Question: 29 of 83

A 54-year-old man was referred to clinic with a two month history

of pain in both knees. He had no past history of note, other than an
appendicectomy as a child.

He worked as a property developer, spending six months of the

year in the United Kingdom and six months in southern Spain. He
smoked 15 cigarettes a day and drank 30 units of alcohol per
week. He had three children but had recently separated from his
wife following two years of marital difficulties brought on by his
becoming impotent.

On examination he appeared well. Crepitus was noted in both

knees. He had sparse pubic hair and both testes were small.

Investigations showed:

Haemoglobin 14.5 g/dL (13.0-18.0)

White cell count 7.5 x109/L (4-11 x109)
Platelets 350 x109/L (150-400 x109)
Serum sodium 139 mmol/L (137-144)
Serum potassium 3.7 mmol/L (3.5-4.9)
Serum urea 4.1 mmol/L (2.5-7.5)
Serum creatinine 82 µmol/L (60-110)
Urine dipstick Glucose (+)

What investigation will definitively confirm the underlying

diagnosis?

(Please select 1 option)

CT scan of thorax
Glucose tolerance test
Knee aspiration
Liver biopsy
Serum gonadotrophin levels
(Please select 1 option)

CT scan of thorax
Glucose tolerance test
Knee aspiration
Liver biopsy Correct
Serum gonadotrophin levels

The patient has haemochromatosis, tanned skin, hypogonadism,

diabetes and arthropathy (chondrocalcinosis).

Liver biopsy remains the gold-standard diagnostic tool since it

allows an estimation of the degree of iron loading.
Question: 30 of 83

A 46-year-old marketing director for a travel company returns from

an overseas' trip with diarrhoea. He has had loose stools for 5
weeks and has lost 3 kg weight. He denies any blood in the stool,
episode of acute illness, and has not taken any medication whilst
abroad. He is a smoker of 10 cigarettes per day and drinks 21
units of alcohol a week but confesses to having drunk more in the
past. Previously he has had no medical problems.

On examination he is slightly underweight. Chest, heart and

abdominal examination are unremarkable. BP 140/90, pulse 84
bpm regular. Dipstick urine normal, PR examination normal.

His plain abdominal X-Ray is shown.

What would be the most appropriate treatment for this man's
diarrhoea?

(Please select 1 option)

Co-amoxyclav
CREON
Metronidazole
Octreotide
Praziquantel
(Please select 1 option)

Co-amoxyclav
CREON Correct
Metronidazole
Octreotide
Praziquantel

The X-ray shows calcification in the area of the pancreas which

would support a diagnosis of diarrhoea secondary to chronic
pancreatitis with pancreatic insufficiency. The treatment is CREON
pancreatic enzymes which prevents the malabsorption associated
.with pancreatic insufficiency

Co-amoxyclav therapy would be useful for treating bacterial

.overgrowth

Metronidazole is used for the treatment of pseudomembranous

.colitis caused by Clostridium difficile

Octreotide (long acting synthetic somatostatin) is used in the

treatment of Carcinoid syndrome which may present with secretory
.diarrhoea (in about 83% of cases)

Praziquantel is the treatment of choice for schistosomiasis.

Continuing infection with Shistosoma may cause granulomatous
reactions and fibrosis in the affected organs, which may result in
manifestations that include: colonic polyposis with bloody diarrhea
(Schistosoma mansoni mostly); portal hypertension with
hematemesis and splenomegaly (S. mansoni, S. japonicum, S.
mansoni); cystitis and ureteritis (S. haematobium) with hematuria,
which can progress to bladder cancer; pulmonary hypertension (S.
mansoni, S. japonicum, more rarely S. haematobium);
.glomerulonephritis; and central nervous system lesions
Question: 31 of 83

A 69-year-old lady was seen in the Medical Admissions Ward. She

presented with coffee ground vomiting and melaena stool on the
day of admission. Although she had vomited coffee grounds only
once she had passed three melaena stools. She had a past history
was of significant ischaemic heart disease, for which she took
aspirin, atenolol, ramipril and simvastatin. She did not consume
alcohol and had not smoked since her myocardial infarction ten
years previously.

On examination at the time of admission she was pale. Blood

pressure was 95/55 mmHg pulse 60 beats per minute. Heart
sounds normal, chest clear abdomen soft, non tender with no
masses and melaena stool was seen per rectum

Investigations revealed:

Haemoglobin 8.5 g/dL (11.5-16.5)

White cell count 7.2 x109/L (4-11 x109)
Platelets 200 x109/L (150-400 x109)
Serum sodium 140 mmol/L (137-144)
Serum potassium 4.2 mmol/L (3.5-4.9)
Serum urea 14 mmol/L (2.5-7.5)
Serum creatinine 60 μmol/L (60-110)

An upper gastrointestinal endoscopy revealed a duodenal ulcer. A

biopsy from the gastric antrum was positive for urease activity
when tested in the endoscopy department. She was given one
week of Amoxicillin 1 gm twice daily, Clarithromycin 500 mg twice
daily and omeprazole 20 mg twice daily as Helicobacter pylori
eradication therapy.

Two months later in the follow-up clinic, a letter from her

Cardiologist was noted, in which he asked whether the aspirin
could be restarted.
What course of action is most appropriate?

(Please select 1 option)

Check Helicobacter pylori serology and treat if positive,

then restart the Aspirin with proton pump inhibitor cover.
Repeat the upper gastrointestinal endoscopy and repeat
antral biopsy for a urease test, treat if positive then
restart the Aspirin with proton pump inhibitor
Restart the Aspirin with proton pump inhibitor cover.
Urea breath test and treat if positive then restart the
Aspirin with proton cover.
Withhold Aspirin
(Please select 1 option)

Check Helicobacter pylori serology and treat if positive,

then restart the Aspirin with proton pump inhibitor cover.
Repeat the upper gastrointestinal endoscopy and repeat
antral biopsy for a urease test, treat if positive then
restart the Aspirin with proton pump inhibitor
Restart the Aspirin with proton pump inhibitor cover.
Urea breath test and treat if positive then restart
the Aspirin with proton cover. Correct
Withhold Aspirin

This lady given her age and co-morbidity would be at high risk
(Rockall score) if she re-bled. Ideally we would stop Aspirin but it
carries significant benefit for her. The fact that she is Hpylori +ve
allows us to address an important risk factor for peptic ulcer
.disease
H pylori eradication is >90%successful however in her case you
may want to re-check, Serology remains + ve for many years,
repeat endoscopy is un-necessary. You could just restart ASA but
a simple breath test would give the best answer (or faecal antigen)
NICE recommends PPI cover if NSAIDs cannot be avoided

Question: 32 of 83
This 21-year-old female presents with weight loss, weakness and
dizziness.

Which of the following antibodies would provide diagnostic

information?

(Please select 1 option)

Anti-21 hydroxylase antibodies

Anti-endomysial antibodies
Anti-glutamic acid decarboxylase antibodies
Anti-intrinsic factor antibodies
Anti-thyroid peroxidase antibodies

(Please select 1 option)

 Anti-21 hydroxylase antibodies Correct
Anti-endomysial antibodies
Anti-glutamic acid decarboxylase antibodies
Anti-intrinsic factor antibodies
Anti-thyroid peroxidase antibodies

This patient has Addison's disease as reflected by the pigmented

appearance and the symptoms.

Anti-21 hydroxylase antibodies are typically seen in a high

percentage (80-90%) of such cases.

Although other antibodies may be present, they are not as

frequent.

Question: 33 of 83
A 19 year-old student presents to Casualty with a seven-day
history of fever, sore throat and malaise. He has not managed to
eat food for several days: partly because of the severity of the
pharyngitis, but also because of a loss of appetite. On
examination, it is noted that he is jaundiced.

Investigations reveal

Haemoglobin 14.9 g/dL (13.0-18.0)

MCV 89 fL (80-96)
White cell count 6.5 x109/L (4-11 x109)
Platelets 350 x109/L (150-400 x109)
Reticulocytes 0.8% (0.2-2.0)
Serum bilirubin (total) 60 µmol/L (1-22)
Conjugated bilirubin 10 µmol/L (0-3.4)
Serum AST 19 U/L (5-35)
Serum ALP 117 U/L (45-105)
Serum albumin 42 g/L (37-49)

What is the most likely diagnosis?

(Please select 1 option)

Autoimmune hepatitis
Chronic hepatitis C virus infection
Gilbert’s syndrome
Primary biliary cirrhosis
Recurrent cholecystitis
(Please select 1 option)

Autoimmune hepatitis
Chronic hepatitis C virus infection
Gilbert’s syndrome Correct
Primary biliary cirrhosis
Recurrent cholecystitis

The level of unconjugated bilirubin is elevated in the

absence of any other liver function abnormalities. From
the history given, it appears that the hyperbilirubinaemia
occurred following an upper respiratory tact infection that
may have been viral; this illness had been associated with
anorexia. When calorie intake falls, the plasma levels of
unconjugated bilirubin can double and this rise may be
sufficient to produce clinical jaundice in patients with
Gilbert’s syndrome.

Question: 34 of 83
A 16-year-old mentally handicapped boy is brought to clinic by his
parents who are concerned that he has lost 3 kg over the last six
weeks and has had some problems with lower abdominal pain. He
has attended day centres for the last one year and has a long
history of severe epilepsy for which he takes lamotrigine and
carbamazepine. He had one fit two weeks ago.

On examination he appears well, apyrexial and no abnormalities

are noted on abdominal examination. Examination of his faeces
reveals fine, thin white worms approximately 1-2 cm in length.

What is the most appropriate treatment for this patient?

(Please select 1 option)

Levamisole
Mebendazole
Niclosamide
Piperazine
Praziquantel

(Please select 1 option)

Levamisole
Mebendazole Correct
Niclosamide
 Piperazine
Praziquantel

This patient has threadworms, which is not uncommon amongst

institutionalised individuals. The most appropriate treatment is
mebendazole.

Other drugs that are used include piperazine but this drug is not
recommended for use in epilepsy. Therefore mebendazole is most
appropriate.

Praziquantel may be used for tapeworms.

Question: 35 of 83
An 18 year-old female was admitted under the surgical team with
right upper quadrant discomfort, mild jaundice and nausea. She
had a history of headaches which were not sinister in character.
She admitted to drinking heavily on 4 nights of the week. The
surgical registrar requested a review.

On examination she was generally well but jaundiced there were no signs of chronic
liver disease. There was no organomegaly; she had a mildly tender right upper
quadrant. She stated that she was feeling much better than she had the previous day.

Haemoglobin 13.2 g/dL (11.5-16.5)

White cells 9.0 x109/L (1.5-7
x109)
Platelets 150 x109/L (150-400
x109)
MCV 92 fL (80-96)
Albumin 46 g/L (37-49)
Bilirubin 128 µmol/L (1-22)
Alanine aminotransferase 9000 U/L (5-35)
Alkaline phosphatase 120 U/L (45-105)
Gamma gluteryltransferase 100 U/L (<50)
Smooth muscle antibody: not detected Anti mitochondrial antibody:
not detected
Prothrombin time 20 seconds (Control 10
seconds)
Serum sodium 143 mmol/L (137-
144)
Serum potassium 4.0 mmol/L (3.5-4.9)
Serum urea 14.0 mmol/L (2.5-7.5)
Serum creatinine 200 µmol/L (60-110)

What is cause of this patients problems?

(Please select 1 option)

 Alcoholic hepatitis
Cholelithiasis
Hepatitis A
Paracetamol poisoning
Pancreatitis

(Please select 1 option)

Alcoholic hepatitis
Cholelithiasis
Hepatitis A
Paracetamol poisoning Correct
Pancreatitis

The history of headache and the age of the patient are important
here. The ALT is very high far in excess of that seen in alcoholic
hepatitis or gallstone/ pancreatic disease, the history would fit a
little with HAV but is not typical The combination of coagulopathy
renal impairment and marked hepatitis strongly suggests
accidental or deliberate paracetamol toxicity. This lady was
drinking heavily (enzyme inducer) and taking daily maximum
!paracetamol for her headaches and hang over

Question: 36 of 83

A 55-year-old builder was referred to clinic with a seven-month

history of central chest discomfort. He described the pain as being
central and ‘burning’ in character. The pain frequently occurred at
night and was associated with an acidic taste in the mouth. He had
found some relief by taking over-the-counter antacid tablets and
had seen his GP, who prescribed a proton pump inhibitor.
However, despite a two-month course of omeprazole, the patient
was still experiencing frequent episodes of chest discomfort. His
GP had also sent blood for Helicobacter pylori serology, which was
found to be negative.
He was otherwise well and did not give a history of any weight
loss, vomiting or dysphagia. There was no other past medical
history of note.

On examination, he looked well. He was not clinically anaemic. His

pulse was 80 beats per minute and regular with blood pressure of
135/70 mmHg. His heart sounds were normal and the chest was
clear. His abdomen was soft and non-tender with no palpable
organomegaly or masses. A rectal examination was unremarkable
and normal stool was noted on the examination glove.
An outpatient upper gastrointestinal endoscopy was arranged. This
revealed a 10cm area at the lower oesophagus that had the
appearances of non-inflamed Barrett’s epithelium. Multiple
biopsies were taken. The histology was reported as columnar lined
mucosa with intestinal metaplasia. No dysplasia seen.

What advice should be given?

(Please select 1 option)

Reassure and discharge

Repeat the endoscopy and biopsy in two months
Start a proton pump inhibitor
Start a proton pump inhibitor and repeat the endoscopy
 and biopsy in two years
Start a proton pump inhibitor and repeat the endoscopy
in five years

(Please select 1 option)

Reassure and discharge

Repeat the endoscopy and biopsy in two months
Start a proton pump inhibitor
Start a proton pump inhibitor and repeat the
 endoscopy and biopsy in two years Correct
Start a proton pump inhibitor and repeat the endoscopy
in five years

The histology is typical of Barrett’s oesophagus. The risks of

adenocarcinma are relatively high (30 x normal) but absolute risk
is low 1% per year develop adeno-carcinoma. This patient has no
dysplasia and so at present we would start a PPI and re-scope in 2
years. This is appropriate in an otherwise healthy person, the
merits of surveillance needs assessing on a patient to patient basis
i.e. would the patient tolerate any intervention? Evidence for PPI
not great but recommended by guidelines. Low grade dysplasia
merits 6 monthly biopsy but high grade dysplasia needs therapy;
oesophagectomy, photodynamic therapy, ablative therapy. See
2005 guidelines from British Society of Gastroenterology
(bsg.org.uk)

Question: 37 of 83

A 68-year-old lady was referred to the out patient clinic by her

general practitioner.

She had experienced 2 kg of unplanned weight loss in two months.

Her appetite was decreased. On direct questioning she admitted to
feeling low in mood after the recent death of her husband.
There was alteration of her bowel habit with worsening
constipation and occasional fresh blood passed per rectum. She
complained of a vague discomfort in the left iliac fossa (LIF). She
had a past history of carcinoma of the left breast ten years
previously. She was an ex-smoker having given up fifteen years
ago, she did not consume alcohol. She did not take any regular
prescribed medications, but took over-the-counter analgesia for
her abdominal discomfort.

On examination, she appeared thin. She was not clinically

anaemic. Pulse 80 beats per minute with blood pressure 115/65
mmHg.Temperature 38°C. Heart sounds were normal. Chest was
clear. Examination of the breast confirmed a left total mastectomy,
no masses per palpable. Abdominal examination revealed a
palpable liver edge 3 cm below the right costal margin, it was
somewhat tender. There was mild tenderness in the left iliac fossa,
but no mass.

Investigations revealed:

Haemoglobin 10.9 g/dL (11.5-16.5)

White blood cells 15.5 x109/L (4-11 x109)
Platelets 600 x109/L (150-400 x109)
Serum C-Reactive Protein 100 mg/L (<10)
Serum Albumin 28 g/L (37-49)
Serum AST 36 U/L (1-31)
Serum Alkaline Phosphatase 220 U/L (45-105)

A CT scan of the abdomen was performed. An image from this

study is shown below:

What investigation would be most appropriate?

(Please select 1 option)

 Blood cultures
Chest x ray
Guided liver biopsy
Mammogram
Upper and lower gastrointestinal endoscopy

(Please select 1 option)

Blood cultures Correct

Chest x ray
Guided liver biopsy
Mammogram
Upper and lower gastrointestinal endoscopy
This lady has a pyogenic hepatic abscess as shown on the CT
scan.

The elevated temperature, CRP, decreased albumin and elevated

alkaline phosphatase as well as the tender liver supports this.
Given her breast history, these findings may point to metastatic
carcinoma but the CT shows otherwise.

A blood culture is positive in 50% of cases and is likely to be most

helpful.

The other investigations are mainly aimed at the investigation of

malignant disease. Sources can be gastrointestinal tract and given
LIF symptoms and altered bowels. Diverticular infection may be
the cause.

Liver abscesses are often fatal if untreated.

Treatment consists of drainage of the abscess (usually

percutaneously) and antibiotics.

Question: 38 of 83

A 60-year-old male is admitted with a two day history of lower

abdominal pain and marked vomiting.

On examination he has abdominal swelling, guarding and

numerous audible bowel sounds.

What is the diagnosis?

 (Please select 1 option)

Gallstone ileus.
Ischaemic colitis
Large bowel obstruction
Sigmoid volvulus.
Small bowel obstruction

(Please select 1 option)

Gallstone ileus.
Ischaemic colitis
Large bowel obstruction
Sigmoid volvulus. Correct
Small bowel obstruction

The diagnosis is sigmoid volvulus.

The loop of sigmoid colon has a classical bean-shape, with the
apex over the S2/3 junction in the left iliac fossa with the loop of
sigmoid colon distending covering the liver and descending colon.

The most important feature of a sigmoid volvulus rather than a

large redundant distended loop of sigmoid colon is the absence of
haustra.

Question: 39 of 83

A 20 year-old male student was seen in the accident and

emergency department. He complained of nausea and he had
noticed yellow discoloration of his eyes.

He had recently been on an exchange visit to Egypt where he had

worked in a hospital. He recalled some travelers diarrhea for which
he had taken ciprofloxacin that he had taken with him. Since that
time he had generally felt unwell but over the past few days had
started to feel better.
He admitted to consuming more than his average alcohol on his
trip, but was reluctant to discuss a sexual history.

On examination he was clearly jaundiced, there were no signs of chronic liver disease;
he had a mildly tender liver edge but no other organomegaly.

Haemoglobin 14.2 g/dL (13-18)

White cells 9.0 x109/L (4-11 x109)
Platelets 300 x109/L (150-400 x109)
MCV 90 fL (80-96)
Albumin 40g/L (37-49)
Bilirubin 90 μmol/L (1-22)
Aspartate transaminase 1550 U/L (5-35)
Alkaline phosphatase 140 U/L (45-105)
Gamma gluteryltransferase 70 U/L (<50)
C reactive protein 25 mg/L (<10)

What disease process is likely to be causing this picture?

(Please select 1 option)

Alcoholic hepatitis
Autoimmune hepatitis
Drug induced hepatitis
Hepatitis A
Hepatitis C

(Please select 1 option)

Alcoholic hepatitis
Autoimmune hepatitis
Drug induced hepatitis
Hepatitis A Correct
Hepatitis C

Story is classic for HAV with initial GI symptoms then improved

condition followed by jaundice, the AST is too high for alcoholic
hepatitis which in general is around the 200 mark in alcoholic
hepatitis. Acute jaundice in HCV is seen but is rare but note that
Egypt has a high prevalence of HCV and should be checked.
Diarrhea is not really a feature of Autoimmune Hepatitis or drug
induced but the latter should be considered given the history of
.antibiotic use

Question: 40 of 83

Ten individuals are admitted to casualty with profuse vomiting after

attending a retirement dinner in a Chinese restaurant.

They all ate at roughly 7 pm and became ill at roughly midnight.

Nine ate a mixture of dishes except one female who ate vegetarian
dishes with her rice.

What is the most likely infective organism?

(Please select 1 option)

Bacillus cereus
Clostridium perfringens
 Escherichia coli
Salmonella enteriditis
Staphylococcus aureus

(Please select 1 option)

Bacillus cereus Correct

Clostridium perfringens
Escherichia coli
Salmonella enteriditis
Staphylococcus aureus

This is a typical case of Bacillus cereus, with profuse vomiting

which occurs approximately one to five hours after eating.

In this case it is likely that the rice itself had been infected.

Another possibility is Staph. aureus although this is less likely.

Question: 41 of 83
A 70-year-old male presents with a two day history of deteriorating
abdominal pain, and over the last 24 hours he has developed
bloody diarrhoea. He has a past history of hypertension for which
he takes bendroflumethiazide 2.5 mg daily and lisinopril 5 mg
daily.

On examination, he is in pain, has a temperature of 38°C and a

distended and diffusely tender abdomen. His plain abdominal x ray
is shown.

Which investigation should be performed next?

(Please select 1 option)

Colonoscopy
CT scan of abdomen
Daily abdominal x rays
Double-contrast barium enema
Flexible sigmoidoscopy

Please select 1 option)

 Colonoscopy
CT scan of abdomen
Daily abdominal x rays
Double-contrast barium enema
Flexible sigmoidoscopy This is the correct
answer
The AXR suggests a colitic process (thickened mucosa with thumb
printing) particularly around the area of the splenic flexure and
below.

These appearances are highly suggestive of an ischaemic colitis

but other causes would need to be excluded, for example, infective
colitis (including Clostridium), ulcerative colitis and radiation colitis
(usually suggested by the history).

Flexible sigmoidoscopy would be the best investigation - safer than

colonoscopy (relative contraindication in active colitis), allowing
biopsies to be taken and the viewing of a possible
pseudomembrane. Occasionally the mucosa has a characteristic
appearance.

Ischaemic colitis is more common in elderly arteriopaths with pain

as a predominant feature. Biopsies show ulceration and a
polymorphonuclear infiltrate.

Haemosiderin-laden macrophages are characteristic but

uncommon.

Question: 42 of 83
A 55-year-old male previously diagnosed with alcoholic liver
disease was admitted with increasing confusion. He consumed at
least 40 units of alcohol weekly.

On examination he was confused with a Glasgow Coma Scale of

14, and had a slight flap of the outstretched hands. His
temperature was 36.8°C and he had a blood pressure of 122/88
mmHg. He was noted to be jaundiced with spider naevi and
palmar erythema. Abdominal examination revealed slight
distension but no abnormal enlargement of an organ.

Investigations revealed:

Serum sodium 139 mmol/l (137-144)

Serum potassium 3.6 mmol/l (3.5-4.9)
Serum urea 2.7 mmol/l (2.5-7.5)
Serum creatinine 65 µmol/l (60-110)
Serum bilirubin 65 µmol/l (1-22)
Serum aspartate aminotransferase 150 U/l (1-31)
Serum alanine aminotransferase 110 U/l (5-35)
Serum alkaline phosphatase 450 U/l (30-100)
Serum gamma glutamyl transferase 500 U/l (<50)

At that stage, he was commenced on the rapid detoxification

programme consisting of diazepam 20 mg at a minimum interval of
two hourly (maximum dose 200 mg on 24 hours, standard regime).
The following day, he was found collapsed in the bathroom on
ward.

Which of the following agents should be administered

immediately?

(Please select 1 option)

Cefotaxime
Flumazenil
Naloxone
Thiamine
Vitamin K
(Please select 1 option)

Cefotaxime
Flumazenil Correct
Naloxone
Thiamine
Vitamin K

The rapid detoxification programmes now used are excellent for

acute withdrawal from alcohol but should not be used in patients
who are encephalopathic (as suggested by his confusion and
flapping tremor).

Causes of his encephalopathy should be sought, for example,

spontaneous bacterial peritonitis, gastrointestinal bleed or
infection.