EFA Amalgamation Mock
SBAs
1. A 35 year old woman, with primary hypothyroidism diagnosed 13 years ago,
complains of feeling exhausted for several months. She also complains of weight loss
and dizziness. Blood pressure in clinic is 110/80 mmHg lying and 90/70 mmHg
standing. Blood tests show: Sodium 128 mmol/L (133 – 146) Potassium 5.5 mmol/L
(3.5 – 5.3) fT4 18 pmol/L (9 - 23) TSH 3.9 mU/L (0.3 – 4.2) What is the next step in
her management?
a. Increase her thyroxine dose
b. Measure 9AM cortisol and ACTH
c. Measure a full blood count
d. Measure plasma osmolality
e. Reduce her thyroxine dose
2. 55 year old man sustains a head injury in a road traffic injury. A few days afterwards,
he notices that he is very thirsty and passes lots of urine, both during the day and at
night. After several weeks of these symptoms, he sees his GP who performs some
investigations. Sodium 150 mmol/L (133 – 146) Potassium 4.9 mmol/L (3.5 – 5.3)
Random glucose 6.9 mmol/L HbA1c 38 mmol/mol (10 - 41) Plasma osmolality 300
mOsm/kg H2O (275 - 295) What is the most likely diagnosis?
a. Cranial diabetes insipidus
b. Diabetes mellitus
c. Post-traumatic stress disorder
d. Psychogenic polydipsia
e. Syndrome of Inappropriate Antidiuretic Hormone
3. At his annual diabetes review, 55 year old man with a 10 year history of well
controlled type 2 diabetes mellitus complains of erectile dysfunction. He takes
metformin only. His GP checks some bloods. HbA1c 48 mmol/mol (20-41)
Testosterone 3 nmol/L (10-20) Prolactin 25 000 IU/mL (45-375) FSH 0.1 mIU/mL (1.611) LH 0.2 mIU/mL (1.3-8) What should the GP do next?
a. Anterior Pituitary MRI
b. Counsel him that erectile dysfunction is common in type 2 diabetes mellitus
c. Intensify his glycaemic control
d. Perform a testicular examination
e. Repeat the blood tests at a different time of day
4. Which lobe of the brain is primarily concerned with processing sensory information
such as touch and pain?
a. Frontal
b. Limbal
c. Occipital
d. Parietal
e. Temporal
5. The table below shows the pKa of four different opioid drugs. All four drugs are weak
bases. Which of the four drugs would be most unionized at a tissue pH of 7.4?
6.
7.
8.
9.
a. Alfentanil
b. Morphine
c. Pethidine
d. Remifentanil
A 67-year old man visits his opticians after noticing that he finds it increasingly
difficult to focus on the words in his books and newspapers, even when wearing his
glasses. What is a likely cause of this?
a. Astigmatism
b. Emmetropia
c. Hypermetropia
d. Myopia
e. Presbyopia
A 23 year old patient with type 1 diabetes goes out clubbing and forgets to take his
long acting insulin before he leaves the house. He gets home late and feels too tired
to check his capillary blood glucose or to take any insulin. When he wakes
the following morning, he feels thirsty, but blames this on a hang-over.
He notices he is passing urine frequently. He tries to drink some water,
but can’t manage it as he starts to retch and vomit. He attends his local Accident and
Emergency department. Some bedside blood tests show:pHL:7.1 (7.35-7.45) Glucose
:24 mmol/L (3.7-5.2)Bicarbonate:8 mmol/L (22-29) Capillary blood ketones
: 4.1 mmol/L (<1 mmol/L) What is the next step in his management?
a. Start intravenous 5% dextrose
b. Start intravenoussodium chloride
c. Give him a large dose of subcutaneous short acting insulin
d. Give him an anti-emetic (anti-sickness drug)
e. Withhold his insulin until he stops vomiting
In the cerebral cortex, which functional area relates to the cytoarchitectural regions
1,2 & 3 based on Brodmann’s classification system?
a. Premotor
b. Primary auditory
c. Primary somatosensory
d. Primary motor
e. Supplementary
Which drug targetsite (labelled 1-5) is partly responsible for the therapeutic
effectiveness of venlafaxine?
a. 1
b. 2
c. 3
d. 4
e. 5
10. What evidence supports a strong genetic component for obesity?
a. Non identical twins have more similar body mass indexes than identical twins
b. Obesity rates have increased rapidly across the developed
world over the last 30 years
c. Specific gene variants have been associated with
differences in body mass index
d. More than 650 million adults worldwide are estimated to be clinically obese
e. Lifestyle changes are usually ineffective in obesity management
11. Alcohol withdrawal can be potentially fatal. Which medication is most commonly
used, in hospital, for acute detoxification in order to prevent complications?
a. Buprenorphine
b. Chlordiazepoxide
c. Naltrexone
d. Acamprosate
e. Methadone
12. A 48 year old man reports a burning sensation in his chest. His electrocardiogram is
shown below. Estimate his ventricular axis
a. -30 to 0 degrees
b. 0 to 30 degrees
c. 30 to 60 degrees
d. 60 to 90 degrees
e. 90 to 120 degree
13. A 48 year old male presents to A&E with shortness of breath, coughing and a fever
and is suspected of having a SARSCoV-2 infection. As a result more invasive
monitoring is carried out. Observations were O2 saturation of 90% on BiPAP, a heart
rate of 80 bpm, a respiratory rate of 20/minute, blood pressure of 145/85 mmHg
and a temperature of 38 degrees Celsius. A Schwanz ganz catheter indicates end
diastolic volume of 256 mL and end systolic volume 111 mL. Which of the following
describes his cardiac output, ejection fraction and mean arterial blood pressure?
a. CO: 11.6L EF: 64% MAP: 95 mm Hg
b. CO: 11.6L EF: 57% MAP: 105 mm Hg
c. CO: 10.5L EF: 57% MAP: 105 mm Hg
d. CO: 10.5L EF: 65% MAP: 95 mm Hg
e. CO: 10.5L EF: 63% MAP: 101 mm Hg
14. What is the main mechanism by which low density lipoprotein promotes
atherosclerosis?
a. Deposited in artery walls, it easily oxidises, and is taken up by plaque
macrophages, causing their activation.
b. It interacts with plaque macrophage cholesterol transporters leading to
removal in so-called reverse cholesterol transport
c. It is taken up into macrophages primarily via Toll-like Receptor 4 thereby
activating nuclear factor kappa B.
d. Directly triggers apoptosis in plaque vascular smooth muscle cells.
e. Promotes upregulation of adhesion molecules on the vascular endothelium
promote leukocyte recruitment.
15. A 67 year old man with a history of COPD and lung cancer is admitted to hospital
confused, breathless and with a fever. His O2 saturation is 95 %, he his blood
pressure is 85/65 mmHg and his respiratory rate is 32 breaths per minute.
Microbiological cultures reveal the presence of Mycoplasma pneumoniae. What
classes of antibiotics should be administered to this person?
a. Penicillins and Rifamycins
b. Penicillins and Tetracyclins
c. Aminoglycosides and Macrolides
d. Penicillins and Macrolides
e. Penicillins and aminoglycosides
16. A patient reported to his GP complaining of stomach bloating, swelling in legs,
headache, and fatigue. Urine dipstick test results showed high specific gravity, and
further urine analysis showed high [Na+]. Blood tests showed decreased plasma
[Na+]. What is the most plausible diagnosis and treatment?
a. Central Diabetes Insipidus; External ADH.
b. Central Diabetes Insipidus; Non-peptide inhibitor of ADH receptor.
c. Syndrome of inappropriate ADH secretion (SIADH); External ADH.
d. Syndrome of inappropriate ADH secretion (SIADH); Non-peptide inhibitor of
ADH receptor.
e. Nephrogenic Diabetes Insipidus; External ADH.
17. Patient data showed pH = 7.5, [HCO3-] = 27mEq/L, PCO2 = 47mmHg. Identify the
acid-base disorder and the compensatory response employed by the body.
a. Metabolic alkalosis; Hypoventilation
b. Metabolic alkalosis; Hyperventilation
c. Respiratory alkalosis; Hypoventilation
d. Respiratory alkalosis; Hyperventilation
e. Respiratory alkalosis; increased bicarbonate excretion
18. What does the radiograph below shows?
a. Transverse fracture of fibula
b. Spiral fracture of tibia
c. Transverse fracture of radius
d. Transverse fracture of tibia
e. Spiral fracture of fibula
19. A 55-year old woman developed a rash affecting her face and upper trunk in recent
weeks, along with other symptoms including feeling generally unwell and weak. She
mentions painful fingers also. Examination reveals an erythematous photosensitive
eruption affecting her face and upper trunk. On her fingers, there are ulcers. Blood
tests show increased creatine kinase, and positive ANA and anti-MDA5 antibodies.
Which one of the other conditions is most likely to be also present?
a. Hepatic fibrosis
b. Interstitial lung disease
c. Pericarditis
d. Lung malignancy
e. Renal impairment
20. A 1-month-old female infant is referred with a facial rash that developed in the
preceding days. Examination reveals an annular eruption in a periorbital distribution.
There are no blisters or erosions and there is no rash elsewhere. The baby has no
other known health issues. The mother is healthy, and the pregnancy was
uneventful. What is the most important diagnostic test?
a. Skin biopsy
b. Syphilis serology of both mother and infant
c. Mycology studies
d. ECG
e. Abdominal Ultrasound
21. Angiotensin Converting Enzyme inhibitors (ACEi’s) can be used to treat proteinuria.
In the diagram below, where is the main site of action of ACEi’s in treating
proteinuria?
a. 1
b. 2
c. 3
d. 4
e. 3&4
22. A 47 -year-old bird-watcher attends his GP due to an area of mildly pruritic redness
over his right arm over the preceding 5 days. He has been feeling mildly unwell with
subjective fever and joint pain for the preceding 1 week. He has not come into
contact with any new chemicals, nor taken any new medications. He has not injured
himself, nor recalls any bites. He has not travelled overseas in recent months.
Examination revealed an erythematous and annular plaque over inner aspect of the
right arm, with a ring of pallor within the lesion. Full blood count is normal Biopsy
from the lesion showed non-specific findings. He had not taken any recent new
medications. What is the likely diagnosis?
a. Lyme disease
b. tularaemia
c. Ecthyma
d. erythrasma
e. PVL Staph aureus
23. A 46-year-old cattle and sheep farmer based in Devon presents to his GP due to an
eruption on his right forearm in recent days. He is systemically well. Examination
revealed firm dome-shaped bullae on the inner aspect of her right forearm. Some of
them exhibit crusting. The GP reassures the patient and advises that no specific
treatment is required. What is the likely cause of the eruption?
a. Histoplasmosis
b. Coxsackie virus A16
c. Human papilloma virus
d. Parapoxvirus
e. Blastomycosis
24. These submucosal immune sensors are found throughout the small intestine, but
mainly in the distal ileum. They consist of aggregated lymphoid follicles covered with
follicle associated epithelium. They detect bacteria by antigen uptake via M
(microfold cells). What is the above description describing?
a. Goblet cells
b. Villi
c. Peyer’s patches
d. Mesenteric lymph nodes
e. Haustrations
25. Identify the compensatory response being used by the body through analysis of the
patient’s data: pH = 7.5, [HCO3-] = 31mEq/L, PCO2 = 47mmHg ( Normal ranges:
Blood pH = 7.4, [HCO3-] = 24mEq/L, PCO2 = 40mmHg
a. Renal compensation – Increased reabsorption of Bicarbonate ions
b. Renal compensation – Increased excretion of ammonia and proton ions
c. Respiratory compensation – Hypoventilation
d. Respiratory compensation – Hyperventilation
e. Intracellular buffering
VSAQ
1. A 65 year old woman presents to the Accident and Emergency department with
vomiting and constipation. She has a previous history of lung cancer which was
treated by surgery and chemotherapy 1 year ago. On examination, she looks
dehydrated. Routine biochemistry shows: normal renal function, calcium 2.90
(reference range 2.15-2.60 mmol/L), phosphate 0.90 (reference range 0.80-1.40
mmol/L), 25 hydroxyvitamin D 60 (reference range 70-150 mmol/L), PTH <0.1 (1.16.8 mmol/L) Abdominal X-Ray is normal. What treatment should she receive next?
2. A 34 year old woman presents to her GP with weight loss and palpitations. Her GP
checks some thyroid function tests: fT4 32 pmol/L (9 - 23) fT3 13 pmol/L (3.1 – 6.8)
TSH <0.01 mU/L (0.3 – 4.2)
Prior to this, she has been fit and well, with no medical problems and is not taking
any medications. What two medications should the GP start?
3. A patient has a stroke which causes weakness and sensory deficits in the right arm
and the right side of the face. Precisely which major artery is likely to have been
involved?
4. A patient is due to undergo neurosurgery in an attempt to prevent the spread of
electrical activity during epileptic seizures from one hemisphere to the other. Which
white matter tract will be severed during this surgical procedure?
5. Thirty minutes after administration, blood levels of a drug are higher in the hepatic
portal venous system than in the major arteries (systemic blood levels). Which route
of administration was utilized for this drug?
6. The amnestic presentation of Alzheimer’s disease is related to atrophy
of which temporal lobe structure?
7. The table below provides mechanistic information for one of the anti-epileptic drugs
– labelled drug A. Which drug do you think this is?
8. A 44 year old woman presents to her GP because she has not enjoyed anything,
including things that she used to enjoy, for 5 weeks. What is the best term to
describe this symptom?
9. Which phase of migraine can include visual, sensory disturbances
(numbness/paraesthesia) and weakness?
10. The TNM8 lung cancer staging system uses primary tumour site, tumour size,
regional lymph node metastases and which other characteristic to score lung cancer
progression
11. A patient admitted with bacterial pneumonia but despite antibiotics develops sepsis,
and acute respiratory distress syndrome. The clinical team have measured O2
saturation, positive end point pressure and chest radiology. What else would they
measure in order to accurately score the severity of ARDS.
12. The arterial blood gases of a patient are the following:
Describe the patients’ acid-base status.
13. Acute alcohol withdrawal can present with a variety of signs and symptoms. Which
condition, related to alcohol withdrawal, represents a life-threatening medical
emergency?
14. Name a commonly used, validated, cognitive questionnaire (scored out of 30) that is
used in routine clinical practice to screen for dementia?
15. Which diuretic generally acts on the distal convoluted tubule and causes higher Ca2+
reabsorption due to its mode of action?
16. Chronic infection with the parasite Trypanosoma cruzi can cause an oesophageal
motor abnormality similar to which commoner functional disorder?
17. What is the first priority in the management of a patient with a suspected fracture
following a road traffic acid involving two cars each travelling at 60 miles per hour?
18. Ghrelin directly modulates neurones in which brain area?
19. What name is given to a fracture in children where one cortex breaks but the other
side does not?
20. I bind to a target on the basolateral side of the parietal cell. I prevent the cAMP
dependent movement of hydrogen ions into the stomach lumen. What drug am I?
21. Which drug might be responsible for the blood test results observed in Patient A?
22. A 40-year-old CEO of a start-up company presents with worsening back pain. He has
gained 6 stone in weight over the last two years. He says that although he tries to
incorporate physical activity and healthy meals, the demands of his job don’t allow
it. He has a BMI of 42 and is a prediabetic. What weight loss option would you
recommend for this gentleman when all lifestyle measures fail?
23. Which bacteria causes 'hot tub folliculitis' (aka 'wetsuit folliculitis', 'jacuzzi
folliculitis')
24. If a patient reports to his GP with symptoms such as cold and clammy skin, increased
heart rate and no urine output. What is likely to be his blood fluid volume status?
SAQs
A 30y old woman discontinued the oral contraceptive pill nine months ago to plan
for a pregnancy. She has not had a period since. She attends her GP surgery
concerned about what to do next. Pregnancy test negative BMI 22 kg/m 2
1. What hormone is measured in the urine to confirm pregnancy (full name, no
abbreviated).
Her GP checks some blood tests.
Oestradiol <70 pmol/L (>200)
FSH 0.7 mU/L (1.5 – 10)
LH 0.8 mU/L (2 - 10)
Prolactin 15 000 IU/L (<500)
Macroprolactin negative
Normal thyroid function
2. Name two other symptoms, in addition to her amenorrhoea, which you should ask
her about. (2 marks)
3. Describe the mechanism by which high prolactin can cause secondary
hypogonadism. (4 marks)
The GP requests a pituitary MRI which shows a small (0.5cm) pituitary tumour.
4. Looking at the blood tests results and pituitary MRI findings, what is the diagnosis?
5. What treatment should she be offered? How does this work? (2 marks)
6. Identify the arteries providing the blood supply in the perfusion fields indicated on
the diagram above. (3 marks)
7. List 3 of the main risk factors for stroke. (3 marks)
8. List 2 symptoms that might be associated with a thrombo-embolic stroke affecting
the vessels perfusing areas A (2 marks) and B (2 marks) in the diagram above.
A 61 year-old male patient with presents with a cough and fatigue. The patient is a
never smoker, and does not have occupational exposures, but has developed COPD.
The patient has been able to continue their job in administration, but has
increasingly found the twenty-minute walk to work challenging and struggles with
stairs between floors at the office. Initial chest X-ray reveals an isolated peripheral
tumour mass of ~2.5cm in diameter. There is no evidence of metastasisto the lymph
nodes or elsewhere. Biopsy determines the presence of a mutation in ALK.
9. What WHO performance score would you assign the patient? (1 mark)
10. Based on the information above, what stage would you estimate the tumour to be?
(1 mark)
11. What approach would you use to confirm the diagnosis histologically? (1 mark)
12. Identify two additional pieces of information that would be useful before proceeding
with treatment (2 marks)
13. What would be your initial approach to treatment? (2 marks)
14. Despite the initial treatment metastases are later detected in the liver. What
systemic treatment approach would you choose? (1 marks)
15. Below is a schematic diagram of the lower oesophageal sphincter (LOS) and its
surrounding anatomical structures.
A – D are known to make important anatomical contributions to maintenance of a
competent LOS. Identify the structures/anatomical features A, B, C & D: (4 marks)
16. Name 3 mechanisms which help protect the distal oesophagus if reflux of gastric
contents does occur: (3 marks)
17. Name 3 consequences of persistent gastro-oesophageal reflux disease: (3 mark)
Anatomy
1. Identify the structure indicated by the arrow (please state side).
2. The part of the fibrous pericardium indicated by the arrow attaches to which part of
the diaphragm?
3. The arrow indicated by the arrow is the right coronary artery. ”Right dominance” is
referring to which artery which arises from the right coronary artery in
approximately 80% of people?
a. Posterior interventricular artery
b. Right marginal artery
c. Left coronary artery
d. Left circumflex artery
e. Anterior interventricular artery
4. Which statement is correct about the structure indicated by the arrow?
a.
b.
c.
d.
e.
It is the femoral artery and it continues as the popliteal artery
It is the femoral vein and it drains into the external iliac artery
It is the femoral nerve and arises from L2-L4 spinal roots
It is the profunda femoris artery which branches from the femoral artery
It is the great saphenous vein and drains into the femoral vein via the
saphenous opening
5. Which statement is correct about the structure indicated by the arrow?
a.
b.
c.
d.
e.
It is the tensor fasciae latae muscle
It is innervated by the femoral nerve
It is in the anterior thigh compartment
It is the sartorius muscle
It inserts into the quadriceps tendon
6. Identify the structure indicated by the arrow in this superior view of the right knee.
Answers:
SBAs
1. Measure 9AM cortisol and ACTH
2. Cranial diabetes insipidus
3. Anterior Pituitary MRI
4. Parietal
5. Alfentanil
6. Presbyopia
7. Start intravenous sodium chloride
8. Primary somatosensory
9. 2
10. Specific gene variants have been associated with differences in body mass index
11. Chlordiazepoxide
12. 30 to 60 degrees
13. CO: 11.6L EF: 57% MAP: 105 mm Hg
14. Deposited in artery walls, it easily oxidises, and is taken up by plaque macrophages,
causing their activation.
15. Penicillins and macrolides
16. Syndrome of inappropriate ADH secretion (SIADH); Non-peptide inhibitor of ADH
receptor.
17. Metabolic alkalosis; Hypoventilation
18. Transverse fracture of tibia
19. Interstitial lung disease
20. ECG
21. 1
22. Lyme disease
23. Parapoxvirus
24. Peyer’s patches
25. Respiratory compensation – Hypoventilation
VSAQs
1. IV fluids/ Intravenous
2. Non selective beta blocker/beta blocker/propranolol plus AND antithyroid
drug/carbimazole/propylthiouracil
3. Left Middle cerebral artery
4. Corpus callosum - Callosal fibres connect hemispheres. The major tract connecting
the left and right hemispheres is the corpus callosum.
5. Oral route - Drugs administered via the oral route are absorbed from the
gastrointestinal tract into the hepatic portal venous system. The drug is then
transferred to the liver (where drug metabolism can occur). The drugs will then drain
into the venous system before returning to the heart and then finally accessing the
systemic arterial system from where they can then access other tissues.
6. Hippocampus - Amnestic – involved in memory - pertaining to amnesia. Loss of
neurons in the hippocampus is seen in Alzheimer's disease
7. Levetiracetam
8. Anhedonia
9. Aura
10. Extrathoracic metastasis
11. Compliance
12. Uncompensated mixed alkalosis
13. Delirium tremens.
14. Mini Mental State Examination (MMSE) OR Montreal Cognitive Assessment (MoCA)
15. Thiazides
16. Achalasia
17. Resuscitation
18. Arcuate nucleus
19. Greenstick fracture
20. Histamine H2 receptor antagonist or H2 receptor antagonist
21. Trimethoprim
22. Bariatric surgery
23. Pseudomonas aeruginosa
24. Hypovolemic, hypovolaemic
SAQs
1. Beta human chorionic gonadotrophin (1 mark)
2. Galactorrhoea, Low libido, vasomotor symptoms
3. Prolactin binds to prolactin receptors on hypothalamic kisspeptin neurons to inhibit
kisspeptin release (2 marks), this results in a reduction in gonadotrophin releasing
hormone pulsatility (1 mark) which in turn reduces FSL and LH secretion from the
anterior pituitary (1 mark).
4. Microprolactinoma
5. Dopamine agonist treatment eg cabergoline (1 mark). Binds to D2 receptors on
prolactinoma to reduce prolactin and shrink tumour. (1 mark)
6. A - Anterior cerebral B - Middle cerebral C - Posterior cerebral
7. Max 3 from: Age, Hypertension, Cardiac disease, Smoking, Diabetes mellitus
8. A:- 2 from: Paralysis of contralateral leg > arm, face, Disturbance of intellect,
executive function and judgement (abulia), Loss of appropriate social behaviour
B:- 2 from: Contralateral hemiplegia: arm > leg, Contralateral hemisensory deficits,
Hemianopia, Aphasia (L sided lesion)
9. PS1
10. T1cN0M0
11. Peripheral tumour, so would use CT-guided lung biopsy
12. Any 2 of: comorbidities, medication history, lung function.
13. Lobectomy (possibly sublobar) and lymphandectomy
14. ALK inhibitor e.g. Crizotinib
15. A: Diaphragm B: Angle of His C: Phrenoesophageal ligament D: Distal oesophagus
within the abdomen
16. Volume clearance or oesophageal peristalsis reflex / pH clearance or swallowing of
saliva / Barrier properties of the oesophageal epithelium
17. A mark for any of the following: Oesophagitis / Peptic stricture / Barrett’s
oesophagus / Oesophageal cancer
Anatomy
1. Left common carotid artery
2. Central tendon
3. Left or right dominance refers to whether the posterior interventricular artery arises
from the left or right coronary artery.
4. This is the femoral artery at the femoral triangle. From lateral to medial the contents
of the femoral triangle are femoral nerve, artery, vein and lymph.
5. This is the tensor fasciae latae muscle. It is not a muscle of the thigh; it is a muscle of
the gluteal region.
6. Lateral meniscus