A pattern of intense a nd stormy relationships with fa mi ly, friend s, and loved ones, often
veerin g from extre me closeness and love to extreme dislike or anger
3) Distorted and unstable self-image or sense of self, which can result in sudd en changes
in feelings, opinions, values, o r plans and goals for the future (such as school or ca reer
choices)
4) Impulsive and often d angerous behaviours, such as spendi ng sprees, unsafe sex,
su bsta nce abuse, reckless driving, and b inge eating
5) Recurring su icidal behaviou rs o r threats o r self-ha rming behaviour, such as cutting

Intense an d highly changeable moods, with each ep isod e lasting from a few hours to a
few days
6) Chronic feelings of emptiness and/or boredom
7) Inappropriate, inte nse anger or p rob lems controlling a nger
8) Having stress- re lated paranoi d thoughts o r seve re dissociative symptoms, such as

feeling cut off from oneself. o bserving oneself from outsid e the bo dy, or los ing touch with
reality.
There are no features consistent with endogenous depression, such as ea rly morning
wakening o r loss of appetite, and no featu res consistent with hypomania such as p ressure
o f sp eech, flight of id eas, or over exu berant behaviour. We are given no indication o f drug
abuse which may indicate drug ind uced psychosis. Anti-social pe rsonality diso rder is
cha racterised by a fail ure to conform to socia l norms, an d re peated law b rea king. There is
consistent irresponsi bility, impulsivity and dis regard for both their own safety and that of
em
o th ers.
s
As
Dr
The mother of a 28-year-old male who has been diagnosed with a persona lity disorder
comes to see you. She reports that her son ha s been arrested mu ltiple times and can
o hen be agg ressive getting into fights. As a teenager, he wou ld lie to obta in money,
played truant and would say unpleasant hurtful things to her without apology or a p parent
regret. He has never held d own a jo b and relies on his pa rents fo r financial support.
His mother has the name of the condition he ha s been d iagnosed with and knows you are
not able to di scuss the individual case. She asks if you can provide generic information on
his condition to a id her und e rstandin g as s he has always bla med herself for his behaviou r.
What is the most likely condition he r son has been d iagnosed with?
Avoidant pe rsonality d isorder
Antisocial personality di sord er
Bo rde rline persona lity diso rde r
Na rcissistic personal ity d iso rder
m
se
As
Histrionic perso na lity diso rde r
Dr
Avo idant personality d isord e r
Antisocial personality disorder
Borderline perso nal ity disorder
Narciss istic p ersonal ity disorder
Histrionic personal ity disorder
Patients with antisocia l personal ity diso rder often fa il to conform to social norms,
and show lack of re morse, deception and irres ponsibility
The correct a nswe r here is 2 - a ntisocia l personality d isorder. Patients with th is cond ition
often fail to com ply with socia l no rms in terms of lawful b ehaviour resu lting in multiple
a rrests. They a re pro ne to getting into fights d ue to aggressiveness and can be d ece itful
pa rticula rly when see king material gain. They can have a disreg a rd fo r the safety of
themselves and others and are irresp onsible, fa iling to sup port themse lves financia lly.
When they d o act inap prop riately o r in a hurtful way to others, they are una ble to s how
remorse fo r their actions. There is often a histo ry of p ro blems such as truancy in
child hood. Their b ehaviour can have a sig nificant impact o n fami ly life a nd so it is
unde rstand a ble that his mother may have blamed herself in the past a nd want more
info rmation. It is im po rtant to ensure that d u ring this consultatio n confidentiality is not
breached.
Patients with avo id ant pe rsonality d iso rder tend to avo id social contact/re lationships due
to fear of b eing criticised, rejected o r e mba rrassed. They view themselves as inferior to
o thers and so are not keen to be invo lved u nless they a re certain of being liked. Hence
this is not the correct answe r.
Bo rde rline persona lity diso rde r is cha racterised by e motional insta bility, impulsive
behaviour and intense but unstable re lationships with othe rs . Patients often have feeli ngs
o f emptiness, poor self-image and recurrent attem pts at self-ha rm. Ag a in making this an
inco rrect answer.
Narcissistic p ersonality diso rder is a lso incorrect. These patients have an ove r exaggerated
perceptio n of self- im portance, lack empathy a nd t en d to have a sense of entitlement.
Histrionic persona lity diso rde r is seen in patients who crave to be the centre of attention.
They can also b e sexually inap prop riate and su ggestible and as such, this is not the
em
correct answer.
s
As
I •• I •• I tt Discuss
Dr
Improve J
A 84-year-old female att ends cli nic w ith her daughter. She has a past medical history of
hypertension and a fractured neck of femur six months ago. Her daughter reports over
the last few months she has become highly preoccupied with her blood pressure and diet
measuring her blood pressu re multiple times per day. Her daughter f eels that her
concerns over her physical health are affect ing her mood. She becomes easily agitat ed
and ohen snaps at her daught er. The patient denies any problems with her memory or
mood but does repo rt difficulty in getting to sleep.
Alzheimers' disease
Lewy body dementia
Depression
Vascular dementia
m
se
As
Hypochondriasis
Dr
Alzheimers' disea se fD
Lewy body dementia .
(D
Depression CD
Vascular dement ia GD
Hypochondriasis tiD
Elderly patients with depression are less likely to complain of low mood and instead
may present with health anxiety, agitation and sleep disturbance
Depression in elderly patients can be challenging to diagnose and less commonly

p resents w ith low mood or classica l featu res of depression. Patients ohen present with
health anxiety, poor sleep and agitation as in the question here making 3 the most correct
answer. Her recent hip fractu re and subsequent hospitalisation may have acted as a
trigger of t he low mood.
The patient does not repo rt any memory p ro blems and there is nothing else in the history
to suggest signif icant memory impairment or Parkinson's like symptoms. Whilst vascular
dementia can present w ith a change in persona lity there is no suggestion of altered
executive funct ion or confusion and hyperte nsion is her on ly vascu lar risk facto r. As such
1,2 and 4 are less likely than depression given the history. Memory problems shou ld
however be ru led out with a MMSE as pat ients w ill ohen not report concerns with t heir
mem ory and depression can be associated with memory impairment.
em
There are features of health anxiety or hypochondriasis in this stem, however together
s
As
wit h agitation and poor sleep, depression is a more likely answer.

Dr
A 84-year-old patient is brought to see you by his wife as she is worried about
hallucinat ions he has been experiencing. She reports t hat he regularly sees cats wa lking
around the house although they have never owned a cat. He is otherwise well in himself
with no o t her concerns and does not seem troubled by t he visions. He has a past medical
histo ry of hypertension, diabetes and cataracts and drinks ap proximately 20 units o f
alcohol per week.
Schizop hrenia
Parkinson's disease
Alzheimer's disease
Alcohol excess
m
se
Charles-Bonnet Syndrome
As
Dr
Schizophrenia
Parkinson's di sease
Alzheimer's disease
I
Alcohol excess
Charles-Bonnet Syndrome
-
~
Patients with Charles-Bonnet syndro me experience persistent o r recu rrent complex

visual or audito ry hallucinations however generally have full insight into their
condition
The correct answer is Charles-Bonnet Syndrome. This classically presents as recu rrent
visual or auditory hallucinations in patients with failing eyesight. It is thought that as the
brain receives less visual stimu lus tha n it is used to, it begins to fill in the gaps with
previously sto red images. Hallucinations can either be simple as in patterns o r lines or
complex as in peo ple or animals. They are usually pleasant hallucinations and most
patients retain insig ht. In this patient with a history of cataract Charles-Bonnet syndrome
is most li kely.
Whilst halluci nations can occu r in both Alzheimer's Disease and Parkinson's Disease, there
is nothing in the history to suggest any problems with memory or a tremor, making 2 and
4 unlikely. Likewise other than ha llucinations there is no fu rther evidence of schizo phrenia
in pa rticu lar no 1st ran k symptoms such as delusions, thought insertion, removal or
broadcasti ng. Additiona lly patients with Alzheimer's tend to experience auditory as
opposed to visual hallucinations.
Whilst 20 units of alcohol a week is over the revised recom mend weekly intake it is
em
unli kely significant enough to cause any serious med ical com plications. Furthermore there
s
As
is nothing else in the history to suggest alcoholism as a cause of his symptoms.

Dr
Which one of the following symptoms may ind icate mania rather than hypomania?
Predominately elevated mood
Delusions of grandeu r
Increased appetite
Flight of ideas
m
se
As
Irritability
Dr
Pred om inately e levated mood
Delusions of grand eur
Increased app etite
Flight of ideas
Irrita bility
m
se
Whilst criteria vary (e.g . ICD-10, DSM-5) the cons istent difference b etween mania and
As
hypo man ia is the p resence of psychotic symptoms.
Dr
A 24 -yea r-o ld man te lls you he is unab le to g o outside without first san itizing the d oor
hand le in a certain way. He a lso washes his ha nd s b efo re and a fte r he leaves the house.
He g oes o n to expla in that if he doesn't d o these things in a certa in o rder he g ets very
a nxious a nd uptight.
This has been go ing o n fo r two years and is upsetting him deep ly.
What is the most ap propriate treatment fo r the likely dia gnos is?
Eye Movement Desensitization and Rep rocessing Thera py (EMD R)
Trauma-focused CBT
Olanza pine
Dialectica l behaviour therapy (DBT)
m
se
As
Exposure- response preventio n (ERP) the rapy
Dr
Eye Movement Desensit ization and Reprocessing Therapy (EMDR)
Traum a-focused CBT
F nzap ine
Dialectical behaviour t herapy (DBT)
G osure-response prevention (ERP) therapy
An obsession is an intrusive, unpleasant and unwanted thought. A co mpulsion is a

senseless action taken to reduce the anxiety caused by the obsess ion
This question requires you to identify the symptoms of Obsessive Compulsive Disorder
(OCD) and know the best initial intervention.
Eye Movement Desensitizat ion and Rep rocessing Therapy (EMDR) - this is not the most
appropriat e answer. EMDR is used for patients su ffering with Post-Traumatic St ress
Disorder (PTSD)
Trauma-focused CBT - this is not t he most appropriat e answer. Trauma-focussed CBT is

also used for pat ients suffering w it h Post-Traumat ic Stress Diso rder (PTSD)
Olanzapine - t his is not the most ap prop riat e answer. Olanzapine is an atypica l
antipsychotic medication and is not used first line to t reat OCD.
Dialect ica l behaviou r t herapy (DBT) - t his is not t he most appropriate answer. DBT is a
psycholo gica l int ervention for patients with bord erline p ersonality disorder.
Exp osure- response prevention (ERP) therapy - t his is the correct answer. ERP therapy, as
em
well as cogn it ive behaviou ral therapy, is recommend ed and a first line int ervent ion for
s
As
OCD.
Dr
You review a 55-year-old woman who has beco me dependant on temazepam, which was
initially p rescribed as a hypnotic. She is keen to end her addiction to tema zepam a nd asks
for help. Her cu rrent dose is 20mg on. What is the most appropriate strategy?
Switch to the equ ivalent zopiclone dose then slowly withdraw over the next 2
weeks
Switch to the equ ivalent d iazepam dose then slowly withdraw over the next 2
weeks
Switch to the equ ivalent zopiclone dose then slowly withd raw over the next 2
months
Switch to the equ ivalent ch lo rdiazepoxid e dose then slowly withdraw over the next
2 months
m
se
Switch to the equ ivalent diazepam dose then s lowly withdraw over the next 2
As
months
Dr
Switch to the equivalent zopiclone d ose then slowly withd raw ove r the next 2
weeks
Switch to the equivalent diazepam d ose then slowly withdraw ove r the next 2
-
"""
weeks
~itch to the equivalent zopiclone d ose then slowly withd raw ove r the next 2
I months
Switch to the equivalent chlordiazepoxide dose then sl owly withdraw over the
next 2 mo nths
I Switch to the equ ivalent diazepam dose then s lowly withdraw ove r the next 2
m
se
months
As
Dr
Which one of the followin g wou ld cause a fall in the carbon monoxide transfer facto r
(TLCO)?
Acute asthma
Polycythaem ia
Exercise
m
se
As
Emphysema
Dr
Acute asthma (fD
Wegener's granulomatosis (fD
I Polycythaemia flD
fD
..
Exercise
I Emphysema
Transfer facto r
• raised: asthma, haemorrhage, left-t o-right shunts, po lycythae mia
m
se
• low: everything else
As
Dr
A 33-year-old woman is prescribed varenicline t o help her quit smoking. What is the
mechanism of action of varenicl ine?
Norepinephrine an d dopamine reuptake inhibitor, and nicotinic anta gonist
Dopamine agonist
Dopamine antagonist
Selective serotonin reupta ke inhibitor
m
se
As
Nicotinic recepto r partial agonist
Dr
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Dopamine agonist
- ~
Dopamine antagonist
Sel~ctive serotonin reupt ake inhibitor
m
se
Nicotinic recepto r partial agonist
As
Dr
You are reviewi ng the results from investigations request ed at the previous respiratory
clinic. A 40-year-old man is b eing investigated fo r increasi ng shortness of breath. The
notes show he has smoked for the past 25 years. Pulmonary function tests reveal the
fo llowing:
FEVl 1.4 L ( predict ed 3 .8 L)
FVC 1.7 L { predict ed 4 .5 L)
FEVl/ FVC 82% {normal > 75% )
Which one of the following is the most likely explanation?
Asthma
Bronchiectasis
Kyphoscoliosis
m
se
La ryngeal malignancy
As
Dr
Astt:____ fD
Bronchiectas is GD
I Kyphosco liosis CID

Chronic obstructive pu lmo na ry d isease tiD
La ryngeal malignancy CD
m
se
These results show a restrictive picture, which may result from a number o f co nditions
As
includ ing kyphoscoliosis. The o ther a nswe rs cause an obstructive p icture.
Dr
Which one o f t he followin g is a contraindication t o surgica l resection in lung ca ncer?
Haemoptysis
FEV 1.9 litres
Hist olo gy shows squamous cell cancer
Voca l cord paralysis
m
se
As
Calcium = 2.84 mmoi/L
Dr
Haemoptysis
FEV 1.9 litres
Hist olo gy shows squamous cell cancer
Vocal cord pa ralysis
Calciu = 2.84 mmoi/L
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5,
MAUGNANT pleural effusion, and vocal cord para lysis
m
se
Paralysis of a vocal cord implies extracapsu lar sp read to mediastinal nodes and is an
As
indication o f inoperability.
Dr
A 27 -year-old woman is reviewed in the asthma clinic. She currently uses salbutamol
inhaler lOOmcg prn combined with beclometasone dipropionate inha ler 400mcg bd.
Despite this she is having frequent exacerbations of her asthma and recently required a
cou rse o f prednisolone. What is the most appropriate next step in management?
Add a leukotriene recepto r antagonist
Add tiotropium
Add sa lmeterol
Start to take the salbuta mo l regula rly, 2 puffs q ds
m
se
As
Switch beclometasone to fluticasone
Dr
I Add a leukotriene recepto r antagonist
Add tiotropium
Add salmeterol
Start to take the salbutamol regularly, 2 puffs qds
Swit ch beclometasone to fluticasone
Following NICE 2017, patients with asthma who are not controlled with a SABA +
m
se
ICS should first have a LTRA added, not a LABA
As
Dr
A 79-year-old man is admitted with a right lower lobe pneumonia. As well as showing
consolidation there also appears to be a moderate sized pleural effusion on the same
side. An ultrasound guided pleural fluid aspiration is performed. The appearance of the
fluid is clear and is sent off for cu lture. Whilst awaiting the cu lture results, which one of
the following is the most important factor when det ermining whether a chest tube is
placed?
Glucose of the pleura l fluid
LDH of the pleural fluid
pH of the pleural fluid
Potassium of the pleural fluid
m
se
As
Prot ein of the pleural fluid
Dr
Glucose of the pleura l fluid .
(D
LDH of the pleural flu id GD
I pH of the pleural fluid ED

Potassium of the pleural fluid m
Protein of the pleural fluid fD
The British Thoracic Society (BTS) state that the following are the main indications for
placing a chest tube in pleural infection:
• Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should

receive prompt pleural space chest tube drainage.
• The presence of organisms identified by Gram stain and/or culture from a non-
purulent pleural fluid sample indicates that pleural infection is established and should
lead to prompt chest tube drainage.
• Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for
chest tube drainage.
m
se
pH of the pleural fluid is therefore the most useful test of the options given. As
Dr
A 29-year-old woman with a history o f asthma presents fo r review. She has recently been
discha rged from hospita l fo llowing an acute exacerbation and reports genera lly poor
control with a persistent night time cough and exertional wheeze.
Her cu rrent asthma therapy is:

• sa lbutamol inhale r lOOmcg prn
• Clenil (beclometasone d ipropionate) inhaler 800mcg bd
• sa lmetero l SOmcg bd
She has a history of missing appointments and requests a medication with as few side-
effects as possible. What is the most appropriate next step in management?
Ip ratropium inhaler
Low-dose prednisolone
Leukotriene receptor antagon ist
Modified-release theophylline
m
se
As
Omal izumab
Dr
Ipratropium inhaler
low -dose prednisolone
leukotriene receptor antagonist
Modified-release theophylline
Omalizumab
Following NICE 2017, patients with asthma who are not controlled with a SABA+
m
se
ICS should first have a l TRA added, not a LABA
As
Dr
A 67 -year-old female is referred to the acute medical unit with an infective exacerbation
of COPD. Despite maximal medical therapy the arterial blood gases continue to show type
II res piratory failure. You are asked t o consider non-invasive ventilation. At w hat pH is the
patient most likely t o receive benefit from non -invasive ventilation?
pH 7.13
pH 7.18
pH 7.23
pH 7.29
m
se
As
pH 7.37
Dr
pH 7.13 m
pH 7.18 m
pH 7.23 fD
I pH 7.29 6D
pH 7.37 CD
The evidence su rrounding t he use of NIV in COPD shows t hat patients with a pH in the
m
se
ra nge o f 7.25-7.35 achieve the most benefit. If the pH is < 7.25 t hen invasive ventilation
As
should be considered if appropriate
Dr
A 45-year-old man is noted to have bilateral hilar lymphadenopathy on chest x-ray. Which
one of the following is the least likely cause?
Amyloidos is
Sarcoidosis
Hist oplasmosis
Tuberculosis
m
se
As
Beryllios is
Dr
I Amyloidosis CD
Sarcoidosis CD
Histoplasmosis «D
I Tuberculosis flD
Beryll iosis GD
m
se
As
Amyloidosis is not com monly associated with bilateral hilar lymphadenopathy
Dr
A 60-yea r-old female with a history of COPD presents to the Emergency Department with
shortness o f b reath. Blood pressure is 120/80 mmHg and her pu lse is 90 bpm. The chest
x-ray shows a pneumothorax with a 2.5 em rim of air and no med iastinal shift.
Intercostal drain insertion
Discharge
Admit fo r 48 hou rs observation and repeat chest x-ray
Immediate 14G ca nnu la into 2nd intercostal space, mid-clavicula r line
m
se
As
Aspiration
Dr
I Intercostal drain insertion
Discha rge
I Adm!t fo r 48 hou rs o bservation and repeat chest x-ray
Immed iate 14G cannula into 2nd intercosta l space, mid-clavicu la r line
-
.......,
m
se
As
Asp iration
Dr
A preliminary diagnosis of extrinsic allergic alveolitis in a 55 -year-old man. Which one of
the following f eatures wou ld most support this diagnosis?
Clubbing
Eosinophilia
Cyanosis
Fibrosis in the upper zones
m
se
As
Hist ory of working in the steel industry
Dr
Clubbing
Eosinophilia
Cyanosis
Fibrosis in the upper zones
Hist ory of working in the st eel industry
m
se
A history o f working in the steel industry and eosinophilia are no t f eatures of extrinsic
As
all ergic alveolitis. Clubbing and cyanosis are non-specific
Dr
Which one of the fo llowin g is least associated with the deve lop ment of COPD?
Cadmium exposure
Smoking
Coal d ust
Iso cya nates
m
se
As
Alpha-1 antitrypsin d eficiency
Dr
Cadmium exposure
~moking
Coal d ust
~cyanates
Alpha-1 antitrypsin deficiency
m
se
As
Isocyanates are more associated with occupational asthma
Dr
You review a 26-year-old woman. She has a history of asthma and is prescri bed
salbutamol lOOmcg 2 puffs prn, beclometasone dip ropionate 400mcg bd a nd salmetero l
SOmcg bd. Last week she foun d out she was pregnant and stopped the beclometasone
and salmeterol inh alers as she was concerned about potentia l harm to the pregna ncy.
What is the most a p propriate action?
Reduce beclometasone to 200mcg bd and co ntinue salmeterol at the sa me dose
Stop beclometasone and salmeterol inhalers + refer to a respiratory physicia n
Reduce beclometasone to 200mcg bd and stop salmeterol
Restart beclomethasone at same dose and stop sa lmetero l
m
se
Reassure + restart beclometasone and salmeterol inhalers
As
Dr
Reduce beclometasone to 200mcg bd and continue salmeterol at the same dose 8
Stop beclometasone and salmeterol inhale rs + refer to a respi ratory physician 8
~duce beclometasone to 200mcg bd and stop salmeterol G)
Restart beclomethasone at same dose and stop sa lmeterol 8

Reassure + restart beclometasone and salmeterol inhalers fZD
Both th e BNF and British Thoracic Society guideli nes stress the need for good control o f
m
se
asthma during pregnancy. The BNF advises that 'inha led drugs, theophyll in e and
As
predn isolone can be taken as norma l during p regnancy and breast-feed ing'.
Dr
A 28-year-old girl wished to b e test ed for alp ha 1 ant itrypsin d eficiency as her mother is
suffering f ro m the condition. She is a non-smoker and has no symptoms. She has b een
t old she is unlikely to develop cl inica lly signif icant sympto ms, especially if cont inues to
not smoke, b ut will be a ca rrier o f the disease, w hat is her most likely g enotype?
PiM Z
PiZZ
PiSS
PiMM
m
se
As
PiSZ
Dr
I PiMZ CD
PiZZ GD
r;ss fD
PiM M GD
PiSZ GD
The genotype MZ has one normal allele and one affected a llele. Patients with this
genotype would be unlikely to d evelop clinically significant symptoms but are at
increased risk o f lung and liver d isease compa red to the normal population and should
avoid smoking. Patients with the genotype MM would have normal function and do not
have an affected allele, therefore, are not carriers. The genotype ZZ will develop
m
se
significant symptoms. Patients with genotype SS and SZ are at more risk of d eveloping
As
clinical symptoms over MZ as they have a more marked d eficiency.
Dr
A 24-year-o ld man with asthma s ince childhood attend ed his regular a ppointment with
his doctor. He p lans to go on a hiking trip with his friend s in o ne mo nth a nd he wants to
know if that will be safe fo r hi m. Which one of the fo llowing scena rios co rrectly describes
the hemoglobin satu ration of blood and the abil ity o f body tissues to extract oxygen from
the b lood in response to various situations?
If the hiking involves a reas of relative ly high a ltitude the hemog lobin saturation of
blood a fter flowing th rough body tissues will be higher
If the body tissues switch to anaerobic metabolism, body tissues wil l be ab le to

extract less oxygen from the b lood
The physica l exertion of hiking will have no effect on the hemog lobin saturation of
the b lood leaving body tissues
If the man is not able to breathe properly and, his bloo d carbon dioxid e level
increases, th is will cause his body tissues to extract mo re oxygen fro m his blood
m
se
An increase in body temperature du ring the hiking will decrease the a bility of the
As
body to extract oxygen from the blood
Dr
If the hiki ng involves a reas o f relative ly high a ltitude the hemog lo bin saturation
of blood after flowing throug h bo dy tissues will be higher
If the body tissues switch to a naerobic meta bolism, body tissues will be ab le to
extract less oxygen fro m the b lo od
The p hysica l e xertio n of hiking will have no effect on the he mog lo bin saturation
of thj blood leaving body tissues
If the man is not able to breathe p roper!! a nd, his bloo d carbo n dioxid e level
-~
increases, th is will cause his body tissues to extract mo re oxygen fro m his blood C!D
An increa se in body temperature du ring the hiking will decrease the ability o f
the bo dy to extract o xygen from the blood
One o f the main functio ns of the b lood is fo r hemog lobin to bind to oxygen in the lung s
a nd the n delive r the oxyg en to the bo dy tissues. Hemog lobin is s pecifica lly a dapted fo r
this fu nctio n and de monstrates pos itive coop erativity. This means that as oxygen bind to
he mogl ob in mo lecu le, it increa ses the a bility of the remaining hemog lobin molecules to
b ind oxyg en. Seve ral other para mete rs affect he moglo bin saturatio n, such as acidity,
b lood carbo n d ioxide leve ls a nd temperature a mo ngst othe rs.
1: At h ig h altitudes, the re is a rig ht s hift of the he mog lo bin dissociation cu rve. Th is mea ns
that fo r the sa me pa rtial p ressure o f oxygen, the hemog lobin saturation will b e less.
2: Ana ero b ic meta bo lism will resu lt in the pro d uct ion of lactic acid. La ct ic acid will shift
the hemoglob in saturation curve to the right and tissues will, therefo re, be a ble to extract
mo re oxyge n fro m the b lood, resulting in a lower he moglo bin saturation o f the blood
leaving the body tissues.
3: Physical activity is known to prod uce a right shift in the he mo glo bin di ssociatio n cu rve.
Phys ical activity will also increase the body's te mperatu re wh ich a lso co ntributes to the
right shift.
4 : Ca rbo n dioxide will pro d uce a rig ht shift in the hemoglo bin d issociation curve and this
will a llow the body tissues to extract mo re oxyge n fro m the blood, resulting in a lowe r
he mogl ob in saturatio n of the blood leaving the body tissues.
5: An increase in temperature is known to pro d uce a rig ht shift in the hemoglob in
dissociatio n curve allowing more oxygen to be unload ed from the blood to the body
sem
tissues being su pp lied .

As
Dr
A 64-yea r-old woman with a background of asthma is referred to the respiratory clinic
with worsening s hortness of breath ove r the past few months. She was diagnosed with
asthma when she was in her teens and currently takes an inha led corticosteroid inha ler
with an as required salbutamol inhale r which she ra rely uses. She does not d escribe any
wheeze o r noctu rna l symptoms and he r inhaler technique in the clinic is excellent. She
te lls you that she is compliant with he r medications. She has no other medica l problems
and is a non-smoker.
On exam ination, the patient is sitting com fortably at rest and talking in full sentences. Her
oxygen saturations a re 96% on a ir and her body mass index is 30 kg/ m 2 . Chest
exam ination is clea r.
As part of the work up the patient had a chest x-ray which shows a normal sized heart
and clear lu ng fie lds. She has also had some lung function tests which show:
FEVl 3 .30L (96. 1%)
FVC 3 .92l (88.6%)
FEVl/ FVC 0 .84
TLCO 77.4%
KCO 101.9%
What is the likely cause of the patient's shortness of b reath?
O bes ity
Acute exacerbation of asthma
Pulmonary haemo rrha ge
Pulmonary fibrosis
sem
As
Polycythaem ia
Dr
I Obesity ED
Acute exacerbati on o f asthma CD
Pulmonary haemorrha ge CD
Pu lmonary f ibrosis fD
Polycythaem ia CD
Before attributi ng a patient's shortness of breath t o their ob esity we must ensure the re
are no ot her causes.
The pat ient 's history suggest s t hat her asthma is well co ntrolled and she is co mpliant with
her medication. The examination findings are also normal so it is very unlikely that t he
patient is having an exacerbation o f her asth ma. The t ime frame also goes against t his as
the patient has been having symptoms for several months.
Pulmonary f ibrosis d oes give a restrictive p icture on sp irometry but wou ld not give an
increased KCO. Also, t he normal chest x-ray d oes go against t his.
Polycythaemia and p ulmonary haemorrhage d o give a raised KCO but t he patient is t oo

well fo r t he diagnosis t o be a pulmonary haemorrhage. These pat ients are often very
m
se
unwell and have changes seen on chest x-ray. Polycyt haemia per se should not cause As
shortness of b reath.
Dr
A 24 -yea r-old female presents with episodic wheezing and shortness of b reath for the
past 4 months . She has smoked fo r the past 8 years and has a history of eczema.
Exa mination of her chest is unremarkable. Spirometry is a rranged and is reported as
no rma l.
What is the most appropriate next steps?
Trial of a sa lbutamo l in ha ler
Fractiona l exhaled nitric oxide + sp iro metry/bronchodilator reversibility test
Baseline FEVl repeated fo llowing inhaled corticosteroids
Arra nge a chest x-ray
m
se
As
Trial of a salbutamol in ha ler and low-dose inha led corticostero id
Dr
Trial of a salbutamol inha ler
I Fractional exhaled nitric oxide + spirometry/bronchodilator reversibility test
Baseline FEVl repeated fo llowing inhaled corticosteroids

-~
Arrange a chest x-ray
Trial of a salbutamol inha ler and low-dose inhaled corticosteroid
m
Adu lts with suspected asthma should have both a FeNO test and spiro metry with
se
reversibility
As
Dr
A 55-year-old man attends his GP with 7 d ay hist ory of general fever and malaise, an d a 2
d ay history o f non- productive cough. His eyes have also been sticky and sore for t he last
f ew days. He appears visibly unwell, with a fever o f 38.2°C and a resp iratory rate o f 20
/m in. There is also some mild sp lenomegaly.
He has no hist ory of recent forei gn t ravel and denies any t uberculosis exposure or cont act
wit h anyone who ha s been ill. He is, however, t he proud new owner of George, a red -
crested Austra lian King Parrot, w ho he has ha d for a month.
What is the most likely cause of this gent leman"s sym ptoms?
HSNl pneumonia
Chlamydia psittaci in fecti on
Mycoplasma in fecti on
Acute hypersensitivity p neumonitis
m
se
As
Crypto sporidiosis
Dr
HSN l pneumonia
Chlamydia psittaci infection
Acute hypersensitivity p neumonitis
Crypto sporid iosis
Chlamydia psittaci is a cause of pneumonia in bird keepers

This gentlema n has acqu ired a n atypica l p neum onia caused by the gram - neg ative
bacte ria Chlamydia psittaci, a patho ge n commonly found in domestica ted a nd e xotic
birds. C. psittaci cla ss ica lly causes a respirato ry infectio n as well as an acute o r chro nic
conjunctivitis, but p resentatio n ca n range from mild flu-like illness to multi-organ failure.
HSN l, a lso known as avia n influe nza or 'bird flu', has received s ig nificant attention g ive n
its hig h levels o f pathog e nicity, howeve r, it does not tra nsmit easily from birds to humans
and cases have been limited to date to the fa r a nd middle east.
Mycoplasma is a more com mon cause of atypical pneumonia and wo uld have a s imila r
presentation. The bird keeping is the prima ry discrim inating element here. Additiona lly,
mycoplas ma infection would not typically cause sp le nom ega ly.
Hype rsens itivity pneumon itis, a lso known as extrinsic a ll ergic alveolitis, is a
hypersensitivity reaction caused by exposure to organic dusts. Th is can include b ird
droppings, su ch a s in Bird Fancie r's Lung. Sympto m onset is usua lly within 4-6 hours
however as this is an al lergi c-type react ion, which do es not fit with this cli nica l histo ry.
Crypto spo rid ios is is a parasitic infection that can be contracted from conta ct with infe cted
em
individuals o r a nima ls. It is, howeve r, an op portun istic infectio n a nd typically on ly pre se nts
s
As
in im muno co mprom ised individ uals, particula rly those with HIV.
Dr
A 55-year-old diabet ic patient has recently returned from pilgrimage from Saudi Arab ia.
He d escrib es a respiratory illness comprised of cou gh, coryza and fever. He had had
petted a dog and visited a camel farm wh ilst on his trip.
Which of the following diagnoses is most important to consider?
Severe acute respiratory syndrome coronavirus (SARS-CoV)
Ebola
Rabies
Middle East resp iratory syndrome coronavirus (MERS-CoV)
m
se
As
Malaria
Dr
Severe acute respirato ry syndrome coronavirus (SARS-CoV)
Ebola
RaBies
Middle East respi ratory syndrome coronavirus (MERS-CoV)
Malaria
Conta ct with camels (including camel product s such as mil k) is a significant risk
factor for MERS-CoV
There have been outbreaks of MERS-CoV in the middle east, pa rticularly centered around
Saudi Arabia.
It is an airborne virus that ca n present with a flu-like ill ness and respiratory illness. The
mortality is significant, hence clinicians should be alert to the possibility in patients
presenting with these features and having returned from epidemic countries. It is
pa rticularly linked with camel contact.
Ebola is confined mainly to Sub-Saharan Africa.
The severe acute respiratory syndrome coronavirus (SARS-CoV) pa ndemic was centered
around China. It was bought under control in 2003. There have been no outbreaks
reported since 2004.
The ris k of malaria is low from Saudi Arabia.
Saudi Arabia is a high-risk country for rabies. It is mainly spread throu gh contact with
saliva of an infected ani mal (usually via bite or scratch). There is nothing in the question
em
however to denote potential exposu re. Rabies cannot be transmitted from petting a dog
s
As
unless there is contact with infected bodily animal fluid.

Dr
A 65-yea r-old wo man is investigated fo r a 6 week history of wo rsening shortness of
b reath, letha rgy and weight loss. Her past med ical h isto ry incl udes chron ic o bstructive
pulmonary disease, hype rtension and she is a n ex-smo ke r. Clinica l exa minatio n is
unremarka ble. Investigation results a re as follows:
Chest x-ray
Hyperinftated lung fields, normal heart size
Blood s
Sodium 131 mmol/ 1
Urea 7. 2 mmolfl
Hb 10.4 g/dl
MCV 91 fl
Pit 452 * 109/ 1
WBC 3.7 * 109/ 1
Screen fo r d e pression
Short syna cthen test
Urgent re fe rra l to the chest clinic
Stop ben droflum ethiazide

s em
As
Urgent gastrosco py
Dr
Screen for depress ion
Short synacth en test
Urgent referral t o the chest clinic
Stop bendroflumethiazide
Urgent gastroscopy
Despite a normal chest x-ray an ex-smoker with shortness of b reath, weight loss and
-
~
hyponatraemia should be investigated on an urgent basis for lung cancer. This approach
m
se
is su pported by current NICE guid elines. Whilst gast rointesti nal ca ncer is a possib ility the
As
normal MCV is no t enti rely consistent with chronic b lood loss
Dr
Yo u review a 28-year-old woman with no past medica l history of note. For the past week
she has being expe riencing left sid ed p leu ritic chest pa in. Her GP treated he r for pleurisy
with a moxicillin but there has been no imp rovement in her symptoms. She denies any
shortness of b reath an d oxygen satu rations on room a ir a re 98%. A chest x-ray shows a
20% pneu mothorax o n the left sid e. What is the most a ppro p riate ma nagement?
Observe for 24 hours before discharging with standard advice
Inse rt a chest drain
Discha rge with standa rd a dvice
Asp iration
m
se
As
Observe for 48 hours then repeat chest x-ray
Dr
Observe for 24 hours before d ischarging with standard advice
Insert a chest drain
Discha rge with standa rd a dvice
Asp iratio n
Observe for 48 hours the n repeat chest x-ray
Questions someti mes discuss the size of the pneumothorax in percentage te rms rather
than g iving the inte rp leura l distance. A va riety o f fo rmu las have been p ro posed to convert
between the two.
As a very genera l rule of thu mb:
Average int erpleural distance Approximate size of pneumothorax
0 .5 e m 10%
1 em 15%
2 em 30%
3 em 45%
4cm 60%
sem
A pneu mothorax o f 20% if the refo re within the 2 em limit suggested by the British
As
Tho racic Society fo r o bservation, if the patient is not short of breath.

Dr
A 43 -yea r-o ld wo man with a histo ry o f poorly controlled asthma is reviewed in the chest
clinic. Tests showed an eos inophilia associated with a ra ised Ig E level. Given the like ly
diag nosis of a lle rg ic bro nchopulmonary asp erg illosis, what is the most a pp ro priate
treatment to contro l he r sympto ms?
Itraconazole
Neb ul ised p enta midine
Fluco nazole
Cyclop hospha mide
m
se
As
Predniso lone
Dr
Itraconazole
Nebulised p entam idine
Fluconazole
Cyclophosphamide
I
m
se
As
Prednisolone
Dr
A 41-year-o ld man presents to his doctor with a persistent coug h. This has been present
for the past six months and for the past two weeks he ha s been cough ing u p b lood o n a
daily basis. He also feels more short-o f-b reath when exerting himself than normal. He is a
non -smoker and has no past medica l history o f note. On examination he is noted to have
reduced a ir entry in the right upper zone. A chest x- ray shows a right upper lobe collapse
and a subsequent bronchoscopy demonstrates a cherry- re d lesion in the right superio r
loba r bronchus. What is the most likely diagnosis?
Sma ll cell lung ca rcinoma
La rge cell lung carcinoma.
Lung carcinoid
Bronchio loalveo la r carcinoma
m
se
As
Bronchia l adenoca rcinoma
Dr
Small cell lung ca rcinoma
La rge cell lung carcinoma.
Lung ca rei noid
Bronchioloalveo lar carcinoma
Bronchial adenoca rcinoma
m
se
As
The 'cherry-red' les ion is a typical f inding o f lu ng carcinoid.
Dr
A 63-year-old man is noted to have a p leural effusion on CXR. Wh ich one of the following
wou ld typically cause a transudate?
Pancreatitis
Pneumonia
Yellow nail syndrome
Hypothyroi dism
m
se
As
Dressier's syndrome
Dr
Pancreatitis m
Pneumonia CD
~
Yellow nail syndrome «ED

Hypothyroidism CD
m
se
Dressier's sync rome .
fiB
As
Dr
A 62-year-old fema le with a 40 pack year history of smoking is investigated fo r a ch ronic
cough associated with haemoptysis. She has no past medical history of note and still
works as a schoo l secretary. Bronchoscopy reveals a small l em tumou r confined to the
right main bronchus . A biopsy taken shows small cell lung cancer (SCLC). Extensive
staging investigations show no evidence o f noda l spread or metastases, g iving a TNM
grad ing of (Tl, NO, MO). What is the most appropriate management?
Laser therapy
Chemotherapy + radiotherapy
Referral for consideration of su rgical resectio n
Radiotherapy
m
se
As
Interferon-alpha
Dr
Laser therapy
Chemotherapy + radiotherapy
I Referra l for consideration of surgical resection
Radiotherapy
Interferon-alpha
Surgery still plays little role in the management of most patients with SCLC but recent
m
se
stud ies, in add ition to the NICE 2011 Lung cancer guidelines, support the role of surge ry
As
in very early stage d isease.
Dr
Which of the following features is associated with a g ood p rognos is in sa rcoidos is?
Insidious onset
Splenomegaly
Disease in b lack people
Stage ni features o n CXR
m
se
As
Erythema nodosum
Dr
Insidious onset GD
Splenomegaly
Disease il b lack people «D

•
Stage ni featu res on CXR
Erythema no dosu m
•
ED.
m
se
Erythema nodosum is associated with a good prognosis in sa rcoidosis
As
Dr
Vital capacity may be defined as:
Volume inspired or expired with each breath at rest
Volume of air remaining after maximal expiration
Maximu m volume of air that can be inspired at the end of a normal tidal inspiration
Maximu m volume of air that can be expired at the end of a normal tidal expiration
m
se
As
Maximu m volume of air that can be expired after a maxima l inspiration
Dr
Volume inspired or expired with each brea th at rest
Volume of air remaining after maximal expiration
Maximum volume of air that can be inspired at the end of a normal tidal
inspiration
Maximum volume of air that can be expired at the end of a normal tidal
expiration
Maximum volume of a1r that can be expired after a maximal inspiration
Vital capacity- maximum volume of air that can be expired after a maximal
m
se
inspiration
As
lmportar i tor me _ess r-ocrtant
Dr
A 23-year-old female is commenced on varenicline to help her

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Question 1 of 382

Blood pressure 90/40 mmHg

Give 5 mg vitam in K intravenously

Stop warfarin and commence treatment dose enoxaparin only

Continue warfarin but bridge with enoxaparin immediately after surgery

Give four-factor proth rombin complex concentrat e 25-50 units/ kg

Stop warfarin and commence treatment dose enoxaparin only

Continue warfarin but bridge with enoxaparin immediately after surgery

I Give four-factor prothrombin complex concentrate 25 -50 units/ kg

Patients on warfarin undergoing emergency surgery - give four-factor prothrombin

British Journal of Haemat ology Guidelines in patients on warfarin having emergency

If surgery can wait for 6-8 hours - give 5 mg vitamin K IV

A septic embolism in the right kidney

Persistent pyrexia after 48 hou rs of antibiotics

Lengthening o f the PR int erval on ECG

Pre-existing left ventricular impairment

Persistent pyrexia after 48 hou rs of antibiotics

Lengthening of the PR interval on ECG

Pre-existing left ventricular impa irment

Streptococcus viridans isolated on b lood cu ltures

Infective e ndoca rditis - indications for su rge ry:

Important for me Less 'mpcrtant

What is the mecha nism o f action of dabigatran?

Activates anti -thrombin III

Glycoprotein lib/Ilia inhibitor

Glycoprotein lib/lila inhibitor

Direct throm bin inhibitor

Direct factor X activator

Dabigatran is a direct thrombin inhibitor

Below is a table of the drugs and their mechanisms of actions (MOA):

Drug name MOA

Heparin activates anti-thrombin III

Clopidogrel P2Y12 inhibitor

Abciximab glycoprotein lib/lila inhibitor

Dabigatran direct thrombin inhibitor

Mitral regurgit ation «ED

Second heart sound (S2)

Important for me Less imocrtont

Can stop immediately

Continue warfarinisation for 1 week then review following

Continue warfarinisation for 1 week then review following

Lifel ong warfarin

Ref lexes difficu lt to elicit

Low platelet count

Reflexes difficult to elicit

Low platelet count

Bicuspid aortic valve

Which of the following is the most appro priate next st ep?

Surgical valve replacement

Percuta neous mitra l valvotomy

Increased furosemide dose

Increased furosem ide d ose

Surgica l va lve re p lace ment is on ly indicated where valvotomy is contra indicated o r is

Accessory pathway a blation

Im p la nta ble ca rdioverter defibrillator

Accessj ry pathway a blatio n

~plantable cardioverter defibrillator

Secreted ma inly by the ventricles

Leve ls rise in leh ventricula r fa ilu re

Leve ls rise in leh ventricula r fa ilu re

Component of the thick filaments

Acts as a linin g of the T tubules

Anchors thick filament to Z-discs

Component of the thin filaments