Answers

(1) Key C. This question explores hormone replacement therapy (HRT) which can be complex due to
many factors that influence what can be offered.

For women with vasomotor symptoms with a uterus oral or transdermal oestradiol preparation AND
progesterone should be offered. Progesterone is important for preventing endometrial hyperplasia.

The IUS is a long acting reversible contraception and provides localised progesterone for endometrial
protection.

(2)Key B. The new resuscitation council guidelines have removed the use of steroids in the management
of anaphylaxis. Intramuscular adrenaline 0.5mg (1:1000) should be administered as soon as possible and
repeated after 5 mins. if ongoing symptoms. IVF should also be administered followed by anti-histamines.

(3) Key A. Cavernous sinus thrombosis(CST) is the formation of a thrombus within the cavenous sinus
resulting from either trauma or infection. Septic CST can rapidly progress and usually spreads from
infection originating in the sinuses, faces, ears, teeth or mouth. This patient has a history of chronic
sinusitis, making the origin of CST from her sinuses. Patients who present with CST need urgent treatment
with IV antibiotics and anticoagulation.Periorbital cellulitis presents similarly to CST; however in CST
there is bilateral eye involvement compared to cellulitis which is usually unilateral.

Meningioma is non-infective benign mass of the meninges and would not present acutely, nor would there
be symptom of fever or bilateral eye involvement.

Orbital apex syndrome is a cranial nerve deficit associated with a mass legion near the orbit of the eye.
There would be trigeminal nerve involvement.

(4)Key D. This is subacute combined degeneration of the cord caused by vit B12 deficiency. The clue here
is a partial gastrectomy leading to the loss of intrinsic factor and inability to absorb vit B 12. Presentation
is delayed due to the stores of B12 lasting up to 5 years. GBS is characterized by an ascending weakness
with loss of deep tendon reflexes.

(5) Key E. Topical ivermectin is 1st line

(6)Key C. Tamsulosin is an alpha adrenoreceptor antagonist . Most common side effects is postural
hypotension.

(7)Key B. The most likely diagnosis is Bartholin’s cyst which is an non-infectious blockage of the distal
Bartholin duct which potentially can become infected and develop into an abscess. This is a clinical
diagnosis and it is common in women of reproductive age. Bartholin cyst if small doesn’t cause any
problems and can be managed conservatively with warm baths to promote spontaneous rupture.

If there are features of infections (fever,pain or erythema of the affected area) or suspicion of abscess then
broad spectrum antibiotics would be appropriate. 1st line antibiotics is CO-AMOXICLAV. If abscess is
suspected, incision and drainage may be required.

(8)Key C. A referral should be made to secondary paediatric services if a child is not crawling by 12
months.

(9)Key B. Cat, dog and human bites are the commonest bites that present for acute treatment. One of the
first line antibiotics is CO-AMOXICLAV

(10)Key B. Wilm’s tumor(Nephroblastoma) is a rare child tumour presenting with an abdominal mass or
haematuria.

(11)Key C. Pancreatic cancer is a pancreatic ductal adenocarcinoma and is one of the most common causes
of cancer related deaths. Typical presentation is painless jaundice with rapid unintentional weight loss.
Patients usually present late with advanced disease.

Painful jaundice can be caused by bile duct stones which can also be formed in patients with pancreatic
cancer. However, bile duct stones wouldn’t cause significant unintentional weight loss.

Chronic pancreatitis can present similarly to pancreatic cancer and the two are difficult to distinguish
clinically. Typically, patients with chronic pancreatitis present with symptoms of pain which radiatesto the
back and there would be a significant history of alcohol abuse

Ascending cholangitis is a acute onset infection of the biliary tree which wouild present with Charcots
triad symptoms.

(12) Key E. Haemophilia A is an X-linked recessive condition associated with factor 8 deficiency. Major
bleeds require factor 8 replacement. Minor bleeding can be managed with desmopressin and tranexamic
acid.

(13) Key C. The patients history suggests a psychogenic cause for sexual dysfunctiongiven the history of
normal morning erection and decreased libido in the absence of cardiovascular risk factors.

Morning serum total testosterone is warranted to test for hypogonadism( reduction of hormone secretion of
the testes). If the serum testosterone is low then LH, FSH and prolactin should also be measured.

(14) Key A. Patients prescribed metronidazole should be advised not to drink alcohol while taking the
medication due to risk of severe vomiting (Disulfram-like reaction0

(15)Key E. According to the DSM 5, histrionic personality disorder (HPD) is characterized as a cluster B
personality disorder . HPD is a condition where the person is superficial has a labile mood and display
constant attention seeking behavior which is an excessive desire for approval and often inappropriate
sexual conduct. It is diagnosed 4 times more often in women thsn men. Those with HPD crave excitement
and need the focus of a group’s attention to be on themselves. They may act irrationally and dangerously
to achieve these needs.
(16) Key A. Hemorrhagic disease of the newborn can be prevented by administering IM vit k soon after
birth.

(17) Key B. This is the most appropriate management since it is a HIGH risk tetanus prone wound. It is
high risk because it is contaminated with soil. Given that he has his last booster more than 10 years ago, he
should receive both immunoglobulins and a booster.

(18) Key D. There is a typical presentation of fibromyalgia

(19) Key D. This question tests your knowledge of the paediatric basic life support guidelines as set by the
Uk resuscitation council.

For a choking child, the guidelines state that where a child is coughing effectively no actions are required
other than to encourage coughing. If the cough becomes ineffective or the child begins to lose
consciousness then 5 back blows followed by 5 abdominal thrusts should be delivered. Back blows and
thrusts should be repeated until the obstruction is relieved or the child becomes unconscious.

(20) Key B. HHS is associated with significant hyperglycemia and raised serum osmolality without ketosis.
It is a severe complication of type 2 Diabetes. Treatment is mainly fluid replacement

(21)Key A. BPH with evidence of AKI is something to be taken seriously. Catheterisation is needed to
relief him. Then he should be taken in for a TURP electively to reduce the size of the prostrate. There is
no point trying to do a TWOC in this patient given that he is already on tamsulosin and we wouldn’t want
to risk an episode of an AKI. Finasteride takes around 6/12 to work.

(22) Key A. This is placenta abruption with fetal distress (raised fetal HR, decelerations and reduced
variability) the baby needs delivering quickly. Category 1 CS is the most urgent procedure aiming to
deliver the baby within 30 minutes.

(23)Key C. This is the common mistake where the 2 drugs have similar names. It is even more common
because repeat prescriptions are generated through technology and can be often missed. Reporting to
NPLS is important so they are aware of how many of these errors occur and figure out widescale ways to
prevent this.

(24) Key B. Appendicitis is the most common surgical emergency in pregnancy. The skin incision should
be performed over the area of maximal tenderness.

(25)Key D. As there is an identifiable trigger, single dose antibiotics when she has her intercourse would
be suitable.

(26) Key A. CURB-65 score =0. This patient can be managed as an outpatient on Amoxicillin alone.

(27)Key B. As he is not informing the DVLA himself, the duty now falls on the GP to inform the DVLA.

(28) Key B. The reversal agent for unfractionated heparin is Protamine . Note; the APPT ratio is used for
monitoring during an intravenous infusion of unfractionated heparin.

(29) Key D. The diagnosis of T2DM should not be made on a SINGLE test in an asymptomatic patient . A
repeat HbA1c would be required. If the second test is abnormal, a diagnosis of diabetes is made
(30)Key A. Isonidazide can cause peripheral neuropathy and therefore vit B6; pyridoxine should be
prescribed

(31) Key A. Knife wounds in relation to gang fights must be reported . Police need to know if action needs
to be taken. Names and address do not need to be disclosed on initial contact but they need to know a case
is in the hospital.

(32)Key C. Axillary nerve injury occurs either due to compressive force, humeral fracture or following
anterior dislocation of the shoulder. A characteristic sign is loss of sensation over the deltoid.

(33) Key C. In a situation where eGFR drops below 30 gradually, refer to nephrology for management of
CKD.

(34)Key B. Barett’s oesophagus is associated with metaplasia from squamous to columnar epithelium. It
predisposes patients to adenocarcinoma

(35)Key E. The managing authority would need to make an application to the Supervisory Body
responsible for the person’s care. Urgent authorisation would need to take place to deprive the patient’s
liberty until an assessment takes place.

(36) Key C. The high risk HPV subtypes are 16 and 18. If HPV is detected on the smear, cytology is
reviewed. If cytology is negative, a repeat smear is performed in 1 year.

(37) Key A. The patient in this stem is likely suffering from polycystic kidney disease , which is the
progressive enlargement of normal kidney tissue by cysts ,leading to renal enlargement and renal failure. It
commonly presents as a visible swelling , HTN, recurrent UTIs , abdominal pain (bleeding into cyst and
cyst infection) or haematuria, as is the case for thus patient.

As alluded to in the stem, there are multiple extra-renal manifestations of polycystic kidney disease, the
most frequent of which are liver cysts (70% of patients)

The remaining options here may also be seen in patients with polycystic kidney disease however they are
much less common.

(38)Key C. Aplastic anaemia is a rare condition where there is destruction of the bone marrow stem cells
leading to replacement with fat. In comparison, myelofibrosis is associated with a ‘dry tap’ as no
aspiration is obtainable due to fibrosis

(39) Key A. The patient in this stem is likely presenting with nephrotic syndrome, which is a triad of
peripheral edema (as evidence by this patient’s pitting edema and puffy face), hypoalbuminaemia and
proteiunuria

All patients presenting with nephrotic syndrome should undergo a renal biopsy which assists in identifying
the underlying pattern of glomerular drainage.

(40)Key D. Persistent and distressing thoughts about the electrical appliances (obsession). Need tom
check them to relieve anxiety(compulsion)

(41) Key A. The following patients should be referred urgently (within 2 weeks) to colorectal services for
investigation
Patients 40 years or older with unexplained weight loss AND abdominal pain

Patients 50 years or older with unexplained rectal bleeding

Patients 60 years or older with iron deficiency anaemia or change in bowel habit , tests show occult blood
in faeces

Whilst this patient may well have an iron deficiency anaemia, given the microcytic picture seen in his
blood results , patients are usually treated initially with oral ferrous sulphate/fumarate, once any
underlying causes as been ruled out.

Patients will typically have a CT chest/abdomen and pelvis for staging of colorectal cancer once
diagnosed .

A bone marrow trephine can be used to assist in identifying the cause of a patient’s anaemia . However ,in
this case a 2 week wait referral is the most appropriate next step of management

(42) Key B. Premature ovarian failure is usually an autoimmune process. It is diagnosed in patients under
the age of 40 with at least 4 months of amenorrhea and FSH>25 on 2 occasions (4 weeks apart). Post pill
amenorrhea has normal values, 6 months following cessation of contraception. Note bHCG is negative, so
it is not pregnancy.

(43)Key A. This is Kaposi sarcoma, which is an AIDS-defining illness, seen in established HIV when a
patient's CD4 count is 200 or less. The lesions of Kaposi sarcoma behave like a malignant vascular
sarcoma and are caused by infection with herpes virus. In Kaposi sarcoma, the virus infects endothelial
cells, resulting in the formation of tumours, which may bleed after minor trauma. Whilst the most obvious
lesions are on the skin, similar lesions may be found in the internal organs and can give rise to internal
bleeding, as is alluded to in the stem.

Contact dermatitis would typically be red and itchy. It would not cause internal bleeding

Haemophilia B could cause internal bleeding, but would not result in the skin

lesions described here.

Melanoma typically presents as a single lesion, resembling a mole.

Staphylococcal scalded skin syndrome is a dermatological emergency. Not only would staphylococcal
scalded skin syndrome not persist for a year, but the rash is typically described as red, blistering skin that
looks like a burn or scald.
(44)Key E. Bladder pain syndrome (Previouly interstitial cystitis - but this phrase is not used anymore).
Hunner lesions are pathopneumonic

(45)Key D. The combination of the symptoms raised WBC , raised platelets, and normal ferritin is
indicative of a haematological malignancy . The most likely being CML. A peripheral blood smear would
typically be automatically performed in the haematology laboratory after processing such blood test results
in the laboratory. In CML, the peripheral blood film would show mature or maturing myeloid cells. A
bone marrow biopsy would be needed to confirm the diagnosis.

The high platelet count may indicate essential thrombocytopenia. However, this doesn’t explain the raised
WBC count.

ALL presents with symptoms more rapidly associated with B symptoms of fever , night sweats and
weight loss. ALL typically presents in children <5 years old and then in people in their 30s and 80s

The ferritin is within the normal range , therefore , this is not an iron deficiency Anaemia

Non-Hodgkin’s lymphoma presents at a similar age as the patient in this stem however , it typically
presents with lymphadenopathy.

(46)Key A. Morton’s neuroma -benign growth usually affecting the foot. It is located between the 3rd and
4th toes

(47)Key D. Pseudogout is associated with chronic osteoarthritis. with the presenting symptoms of
intermittent painful joint swelling and warmth of the joint. Pseudogout is the most likely diagnosis from
the given answers.

Pseudogout (also known as Calcium Pyrophosphate deposition CPPD) is the build of calcium
pyrophosphate dihydrate crystals in the joints causing acute inflammatory arthritis of one or more joints

(48)Key B. Lateral MI - Left circumflex artery

(49)Key B. The “clawing” of the hand is pathognomonic for ulnar nerve compression. The sensory loss in
the 5th and half of the 4th digit indicates an ulnar nerve disorder.

The most common area of the ulnar nerve to become entrapped is in the elbow, followed by the wrist . The
ulnar nerve can be damaged or compressed by a previous humerus fracture or poorly healed supracondylar
fracture. Ulnar nerve compression is also associated with medial epicondylitis (golfer’s elbow), as
mentioned in the above patient’s history

(50)Key D. First test (screening) - insulin like growth factor 1. Diagnostic test -OGTT with serial growth
hormone measurements. Once acromegaly is confirmed , an MRI head is performed to characterise the
lesion.

(51)Key D. Myasthenia gravis is an autoimmune disorder the post-synaptic membrane in the

neuromuscular junction in skeletal muscle due to acetylcholine receptor antibodies binding. Myasthenia
gravis causes muscle weakness that increases with activity causing fatigue and improves with rest.
Symptoms include generalised muscle weakness, fatigue, eye muscle weakness and weakness of the
respiratory muscles and reduced mechanical ventilation, leading to respiratory failure.

GBS would be ascending.

(52)Key A. The MMR is a live attenuated vaccine

(53) Key A. The patient in the stem is presenting with symptoms suggestive of osteosarcoma- a cancer of
the bone common in children and adolescents.

According to the NICE guidelines, the 1st line investigation to request if there is an unexplained bone
swelling or pain in children is an urgent X-ray within 48 hours.

ALP is usually elevated in osteosarcoma but is not 1st line investigation nor is it diagnostic.

Serum calcium has no diagnostic value in osteosarcoma

If there was an unexplained lump that was increasing in size then an urgent ultrasound (within 48 hours)
would be warranted.

(54)Key E. Acamprosate reduces cravings for alcohol and is used in alcohol detoxification.

(55) Key C. This patient is likely suffering from a cytomegalovirus infection. Certain viral and other
atypical infections are more common in patients receiving immunosuppressive medications (for example
Tacrolimus or mycophenolate mofetil) for kidney transplants. CMV infection is common in the early post
transplant period around 3-6 months. Symptoms include fever, malaise, myalgia, and arthralgia, usually
associated with leukopenia. CMV causes pneumonitis, retinitis and colitis and may also cause graft
dysfunction. CMV retinitis is typically described as “pizza pie retinopathy” or “cottage cheese with
ketchup” and it is characterised by confluent retinal necrosis with hemorrhage that develops mostly in the
posterior retina. CMV is usually treated with valganciclovir and a reduction in immunosuppression.
Pneumocystis jirovecii infection typically presents with dry cough.

The fundoscopic findings of HTN retinopathy typically include silver wiring, AV nipping, flamed
hemorrhage and retinal oedema.

The symptoms of orbital cellulitis include pain on eye movement, redness and swelling.

Blepharitis is inflammation of eyelid. It would typically present with symptoms such as itching and
watering of the eye due to irritation, as opposed to visual disturbance.

(56) Key B. Cushing syndrome is associated with proximal muscle weakness, hirsutism and HTN. PCOS
doesn’t cause muscle weakness or HTN.

(57) Key B. This patient is most likely suffering from secondary hyperthyroidism. Renal dysfunction from
CKD leads to deficiency in activated vit.D, resulting in hypocalcaemia. As a result of this, parathyroid
levels rise to stimulate the release of calcium stores from the bones, reducing bone mineral density.

(58) Key E. Removal or disruption of the blood supply to the parathyroid glands during total
thyroidectomy is a serious complication. Tetany following BP cuff inflation is called Trousseau sign

(59) Key C. The child in the stem is presenting with a retractile left testis, as evidenced by the descent into
the scrotum whilst bathing. As the child is only 6 weeks old, and his testis is retractile, this can be
expectant with a review at 6 months.

(60) Key A. BTS guidelines = Add LABA, NICE guidelines = Add LTRA

(61)Key E. Urinary incontinence is the involuntary leaking of urine which is objectively demonstrable and
is a social or hygienic problem. The woman in this stem is most likely suffering from stress incontinence,
in which patients leak small amounts of urine when coughing or laughing. Valsalva-type manoeuvres such
as weightlifting are notorious for causing stress incontinence.
(62)Key A. Streptococcus pneumonia is the leading cause of community acquired pneumonia. It leads to a
lobar pneumonia.

(63) Key E. Thrombosed hemorrhoids are characterised by anorectal pain and a tender purple-coloured
lump on the anal margin. The patient’s recent history of constipation makes this diagnosis most likely.

(64)Key C. Celiac symptoms with travel history = Giardiasis

(65) Key D. Lewy dementia- characterised by memory loss, cognitive function fluctuations and visual
hallucinations.

(66) Key D. These are the Ottawa knee rules..

Knee radiography is indicated when:

• Age 55 years or older

• Tenderness at head of fibula

.Isolated tenderness of patella

• Inability to flex to 90 degrees

.Inability to weight bear immediately and in the emergency department (4 steps)

(67) Key B. This is primary hyperparathyroidism as seen in the labs. High calcium, low phosphate and
high PTH. Most patients present asymptomatic. Symptomatic patients who have polydipsia and polyuria
would likely need an urgent referral or admission for rehydration. This is usually seen when calcium levels
go beyond 3.
(68)Key B. The patient has hemolysis (low Hb and evidence of fragmented red blood cells on film)
uraemia associated with a diarrheal illness(E.coli) =HUS

ITP= Low platelets only (diagnosis of exclusion)

TTP= Neurological features (reduced consciousness, focal neurology, seizures) and low ADAMTS13
activity.

IgA nephropathy develops after a streptococcal infection (usually URTI). It is not associated with low
platelets or hemolysis.

HSP isn’t associated with low platelets (they are usually high) or hemolysis.

(69)Key C. Simple urinary tract infection. Nitrofuratoin or trimetoprim would be first line. Culture is not
required.

(70)Key A. Hepatitis B surface antigen is the 1st laboratory marker of infection.

(71) Guidance have changed in such that you do NOT need to do a DMSA 4 to 6 months for atypical UTI
in children above 3. It is only RECURRENT UTIs that now need to have a DMSA 4 to 6 months after an
acute infection.

(72)Key A. Pericarditis following myocardial infection:

-post myocardial infarction (2-7 days post MI)

-Dressler’s syndrome (2-4 weeks post MI)

(73)Key A. She has features of a postdural puncture headache. There is a low pressure component when
she sits upright. That is particularly seen in postdural puncture headache. Observation is all that is required.

(74)Key C. Following splenectomy, patients should be on life long antibiotics such as

Phenoxymethylpenicillin (Penicillin V). Clarithromycin can be used if penicillin allergic
(75) Key A. Increased appetite is one of the side effects patients get with corticosteroid use. Other ones
include sleep disturbances, osteoporosis, central obesity and bruising only occur if he is taking oral
steroids for years.

(76) Key D. Stage 1= Normal eGFR >90ml/min, but other signs of kidney damage.

Stage 2= eGFR 60-89ml/min

Stage 3a = eGFR 45-59ml/min

Stage 3b= eGFR 30-44ml/min

Stage 4= eGFR 15-29 (plan for renal replacement therapy/transplant)

Stage 5= eGFR < 15ml/min (requires renal replacement therapy)

(77)Key D. You should suspect testicular cancer here with a hard fixed mass on the testes. A 2-week wait
referral to urology would be appropriate.

(78)Key A. Glandular fever/ infectious mononucleosis - no indications for antibiotics. Patients develop a
maculopapular rash on taking amoxicillin /ampicillin.

(79)Key E. The submandibular gland likely has a stone which restricts salivation. Every time he has to
salivate, the pain is worse.

(80) Key A. Itchy, jaundiced woman with hypercholesterolemia, deranged LFT and anti-mitochondrial M2
antibody (AMA-M2) = Primary biliary cirrhosis. Staging is with a liver biopsy and treatment is with
Ursodeoxycholic acid.

Autoimmune hepatitis is a diagnosis of exclusion - usually associated with other autoimmune conditions
and negative anti-mitochondrial antibodies.

(81)Key B. SC Midazolam would help her anxiety. She may continue to bleed to death but at this stage,
this would be the most humane action. Palliative care is all about ensuring a dignified death and NOT
prolonging or shortening life.

(82) Key B. Crohn’s flare =steroids, Mesalazine is used in UC not Crohn’s.

(83)Key E. It is very possible that it is just her periods which have returned. No action is required.

(84) Key D. Don’t use amoxicillin in penicillin allergy. Cefalosporins can be used if only a penicillin
induced rash( 10% cross reactivity so caution if anaphylaxis). Nitrofuratoin should be avoided in G6PD .
Gentamicin should not be used for a simple lower urinary tract infection unless no other sensitivities.

(85)Key B. Postmenstrual bleeding

-10% chance of endometrial cancer

(But most commonly vaginal atrophy)

-Examine them first

-TVUSS/ Pelvic USS (to assess endometrial thickness)

IF endometrial thickness is >4mm then do endometrial biopsy.

IF <4mm, look for other cause and reassure

(86) Key C. Behçet’s disease is a systemic illness associated with mouth and genital ulcers. Anterior
uveitis and HLA B51 are clinchers here.

(87) Key C. Hypromellose are artificial tears. Use them liberally.

(88) Key B. Height is a continuous variable (can be given to decel places e.g 172 643 cm) An example of a
discrete variable would be number of children (you can’t have 2.3 children)

(89)Key A. He needs intubation as he is unconscious. He would need 100% oxygen. A transfer to

hyperbaric chamber is questionable for carbon monoxide poisoning. When carboxyhaemoglobin levels are
above 25% and there is mental disturbance, the optimal treatment is hyperbaric chamber but NICE makes
no recommendation because it is not easy to facilitate transfers. Further more, he is UNCONSCIOUS.

(90) Key E. An audit is an assessment of current practice against a set standard. In this case, NICE
guidelines. Data is being reviewed retrospectively (in the past)

(91)Key E. Her symptoms of social anxiety are clear. The overwhelming fear of social situations are
indicative of social phobia.
(92)Key C. New murmur and temperature = infective endocarditis. The tender nodules on the pulps of the
fingers are Osler’s nodes.

(93) Key E. He presented himself to A&E with history of recurrent bruises at places you wouldn’t expect
bruises(unless of course NAI). Rivaroxaban can increase INR but usually not enough to raise concern like
warfarin does. Hence, why DOACS do not require INR monitoring.

(94)Key A. To reduce the risk of TURP syndrome/ hyponatriemia. NaCl 0.9% should be used as a non-
conductive fluid -rather than glycine(old school)

(95) Key B. This is the correct dose for adrenaline for CPR. The other dose to look out for in adults is
anaphylaxis which is 0.5ml in 1000 intramuscularly.

(96) Key B. This is minimal change disease. Quantify the proteinuria with uPCR. Renal function is likely
to be normal and a renal biopsy is not usually done unless the diagnosis is unclear.

(97) Key E. She has features of lower respiratory tract infection which is the most likely reason for her
death. Although she has a left lower lobe consolidation, there is no evidence like a biopsy for cancer.
Pulmonary fibrosis can be filled in part 2 of the death certificate which are contributory factors but not
related to the direct cause of death.

(98)Key C. Hand, foot and mouth disease is associated with oral ulcers and maculopapular rash on the
hands and feet. It is not associated with itch( unlike chicken pox) and child can go back to nursery.

(99)Key A. Lorazepam is used for delirium tremens which can be defined as acute confusion secondary to
alcohol withdrawal. His blood pressure is high which can be seen with alcohol withdrawals as oppose too
low seen in septic patients.

(100)Key B. This is acute severe asthma. After salbutamol, steroids and ipratropium , give IV MgSO4.
(DONT choose IV Salbutamol or aminophylline.

(101)Key A. These are typical xanthelsma which are associated with high cholesterol.
(102)Key E. Neuropenic sepsis =IV tazocin. Treat even before getting FBC back. This is the NICE
guideline

(103)Key E. All features point towards periorbital cellulitis. The peanut history is just a distractor.

(104)Key E. The right eye is failing to abduct. This is caused by an injury to the right Abducens nerve
leading to right lacteral rectus palsy.

(105)Key C. This is part of Beck’s triad , low BP, distant heart sounds,(or muffled heart sounds) + elevated
JVP

(106) Key E. Broca’s area = center of speech articulation.

(107)Key C. Haemophilus ducreyi which causes chancroid results in all of his symptoms. It can cause a
unilateral lymphadenopathy. There may be a travel history to an underdeveloped country since majority of
cases in the UK come from travel abroad. HSV which is the only other differential here that can cause
painful ulcers is not the answer because it causes VESICLES first, as oppose to an inflamed papular lesion.

(108)Key A. Fragile X syndrome is a genetic disorder characterised by mild to moderate intellectual

disability. It is X-linked recessive and therefore men can not be carriers of the disease( if they inherit an
abnormal X chromosome, they have the condition)

(109) Key A. This question tests your knowledge on oxygen requirements in COPD. As he is not acidotic,
there is no need for NIV or ventilation. There is evidence of hypercapnia so just continue with Venturi
mask 24-28% and repeat ABG in 30-60 minutes. Consider reducing oxygen levels once PaO2 is more than
8.

(110)Key E. Magnesium, Phosphate and Potassium all decrease in re-feeding syndrome and requires
monitoring/ replacement.

(111) Key B. She is suffering from a panic attack. Likely she is over breathing which would result in CO2
being let go. It can result in respiratory alkalosis.
(112) Key A. Wegener’s granulomatosis= p-ANCA, glomerulonephritis and saddle shaped nose.

(113) Key A. Routine referral for people if they have a skin lesion that raises suspicion of a basal cell
carcinoma. It is one of the only cancers that routine referral is acceptable because of the slow growth of it.

(114) Key D. Acute gout crystals = Monosodium urate crystals which which are needle-shaped and
demonstrate negative befringement reaction.

(115) Key E. This is typical of an abdominal migraine. There is no use doing any further investigation.
Stool cultures are not required especially since he is not having any diarrhea.

(116) Key A. A raised ABPI >1.3 indicates that the artery is abnormal stiff, likely due to calcium
deposition. This is seen in diabetes and means the test can not be interpreted.

(117)Key B. The patient is suffering with epididymo-orchitis. A urine dip could show leukocytes. There is
usually no nitrites like in a UTI. As he is young and sexually active, the chances of chlamydia being a
cause of epididymo-orchitis is higher than E.coli.

(118)Key C. Patient should be advised to not drive for 4 weeks following a stroke/TIA. They do not need
to inform the DVLA unless they have residual symptoms after 4 weeks (obviously TIA patients won’t
have symptoms)

(119) Key C. 1st line pharmacological treatment of aphthous ulcer is a topical corticosteroid such as
hydrocortisone oral-mucosal tablets.

Other therapies can be offered as adjuncts such as topical lidocaine , Bonjela gel or Doxycycline rinses.

If aphthous ulcers are recurrent, a short course of oral prednisone can be offered.

(120)Key E. Scarlet fever is caused by streptococcus pyogenes. Characteristically, children develop a

strawberry tongue, lymphadenopathy and a diffuse red rash with small papules resembling goose bumps.

(121)Key E. Vitamin D deficiency is defined as a serum 25(OH)D level <25 nmol/L. Vitamin D
insufficiency is defined as serum level between 25-50 nmol/L.
This person needs treatment dose of vitamin D which is around 20.000 units twice in a week.

(122) Key A. Antiphospholipid syndrome = aspirin and low molecular weight heparin from conception.

(123)Key E. This patient is having features of ACS. He needs to be seen in the A&E.

(124) Key C. The girl 13-16 and the red flag is that she is having sex with somebody older than her. Local
safeguarding officer, not police.

(125)Key A. For patients with a BMI of 35kg/m2, exercise and diet should be advised as 1st line treatment
with consideration of drug therapy. Drug therapy can be offered once exercise and dietary interventions
alone have not made any beneficial weight loss. Orlistat is licensed for weight loss in conjunction with a
low calorie diet.

Bariatric surgery is offered when all non-surgical measures have been tried and failed.

(126)Key B. Primary progressive = Symptoms remain and get worse(no remission)

(127) Key B. The patient in this stem has symptoms of bacterial keratitis. This is a microbial infection of
the cornea caused by damage to the cornea. The presentation is mostly likely due to bacterial keratitis
given the lid oedema and yellow discharge (white cell infiltrate)

(128) Key E. POP can be used short term and has no absolutely contraindications.

COC pill is contraindicated due to migraine with aura.

Depo Provera has a significant delay in the return of fertilization.

Mirena/Copper coil are not for short-term use (should be kept at least for 1 year)

(129) Key C. Most gastroenteritis are self-limiting. Antibiotics, anti-emetics or anti-diarrhea are not
recommended for the treatment of acute gastroenteritis. Stool culture and sensitivity testing is routinely
performed. They would be indicated in certain scenarios eg presence of bloody diarrhea or recently
completed a course of antibiotics.

(130)Key C. Trastuzumab (Herceptin) is associated with heart failure.

(131) Key A. A suspected penetrating injury or an injury caused by sharp objects or high velocity such as
drilling, lawn mowing or hammering should be referred urgently (same day) to an ophthalmologist.

(132)Key D. Constipation in pregnancy = (1) hydrate/diet modification (2) Isphagula husk (3) Lactulose

(133)Key A. Hypercalcaemia of malignancy can be quite symptomatic. They usually present with thirst,
confusion and constipation.

(134) Key B. Anyone with cirrhotic varices should be prescribed propranolol as secondary prevention.

(135)Key A. It is more than 4.5 hours since his symptoms of stroke started so you can’t thrombolyse with
alteplase. He would need 300mg of aspirin to manage an ischemic stroke( or potentially a TIA if his
symptoms resolve- unlikely). It should only be given once a CT scan has ruled out a hemorrhagic stroke
like in this case.

(136)Key A. Pancoast tumor is an apical lung cancer that can invade the sympathetic chain (Horner’s
syndrome) or recurrent laryngeal nerve.

(137)Key A. She is presenting with features of DKA. Remember DKA is diagnosed with capillary blood
glucose, urinary ketones/capillary ketones and a blood gas that shows metabolic acidosis.

(138)Key D. HBsAg =Negative ( not currently needed)

Anti-HBs =positive ( seen the antigen before)

Anti- HBc (IgM) -Positive (seen the virus before)

Anti-HBc (IgM)- Negative ( not currently fighting the virus)

(139)Key B. The most likely diagnosis here is ureteric trauma which can be a complication of
gynaecological surgery. Ureteric trauma may present in various ways, including vague abdominal pain and
prolonged postoperative ileus. The key here is the fluid creatinine level, which is raised above that of the
serum creatinine, which identifies the drain fluid as urine.

(140)Key E. RUQ, pain and fever = acute cholecysitis. Amylase not high enough for pancreas.

(141) Key B. The patient here is presenting with paraphimosis, a condition where the foreskin is retracted
and can’t return to its original position. This should be considered a urological emergency, so it would be
inappropriate to discharge a patient presenting with this.

The initial management of paraphimosis, where there is no signs of penile ischemia should be attempted
manual reduction with adequate analgesia.

(142) Key B. Complete molar pregnancy =46XX/XY (x2 sperm, empty egg)

(143)Key A. This is IBS. FODMAP is bad. It is short chain carbohydrates that are poorly absorbed in the
small intestine. Having a LOW FODMAP has been seen to improve IBS.

(144) Key D. Normal pressure hydrocephalus =Unsteady gait, dementia and urinary incontinence.
Treatment is with a ventriculo-peritoneal shunt

(145) Key B. At this age, you have to consider ovarian cancer and screen for it. IBS at this age is unlikely
and should only ever be considered once every sinister pathology has been ruled out. You would do a CA-
125 first before proceeding to consider an ultrasound.

(146) Key A. Spinal cord compression due to slipped disc. Cauda equina syndrome is assoicated with
saddle anaesthesia, urinary retention and reduced anal tone.

(147) Key C. Gl manifestations can be seen in addison's disease. It is usually seen at the begining of an
Addisonion crisis. Hyponatraemia and hyperkalaemia in the exam should always make you think of
Addison's disease.
(148) Key A. Public health england should be informed as soon as meningococcal infection is suspected.

(149) Key D. DOAC should be prescribed to reduce risk of VTE. One can also be prescribed a LMWH like
dalteparin prophylactic dose (not treatment dose). Given that LMWH is given subcut instead of orally like
rivaroxaban, rivaroxban is now the preferred choice. You can read question code "HE 3020" for more
information.

(150) Key B. D-dimer should not be used in pregnancy as the patient has a high pre-test probability and the
test should not change your management. This woman needs a VQ scan to rule out PE. Arterial blood gas
is not routinely required unless saturations <94%.

(151) Key A. He scores 3 on a CHADSVASC score. Age, T2DM, hypertension history. Anticoagulation is
needed if he is in A.fib. DOAC is first choice now instead warfarin.

(152) Key B. Impetigo is a high contagious skin infection characterised by cold crusts around lesions.

(153) Key E. You can be very certain that the intrauterine device has come out on it's own unknowingly.
Just reassure the patient and offer a replacement contraception.

(154) Key A. Pleural aspiration for pneumothorax should be performed at the 2nd intercostal space
midclavicular line. This is different from pleural aspiration for effusion - which is in the safe triangle.

(155) Key C. Foul-smelling + evidence of vulvovaginitis + frothy discharge. These are features of
trichomoniasis.

BV also has a high pH like trichomoniasis but there should be no evidence of vulvar erythema since it is a
non-inflammatory process.

Candida infections have pH that are less than 4.5.

Gonorrhoea typically does not cause foul-smelling discharge.

(156) Key C. Cloudy pleural aspirate with pH <7.2= empyema. A large surgical chest drain is required.
Mesothelioma presents with similar symptoms (but no temperature) and unilateral effusion. On CT scan, it
will demonstrate thickened/nodular pleura.

(157) Key B. She has features of acute pericarditis. Widespread ST elevation is typical. Pericarditis usually
occurs in ages 20 to 50 years old. Her viral history also points towards pericarditis. NSAIDS are the best
treatment for viral pericarditis.

(158) Key E. Suspect mitral stenosis (in the PLAB exam) when patients with previous rheumatic fever or
SLE present with evidence of heart failure and a diastolic murmur.

(159) Key A. Oral metro is the treatment. Oral vancomycin is second line but IV vancomycin is not used
for C. diff.

(160) Key A. Anything in the neonatal heel prick test is autosomal recessive! Cystic fibrosis, sickle cell,
PKU, Maple syrup urine disease.

(161) Key B. The patient in this stem presents with entropion, a condition that causes the eyelid to tum
inward towards the eye causing the eyelashes to rub against the comea. The lower lid is more often
affected and is associated with a previous history of trachoma infection which is common in tropical
countries. This eye infection can cause scarring of the eyelids causing them to turn inwards.

(162) Key D. Heparin-induced thrombocytopenia.

(163) Key E. The signs and symptoms of unilateral red eye and watering with a vesicular rash is highly
suggestive of herpes zoster ophthalmicus caused by herpes simplex. This typically presents with lesions on
the eyelid or on the nose (Hutchinson's sign) with unilateral red eye.

(164) Key A. She has a positive serology and therefore needs diagnostic testing for coeliac disease. A
duodenal biopsy should be performed.

(165) Key D. The symptoms of excruciating unilateral headaches, associated with red eye. lacrimation and
rhinorrhea lasting at least two hours, alongside risk factors of male sex and smoking history, makes the
most likely diagnosis cluster headache.
One of the treatments for migraine is oral sumatriptan. The fact that there was no response to oral
sumatriptan is a hint that cluster headaches are more likely.

(166) Key C. Treatment of alcohol withdrawal (occurs within 6 hours of no alcohol) is with oral
chlordiazepoxide. Delirium tremens (occurs 2-3 DAYS of no alcohol) = lorazepam.

(167) Key C. Ankylosing spondylitis is a progressive inflammatory arthropathy that typically presents with
severe back and hip pain with morning stiffness, alleviated by mobility/exercise.

The other bit that candidates may choose is paraspinal muscle spasms. Paraspinal muscle spasms would
not cause spinal tenderness and would be associated with symptoms worsening with mobility.

(168)Key E. The 68-95-99.7 rule:

-68% of values fall within one standard deviation of the mean.

-95% of the values fall within two standard deviations from the mean.

-99.7% of the values fall within three standard deviations from the mean.

(169)Key E. The patient has genital herpes, a sexually transmitted infection (STI) that is caused by the
herpes simplex virus (HSV).

Genital HSV is one of the most common STIs and is an incurable infection. Once the primary infection
has occurred, the virus becomes latent in the local sensory ganglia and can be reactivated.

Recurrent genital herpes can be treated with oral antiviral treatment such as oral aciclovir.

(170) Key D. Serum lipase is more sensitive than amylase for the diagnosis of pancreatitis.

(171) Key A. Melasma (also known as the mask of pregnancy) is a condition where there is an increase of
melanin in the skin typically caused by triggering factors that cause skin changes in those who are
genetically predisposed. Melasma is common in those from Asia, the Middle East, Mediterranean-Africa
and Hispanic America. Hormonal factors in pregnancy can increase melanin production and melasma
commonly occurs in the first trimester of pregnancy.

A phototoxic reaction occurs when patients are exposed to medicines, cosmetics or UV reaction and occur
acutely, whereas melasma's onset is gradual

Post-inflammatory hyperpigmentation is caused by previous inflammation from conditions such as

eczema/dermatitis. This is not mentioned in the stem, therefore, is incorrect.

Solar lentigo is related to sun exposure and appears as flat brown lesions.

Lichen planus pigmentosus is a papular eruption often found on the flexor surfaces of the upper limbs,
genitalia and mucous membranes.

(172) Key A. Very typical to have olecranon bursitis after an injury of the elbow. Repetative movements
can also cause bursitis eg playing cricket.

(173)Key A. This is a preseptal cellulitis. He needs to go to the hospital right away for antibiotics.

Periorbital/preseptal cellulitis is an infection of the eyelid which can spread to the orbital soft tissue
resulting in orbital cellulitis. Orbital cellulitis infection results from periorbital cellulitis and presents with
the same symptoms, along with proptosis (abnormal protrusion of the eye) and gaze restrictions.

(174) Key B. The patient has overdose on a tricyclic antidepressant. Cardiac abnormalities such as a
widened QRS should prompt the use of intravenous sodium bicarbonate.

(175)Key D. The history of recent travel/migration with productive cough, night sweats and weight loss is
highly suggestive of tuberculosis (TB) infection. Extrapulmonary TB can cause preganglionic nerve
lesions that can result in disruption of the sympathetic nerves supplying the eyes.

Horner's syndrome presents with a triad of: Ptosis (upper eyelid drooping) Hemifacial anhidrosis (absence
of sweating) Miosis (pupillary constriction)
(176) Key D. This is lyme disease. Erythema migrans.

(177) Key D. The symptoms of painless curtain-like visual loss with new-onset floaters and flashes are
highly indicative of retinal detachment. The history in the stem also includes risk factors: cataracts surgery
(trauma to the eye) and myopia (short-sightedness) which also point to a diagnosis of retinal detachment

(178) Key B. Metoclopramide is a Dopamine D2 receptor antagonist. Domperidone is also a Dopamine D2

receptor antagonist, but it does not cross the blood brain barrier (unlike metoclopramide). Carbergoline
and Bromocryptine are examples of Dopamine D2 receptor agonists.

(179) Key B. Polymyositis is a rare inflammatory connective tissue disorder that causes progressive
multiple muscle limb weakness and pain. Patients typically present with a history of frequent falls
secondary to muscle weakness due to difficulty rising from seated position and hand weakness. Symptoms
are usually progressive and present between the ages of 30 - 60 years old. The condition is more common
in women than men.

Multiple sclerosis is a condition that causes neurological dysfunction that presents with variable
neurological symptoms that vary in location and duration.

Guillain-barré syndrome is a rapidly progressive condition that causes neuropathy and muscle weakness.
Typically there is a recent history of viral/bacterial infection.

Myasthenia Gravis presents with fatigability that worsens with activity or later in the day, with symptoms
abating in the morning. An example here is if the patient were to count to 100, the patient's voice becomes
less audible and fatigue as the patient reaches 100.

Scleroderma presents with dermatological symptoms, and there would be signs and symptoms of organ
involvement.

(180) Key B. Pemphigus = superficial blisters (that burst) and oral involvement. The skin biopsy is also
typical. Pemphigoid usually has tense blisters that have no rubbed off due to deeper skin involvement (and
therefore thicker skin).