Ccardiac Arrest with Agonal Rhythm

QUESTION 1

Option List

ABarbiturate coma

BBrain stem death

CCardiac arrest with agonal rhythm

DClinical diagnosis of death

EElectromechanical dissociation

FHypothermia

GHypoxic cerebral depression

HRigor mortis

ISudden cardiac arrest

JVentricular tachycardia

For each of the following clinical situations, indicate the most appropriate diagnosis from the list of options

1A patient on a medical ward is known to have carcinomatosis; there are no signs of life

Answer:D

2A patient has been pulled out of a lake, and has a deep body temperature of 28.10 C; the femoral pulses are not palpable

Answer:F

3A patient has been found in bed with a deep body temperature of 22.10 C; the arms and legs are stiff

Answer:H

4A patient has been in cardiac arrest for 15 minutes; the ECG appears to show a relatively normal sinus rhythm

Answer:E

5A patient has been cardiac arrest for 10 minutes; the ECG shows wide regular complexes at a fast rate.

Answer:J

QUESTION 2

Option list

AAmoxycillin

BAspirin

CAstemizole

DBendrofluazide

ECimetidine

FFerrous sulphate

GLactulose

HOral contraceptive pill

IPropranolol

JRifampicin

All of the following patients are taking one or more drugs, and each suffers iatrogenic harm because of a drug interaction when a further drug is prescribed; in each case, the mechanism of the interaction is described. For each patient, select from the list of options the further drug that was introduced.

1A drug user complains of symptoms of opiate withdrawal. Induction of hepatic enzymes by the introduction of a further drug has increased the metabolism of his heroin substitute, methadone

AnswerJ

2A woman becomes pregnant even though she took her combined oral contraceptive pills regularly; she was not advised of the risk associated with the introduction of a further drug, which reduced recycling of ethinyl oestradiol from the large bowel

AnswerA

3A man taking oral anticoagulation suffers from bleeding; the oxidative hepatic metabolism of warfarin has been blocked by the introduction of a further drug which binds to microsomal cytochrome P450

AnswerJ

4A man taking cisapride for gastro-oesophageal reflux experiences a cardiac arrythmia because he has been given a further drug which interferes with potassium channels in the myocardium

AnswerC

5Atrial fibrillation recurs in an individual who was previously well-stabilised on digoxin because a further drug was administered; this drug led to the loss of potassium from the kidney

AnswerD

QUESTION 3

Option List

AAlcoholic gastritis

BAnorexia nervosa

CBulimia nervosa

DDiabetic ketoacidosis

EErythromycin sensitivity

FGastroenteritis

GGlaucoma

HHepatitis

IHypertrophic pyloric stenosis

JLabyrinthitis

KOverdose

LPancreatitis

MPregnancy

Each of the following is a patient who presents with vomiting. Select the most likely diagnosis from the list of options.

1A 23 year old woman has gradually developed nausea and vomiting over the last two weeks. On questioning, she admits to breast tenderness, and is unsure of the date of her last period.

Answer: M

2A 24 year old man presents to his general practitioner on a Monday morning with repetitive vomiting over the previous 12 hours. There is blood in his vomit, and he has mild epigastric discomfort. There are no other gastric symptoms, and he denies diarrhoea. He has a generalized headache. He is not jaundiced.

Answer: A

3A 15 year old girl presents with a history of vomiting for the past two days. She has lost weight over the last month, and she is clearly dehydrated; she has sweet-smelling breath. She is slightly confused and has a tachycardia.

Answer: D

4A 25 year old woman is brought to the general practitioner by her sister because of episodes of vomiting; in particular, she has been vomiting after meals for the last month. Her periods have been irregular. She is not dehydrated or otherwise physically unwell. She refuses to discuss the problem.

Answer: C

5A 24 year old man demands urgent assistance. He has developed severe upper abdominal pain and vomiting. The pain is worse on moving. He has a history of heavy alcohol intake since the age of 15 years.

Answer: L

QUESTION 4

Option list

A24% oxygen

B24% oxygen and antibiotics

C24% oxygen and intravenous frusemide

D24% oxygen and nebulised bronchodilators

E24% oxygen, antibiotics and nebulised bronchodilators

F24% oxygen, diamorphine and intravenous frusemide

G60% oxygen

H60% oxygen and antibiotics

I60% oxygen and intravenous frusemide

J60% oxygen and nebulised bronchodilators

K60% oxygen, antibiotics and nebulised bronchodilators

L60% oxygen, diamorphine and intravenous frusemide

For each of the following clinical situations, select the most appropriate option for immediate management from the list above

1A previously healthy 24 year old man presents with acute dyspnoea, left sided chest pain, and cough productive of green sputum tinged with blood. On examination he is pyrexial and looks ill, with signs of consolidation at the left lung base but no wheezes.

AnswerH

2A 68 year old smoker presents with acute shortness of breath, on a background of chronic productive cough. On examination he is centrally cyanosed and pyrexial, with widespread crackles and wheezes.

AnswerE

3A 55 year old man develops sudden onset of right sided chest pain and dyspnoea in Terminal 2 of Manchester Airport on arrival from Hong Kong. On examination he is ill, cyanosed and apyrexial. There are no localising signs on chest examination.

AnswerG

4A 57 year old man is on the waiting list for coronary artery bypass grafting; he develops acute dyspnoea and cough with frothy pink sputum. On examination he is tachypnoeic and distressed, with profuse basal crackles but no wheeze.

AnswerL

5An 18 year old woman with a previous history of asthma develops acute dyspnoea following a row with her boyfriend. On examination she is tachypnoeic and distressed, with widespread wheezes.

AnswerJ

QUESTION 5

Option List

ABenign prostatic enlargement

BConstipation

CDementia

DDetrusor instability

EDiabetes mellitus

FDiuretics

GInfection

HMultiple sclerosis

IPelvic floor weakness

JStroke

KTrauma

Each of the following is a patient who suffers from urinary incontinence. Choose the most likely cause of each individual’s symptoms from the list of options

1A 69 year old man suffers from slight wetting after micturition. He also has to get up three times every night to pass water. This has been going on for several months.

Answer: A

2A 71 year old man is brought to the general practitioner by his wife because he has been micturating in inappropriate places. She reports that he micturated in the corner of the living room twice in recent days. He says he can’t remember doing this and he is sure that it is not true.

Answer: C

3A 27 year old woman comes to her general practitioner because she has had urgency of micturition for the past few weeks. Dipstick testing of urine is clear. The general practitioner notes that, two years previously, she had episodes of visual disturbance over a period of a few weeks; these resolved spontaneously.

Answer: H

4A 55 year old mother of seven children has had several unfortunate episodes recently, when she has been incontinent of urine. These occurred while she was running for a bus, and when she had a bad cough.

Answer: I

5An 83 year old man has recently received treatment in hospital for congestive cardiac failure. Since discharge back to his two bedroomed terraced house, he has been incontinent of urine on several occasions during the day.

Answer: F

QUESTION 6

Option List

AMetabolic acidosis – acute, normal oxygenation

BMetabolic acidosis – acute with hypoxaemia

CMetabolic acidosis – compensated, normal oxygenation

DMetabolic alkalosis – acute, normal oxygenation

EMetabolic alkalosis – acute with hypoxaemia

FMetabolic alkalosis – compensated, normal oxygenation

GNormal blood gases

HNormal ventilation with hypoxaemia

IRespiratory failure – acute

JRespiratory failure – compensated, normal oxygenation

KRespiratory failure – compensated with hypoxaemia

For each of the following blood gas results, select the most appropriate designation from the list of options. The line labelled [O2] represents the concentration of oxygen that each individual is inhaling

12345

PaO2 kPa16.312.96.714.34.7

PaO2 mmHg122975010835

PaCO2 kPa 7.55.810.16.312.7

PaCO2 mmHg 56 44764895

pH 7.267.247.387.527.12

H+ molarity nmol/l 55 57 42 30 76

Bicarbonate mmol/l24.118.042.239.029.5

Base excess mmol/l-2-7+14+14-4

[O2]75%40%21%30%21%

AnswersIBKDI

Normal values

PaO2 kPa12.0 - 14.7

PaO2 mmHg90 - 110

PaCO2 kPa 4.5 - 6.0

PaCO2 mmHg 34 - 45

pH 7.36 - 7.44

H+ molarity nmol/l35 - 45

Bicarbonate mmol/l24 - 30

QUESTION 7

Option list

AAbdominal aortic aneurysm

BAchalasia of the oesophagus

CAcute prolapsed intervertebral disc

DAnkylosing spondylitis

EChronic low back pain

FChronic pancreatitis

GCostochondritis

HDissection of thoracic aorta

IMetastatic prostatic carcinoma

JMultiple myeloma

KMyelomeningocoele

LNeurofibroma

MOsteomalacia

NOsteoporotic vertebral collapse

OPaget’s disease of bone

PPleural effusion

QPsoriatic arthropathy

RStaghorn calculi

SSyringomyelia

TTuberculosis

UUric acid arthropathy

For each of the following subjects with back pain, select the most likely diagnosis from the list of options

1A previously healthy 75 year old white woman presents with acute onset of severe pain over the mid-thoracic spine. Examination reveals localised tenderness over T5. Serum calcium and alkaline phosphatase are normal, and ESR is 20mm in the first hour.

AnswerN

2A 30 year old Asian woman complains of poorly localised pain in the shoulders and pelvis. Examination reveals no localising signs. Serum corrected calcium is 2.1mmol/l, the alkaline phosphatase is raised, and ESR is 10mm in the first hour.

AnswerM

3A 68-year old white man has been unwell for 3 months and develops pain over the thoracic spine. On examination there is evidence of recent weight loss; there is tenderness over T10. Serum corrected calcium is 3.3mmol/l, creatinine is 350µmol/l, and ESR is 110mm in the first hour.

AnswerJ

4A 47-year old white man complains of chronic pain in the lumbosacral region. Examination reveals tenderness over the sacro-iliac joints and restricted range of spinal movements. Serum corrected calcium is 2.3mmol/l, alkaline phosphatase is normal, and ESR is 30mm in the first hour.

AnswerD

5A 66 year old man presents with a fracture of the right hip after suffering a fall in the kitchen at home. In addition to the fracture, the hip X-ray shows multiple well-defined lytic lesions in the pelvic bones and the femur. Urinalysis shows heavy proteinuria.

AnswerJ

Normal values: serum corrected calcium 2.15 - 2.65mmol/l, creatinine <110µmol/l

QUESTION 8

Option list

ABrain stem

BCerebral hemisphere

CConus medullaris

DCommon peroneal nerve

EL5 nerve root

FLumbosacral plexus

GMuscle (ie, a myopathy)

HPeripheral nerve (ie, a polyneuropathy)

ISciatic nerve

JSpinal cord

KSural nerve

LTarsal tunnel

Each of the items below is an extract from the medical history and examination findings of a patient with leg weakness. For each one, select the most likely location of the lesion from the list of options

1“ ... right leg weakness of subacute onset involving ankle dorsiflexion, eversion and inversion, with depression of the ipsilateral ankle jerk and sensory loss confined to the dorsum of the foot and the anterior aspect of the leg ...“

Answer: E

2“. weak left leg evolving over a few weeks with tingling in the foot and, on direct questioning, urinary urgency; examination showed increased tone in both lower limbs and bilaterally extensor plantar responses; weakness restricted to left hip flexion and ankle dorsiflexion; pain sensation reduced in the right foot but joint position sense lost in the left foot .”

Answer: J

3“. gradually evolving difficulty rising from a chair and climbing stairs, without sensory loss; electromyography of the quadriceps muscle showed small, broken up motor unit potentials in normal numbers .”

Answer: G

4“. severe pain in the lower back and left thigh and leg in a patient on anticoagulants; marked weakness of hip flexion and knee extension on the same side with impaired sensation on the anterior aspect of the thigh .”

Answer: F

5“. weakness and wasting of the right tibialis anterior and calf, absent right ankle jerk and extensor plantar responses; nerve conduction studies showed normal motor conduction velocity and sensory responses from the right common peroneal nerve .”

Answer: C

QUESTION 9

Option List

AABO incompatibility

BBreast milk jaundice

C Cephalhaematoma

DCongenital biliary atresia

ECongenital cytomegalovirus infection

FCongenital haemolytic anaemia

GCongenital spherocytosis

HGalactosaemia

IGlucose-6-phosphate dehydrogenase deficiency

JHaemolytic disease of the newborn

KHypothyroidism

LPreterm birth

MSepsis

A 6 day old infant is admitted with jaundice (serum bilirubin 300mol/l) and feeding poorly for the past 48 hours. The infant was born at a gestational age of 36 weeks and weighed 2680g at birth. The following are some of the clinical findings and results of investigations. In each case, select the most likely cause of the jaundice from the list of options.

1The infant was born after a difficult forceps delivery and the head appeared to be swollen in the right parieto-occipital area. Jaundice developed after 24 hours. The haemoglobin is 12 g/dl; there is indirect hyperbilirubinaemia

Answer:C

2The baby has a temperature of 38.00C and tends to bring up its feeds. The circulating white cell count is 18x109/l. Microscopy of urine from a suprapubic aspirate shows large numbers of neutrophil polymorphs

Answer: M

3The liver and spleen are palpable and there is a family history of lethargy, hepatosplenomegaly and poor feeding. The raised bilirubin is initially unconjugated; in the second sample, the conjugated fraction tended to rise. Urine examination is positive for reducing substances using Clinitest.

AnswerH

4On initial assessment, petechiae and hepatosplenomegaly are noted, and on investigation, thrombocytopenia and partially conjugated hyperbilirubinaemia are found. Chorioretinitis is noted later and intra-cranial calcification is reported on a CT brain scan.

AnswerE

5The baby was mostly breast fed and 20% of the bilirubin is conjugated. Increasing formula milk feeds caused a rapid fall in bilirubin levels.

AnswerB

QUESTION 10

Option List

AAdenovirus

BCytomegalovirus

CEpstein-Barr virus

DEscherichia coli

EGiardia lamblia

FHaemophilus influenzae type B

GListeria monocytogenes

HMycobacterium tuberculosis

IMycoplasma pneumoniae

JNeisseria meningitidis

KPseudomonas aeruginosa

LPneumocystis carinii

MRespiratory syncytial virus

NRotavirus

OStaphylococcus aureus

PStaphylococcus epIdermidis

QStreptococcus agalactiae

RStreptococcus pneumoniae

SStreptococcus pyogenes

TToxoplasma gondii

All of the infectious diseases described below occur in children. For each one, select the most likely underlying causative agent from the list of options

1A 3 year old boy is referred to hospital with a two day history of lethargy, irritability and poor feeding. On examination, he is pyrexial, drowsy and has a purpuric rash on his trunk and extremities. CSF obtained from a lumbar puncture is cloudy and contains 540 white cells/mm3 (90% polymorphs) and 5 red blood cells/mm3.

Answer:J

2A 6 year old girl presents with a one week history of febrile illness with sore throat and headache. One day prior to hospital admission, the patient awoke with pain and swelling in the right ankle. On examination, she has a warm swollen right ankle and a systolic heart murmur, consistent with mitral regurgitation.

Answer: S

3A new born infant is found to be lethargic and has a distended abdomen immediately after birth. On examination, the infant is jaundiced and has hepatosplenomegaly. A cranial CT scan reveals periventricular calcification.

Answer:B

4A 7 year old male child is referred to hospital by the general practitioner with acute renal failure. The child had bloody diarrhoea and a low grade fever a week ago; both resolved with rehydration.

Answer: D

5.A 4 month old female infant is brought to the hospital with severe respiratory distress. Five days previously, she had a cough and rhinitis. On examination her temperature is 38.90C, pulse 180/min and the respiratory rate 80/min. She had subcostal retractions and nasal flaring. On auscultation, there are rhonchi and wheezes all over her chest.

Answer: M

QUESTION 11

Option List

AAcute angle-closure glaucoma

BAcute anterior uveitis

CAcute bacterial conjunctivitis

DAcute viral conjunctivitis

ECorneal foreign body

FCorneal ulcer

GEpiscleritis

HMeibomian cyst

ISubtarsal foreign body

JUltraviolet keratitis

Each of the items below is an extract from the symptoms and signs of a patient with a red eye. For each one, select the most likely underlying diagnosis from the list of options

1The eye is difficult to open after sleeping; it shows diffuse conjunctival injection

AnswerC

2The eye is irritable, with fine vertical streaks of corneal epithelial staining after the instillation of drops of fluorescein dye

AnswerI

3There is bilateral severe irritation and photophobia in a sheet metal worker, with diffuse corneal epithelial staining after the instillation of drops of fluorescein dye

AnswerJ

4There is ciliary injection and a semi-dilated irregular pupil; the patient complains of nausea and local pain

AnswerA

5There is ciliary injection and a small pupil; the patient complains of local pain, especially on reading.

AnswerB

QUESTION 12

Option List

AAmitriptyline

BChlordiazepoxide

CChlormethiazole

DChlorpromazine

ECognitive behavioural therapy

FElectroconvulsive therapy

GFamily therapy

HFluoxetine

IHaloperidol

JMethadone

KOlanzepine

For each of these patients, select the most appropriate therapy from the list of options

1A 63 year old man is known to suffer from Parkinson’s disease. He develops paranoid ideas and auditory hallucinations.

Answer: K

2A 39 year old woman with stable chronic schizophrenia continues to hear voices, even though she is fully compliant with medication, and her schizophrenia is otherwise well controlled

Answer: E

3A 24 year old schizophrenic man is acutely disturbed, and needs to be urgently sedated. He will not take oral medication.

Answer: I

QUESTION 13

Option List

AAlcoholic hallucinosis

BAnxiety disorder

CBereavement

DBipolar affective disorder

EDrug-induced psychosis

FHuntington’s chorea

GMalingering

HMultiple sclerosis

IParaphrenia

JPersonality disorder

KSchizophrenia

LSteroid-induced psychosis