FBMV 4751 Enter candidate number

Second Examination for the Degree of Bachelor of Medicine

Year 3

MEDICINE and SURGERY

MICHAELMAS TERM 2004

Monday, 8 November, 9.30 a.m. - 12.30 p.m.

This examination paper comprises ten Medicine questions and ten Surgery questions.
You are required to answer ALL the questions.
Enter your candidate number in the space provided above and at the top of EVERY page.
This paper is short answer format. Spaces have been left for you to write your answers. Where the
number o f responses is specified (e.g. ‘name five. ..’), the correct number o f spaces has been left for
your answers. Do not exceed the requested number o f answers.
This booklet has 22 numbered pages.
Separate from this booklet is one figure; this is referred to in question 1.
A table of normal values is provided on page 2 of this booklet.

Remember it is your own personal responsibility to ensure that you:

write legibly, in permanent dark ink - pencil is not acceptable;
indicate (by crossing out) anything which is not to be read as part of your answer;
hand in all material.

Do not turn over until told that you may do so.

1
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004

Normal Values

Haematology
Haemoglobin (Hb) (male) ............................. 13.5-17.6 g/dl
(female) .......................... 11.5-16.0 g/dl
White cell count (WBC) ................................. 4.0-1 1.0 x109L

Mean Cell Volume (MCV) ........ ....................

Erythrocyte Sedimentation Rate (ESR)
.
Platelets ........................................................... 150400 x109/L
78-1 00 fl

(male) 17-50 yr .......... 1-10 mm

> 50 yr ............ 1-14 mm
(female) 17-50 yr .......... 1-12 mm
> 50 yr ............ 1-20 mm
C-reactive protein (CRP) ................................ 4 0 mg/L
Biochemistry Blood
Albumin .......................................................... 35-50 g/L
Alanine - amino transferase (ALT) ................ 5-35 IUL
Aspartate - amino transferase (AST) ............. 5-35 I U L
Alkaline phosphatase ...................................... 80-250 I U L
Amylase .......................................................... 25-1 80 Somogyi Units/dl
Bicarbonate ..................................................... 24-30 mmolL
Bilirubin .......................................................... 3-17 pmolL
Calcium ........................................................... 2.12-2.62 mmovL
Gamma-glutamyl transpeptidase (GGT) ........ 11-50 I U L
Creatinine ........................................................ 70-1 50 pmol/L
Glucose (fasting) ............................................. 4.0-6.0 mmoln
Lactate dehydrogenase (LDH)........................ 110-250 I U L
Phosphate ........................................................ 0.8- 1.45 mmolL
Potassium ........................................................ 3.5-5.0 mmol/L
Prostate specific antigen (PSA) ...................... < 4 Pg/L
Sodium ............................................................ 135-145 mmol/L
Total Protein ................................................... 60-80 g/L
Urate (male) .................................................... 210-480 pmovL
Urate (female) ................................................. 150-390 pmoVL
Urea ................................................................ 2.5-6.7 mmolL
Arterial Blood Gases
Pa COz ............................................................ 4.7-6.0 kPa
Pa 0 2 ............................................................... 12.0-14.5 kPa
pH ................................................................... 7.38-7.44
Base excess ..................................................... k2 m m o m

FBMV 475 1 2
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 1 (Medicine)
A 70-year old previously well woman presents with a sudden onset o f chest pain associated with
shortness of breath and collapse. On examination in A&E/ED she is dyspnoeic with a respiratory rate
of 20/min, has cool peripheries, pulse 70/min and irregular, blood pressure 100/50, and equal in both
arms, and venous pressure is +1Ocm. Chest examination reveals basal inspiratory crepitations.
(A) Give the two most likely diagnoses. (2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
Her ECG is illustrated in Figure 1 (see separate sheet).
(E!) What is the precise diagnosis? (1 mark)

..............................................................................................................................................
(C) Give five possible complications of this diagnosis. (5 marks)

1...........................................................................................................................................

2. ............................................................................................................. i ............................

3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
@) List four o f the essential treatments that you would institute immediately. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3 ...........................................................................................................................................

4. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail BorderlineFail Clear Pass High Pass Total Marks= /12
FBMV 4751 3 [turn over]
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number1 I
Question 2 (Medicine)

A previously fit 50-year old man with no history o f respiratory illness, presents to you in A&E/ED.
You obtain a four-day history o f fever, a cough productive o f yellow-brown sputum, bilateral chest
discomfort and increasing breathlessness. A chest X-ray has already been performed by the A&E/ED
staff that is consistent with a diagnosis of pneumonia.

It is important for you to assess the severity o f his presumed community-acquired

pneumonia. List four features o f the clinical examination that would indicate a
particularly severe pneumonia. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................

4. ..........................................................................................................................................
Apart from a full blood count, urea and electrolytes, glucose, and liver function tests,
what two essential investigations should you perform on this gentleman at this stage?
(2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
Clinical features and results o f investigations indicate a severe community-acquired
pneumonia. He has no drug allergies. What antimicrobial regimen would you commence
and state the route o f administration? (2 marks)

..............................................................................................................................................
..............................................................................................................................................
Over the next four days his condition improves. However, one week later he remains
unwell with continuing fever, cough and breathlessness. The diagnosis o f pneumonia has
been confirmed and the organism shown to be sensitive to the prescribed antimicrobial
therapy. Give four likely reasons to account for the apparent failure o f your treatment.
(4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ........................... ;..............................................................................................................
4. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
F B W 4751 4
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number1 I
Question 3 (Medicine)

An SO-year old widower, who was previously well, is brought to A&E/ED. He was found by his
home help disorientated, immobile in his chair and not having eaten his lunch. The Mini Mental State
examination was 12/30 (or 5/10). He does not know where he is, his mind keeps wandering and he is
restless although he cannot get out o f bed. His temperature is 37.0"C

(A) What is the precise term for his condition? (1 mark)

..............................................................................................................................................
(B) There is nothing remarkable to find on examination. Routine blood tests (comprising Hb,
WBC,Na, K, creatinine, Ca2+and liver function tests) and chest X-ray are normal. Give
six other investigations that would be essential to do at this stage. (6 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
6. ..........................................................................................................................................
(C) All appropriate initial investigations have been unhelpful. Name two further causes that
should be considered for his acute deterioration. (2 marks)
1 ...........................................................................................................................................

2. ..........................................................................................................................................
@) His condition and mental state improve over the next ten days, and he is deemed
medically fit for discharge. What three other assessments would be appropriate prior to
discharge? (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................

For examiner's use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112

FBMV 4751 5 [turn over]

Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 4 (Medicine)

Whilst examining a 35-year old woman for an insurance medical you discover her BP to be 150/100,
together with bilateral abdominal masses. You arrange an ultrasound which shows polycystic
kidneys.

(A) Give four other renal presentations of this disease. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
State three extra-renal manifestations of this condition. (3 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
3 ...........................................................................................................................................

A blood test reveals a creatinine of 500pmol/L, calcium o f 1.98mmoVL, phosphate of

2.2mmolL and albumin of 4 3 g L . What medications should be started to improve her
calcium and phosphate metabolism? (2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
You start her on an angiotensin-converting enzyme (ACE) inhibitor. State three
important side-effects, other than rashes and gastro-intestinal disturbances, that you
would warn her about. (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
~

FBMV 475 1 6
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 5 (Medicine)

A woman presents with a four-day history o f melaena.

(A) Give four indicators that can be obtained from the history and examination that would be
associated with increased morbidity and mortality in this patient. (4 marks)

1 ...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
(B) After your initial assessment, give four immediate steps for your initial management o f a
severe GI haemorrhage. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3 ...........................................................................................................................................
4. ..........................................................................................................................................
(C) Name two drugs that may lead to this condition. (2 marks)

1 ...........................................................................................................................................

2. ..........................................................................................................................................
(D) Name the infection commonly associated with this condition and give the combination
o f drugs used to eradicate it. (2 marks)

Infection. ..............................................................................................................................
Drugs. ..................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 4751 7 [turn over]
Second Examination for the Degree of Bacbelor of Medicine, 8 Nov 2004 Enter candidate number
Question 6 medicine)

A previously well 41-year old man returned from a month-long trip to India and three days later
presents with diarrhoea. He has four to five loose motions daily and has noticed blood on several
occasions. He has a low-grade fever (37.9"C) and has some mild, generalised abdominal tenderness.
His full blood count shows: Haemoglobin = 12.9 g/dl; WBC 12 x log& 80% neutrophils,
16% lymphocytes, 3% eosinophils, 1% monocytes; platelets 500 x 1 09A. Blood biochemistry is
normal and the CRP is 120 mgL.
Give four of the most likely causes for his symptoms. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ...................................................................................... ....................................................
4. ..........................................................................................................................................
State three diagnostic investigations, other than Hb FBC, U&E, CRP, ESR, that you
would initiate. (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
List three complications associated with dysentery. (3 marks)

1 ...........................................................................................................................................
2. ..........................................................................................................................................
3 ...........................................................................................................................................
Give two treatments for diarrhoea due to Clostridium dificile. (2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................

For examiner's use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /12
FBMV 4751 8
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 7 (Medicine)

A 76-year old lady is brought to A&E/ED by ambulance having been found on the kitchen floor by
her neighbours. The GP's letter indicates that for the last year she has been prescribed thyroxine,
glibenclamide, co-proxamol and Prednisolone 7.5 mg/day. On examination she was obese,
oedematous, pale and very drowsy. There was sparse hair and she was mumbling in a low, hoarse
voice. Rectal temperature was 29.2"C. Pulse was 55/min, regular, BP was 105/50.

Give the four most likely diagnoses. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3, ..........................................................................................................................................
4. ..........................................................................................................................................
List the three most important points of your initial management. (3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
List two essential parameters that you would monitor. (2 marks)

1...........................................................................................................................................

2. ........................................... ..............................................................................................
:

She is found to have a haemoglobin of 7.9 g/dl with an MCV o f 110fl. Give the three
most likely causes to account for these combined abnormalities. (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ............................................................................................. ............................................
i

For examiner's use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 475 1 9 [turn over]
 Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 8 (Medicine)

A 54-year old Afrocarribean man is brought to A&E/ED by ambulance having been found
unconscious by his neighbours. His ‘BM’ is off the top of the scale, he has 1+ ketonuria and his
U+Es show: Na = l66mmol/L, K = 5.4mmol/L, Urea = 22.3mmol/L, Creatinine = 256pmol/L,
glucose = 48.lmmollL.
What is the calculated serum osmolaity? (1 mark)
..............................................................................................................................................
Give the precise diagnostic term for this condition. (1 mark)

..............................................................................................................................................
List the six most important points of your initial management. (6 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
6. ..........................................................................................................................................
List four complications you will be monitoring for. (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
~~

FBMV 4751 10
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number I 1
Question 9 (Medicine)

You are a PRHO in General Practice and asked to see a 73-year old woman who was diagnosed to
have Parkinson’s disease 12 months ago. Her daughter, who is a nurse, is apprehensive about the
diagnosis and would like confirmation.

(A) Give four physical signs you might elicit in this patient, that would help to confirm the
diagnosis of Parkinson’s disease. (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3...........................................................................................................................................
4. ..........................................................................................................................................
(B) Give three causes for Parkinsonism other than Parkinson’s disease. (3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3 ...........................................................................................................................................

(C) You decide to prescribe a course of levodopa therapy. Give two important common side
effects that you would alert the patient and daughter about. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
(D) Outline three points of practical guidance that you would give to help with her activities
of daily living. (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 4751 11 [tum over]
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 10 (Medicine)

A 35-year old physically fit executive, who has returned from a walking holiday in the Andes,
presents with a disabling, painful, swollen left knee, such that he is unable to walk. There is no
locking or giving way to suggest a mechanical cause. He feels unwell and his temperature is 37.8"C.
Give the three most likely diagnoses. (3 marks)
1. ..........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Give three additional clinical features that you would look for in this patient. (3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
You decide to aspirate the joint. State three investigations that you would request on the
aspirate. (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Give three blood tests, other than Hb,FBC, CRP, ESR, and U&E that you would request
and for each state the disease you are seeking. (3 marks)
Blood test Disease

1............................................. .......................................................................................
............................................. .......................................................................................
3. ............................................ .......................................................................................

For examiner's use only:

Circle one Clear Fail BorderlineFail Clear Pass High Pass Total Marks= 112
FBMV 4751 12
Second Examination for tbe Degree of Bachelor o f Medicine, 8 Nov 2004 Enter candidate number 1 I
Question 11(Surgery)

Two men in their late 50s present their general practitioner with a complaint of four-weeks
intermittent epigastric pain without radiation.

(A) Name six signs or symptoms which you would seek which would increase your concern
that a patient with this history might have cancer in the upper gastrointestinal tract.
(6 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
5 ...........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
6. ..........................................................................................................................................
One man is discovered to have a duodenal ulcer on endoscopy.

(B) Biopsies were taken and confirm the presence of Helicobacter pylori. How and why
should this infection be treated? (2 marks)

How? ....................................................................................................................................
Why? ....................................................................................................................................

The other man is discovered to have Barrett’s oesophagus for the terminal 2 cm of the oesophagus.

(C) What is the histological finding in this condition? (1 mark)

..............................................................................................................................................
@) What is the underlying cause of this condition? (1 mark)

..............................................................................................................................................
(E) What is the first line o f treatment? (1 mark)

..............................................................................................................................................
(F) If this treatment fails, what would be the second line o f treatment? (1 mark)

..............................................................................................................................................

For examiner’s use only:

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FBMV 415 1 13 [turn over]
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number 1 1
Question 12 (Surgery)

A 65-year old man with type 1 diabetes presents to you in A&E/ED with a painful right leg. He
reports that the leg has become progressively more swollen and painful over the preceding two days.
In addition his insulin requirement has increased over the last few days. Your examination confirms
that he has a red swollen tender leg, he is obviously confused and he smells ketotic. The note from
his general practitioner states that a full blood count performed yesterday showed a normal
haemoglobin and a raised white cell count.

Name the three most important investigations in the immediate management of the
patient that you would arrange urgently for this patient. (3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Give two reasons why patients with insulin dependant diabetes are prone to
complications in the feet. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
Name three portals of entry for infection for which you should specifically look.
(3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
He is started on antibiotics. Name two essential features of diabetic management of this
man’s diabetes during the first 24 hours. (2 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
Six hours later you re-examine the foot and you find localised increased redness, pain
and tenderness on the plantar aspect of the foot. Give two possible treatments. (2 marks)
1...........................................................................................................................................
2. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 475 I 14
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 13 (Surgery)
A 53-year old woman attends a rapid access one stop breast clinic with a four-week history o f a lump in
her right breast which she discovered whilst bathing. There is no family history of breast disease.

(A) What are the elements of triple assessment of a patient with a lump in the breast?
(3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
(B) The results of these investigations confirm that she has breast cancer. You are asked to
discuss with her the options for surgical treatment. Name four factors, which you would
consider relevant when advising the woman to have a mastectomy rather than a wide local
excision. (4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
(C) When she is admitted for surgery she brings with her an information leaflet telling her that
patients with breast cancer normally have surgery to the armpit as well as the breast. She is
worried about complications o f the axillary surgery, and asks why such an operation i s
necessary. Name two facts that you would explain to her about the purpose of surgery to the
axilla in a patient with breast carcinoma. (2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
@) When asking for her consent to axillary node sampling name one potential complication
about which she must be warned. (1 mark)

..............................................................................................................................................
(E) The leaflet also has a short paragraph on the common complications of radiotherapy to the
breast. Name two important possible local complications that should be included in this
paragraph. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 475 1 IS
Second Examination for tbe Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 14 (Surgery)

A 40-year old man, who fell from a ladder, presents with left upper quadrant abdominal pain
radiating to his left shoulder tip. His pulse is 100 and his systolic BP is 90mmHg.

After initial assessment of Airway, Breathing & Circulation, what immediate four
measures would you take? (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
A splenic injury is suspected. What is the investigation of choice? (1 mark)

..............................................................................................................................................
What are the two treatment options for an injured spleen other than splenectomy?
(2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
Name three diseases that predispose to splenk rupture. (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Following splenectomy what two medical therapies are mandatory? (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 4751 16
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 15 (Surgery)

A 59-year old man presents to A&E/ED with acute upper abdominal pain radiating to the back. He
has vomited four times and continues to retch whilst being interviewed. Abdominal examination
reveals generalised abdominal tenderness and there are no bowel sounds. The SHO in A&EdED has
measured the amylase which is 2340 Somogyi Unitddl. He has referred the patient to you for
admission with a diagnosis o f acute pancreatitis.

(A) What are the two most common pre-disposing causes of acute pancreatitis? (2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
(B) After taking the history and examining the patient, you agree with the diagnosis and
arrange some investigations to stratify the -severity of the attack. The following results
are obtained: WBC 19.0 x109L, Glucose 4.0 mmoVL, LDH 360 IUL, Urea 9.0 mmoVL,
Calcium 2.0 mmol/L, Pa02 7.9 @a. Would you classify the pancreatitis as mild,
moderate or severe? (1 mark)

..............................................................................................................................................
(C) List four immediate steps which you would institute in the management of this patient.
(4 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
@) The clinical course of acute pancreatitis is variable. List four life-threatening
complications of acute pancreatitis that can occur in the first ten days of the illness.
(4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3 ...........................................................................................................................................

4. ..........................................................................................................................................
(E) What is an indication for surgery in a patient with severe pancreatitis? (1 mark)
..............................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 4751 17 [turn over]
Second Examination for tbe Degree of Bachelor of Mediclne, 8 Nov 2004 Enter candidate number
Question 16 (Surgery)

A 69-year old man is found to have an aortic aneurysm, maximum AP diameter, 4.9 cm during an
ultrasound examination to investigate obstructive urinary symptoms. On examination there is a non-
tender pulsatile mass palpable in the epigastrium. All peripheral pulses are palpable.

(A) List four of the risk factors for aortic aneurysmal disease. (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3 ...........................................................................................................................................

4. ..........................................................................................................................................
(El) What two pieces of advice would you give to this patient? (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
(C) At what size of aneurysm would you consider operative treatment? (1 mark)

..............................................................................................................................................
(D) Two years later the aneurysm has grown substantially. Surgery is now advised. What
four investigations would you use to assess the patient’s fitness for surgery? (4 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
(E) Assuming there are no major co-morbidities what is the range for perioperative mortality
risk? (1 mark)

..............................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 4751 18
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number I
Question 17 (Surgery)

Where is the usual onset of pain in acute appendicitis? (1 mark)

..............................................................................................................................................
What pathological process is often thought to underlie the initiation of acute
appendicitis? (1 mark)
..............................................................................................................................................
List two ways in which the initial pain classically changes. (2 marks)
1. .......................................................................................... ;........e......................................

. .
2. .............................................................................................. ;...........................................
What is responsible for these changes in symptomatology? (1 mark)
..............................................................................................................................................
List two systemic symptoms associated with acute appendicitis. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
List four of the major differential diagnoses most pertinent to a 25-year old female
presenting with symptoms suggestive of acute appendicitis. (4 marks)
1
1. ..........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................

What test should initially be performed to exclude the most serious o f these conditions?
(1 mark)
..............................................................................................................................................

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FBMV 4751 19 [tum over]
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004
Question 18 (Surgery)
Enter candidate number I I
A 35-year old man presents with right sided loin pain. He has never had an episode like this before.
Your working diagnosis is ureteric colic.

Give three key features in the history which suggest a diagnosis o f renal colic as opposed
to acute appendicitis. (3 marks)
1
1. ..........................................................................................................................................
2. ..........................................................................................................................................
3 ...........................................................................................................................................

What feature on examination might suggest that a calculus is causing obstruction of the
kidney? (1 mark)

..............................................................................................................................................
List six investigations that should be undertaken in the assessment o f this patient.
(6 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
6. ..........................................................................................................................................
Analgesia is an important part of the initial management o f renal colic. What is the most
appropriate class of drug and give one specific example o f this drug type? (2 marks)

Class. ...................................................................................................................................
Example. ..............................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /12
FBMV 4751 20
Second Examination for the Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 19 (Surgery)

A 30-year old woman presents with a new pigmented lesion on her leg, with no palpable groin lymph
nodes.

(A) Give five features that might suggest that this is a malignant melanoma. (5 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
5 ...........................................................................................................................................
4. ..........................................................................................................................................
5. ....................................................................................... :..................................................
Name three different aetiological factors for the development of malignant melanoma.
(3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3 ...........................................................................................................................................

Name two sites to which metastases are common. (2 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
What pathological feature is the best prognostic indicator? (1 mark)

..............................................................................................................................................
In this patient, what is the best method to detect micrometastases? (1 mark)

..............................................................................................................................................

For examiner’s use only:

Circle one Clear Fail BorderlineFail Clear Pass High Pass Total Marks= I12
FBMV 475 1 21 [turnover]
Second Examination for tbe Degree of Bachelor of Medicine, 8 Nov 2004 Enter candidate number
Question 20 (Surgery)

A 65-year old man presents to the ENT department with a six week history of an enlarged cervical
lymph node. He is a longstanding smoker and you think that this is probably due to metastatic
cancer.

(A) Name five likely sources for the primary cancer. ( 5 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
What would be the diagnosis if this were a primary malignant tumour? (1 mark)

..............................................................................................................................................
What outpatient procedures could be performed to establish the diagnosis? (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
Diagnosis has not been established, what procedure is now indicated? (1 mark)

..............................................................................................................................................
What cranial nerves are most likely to be injured during radical neck node dissection?
(2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
What is the most likely histology? (1 mark)

..............................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12

FBMV 4751 22 [LASTPAGE]