FBMV 4751 Enter candidate number 1

Second Examination for the Degree of Bachelor of Medicine

Year 3

MEDICINE and SURGERY

TRINITY TERM 2005

Monday, 27 June, 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 odd-numbered
page.
This paper is short answer format. Spaces have been left for you to write your answers. Where the
number of 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 of answers.
This booklet has 44 numbered pages; several pages have been left intentionally blank and these blank
pages are clearly indicated. Do not write on the blank pages.
Separate from this booklet are two figures; these are referred to in questions 1 and 9.
A table o f normal values is provided on page 2 o f this booklet.
Remember it is your own personal responsibility to ensure that you:
0 write legibly, in permanent dark ink - pencil is not acceptable;
0 indicate (by crossing out) anything which is not to be read as part o f your answer;
0 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, 27 June 2005

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 x109/L
Platelets ........................................................... 150-400 x109/L
Mean Cell Volume (MCV) ............................. 78-100 fl
Erythrocyte Sedimentation Rate (ESR)
(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 IU/L
Aspartate - amino transferase (AST) .............5-35 IU/L
Alkaline phosphatase (ALP) ............................ 80-250 IU/L
Amy lase .......................................................... 25-1 80 Somogyi Units/dl
Bicarbonate ..................................................... 24-30 mmol/L
Bilirubin .......................................................... 3-17 pmol/L
Calcium ........................................................... 2.12-2.62 mmol/L
Creatinine ........................................................ 70- 150 pmoVL
Gamma-glutamyl transpeptidase (GGT) ........ 11-50 IU/L
Glucose (fasting) ............................................. 4.0-6.0 mmol/L
Lactate dehydrogenase (LDH) ........................ 1 10-250 IU/L
Phosphate ........................................................ 0.8-1.45 mmol/L
Potassium ........................................................ 3.5-5.0 mmol/L
Prostate specific antigen (PSA) ...................... < 4 Fg/L
Sodium ............................................................ 135-145 mmol/L
Total Protein ................................................... 60-80 g/L
Urate (male) .................................................... 210-480 pmol/L
Urate (female) ................................................. 150-390 pmol/L
Urea ................................................................ 2.5-6.7 mmol/L
Arterial Blood Gases
Pa CO2 ............................................................ 4.7-6.0 kPa .
Pa 0 2 ............................................................... 12.0-14.5 kPa
pH ................................................................... 7.38-7.44
Base excess ..................................................... +2 mmol/L

FBMV 4751 2
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number I
Question 1 (Medicine)

A 75-year old man gives a history of recurrent sudden collapses without warning. These occur every
2-3 days. Clinical examination reveals a soft systolic murmur. His initial ECG is normal.

(A) What two further investigations would you arrange for the patient? (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
(B) He collapses and presents to A&E. His pulse is 32/min and he is hypotensive 80/60. His
ECG is shown in Figure 1 (see separate sheet). What abnormality is shown and give
three non-pharmacological causes for this abnormality.
(4 marks)

ECG abnormality. ................................................................................................................

Cause 1................................................................................................................................

Cause 2. ...............................................................................................................................
Cause 3. ...............................................................................................................................
(C) What two pharmacological treatments would you consider initially for the abnormality
shown by the ECG in Figure l ? (2 marks)

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

2. ..........................................................................................................................................
(D) Give four potential complications, other than death, that you would warn a patient about,
prior to inserting a central venous line via the subclavian route. (4 marks)

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

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

For examiner's use only:

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FBMV 475 1 3 [turn over]
Second Examination for the Degree o f Bachelor of Medicine, 27 June 2005 Enter candidate number I
Question 2 (Medicine)

A 70-year old man presents at the Accident & Emergency Department with a history of increasing
breathlessness over the past few days. He is a lifelong smoker and five years previously suffered an
uncomplicated inferior myocardia1 infarction. He is a retired electrician who had received extensive
asbestos exposure during the construction of Didcot Power Station. He produces a small amount of
sputum each morning, and over the past few days this has become discoloured. When you examine
him you observe him to be extremely unwell.

(A) What three physical signs would you elicit to determine whether he is in established
respiratory failure? (3 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
He has been receiving oxygen in the A&E Department via nasal speculae at a rate of 4 L/min for the
past half hour. You perform an arterial blood gas estimation. The results are as follows: pH 7.25,
PO2 6.8 kPa and PC02 7.0 kPa.

(B) What type of acid-base disturbance does this indicate? (1 mark)

..............................................................................................................................................
(C) What action would you take in terms of oxygen therapy? (1 mark)

..............................................................................................................................................
You arrange for blood tests, sputum culture, chest X-ray and an ECG. The chest X-ray shows no
focal abnormality. Forty-five minutes later you repeat his arterial blood gases, the results of which
are as follows: pH 7.15, PO2 6.5 kPa and PCOz 10.8 kPa.

(D) What additional treatment do these results indicate that your patient requires? (1 mark)

..............................................................................................................................................
After appropriate treatment he recovered from his acute respiratory illness over the next ten days in
hospital. Before discharge you perform lung function which reveal an obstructive defect of
ventilation that is partially reversible with a bronchodilator. In addition, there is increased total lung
capacity and residual volume, with a reduction in gas transfer.
(E) What disease process do these results identify? (1 mark)

..............................................................................................................................................
Question 2 continues on page 7

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 4751
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
Question 2 (Medicine) (continued)

Blood gas analysis before discharge while he is breathing air reveals pH 7.35, PO2 9.8 kPa and PC02
5.0 kPa.

(F) State three therapies, other than home oxygen which you would prescribe before
discharge? (3 marks)

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

2. ..........................................................................................................................................
3 ...........................................................................................................................................
(G) Give two criteria that need to be met for this man to receive home oxygen. (2 marks)
1...........................................................................................................................................

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

For examiner’s use only:

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

FBMV 475 I 5 [turn over]

Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number I I
Question 3 (Medicine)

A 68-year old woman presents with lethargy and breathlessness and is found to be in mild congestive
cardiac failure. Her full blood count shows haemoglobin = 8.lg/dlYMCV = 106 fly platelets = 90 x
109/L, white blood count = 4.0 x 109/L (normal differential). Other investigations show Na =
136 mmol/l, K = 3.8 mmol/l, creatinine = 80 pmol/l, AST = 45 IUA, bilirubin = 32pmol/l , alkaline
phosphatase = 179 IWl, albumin = 38 g/l, and clotting studies are normal.

(A) Give two possible causes, other than vitamin Blz and folate deficiency and drugs, for her
haematological results. (2 marks)

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

2. ..........................................................................................................................................
(B) Investigations reveal that she has vitamin B,z deficiency. A more detailed history reveals
that she has suffered from numbness in her feet and has difficulty in walking. You
suspect that she has sub-acute combined degeneration of the cord. Which tracts of the
spinal cord are affected in this condition and list four signs that you would expect to find
in her legs. (5 marks)

Spinal cord tracts. ................................................................................................................

Sign 1. ..................................................................................................................................

Sign 2. ..................................................................................................................................
Sign 3. ..................................................................................................................................
Sign 4. ..................................................................................................................................
(C) You start treatment with vitamin Blz injections; name two laboratory tests you would
request for monitoring her response to therapy. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
One year later her haematological condition has responded but her liver function tests have
deteriorated. Your consultant suspects she has developed primary biliary cirrhosis and wants to
perform a liver biopsy.

(D) Give three investigations that must always be performed before it is safe to proceed with
a liver biopsy. (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 6
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number I I
Question 4 (Medicine)

A 23-year old woman who is an I.V. drug user and lives in a hostel presents with a history of weight
loss, cough and generally feeling unwell. The only prescribed medication she is taking is the oral
contraceptive pill. You are suspicious that she may have tuberculosis.

Apart from history, examination and chest X-ray, what 2 other initial tests would you do
to diagnose TB? (2 marks)

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

2. ..........................................................................................................................................
What other infection would you offer testing for? (1 mark)

..............................................................................................................................................
The diagnosis of pulmonary tuberculosis is confirmed. It is decided to treat her with
quadruple therapy. List the anti-microbial agents that are used in this regimen. (4 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
What important drug interaction would you warn her specifically about and what advice
would you give to her? (2 marks)

Drug interaction. ..................................................................................................................

Advice. .................................................................................................................................

She fails to respond to the anti-tuberculous treatment. What is the most likely cause?
(1 mark)
..............................................................................................................................................
What two public health measures would you undertake? (2 marks)

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

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

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 4751 7 [turn over]
 I I
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number1 I
Question 5 (Medicine)

A 60-year old woman is referred from her GP with a three week history of painless jaundice and one
week of abdominal distention. She has lost about one stone in weight over the last year. On
examination she has ascites and peripheral oedema.

(A) Give three of the most likely conditions, each with a different underlying pathology, that
could explain this presentation and list the best diagnostic test for each. (6 marks)

Condition Diagnostic test

1............................................................ ...............................................................
2. ........................................................... ...............................................................
3. ........................................................... ...............................................................
She is admitted and given furosemide and a 5% dextrose infusion. The next day she becomes
progressively more drowsy and her blood tests show a Na = 1lSmmol/L, K = 3.0mmol/L,
Urea = lhmmol/L, Creatinine = 85pmol/L.

(B) Name three possible causes, other than hyponatraemia and hypokalaemia that could
explain the change in her condition. (3 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
(C) List three things you would do to treat her hyponatraemia. (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 8
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005
Question 6 (Medicine)
Enter candidate number 1
A 66-year old woman has been diagnosed to have temporal arteritis associated with polymyalgia
rheumatica. She has been started on oral Prednisolone with an initial dose of 30mg per day.
List four important side effects, other than gastrointestinal bleeding, osteoporosis and
fractures, that you would discuss with the patient. (4 marks)

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

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

4. ..........................................................................................................................................
State two important points of advice that you could give the patient regarding her steroid
treatment. (2 marks)

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

2. ..........................................................................................................................................
Over the next six months the dose of steroids is gradually reduced, with no recurrence of symptoms.
When the patient is taking 5mg of Prednisolone per day she is admitted to hospital with a right lower
lobe pneumonia. At the time of admission her blood pressure is noted to be 80/60.

(C) What immediate action would you take with regard to her dose of steroids? (1 mark)

..............................................................................................................................................
(D) She continues to make good progress thereafter and is maintained on 3mg of
Prednisolone per day. Twelve months later she remains well with a normal ESR. What
investigation would you undertake to identify whether she could stop her dose of steroids
altogether? (1 mark)

..............................................................................................................................................
During the following two months she presents with low back pain and is found to have a
compression fracture at L3/4.

(E) Give three risk factors for this occurrence apart from steroid use. (3 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
(F) What long term therapy should she have received to prevent this complication? (1 mark)

..............................................................................................................................................
For examiner’s use only:
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FBMV 475 1 9 [turn over]
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
Question 7 (Medicine)

An 82-year old man is referred to hospital by his GP as an emergency. The patient was well the day
before admission, and shopping. He has now become very confused and, in the early hours of last
night, was disruptive to other residents in his block of flats. The warden telephoned the GP, who
found the patient to be muddled and restless, but detected no other physical abnormality on a brief,
screening examination. Specifically, there is no focal weakness or sign of head injury.

(A) What is the preferred term for this clinical condition? (1 mark)

..............................................................................................................................................
(B) List three conditions that commonly precipitate this condition. (3 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Observations on admission are as follows: blood pressure 140/90, respiratory rate 24/min, pulse
1OYminute, arterial oxygen saturation 96% on air, temperature 37.7"C tympanic.

(C) State the four urgent (i.e. the results of which are needed within 24 hours) routine
investigations (other than Hb, FBC, CRP, ESR, Urea and electrolytes) that you consider
it most important to perform, and state the abnormality that you are expecting. (8 marks)

Investigation Abnormality

1............................................................ ...............................................................
2. ........................................................... ...............................................................
3 ............................................................ ...............................................................
4. ........................................................... ...............................................................

~~ ~~

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FBMV 475 1 10
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
Question 8 (Medicine)

You are a PRHO in General Practice and a 40-year old man with a five year history of diabetes joins
your list after a period of failed attendances with another practice. Your initial assessment reveals a
blood pressure o f 170/100, a bruit over the central abdomen, absent right foot pulses and absent
tendon reflexes at both ankles and knees. Urine analysis shows glycosuria and proteinuria ++, but is
otherwise normal.

State precisely the three most likely renal diagnoses that you would consider him to
have. (3 marks)

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

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

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Blood tests reveal: Hb = 8.9gldl. MCV = 92fl, WBC = 6.0 x 109/L, platelets = 184 x
109/L, CRP <6 mg/L, glucose = 12.6 mmol/L, HbAlc = 9.4%, urea = 28.2 mmol/L,
creatinine 5 0 6 p o l / L , Na = 138 mmol/L, K+ = 5.8 mmol/L, calcium = 1.90 mmol/L,
phosphate = 2.3 mmol/L, and albumin = 40g/L. What medications should be started to
improve his calcium and phosphate metabolism? (2 marks)

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

2. ..........................................................................................................................................
Four years later he is in end-stage renal failure. List in order of preference the four
options for renal replacement treatment that could be offered. (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 11 [turn over]
 I
I I
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
I
Question 9 (Medicine)

Sub Question (i)

A 70-year old man (smoker) presents with cough, confusion, irritability and nausea. He is on no
medication. Examination reveals T=3S°C and a BP of 130/80. The plasma Na+ is 120mmol/L, but
the urea and electrolytes are otherwise normal. Plasma osmolality is 250mosmol/kg (Normal = 280-
300) and urine osmolality is 750mosmoVkg (Normal= 50-1200).

What is the term for this hyponatraemic state? (1 mark)

..............................................................................................................................................
Give the two most likely causes for this condition in this man. (2 marks)

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

2. ..........................................................................................................................................
What instruction would you give to the nurses and patient to treat this condition, and if
required, what drug would you prescribe? (2 marks)

Instruction. ...........................................................................................................................
Drug. ....................................................................................................................................
Sub Question (ii)
A 60-year old widower, known to be a chronic alcoholic, presents to casualty at 6 a.m. on Monday
claiming to have taken 30 Paracetamol tablets at 9 p.m. on the Sunday, admixed with a large quantity
of alcohol. The Paracetamol level on presentation to A&E was 130 mg/L. The ‘treatment graph’ is
given as Figure 2 (see separate sheet).

(D) List the three most important investigations you would perform. (3 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
(E) List the four most important points in your initial management. (4 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................

For examiner’s use only:

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

FBMV 4751
12
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number1
I
Question 10 (Medicine)

A 55-year old man is in the CCU, five days following a myocardial infarction for which he received
thrombolysis. You are asked to see him at 2 a.m. because he has developed chest pain.

(A) Name the two most likely causes, other than myocardial infarction or angina, for the
pain, and for each give the investigation you would arrange to confirm the diagnosis.
(4 marks)
Cause Investigation

1............................................................ ...............................................................
2. ........................................................... ...............................................................
(El) He receives oxygen and sublingual GTN and the pain quickly resolves. Three days later
you are supervising his exercise stress test. Name four criteria which would make you
stop the test. (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
(C) His exercise test is normal (he manages 12 minutes of a modified Bruce protocol) and he
is discharged home. When can he return to driving a private car? (1 mark)

..............................................................................................................................................
(D) Give three medical treatments which would reduce his risk of subsequent myocardial
infarction? (3 marks)

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

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 475 1 [turn over]
’ 13
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005
Question 11 (Surgery)
Enter candidate number 1
A 55-year old man with a history of Crohn’s disease presents with recurrent right iliac fossa pain. On
examination, there is a firm, well-circumscribed mass, measuring lOcm in diameter and situated in
the right iliac fossa. This area is markedly tender with guarding.

(A) List two likely differential diagnoses. (2 marks)

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

2. ..........................................................................................................................................
Initial ultrasound and CT are inconclusive.
What would be an appropriate further radiological examination? (1 mark)

..............................................................................................................................................
What two features of Crohn’s Disease would be typical in such a study? (2 marks)

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

2. ..........................................................................................................................................
What would you consider to be the first line medical treatment for this condition?
(1 mark)

..............................................................................................................................................
Describe two distinctive microscopic and two distinctive macroscopic features of
Crohn’s disease. (4marks)
Microscopic 1. .....................................................................................................................
Microscopic 2. .....................................................................................................................
Macroscopic 1. .....................................................................................................................
Macroscopic 2. .....................................................................................................................
Give two indications for surgery in this patient. (2 marks)
1...........................................................................................................................................
2 ...........................................................................................................................................

For examiner’s use only:

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FBMV 4751 14
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number I I
Question 12 (Surgery)

Sub Question (i)

A 56-year old man goes to see his GP with a six month history of hoarseness and right sided earache
for three weeks. He is a heavy smoker and ‘likes a drink or two’. His GP examines his oropharynx
and finds this normal. Examination of the ear through the external meatus is also normal

What is the diagnosis until proved otherwise? (1 mark)

What is the anatomical explanation for the earache? (1 mark)

..............................................................................................................................................
What other physical finding would help confirm the diagnosis? (1 mark)
..............................................................................................................................................
What specific examination would the patient undergo in ENT outpatients? (1 mark)

..............................................................................................................................................
Sub-question (ii)
(E) Name three common symptoms of allergic rhinitis. (3 marks)

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

L. ..........................................................................................................................................
3. ..........................................................................................................................................
Sub-question (iii)
(F) Name three symptoms which would enable you to make a confident diagnosis of
Meniere’s disease. (3 marks)

1...........................................................................................................................................
2 ...........................................................................................................................................

3. ..........................................................................................................................................
(G) Give two possible treatments for Meniere’s disease. (2 marks)

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

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

For examiner’s use only:

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FBMV 4751 [turn over]
15
 I 1
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number( 1
Question 13 (Surgery)

A 55-year old woman was admitted as an emergency with a 12-hour history of passing dark red
blood per rectum. The blood is mixed in with black stools. On examination she is pale and sweating
and her blood pressure is 90/60. Her pulse rate is 130/minute. There has been no vomiting.

(A) What are your two first steps after basic ABC resuscitation and 0, administration? (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
(B) In taking a history what are the four most important features to determine? (4marks)
1...........................................................................................................................................

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

(C) Name four investigations which would help you to determine the source of the
haemorrhage. (4 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................

(D) Investigations show that this patient is bleeding from a duodenal ulcer. Give two
indications for surgical treatment. (2 marks)

1...........................................................................................................................................
n
L. ..........................................................................................................................................

For examiner’s use only:

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FBMV 475 1
16
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
Question 14 (Surgery)
A 45-year old woman is about to have a total thyroidectomy as treatment for Graves’ disease.

Which key nerve is at risk during surgery on the thyroid gland and what is its function?
(2 marks)

Nerve. ..................................................................................................................................
Function. ..............................................................................................................................
What are the clinical results if there is unilateral nerve damage at surgery? (2 marks)

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

2 ...........................................................................................................................................
What is the most serious clinical result if there is bilateral nerve damage during surgery?
(1 mark)

..............................................................................................................................................
The parathyroid glands may be damaged during thyroid surgery. What is the biochemical
abnormality that may be seen on blood testing post-operatively as a result of this?
(1 mark)

..............................................................................................................................................
List two symptoms or clinical signs that may be produced by this biochemical
abnormality? (2 marks)

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

2. ..........................................................................................................................................
The patient returns to the ward and you are asked to see her in the evening after surgery as she is
complaining of breathlessness. On assessment, she is sitting on the edge o f her bed, having difficulty
breathing and cannot talk in full sentences.

(F) Name the two most likely specific complications of her surgery. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
(G) What two treatments may be required as a matter of urgency? (2 marks)

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

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

For examiner’s use only:

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FBMV 475 1 [turn over]
17
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number I
Question 15 (Surgery)

Sub-question (i)
A 55-year old man presents to his general practitioner with an acutely red eye.

(A) Name three diseases of the eye which would require urgent assessment in the Emergency
Department of the Eye Hospital. For each diagnosis give one symptom which is
characteristic of the condition and indicates the need for urgent referral. (6 marks)

Disease Symptom

1............................................................ ...............................................................
2. ........................................................... ...............................................................
3. ........................................................... ...............................................................
Sub-question (ii)
A 72-year-old woman comes to see you as a pre-registration house officer in general practice and
complains that she noticed that morning that the vision in her right eye is blurred. She discovered that
she could only read the headlines in the morning newspaper even when wearing her normal reading
glasses. She had been to the opticians recently for a routine check when early cataracts had been
noticed but she had been told that her vision was adequate for driving in both eyes and a ‘puff of air’
test was normal.

Give two relevant features of the history which, if present, would lead you to think that
this patient has temporal (giant cell) arteritis. (2 marks)

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

2. ..........................................................................................................................................
Give one feature of the examination which, if present, would lead you to think that this
patient has temporal (giant cell) arteritis. (1 mark)

..............................................................................................................................................
Name one test that you would request urgently in order to confirm the diagnosis.
(1 mark)

..............................................................................................................................................
What treatment would you prescribe for temporal arteritis? (1 mark)

..............................................................................................................................................
What does a ‘puff of air’ test measure? (1 mark)

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

For examiner’s use only:

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

FBMV 4751 18
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
Question 16 (Surgery)

A 73-year old lady having had an ultrasound for abdominal pain is found to have an lOcm right renal
tumour with malignant characteristics.

List three possible presenting features of this tumour. (3 marks)

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

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

Name two para-neoplastic features that can be associated with malignant renal tumours.
(2 marks)
1...........................................................................................................................................

L. ..........................................................................................................................................
Suspecting the mass is malignant, it is staged by CT of chest and abdomen. What is the
commonest site of local extension? (1 mark)

What is the most likely specific pathological diagnosis? (1 mark)

What is the appropriate treatment for this lesion? (1 mark)

..............................................................................................................................................
Two years later, she develops some pain from a bony metastasis. List four other
malignancies that typically metastasise to bone. (4 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 475 1 [turn over]
19
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number
Question 17 (Surgery)

A 72-year old man presents one week after a myocardia1 infarction with a four hour history of a
painful, cold, left leg. On examination he is in sinus rhythm and normal pulses are palpable in the
right leg. On the left there is a weak femoral pulse but nothing below this and the leg is pale and cold
to touch.
(A) What is the most likely cause? (1 mark)

..............................................................................................................................................
(B) What are four other possible causes of acute lower limb ischaemia excluding previous
bypass surgery or trauma? (4 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
(C) Name five of the cardinal signs and symptoms of acute limb ischaemia. (5 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
(D) Name two essential components o f the initial definitive treatment for this patient.
(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
20
 I
I I

Second Examination for the Degree of Bachelor of Medicine, 27 June 2005

Question 18 (Surgery)
Enter candidate number I
An 80-year old female presents with abdominal distension, abdominal pain and vomiting. After
examination and appropriate investigations, a diagnosis of large bowel obstruction is made. Plain
abdominal x-ray shows distended large bowel loops. Laboratory tests show mild anaemia only. On
examination: temperature of 37.5"C, pulse 105 and blood pressure of 160/80.
List four underlying differential diagnoses at this point. (4 marks)

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

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
What five components of the management plan would you convey to the nursing staff
looking after this patient? ( 5 marks)

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

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

4. ..........................................................................................................................................
5. ..........................................................................................................................................
What three further specific investigations would be appropriate for this patient?(3 marks)

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

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

For examiner's use only:

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

FBMV 475 1 [turn over]

21
 Second Examination for the Degree o f Bachelor of Medicine, 27 June 2005 Enter candidate number I
Question 19 (Surgery)

A 47-year old lady presents to A & E with a red, painful breast. On examination, there is no palpable
mass but the breast is very tender and feels diffusely firm. She gives no risk factors for breast
malignancy but was seen in the clinic six months previously with nipple discharge from the same
breast.

(A) Name three conditions which may have caused her nipple discharge and give the
characteristic colour of the discharge in each. (6 marks)

Disease Symptom

1............................................................ ...............................................................
2. ........................................................... ...............................................................
3. ........................................................... ...............................................................
(B) At this A & E visit, name the two most likely differential diagnoses. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
(C) What two investigations are most appropriate? (2 marks)

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

2. ..........................................................................................................................................
(D) If the results of these tests are not available straight away, what two aspects of
management would you institute? (2 marks)
1...........................................................................................................................................
2. ..........................................................................................................................................

~~~ ~~~

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /12
FBMV 475 1
22
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005 Enter candidate number I
Question 20 (Surgery)

A 70-year old diabetic man, previously fit and well, presents to the vascular clinic with two episodes
of monocular visual loss affecting his right eye. Duplex sonography shows an 80% stenosis of the
right internal carotid artery and 30% on the left.

If he was your patient, what four medical treatments would you have established?
(4 marks)
1...........................................................................................................................................

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

4. ..........................................................................................................................................
The patient is recommended for carotid endarterectomy. What is the key fact justifying
this advice? (1 mark)

..............................................................................................................................................
Name the two expected benefits to the patient of undergoing carotid endarterectomy.
(2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
List five potential complications that you would warn the patient of prior to surgery.
( 5 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 475 1 [turn over]
23
24
Second Examination for the Degree of Bachelor of Medicine, 27 June 2005

Question 9 (Medicine) (Page 21 of the examination booklet)

Figure 2.
200 . . ... ... ... . . . . . .. . . . . . . . . . . . . . --
. . .. .. .. .. 1.3
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i

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--
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.
1.2
. . . . . . . . . . . . . . .
.. .. .. . .
.. .. .. .. .. .. .. .. ..
.
. . . . .......... . . . . . . .
170 ..... . .. .. .. .. .. .. ......................
. .......................... .. ..
. . . . . . . .
. . . - 1.1
. . . . . . . . .
160 .. .. ..
.. .. .. . ... ... ... ... ... ... ... ... ... ... . . .
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. -
..............................................................
. . . . . . . . . . . . . .

- 0.9 6
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+
m 120 - 0.8 2
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%

c - 0.7 0
0

fj 100 cl
- - 0.6
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i3
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40
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1 1 1 1 1 1 1
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
0 I I I I I I I I I I I I I II I I 0
0 2 4 6 8 12 14 16
10 18 20 22 24
Time (hours)

FBMV 4751

25
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