A 58-year-old man with longstanding hypertension was found to have a serum creatinine
concentration of 275 µmol/L (60-110). Urinalysis showed blood ++ and protein >1 g/L. Renal
ultrasound showed the left kidney to be 9.2 cm long, the right to be 8.9 cm long (normal range for
both kidneys 10-12 cm), and neither kidney was obstructed.
What is the best investigation to diagnose the cause of the renal impairment?
(Please select 1 option)
intravenous urography
isotope renography
renal arteriography
renal biopsy
Correct
retrograde pyelography
The presence of long standing hypertension, haematuria, significant, non, nephrotic proteinuria is
highly suspicious of glomerular pathology, such as IgA nephropathy which is best characterised by a
renal biopsy. In the absence of obstruction on ultrasound, intravenous urography, retrograde
pyelography, and isotope renography are not appropriate. Renal size asymmetry in the presence of
hypertension and renal impairment might prompt the search for renovascular disease. However, in
this case of kidneys are of similar and good size.
Which one of the following is a feature of the VIPoma syndrome?
(Please select 1 option)
a. Alkalosis
b. Hypoglycaemia
c. Hypokalaemia
Correct
d. Increased gastric acid seceretion
e. Provocation of VIP release by somatostatin
a, b,d,e: All opposite to what is expected.
The features of VIPoma include
- vasoactive intestinal polypeptide secreting tumour
- mainly pancreas rarely ganglioneuroblastoma (sympathetic chain or adrenal cortex)
- secretory diarrhoea ('pancreatic cholera')
- weight loss
- dehydration
- abdominal colic
- cutaneous flushing
- raised plasma vasoactive intestinal polypeptide (VIP)
- urea+calcium
- raised plasma pancreatic polypeptide
- hypokalaemic acidosis (loss of alkaline secretions)
- achlorydia
- mildly raised glucose
- normal functions of VIP
-increased intestinal secretion of water and electrolytes
- peripheral vasodilation
- inhibits gastric acid secretion
- potentiates acetylcholine action on salivary glands.
An 17-year-old female presented with a one year history of secondary amenorrhoea. She had been
prescribed Temazepam and Dihydrocodeine previously.
On examination she had galactorrhoea to expression. Her prolactin concentration was 6000 mU/L
(50-450). Pregnancy test was negative. What is the most likely diagnosis?
(Please select 1 option)
Drug-induced hyperprolactinaemia
Non functioning pituitary tumour
Pituitary microadenoma
Incorrect answer selected
This is the correct answer
Polycystic ovarian syndrome
Turner's syndrome
The history and examination findings together with the grossly elevated prolactin concentration are
suggestive of a microprolactinoma. This is not Polycystic Ovarian Syndrome as the
hyperprolactinaemia is far too high. The drugs that she is taking would not cause
hyperprolactinaemia as agents such as dopamine antagonists, antipsychotic agents and tricyclic
antidepressants may be responsible. If she were to have a non-functioning pituitary tumour, stalk
compression would be expected to produce a prolactin concentration of less than 2000 mU/L.
Which of the following statements is true of coronary artery anatomy?
(Please select 1 option)
Right bundle branch block in acute anterior myocardial infarction suggests obstruction
prior to the first septal branch of the left anterior descending coronary artery This is the
correct answer
The AV node is supplied by the left anterior descending coronary artery
The left main stem is about 4 cm long
The posterior descending artery is usually a branch of the circumflex artery
The sinus node is supplied by a branch of the right coronary in over 90% of subjects
Incorrect answer selected
It is sometimes said that questions longer than two lines are usually false ... but not in this case.
The posterior descending artery is most often (85%) a branch of the right coronary artery.
The sinus node artery is a branch of the right coronary artery in 60% of cases.
The AV node is supplied from the posterior descending coronary artery.
The left main stem is much shorter than 4 cm!
Question: 6 of 10 / Overall score: 33%
1822
Which molecule is produced in the nucleus, matures in the cytoplasm, binds to the ribosome and
initiates protein synthesis?
(Please select 1 option)
Messenger RNA
This is the correct answer
Ribosomal RNA
Incorrect answer selected
RNA nucleotide
RNA polymerase
Transfer RNA
Protein synthesis consists of two phases.
Transcription is where one strand of the deoxyribonucleic acid (DNA) double helix is used as a
template by ribonucleic acid (RNA) polymerase to synthesise messenger RNA from RNA nucleotides.
The mRNA then migrates into the cytoplasm maturing, for example, by the splicing of non-coding
sequences.
Translation occurs when the ribosome binds to mRNA at the start codon and transfer RNA brings
amino acids into position along the mRNA template.
The ribosome moves from codon to codon along the mRNA producing a polypeptide sequence.
Elevation of the jugular venous pressure during inspiration is most likely to be found in which of the
following situations?
(Please select 1 option)
A normal physical examination
Cardiac tamponade
Constrictive pericarditis
Correct
Dilated cardiomyopathy
Myocarditis
Kussmaul's sign (a rise in jugular venous pressure on inspiration - the opposite to normal) is seen in
both constrictive pericarditis and pericardial tamponade, but it is more likely to be present in the
former.
However, neither of these are the commonest cause ... can anyone name that?
Question: 8 of 10 / Overall score: 50%
5290
A 17-year-old student presented with recurrent attacks of dizziness.
Which one of the following additional features is most suggestive that she has an anxiety disorder?
(Please select 1 option)
Elevated diastolic blood pressure
Nocturia
Paraesthesia in the hands
Correct
Rotational vertigo
Tinnitus
Paraesthesia is often experienced with hyperventilation associated with anxiety disorders and is
often in hands, feet and peri-orally.
Rotational vertigo and tinnitus suggest an organic disorder, whilst anxiety disorder may be
associated with raised systolic blood pressure.
A 22-year-old lady recently returned from a holiday in Malta was admitted with a 3 day history of
fever, generalised lymphadenopathy and a macular rash over the trunk and legs. Which of the
following is the most likely diagnosis.
(Please select 1 option)
Sarcoidosis
Tuberulosis
Familial Mediterranean Fever
Infectious Mononucleosis
Correct
Actinomycosis
Infectious Mononucleosis occurs most commonly in adolescents and young adults. Clinical features
occur after a 2-5 week incubation period and include fever, malaise, pharyngitis, and
lymphadenopathy. Rashes occur more commonly in patients that have received penicillin or
ampicillin.
You are working for the elderly care team in the hospital when an 82-year-old woman under your
care is found dead by the nursing staff in the early hours of the morning.
She was not resuscitated due to a history of severe chronic obstructive pulmonary disease (COPD).
You have written the cause of death as old age and you complete cremation form 4.
Which of the following is true with respect to completion of the forms?
(Please select 1 option)
Civil proceedings have been taken against doctors who have inappropriately completed
form 5
Old age is usually not an acceptable cause of death for cremation purposes when
completing form 4 Correct
The consultant who heads up the team may complete form 5
The locum staff grade who qualified three years ago in India may sign form 5
Your brother who is a house officer on another team at the hospital may sign form 5
A key point with respect to completing form 4 is that the cause of death must be accurately
established.
Whilst old age may be acceptable when certifying for a burial, it is not accepted by cremation
referees.
The latest guidelines for doctors include specific instructions that members of the same hospital
team as the physician completing part 4 must not complete the form, nor may partners in the same
GP practice complete the form either.
Additionally, relatives of the patient are forbidden from completing either form 4 or 5, and relatives
of the doctor who completes form 4 cannot complete form 5.
Ministry of Justice cremation guidelines
A 35-year-old woman with a five year history of treated hypothyroidism, presented following an
episode of vomiting and collapse.
There was a short history of weight loss.
On examination she had a temperature of 37.7C, a blood pressure of 80/40 mmHg and vitiligo.
Which one of the following, given intravenously, would be the most appropriate initial
management?
(Please select 1 option)
10% dextrose infusion
Cefotaxime
Fludrocortisone
Incorrect answer selected
Hydrocortisone
This is the correct answer
Tri-iodothyronine
This patient is likely to have Addison's disease based upon her history, autoimmune disease, and
presentation.
She requires treatment with intravenous hydrocortisone which can be a life-saving manoeuvre in
acute hypoadrenalism.
A 70-year-old woman presented with an acute, severe occipital headache, unsteadiness of her gait
and vomiting.
She had a history of poorly controlled hypertension.
On examination there was nystagmus to the left, ataxia of the left limbs and gait ataxia.
What is the most likely diagnosis?
(Please select 1 option)
Acute cerebellar haemorrhage
Correct
Basal ganglia haemorrhage
Pontine haemorrhage
Subdural haemorrhage
Temporal lobe haemorrhage
Cerebellar hemorrhage:
The most common symptoms are of severe nausea and vomiting and ataxia. Headache may be
severe. Patients with cerebellar haemorrhage can rapidly become comatose within hours after the
onset from herniation, because of its limited space in the posterior fossa.
Pontine hemorrhage:
There are numerous nuclei located within the pons. Rapidly deteriorating level of consiousness,
impaired extraocular movement and extensive sensorimotor deficits are clinical clues to pontine
hemorrhage.
Basal ganglia haemorrage:
Contralateral hemiparesis, hemisensory loss, or hemi-inattention. Aphasia, especially nonfluency and
impaired comprehension, is frequently seen if haemorrhage occurs in the posterior limb of the left
internal capsule.
A 38-year-old man experiences sudden deterioration after being admitted to the intensive care unit
because of severe pneumococcal pneumonia and septic shock.
Arterial blood gas analysis reveals:
pH
7.2
(7.36-7.44)
PaO2
12 kPa
(10-13.3)
PaCO2
4.7 kPa
(4.7-6)
HCO3-
16 mmol/l
(20-28)
Which one of the following changes will be found in this patient at this time?
(Please select 1 option)
Hyperventilation leading to the increase in CO2 concentration
Increase production of HCO3-
Increased renal excretion of HCO3-
Raised hydrogen ions level in the blood
Correct
Respiratory acidosis
This patient has a metabolic acidosis with a low HCO3 and a normal PaCO2.
In a patient with low pH, increased hydrogen ion concentration will be found.
He is not hyperventilating as indicated by the normal PaCO2.
In chronic acidosis, for instance in advanced renal impairment, bicarbonate levels may be
supplemented to buffer the raised hydrogen ion concentrations. Bicarbonate supplementation in
this situation needs to be undertaken with great care as it may worsen an intracellular acidosis.
A 55-year-old male presented six hours after taking an overdose of lithium tablets which had been
prescribed for a bipolar affective disorder.
On examination he was tremulous, had suffered a convulsion and had a Glasgow coma scale of
12/15. His serum lithium concentration was 5.0 mmol/L (0.5-1.0)
What is the most appropriate management of this patient?
(Please select 1 option)
Activated charcoal
Forced alkaline diuresis
Incorrect answer selected
Furosemide 100 mg intravenously twice daily
Haemodialysis
This is the correct answer
Measure lithium concentration in 2 hours
The patient has a severe lithium overdose as reflected by markedly elevated lithium concentrations
and features of impaired consciousness, tremor and seizures.
This needs urgent management.
Activated charcoal does not bind lithium effectively and is therefore ineffective except where coingestion of other poisons is suspected.
Haemodialysis is the mainstay of treatment for acute lithium toxicity
A 50-year-old male presented with acute respiratory failure during an episode of acute pancreatitis
and was thought to have developed adult respiratory distress syndrome (ARDS).
Which of the following would support a diagnosis of ARDS?
(Please select 1 option)
High protein pulmonary oedema
This is the correct answer
High pulmonary capillary wedge pressure
Hypercapnia
Incorrect answer selected
Increased lung compliance
Normal chest X-ray
ARDS is characterised by:
 hypoxaemia
 reduced lung compliance
 pulmonary hypertension and
 pulmonary infiltrates on the chest X-ray.
There is damage to the capillary and endothelial cell linings resulting in oedema and leakage of
proteins and cells into the interstitial and alveolar spaces at normal pulmonary capillary hydrostatic
pressures.
Wedge pressure unlike the high pressures seen with left ventricular failure (LVF) and pulmonary
oedema is often normal.
Hypercapnia often a late feature of ARDS does not distinguish from any other cause of type 2
respiratory failure
63-year-old female presents with a one day history of confusion with headaches.
On examination she is confused, with a Glasgow Coma Scale of 13 and a temperature of 39.5°C.
She has nuchal rigidity and photophobia.
CSF examination reveals a glucose of 0.5 mmol/L (3.3-4.4), a white cell count of 2500 per mm and
Gram-positive cocci in pairs.
Which of the following is correct?
(Please select 1 option)
A characteristic rash would be expected.
Nerve deafness would be a common complication in this case.
Correct
Rifampicin should be given to close contacts.
The most likely infective organism is Staphylococcus aureus
The organism is likely to be penicillin resistant.
This patient has pneumococcal meningitis, caused by the Gram- positive coccus Strep. pneumoniae.
This is the second commonest cause of bacterial meningitis (commonest in the elderly) and is
associated with the highest mortality (20%) and highest morbidity, such as deafness which may
occur in 50%.
Contacts do not require treatment and there is no rash associated with pneumococcal meningitis.
Meningococcus is Gram-negative.
A 67-year-old man who has a long history of chronic bronchitis is admitted from home with an acute
exacerbation.
Investigations show:
pCO2
11 kPa (4.7-6)
pO2
6.7 kPa (10-13.3)
Which of the following would be expected in this patient?
(Please select 1 option)
A metabolic acidosis with a low bicarbonate would be expected
Extensor plantar responses may be expected
This is the correct answer
Gentamicin would be a reasonable initial treatment until cultures are available
Oxygen therapy should aim to increase the pO2 to above 8 kPa (60 mmHg)
answer selected
Peripheral oedema indicates coexisting heart failure
Incorrect
In chronic bronchitis, a low pO2 with high pCO2 and compensated respiratory acidosis with high
bicarbonate is expected. Consequently with the high pCO2 an encephalopathy may be precipitated
resulting in extensor plantar responses. The figures given suggest a respiratory acidosis.
BTS guidelines would recommend treatment of exacerbations with amoxicillin or cephalosporin.
Oxygen therapy should be given cautiously aiming to maintain a pCO2 between 6.7-8 kPa (see
Harrisons - Principles of Internal Medicine); this is debatable but the point is that the aim should not
be a normal pO2 but rather a sufficient pO2 particularly in 'blue bloaters' (type 2 respiratory failure).
Extensor plantar responses are a feature often reflecting high pCO2.
There may be a dependent (postural) oedema and this does not necessarily indicate heart failure.
A 24-year-old man presents to the emergency department and complains of shortness of breath.
Before his chest x ray is taken he tells the casualty officer that he is known to have an 'azygous lobe'.
What region of the chest x ray would expect to see an 'azygous lobe'?
(Please select 1 option)
Left lower zone
Left mid zone
Left upper zone
Right lower zone
Right upper zone
Correct
An azygous lobe is seen in about 0.5% of routine chest x rays and is a normal variant.
It is seen as a 'reverse comma sign' behind the medial end of the right clavicle.
A 22-year-old man suffers a deep laceration to the forearm resulting in transection of the median
nerve.
Following this injury, the nerve will undergo which of the following pathological processes?
(Please select 1 option)
Chronic inflammation
Coagulative necrosis
Fibrinoid necrosis
Segmental demyelination
Wallerian degeneration
Correct
Degeneration of the portion of the nerve distal to the injury.
Segmental demyelination is a feature seen in axons in the central nervous system with multiple
sclerosis.
A 50-year-old lady is brought into the emergency department with drowsiness following an overdose
of amitriptyline.
She has dilated pupils, a GCS of 12, pulse 140 bpm, BP 85/60 mmHg and her ECG shows a wide
complex tachycardia.
Which of the following is the most appropriate next step in management?
(Please select 1 option)
Carotid sinus massage
DC cardioversion
IV bicarbonate
Correct
IV magnesium
Refer for haemodialysis
This lady has a significant tricyclic overdose and the ventricular dysrrhythmias can be very difficult to
control. Management with intravenous (IV) bicarbonate is indicated.
"The use of sodium bicarbonate in tricyclic poisoning has been shown to have beneficial effects. ... In
a review of 91 patients treated with sodium bicarbonate, hypotension was corrected in 20 of 21
patients (96%) within one hour and QRS prolongation was corrected in 39 of 49 patients (80%). ...
The mechanism of this effect is a subject of debate." Emerg Med J 2001; 18:236-241
A patient has just received intravenous ceftazidime. They immediately become flushed and wheezy,
with a blood pressure of 80/40 mmHg.
Which of the following is the most appropriate immediate management for this patient?
(Please select 1 option)
Chlorphenamine 10mg IV
Epinephrine 0.2mls of 1:1000 IV
Incorrect answer selected
Epinephrine 0.5mg IV
Epinephrine 0.5mg i.m.
This is the correct answer
Hydrocortisone 100mg i.v.
Immediate treatment of anaphylaxis includes cessation of whatever caused it.
Then give oxygen, fluids and adrenaline/epinephrine 0.5 mg intra- muscularly or subcutaneously.
Checking concentrations of adrenaline is very important especially in high pressure situations.
Intravenous adrenaline is potentially hazardous unless diluted appropriately.
A 19-year-old girl has been brought to the emergency department by her friends following a night
out at a party.
Her friends comment that she has been talking by herself about 'irrelevant things'. She seems
agitated and restless.
On examination, her reflexes are increased and an electrocardiogram (ECG) demonstrates
ventricular ectopics.
What kind of substance abuse do you suspect at this point?
(Please select 1 option)
Alcohol
Barbiturate
Cannabis
Ecstasy
Correct
Glue sniffing
This is a case of ecstasy overdose.
Ecstasy (3,4-methylenedioxymethamphetamine, MDMA) stimulates the central nervous system. It
causes:

Increased alertness and self-confidence

Euphoria

Extrovert behaviour

Increased talkativeness with rapid speech

Lack of desire to eat or sleep

Tremor

Dilated pupils

Tachycardia and

Hypertension.
More severe intoxication is associated with:

Excitability

Agitation

Paranoid delusions

Hallucinations with violent behaviour

Hypertonia and

Hyperreflexia.
Convulsions, rhabdomyolysis, hyperthermia, and cardiac arrhythmias may also develop.
In severe cases of MDMA poisoning:

Hyperthermia

Disseminated intravascular coagulation

Rhabdomyolysis

Acute renal failure and

Hyponatraemia
are observed.
Hepatic damage has also been reported.
Rarely, poisoning due to amphetamines may result in intracerebral and subarachnoid haemorrhage
and acute cardiomyopathy; these complications may be fatal.
Hyperthyroxinaemia may be found in chronic amphetamine users.
A 74-year-old man with a thirty year history of psoriasis presented with generalised erythroderma of
three days duration.
Examination reveals him to be shivering but otherwise well. He was treated as an in-patient with
emollients and attention to fluid replacement and temperature control but failed to improve after
five days.
What is the most appropriate next treatment?
(Please select 1 option)
Oral hydroxychloroquine
Oral methotrexate
This is the correct answer
Oral prednisolone
Incorrect answer selected
Topical coal tar
Topical dithranol
Erythroderma is an emergency as patients are susceptible to profound dehydration, infection and
hypothermia.
Methotrexate would be the only correct treatment for someone with erythrodermic psoriasis.
Steroids could lead to unstable pustular psoriasis and would not generally work.
Hydroxychloroquine has little effect on psoriasis.
Topical coal tar and dithranol are good treatments for chronic plaque psoriasis but are highly irritant
and would make the erythroderma much more inflamed and deteriorate his condition.
A 55-year-old man presented to the emergency department with sudden breathlessness.
He is sweaty and obviously short of breath. He is a smoker with a past history of hypertension. There
are crackles on inspiration at both his lung bases and his CXR shows upper lobe venous diversion and
peri-hilar shadowing.
His ECG shows sinus tachycardia only and his cardiac enzymes, when they return the next day, are
normal. His symptoms resolved quickly with oxygen and furosemide.
Which of the following conditions is the most likely explanation of this presentation?
(Please select 1 option)
Hypertrophic obstructive cardiomyopathy
Myocardial infarction
Phaeochromocytoma
Pulmonary embolism
Renal artery stenosis
Correct
Flash pulmonary oedema in someone with a history of hypertension, especially those suspected of
being arteriopaths such as smokers, should raise the possibility of renal artery stenosis.
BMJ 2000;320:1124-1127
A 16-year-old boy is admitted after a blackout at the dentist.
His mother describes how he blacked out as the dentist began performing a filling and that he jerked
his arms a few times and was then incontinent. He awoke after a minute or so and was oriented but
nauseous.There were no similar episodes in the past and he is totally unaware of what happened.
Examination was normal and his ECG was normal.
Which one of the following is the most likely diagnosis?
(Please select 1 option)
Complex partial seizure
Pseudoseizure
Stokes-Adams attack
Tonic-clonic seizure
Vasovagal syncope
Correct
Vasovagal syncope is common during dental procedures, mainly induced by pain (as the dentist
started drilling).
The fact that he recovered very quickly supports the diagnosis of syncope.
It is common to have jerking of limbs due to brain hypoxia.
Electrocardiogram (ECG) is always normal.
Incontinence of urine can occur but not biting of the tongue.
A 45-year-old solicitor had an onset of severe, crushing, substernal chest pain while attending a
football match. He collapsed on his way to the car.
Bystander cardiorespiratory resuscitation was begun immediately and continued until arrival in the
casualty department where an endotracheal tube was inserted and ventilation was maintained on
100% oxygen.
Blood gas analysis revealed:
pH
7.13 (7.35-7.45)
P a O2
560 mmHg (90-110)
PaCO2
18 mmHg (35-45)
Bicarbonate
5.8 mmol/ll (20-30)
SaO2
98% (>90)
Based on these laboratory values, which of the following statements best describes his current
pathophysiology?
(Please select 1 option)
He is demonstrating a primary respiratory alkalosis
He probably developed a large right to left intracardiac shunt
His anion gap is probably normal
His oxyhaemoglobin curve is shifted to the left
His pulmonary artery pressure is probably elevated
Correct
This relatively young patient with severe central chest pain has probably arrested due to myocardial
infarction and arrhythmia.
His gases reveal high PO2 following 100% O2 but severe acidosis due to the arrest and lactic acidosis
thus the anion gap would be high.
He does not have a primary ventilatory failure as his PO2 is high.
There is no left to right shunting and high pulmonary pressures would be expected after this arrest
scenario.
A 42-year-old female presents following an episode of confusion associated with vomiting and
abdominal pain.
She had a one month history of weight loss and receives thyroxine for hypothyroidism which was
diagnosed five years ago.
On examination she appeared unwell, with a temperature of 37.5°C and her blood pressure was
100/50 mmHg.
Investigations revealed:
Sodium
130 mmol/L (137-144)
Potassium
4.8 mmol/L (3.5-4.9)
Urea
7.6 mmol/L (2.5-7.5)
Glucose
2.7 mmol/L (3.0-6.0)
Free T4
9 pmol/L (10-22)
TSH
1 mU/L (0.4-5)
Which one of the following given intravenously would be the most appropriate initial management?
(Please select 1 option)
Cefuroxime
10% Dextrose infusion
Glucagon
Hydrocortisone
Correct
Tri-iodothyronine
This young female presents with classical features of Addison's disease and the most appropriate
and life-saving therapy is steroids given intravenously.
The abnormal thyroid function tests (TFTs) are often encountered in association with acute
hypoadrenalism.
Giving thyroxine may actually exacerbate the condition.
A 50-year-old lady presented to the emergency department with cough and dyspnoea for the past
two days.
She was previously well. She smokes 20 cigarettes per day.
She has a temperature of 38.3°C and is agitated and confused. Her pulse is 110/min and her blood
pressure is 88/60 mmHg. Her oxygen saturation is 89% on air and she has a respiratory rate of
40/min.
Chest X-ray shows left basal consolidation.
Results show:
Sodium
143 mmol/L
(137-144)
Potassium
3.8 mmol/L
(3.5-4.9)
Urea
9.2 mmol/L
(2.5-7.5)
Creatinine
85 µmol/L
(60-110)
Her CURB score is documented and she is admitted to hospital with severe pneumonia.
Which of the following would count towards her CURB score?
(Please select 1 option)
Consolidation on chest x-ray
Oxygen saturation
Peak expiratory flow rate
Raised blood urea
Correct
Temperature
The CURB score is calculated by assessment of core adverse prognostic features which are used in
assessment of severity of pneumonia.
Two from four features indicate a severe pneumonia and hospital admission is advised.
The CURB score is calculated using:
1. Confusion abbreviated mental test score less than 8
2. Urea more than 7mmol/l
3. Respiratory rate more than 30/min
4. Blood pressure; systolic BP less than 90 or diastolic BP less than 60.
A 66-year-old man with insulin-dependent diabetes with a treated potassium of 5.4 mmol/l (3.5-5)
and palpitations develops pulseless ventricular tachycardia.
The anaesthetist is supporting airway and breathing.
Which of the following is the next step in his management?
(Please select 1 option)
Adrenaline 1 mg
Amiodarone 300 mg
Cardiopulmonary resuscitation (CPR) 15:2 for two minutes
Defibrillation at 150J biphasic
Correct
Praecordial thump
In the case of ventricular tachycardia and ventricular fibrillation immediate defibrillation is the
treatment of choice.
The other options come further down the algorithm and CPR is now recommended at 30:2.
A praecordial thump can be administered immediately following a witnessed cardiac arrest.
A 60-year-old male is brought to casualty in the early hours of the morning after being found
unconscious in the street.
On examination, he was drowsy but localised to painful stimuli. There was no evidence of head
injury or meningism.
Investigations revealed:
Sodium
134 mmol/L (137-144)
Potassium
4.0 mmol/L (3.5-4.9)
Urea
4.0 mmol/L (2.5-7.5)
Creatinine
80 µmol/L (60-110)
Glucose
4.5 mmol/L (3.0-6.0)
Chloride
100 mmol/L (95-107)
Bicarbonate
25 mmol/L (20-28)
Plasma osmolality
385 mosmol/kg (278-305)
What is the most likely explanation for his presentation?
(Please select 1 option)
Diazepam poisoning
Ethanol poisoning
Correct
Methanol poisoning
Phenobarbitone poisoning
Phenytoin poisoning
This gent is intoxicated.
He has a normal acid base balance, slight hyponatraemia reflecting dilution, and very high osmolality
reflecting the presence of ethanol.
Methanol would produce an acidosis.
Diazepam is not an osmolyte nor would the other agents produce this picture.
A 52-year-old schoolteacher attends with weight loss and sweats.
She is clinically thyrotoxic with a diffuse goitre.
Subsequent investigations show:
Free T4
40 pmol/L
(9-23)
Free T3
9.8 nmol/L
(3.5-6)
TSH
6.1 mU/L
(0.5-5)
A repeat TFT is similar.
What is the most appropriate investigation for this patient?
(Please select 1 option)
FNA of thyroid gland
MRI scan pituitary gland
Correct
Radio-isotope uptake scan of thyroid gland
Repeat TFT checking for antibody interference
Thyroid auto antibodies
This patient is thyrotoxic, however as the non-suppressed thyroid-stimulating hormone (TSH)
suggests that this is due to excessive TSH production by the pituitary gland the possibility of a
thyrotroph adenoma must be pursued.
In primary hyperthyroidism the TSH should always suppressed by negative feedback, which is not
the case here.
TSHomas are indeed very rare but the giveaway would be the normal or elevated TSH with
thyrotoxicosis.
A 35-year-old woman presents with pains in the right arm.
On examination she has wasting and weakness of the intrinsic muscles of the right hand, absent
tendon reflexes in the right arm and impaired pinprick sensation in the right hand and forearm.
What is the most likely diagnosis?
(Please select 1 option)
Combined median and ulnar nerve lesions
Lower trunk brachial plexus lesion
Incorrect answer selected
Neuralgic amyotrophy
Syringomyelia
This is the correct answer
Thoracic outlet syndrome
Median and ulnar nerve lesions would not cause absent reflexes in the arm.
Lower trunk brachial plexus (C8/T1) would not cause absent reflexes in the arm.
Neuralgic amyotrophy affects the upper plexus (C5-6) and therefore does not cause wasting of small
muscles of hand.
Thoracic outlet syndrome will not cause absent reflexes.
Syringomyelia typically causes loss of reflexes, spinothalamic sensory loss, and weakness. It can be
asymmetrical initially.
A 67-year-old female is admitted with blackouts.
Her electrocardiogram shows ventricular escape with complete heart block. As you are standing
there she blacks out once more. Her rhythm strip shows P wave asystole.
Which of the following would be the initial immediate treatment here after airway and breathing?
(Please select 1 option)
Adenosine 6 mg
Atropine 0.6 mg
Incorrect answer selected
Percussion pacing
This is the correct answer
Transcutaneous pacing
Transvenous pacing
Adenosine and atropine are not front line agents in this scenario, particularly adenosine which
blocks atrioventricular (AV) conduction; minus one mark if you elected this.
Transvenous pacing is not a fast enough intervention here.
Transcutaneous pacing is the immediate management but percussion pacing may be effective as a
holding measure whilst this is instituted.
(Percussion pacing involves gentle thumping of the lower left sternal edge with the fist.)
A 65-year-old man is admitted from home with a community-acquired pneumonia (CAP). He has a
history of skin rash to penicillin documented in his medical notes. He has adverse prognostic
features and a CURB score of 4.
What would be an appropriate empirical antibiotic choice?
(Please select 1 option)
Augmentin and clarithromycin
Augmentin and gentamycin
Cefotaxime and erythromycin
Correct
Cefuroxime and metronidazole
Ciprofloxacin and clarithromycin
Community-acquired pneumonia is most commonly caused by Strep. pneumoniae, hence the use of
a beta lactam antibiotic because of the increased incidence of atypical organisms such as
mycoplasma.
A macrolide such as erythromycin is also recommended.
Augmentin is contraindicated as it is penicillin-based.
Ciprofloxacin has poor cover against Strep. pneumoniae and metronidazole is used for anaerobic
infections.
The issue of cross-reactivity of hypersensitivity reactions between beta-lactam antibiotics is a
concern and is not fully addressed in the British Thoracic Society guidelines for CAP of 2001 or the
update in 2004 for severe hospitalised CAP. They state that alternatives would be a macrolide for
non-severe CAP or levofloxacin or possibly moxifloxacin (but in combination with benzylpenicillin in
severe cases).
The difficulty with the BTS guidelines is that a lot of the available evidence is of a very low level such
as consensus view rather than randomised controlled trials.
An interesting article in the NEJM discusses more generally the topic of cephalosporin crossreactivity: NEJM 2001;345(11):804-809 (log in required).
In this case a credible alternative for beta-lactam sensitivity is not mentioned and the best choice,
because of clinical necessity since severe pneumonia can be fatal if treated with antibiotics that are
not effective, is to go with the only cephalosporin and macrolide combination that is offered.
A 24-year-old female is admitted with palpitations.
Her pulse is 160 beats/min, blood pressure 70/50 mmHg and she has a respiratory rate 32/min. She
is awake, alert and oriented but dyspnoeic.
Her electrocardiogram shows a regular rhythm with QRS complex width of 0.11s.
What is the most appropriate therapy for this patient?
(Please select 1 option)
Adenosine 6mg/6mg/12mg
Incorrect answer selected
Amiodarone 300mg
Atenolol 50mg
Direct current cardioversion
This is the correct answer
Verapamil 10mg
This is higly likely to be a narrow complex tachycardia.
Strictly speaking, as this patient is showing signs of haemodynamic decompromise (that is, systolic
blood pressure less than 90) she should be immediately DC cardioverted under
sedation/anaesthesia.
In practice, most people would try adenosine first whilst organising a cardioversion.
A 19-year-old woman became breathless while travelling on an aeroplane.
Which one of the following features most strongly supports a diagnosis of acute hyperventilation
related to a panic disorder?
(Please select 1 option)
Carpal spasm.
This is the correct answer
Finger paraesthesia.
Incorrect answer selected
Hypotension.
Light-headedness.
Loss of conciousness
We need to distinguish between the signs that may be expected in the tachypnoea associated with
the hypoxia from a pulmonary embolism (PE) or any other serious respiratory problem and the
hyperventilation with increased pO2 in a panic attack.
A carpal spasm would be most likely to reflect this.
Finger paraesthesia can occur with PE, as can hypotension, light-headedness and loss of
conciousness.
Carpal spasm is found in association with hyperventilation due to the respiratory alkalosis which
results in a reduction in ionised calcium concentration.
A 35-year-old man with a known history of acute intermittent porphyria because he carries a
medical emergency card is brought to the emergency department by the police; he has been violent
with acute psychosis.
Which of the following sedatives would be the safest to use in this circumstance?
(Please select 1 option)
Chloral hydrate
Incorrect answer selected
Chlorpromazine
This is the correct answer
Diazepam
Haloperidol
Phenobarbitone
Phenothiazines have antiemetic and antipsychotic properties, making them the medication of choice
for acute porphyria episodes. ( eMedicine)
A 53-year-old woman with inoperable cancer has pain due to posterior abdominal wall infiltration.
This has been controlled well with Kapake (codeine 30mg and paracetamol 500mg), two tablets four
times per day.
The patient has been admitted with nausea and vomiting, the cause of which is, as yet, unknown.
Because she cannot retain her analgesics, she has severe pain in her loin.
What is the best option for controlling her pain until the vomiting settles?
(Please select 1 option)
Fentanyl skin patch
Incorrect answer selected
Intramuscular pethidine
Morphine four-hourly orally and as needed intramuscularly
Rectal non-steroidal anti-inflammatory drug
Subcutaneous diamorphine by continuous infusion
This is the correct answer
This patient has inoperable carcinoma and already needs opiate analgesia orally; as she is vomiting
she will need parenteral analgesia.
The most effective way of achieving this and being able effectively to titrate the dose to achieve
adequate analgesia is subcutaneous diamorphine by continuous infusion
A 78-year-old male who presents with increasing dysphagia is diagnosed with an inoperable
carcinoma of the distal oesophagus. Oesophageal spasm causes food to stick after swallowing
which causes odynophagia. Which drug would be most helpful in relieving his chronic pain?
(Please select 1 option)
Clodronate
Dexamethasone
Nifedipine
This is the correct answer
Oxybutinin
Incorrect answer selected
Pinavarium
Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal
tumours and could be used to relieve his odynophagia. Pinavarium is used to reduce the pain
duration associated with irritable bowel syndrome (IBS). Clodronate inhibits osteoclastic bone
resorption and is used to treat malignant bone pain and the associated hypercalcaemia.
Corticosteroids are used to treat pain from central nervous system tumours and painful bladder
spasm may be relieved by oxybutinin.
A 64-year-old man has terminal cancer with hepatic metastases. He is treated with oral morphine
(Oramorph) solution for pain relief.
Which is the most important pharmacodynamic factor in determining the appropriate timing
between doses?
(Please select 1 option)
Bioavailability
First pass metabolism
Incorrect answer selected
Gastric emptying
Plasma half-life
This is the correct answer
Renal clearance
Morphine undergoes extensive first pass metabolism in the liver.
However it is the plasma half-life which defines the timing of the doses.
An increased dose may be required if the patient develops tolerance to the morphine dose.
Which of the following concerning diamorphine elixir for the relief of pain in terminal patients is
correct?
(Please select 1 option)
Analgesia is enhanced if cocaine is added
Constipation is a characteristic sequel to treatment
Correct
Dependence occurs rapidly
Initial sedation typically continues whilst the drug is administered
The same amount of pain relief is produced as when the same dose is given via
intramuscular injection
Sedation occurring in the first few days typically wears off, leaving the patient alert.
Hallucinations also tend to occur.
An aperient should always be added to the treatment regime.
Addiction is not a problem.
An intramuscual injection is three times more effective than the same oral dose (Cornwall Trainers).
A 68-year-old man has been very ill for months following the onset of chronic liver disease with
hepatitis C infection.
He experiences a sudden loss of consciousness and then exhibits hemiplegia on the right. A cerebral
angiogram reveals lack of perfusion in the left middle cerebral artery distribution.
What is the most likely cardiac lesion to be associated with this finding?
(Please select 1 option)
Acute rheumatic fever
Left atrial myxoma
Libman-Sacks endocarditis
Non-bacterial thrombotic endocarditis
Paradoxical thromboembolus
This is the correct answer
Incorrect answer selected
Marantic endocarditis has platelet-fibrin thrombi that are prone to embolise.
This form of non-infective endocarditis can be seen in persons who are very debilitated or who have
a hypercoagulable state.