1/ mtx tx antidote ……………. ca folinate

1/ MTx Tx antidote ……………. Ca folinate.

2/ Peri-anal ulcers ……………. Nicorandil.

3 Bronchectasis + Fully sensitive Pseudomonas 1st time - IV ticarcillin + IV gentamicin.

4 Ttt of absorptive hypercalcuria type 2-----Low Ca diet. 5/Pulsless VT , 2nd shock , Check pulse or Continue CPR ?? ………………. Continue for2 min.CPR…… continued for 2 min with minimised interruptions without reassessing rhythm or checking a pulse.Adrenalin …… after the 3rd shock ……………. repeated every 3-5 mins.Atropine ……………. no longer recommended.Amiodarone …………… persistent VT.

6/ Red light districT… Amyl nitrite …………… Methemoglobinemia ……………. TREATMENT----Methylene blue.

7/ Test useful in differentiating rare causes of asthma from asthma? …………… ANCA.

8//Pregnant , Hyperthyroid , on PTU 150 mg/d , not controlled , PTU or Carbimazole ??↑…………… Switch to carbimazole.

9//APS & preg , Anti-coagulation ?? ……………… Switch warfarin to aspirin and LMW heparin for the rest of the pregnancy.

10/ To support Dx of empyema in Pleural Tap….. PH < 7.2

10/ Drug improve prognosis post MI… Clopidogrel.

11. Target BP in HTN + IHD … 130/80mmHg

12/ 21 yrs , BP 105/70 , K 3.1 , Na 139 , Urine/Creat ratio 0.15 , Diuretic abuse or Gittelman or bartter ?? …………… Gittelman. Urine Ca/Creat ratio in barter…. > 0.2

13/ HOCM Dx…… Echo.

14/ MVP + < 75 yrs + AF or LVF ……………… TOE before surgery.

15/ Chronic pancreatitis …………..CT scan.

16//Pyoderma gangrenosam + Skin swab Pseudomonas and Staphylococcus epidermidis ……………. IV Ig.

17//Pseudomonas and Staphylococcus epidermidis …………….. Skin commensals + Nosigns of deterioration (Bact Inf)

18// Renal impairment in IEC is dt...... Immune complex GN.

--------#####Old , Back pain , Bilateral hydroureter hydronephrosis , ANA +ve , ESR ↑…………….. Retroperitoneal fibrosis.

19// Young , Transient ST segment elevation , No other abnormality ……………… Early repolarization variant.

20//Young female since father died became mute in any stressful situation ………………Conversion disorder.

21//Preg , Acute asthma , HR 95 , REFR 260 (460) on Nebulizers , Next …………. IV Hydrocortisone.

22//Post-streptococcal , Creat 135 , HTN , Proteinuria 2+ , Hematuria 2+ , ttt ?? …………… Ramipril.

23//DM , HTN , IHD , BMI 28 , HbA1c 8.5 , Creat 135 , DM ttt………. Trial of gliclazide.

Pioglitazone is CI in--- IHD.Sitagliptin is CI in--- pancreatitis.

24///Arrest on street , VT , Immediate management CPR or DC ?? ……………. DC 2oo J then CPR.

25////Previous H/O of DVT , Signs of DVT , Cousin with DVT , Doppler is free , Management ?? …………….. Analgesia + Discharge.

26/ Long standing active RA , Loss of power and sensation in both UL & LL , Occipital pain , Hyperreflexia , no sphincter , vibration sense and proprioception are preserved , pain and temperature sensation is impaired …………….. Atlanto-axial sublxation.

27.CKD ……………. Surgery should be delayed until K < 5.5

28//Previous MI + LVF , Best drug for symptoms …………….. Eplerenone.

29///Definite ttt for Sleep apnea ………………… 1st line Wt loss ……… 2nd line CPAP.

30//PCO want to get Preg ………….. Clomiphen.--------PCO want to get rid of hirtutism ……………. Finasterid---------PCO want to regulate cycle without getting Preg …………… Dianette.-------------PCO want to lose wt …………….. Metformin.

30///COPD + PO2 8.5 + PCO2 9 + PH 7.3 ……………….. NIV.

31/// On thyroxin , TSH , T4 8.4 ………….. Non-compliant.↑

32// MNG developed sudden pain and in size + 1.5 cm firm mass ….. Hge into nodule.↑

33//HCV , Genotype 1 , On Interferon , What to add ?? …………….. Boceprevir and ribavirin.

34//Septic arthritis , Staph Aureus , On fluclo + Fucidic A developed cholestasis , Bl C/Sshows fluclo ………….. DC fucidic A + add gentamicin

35//Diarrhoea , Wt loss , Hypoglycemia , CT 3 cm mass in tail , Bx ill-defined nests of cells separated by vascularised stroma which stained strongly positive for chromogranin and synaptophysin ………………. Insulinoma.

36//Somatostinoma ………….. DM , GB stones , Diarrhoea , Steatorrhoea , Hypochlorhydria , Anaemia , Wt loss.

37//Shallow painless ulcers , Inguinal LN …………… Lymphogranuloma venereum.

38.///Ttt of Lymphogranuloma venereum …………….. Doxy & if preg …………….. Erythromycin.

39///Hashimoto + Mass + LN + Night sweats ……………. Thyroid lymphoma.

40///On paroxetine took drug and developed Serotonin Synd …… Resperidone.

41//Travel , Fever , Haemoptysis , Mild asthma , PLT , RF , CXR BHL + infiltrates in the ↓lower zones ….. Histocytosis X.

42//Stroke + CT free of he + out of window phase …………….. Aspirin 300 mg.

43//Asian on TB meds + Adison ……………… Adrenal TB

44//To confirm suspected wegner ………….. Renal Bx is better than lung Bx.

45//Thai , Fever , RETRO-ORBITAL HEADEACHE, Bleeding , PLT , RF , LFT ↓ ↑……………… Dengue fever.

46//On spironolactone developed gynecomastia …STOP SPIRONOLACTONE………….. START----Eplerinone (Selective).

47//Large pituitary adenoma compressing the stalk ………………. Surgery.

48///Kenya , Collapsed , Meningism , CSF no organism ptn normal Glu ↑…………………… IV quinine.

49///Marathon + Hyponatremia …………… Water intoxication.

50///Dx of marfanoid habitus …………… Genetic analysis.

51///Carbamazipine Tx ……………… Activated charcoal.

52//Ca > 3.6 + Confused …………….IV fluids then Calcitonin.Calcitonin is as effective as Pamidronate but faster in acute setting.

53///Drank a bottle of wine then rapid irregular palpitation ……………. HHS (paroxysmal AF).

54//HTN on spirono Lasix Rami Biso Doxazocin developed overload BP 90/60 HR 95 , K 5.3 ……………… DC Doxazocin.

55// On chemotherapy & Radiotherapy for SCL + Pericardial eff ……………….. Chronic Pericardial effusion.

56///Young + Manic disorder + LFT , ttt …………….. Trientin.↑

57//Old female + Wt loss + Cerebellar signs ……………… Mamogram.Breast cancer is more common than lung ca.

58//To support Behcet Dx……………… Pathergy test.

59////Surgical wound due to trauma become swollen + Blackish… necrotizing fasciitis.

1. 22-year-old woman is admitted from a night club with drowsiness, hallucinations and muscle rigidity. According to her friends she has taken some tablets that she purchased from a local dealer. A past admission 6 month earlier for bladder stones is noted. On examination her BP is 155/82 mmHg, pulse is 85/min and regular, temperature is 37.6oC. Her eyes are open but she doesnâ€™t respond to your questions. There is excessive salivation. On neurological examination you elicit bilateral increased tone with what appear to be involuntary tonic clonic movements.

Which of the following is the most likely cause of her symptoms?

Amphetamine overdose

Cocaine overdose

Diamorphine overdose

Ecstasy overdose

Ketamine overdose

EXP----At high doses, ketamine is noted to be associated with increased muscular rigidity and tonic / clonic movements. Other symptoms of ketamine overdose include hypertension, tachycardia and excessive salivation, which fit with the picture seen here. Lower urinary tract symptoms are seen in long term ketamine users, and include urge incontinence, decreased bladder competence,painful haematuria, and the formation of gelatinous deposits within the bladder. Bladder symptoms in long-term users may partially resolve where the drug is ceased, although permanent damage is common once symptoms

2. A 71-year-old woman presents with a swollen right lower limb some 6 days after beginning low molecularweight heparin. On examination her BP is 132/72 mmHg, pulse is 80/min and regular. Respiratory and abdominal examination is unremarkable, and there is an obvious right DVT.

Investigations;Hb 13.1 g/dlWCC 9.6 x109/lPLT 35 x109/l (195 x109/l on admission)Na+ 138 mmol/lK+ 4.3 mmol/lCreatinine 110 mol/lμWhich of the following is the investigation of choice to rule out heparin induced thrombocytopaenia (HIT)?

Anti PF-4-heparin antibodies

Anti-nuclear antibodies

APPT testing

Anti-platelet antibodies

Anti-cardiolipin antibodies

EXP- HIT is caused by antibodies to the heparin-PF-4 complex. Plasma from over 90% of patients suffering from HIT contains these antibodies. Anti-platelet antibodies are seen in ITP, whereas prolonged APPT and anti-cardiolipin antibodies are seen in anti-phospholipid antibody syndrome. Heparin should be discontinued; warfarin may lead to microthrombosis in patients with HIT, so lepirudin or argatroban should be used instead

3/ 50-year-old man presents to the clinic for review. He suffered a rear shunt road traffic accident some 6 months earlier. Initially his neck pain recovered, but he began suffering occipital headaches, pain over the base of his neck, and the posterior border of the right trapezius some 3 months ago. This has not been helped by visits to a chiropractor. On examination his BP is normal at 110/60 mmHg, pulse is 70/min and regular. Movement of the neck and shoulders is limited by pain, and there is sensory loss over the C3/C4 dermatome. Plain x-rays of the neck are unremarkable.

Which of the following is the most likely diagnosis?

Brachial plexus injury

Cervical discogenic syndrome

Cervical spondylosis

Cervical spondylolisthesis

Torticollis

EXP---The distribution of neck pain and demonstration of C3/C4 sensory loss fit best with a C3/C4 disc lesion. Normal plain films of the neck make spondylosis and spondylolisthesis unlikely, and torticollis presents with unilateral pain over the sternocleidomastoid muscle. Brachial plexus injury would be expected to result from more significant trauma. MRI of the cervical spine is indicated, with possible surgical referral if a significant disc prolapsed is visualised

4/ 55-year-old man presents to the haematology clinic for review. He has recently been diagnosed with multiple myeloma. His creatinine is within the normal range and he is not anaemic.

Which of the following assessments correlates best with poor prognosis?

Anaemia

Amp(5q31.3) and low Serum 2 Microglobulinβ

Del(12p13.31) and high Serum 2 Microglobulinβ

Hepatomegaly on CT abdomen

Mildly elevated creatinine

EXP---A genome wide analysis of newly diagnosed patients with myeloma has revealed insights about the genetic abnormalities most associated with poor prognosis. Patients with amp(5q31.3) alone and low S 2M have an excellent prognosis (5-βyear overall survival, 87%); conversely, patients with del(12p13.31) alone or amp(5q31.3) and del(12p13.31) and high S 2M have a very poor outcome (5-year overall survival, 20%β )

5/56-year-old man comes to the clinic for review. He has a long history of epigastric pain, and an oesophageo-gastro-duodenoscopy some 6 weeks earlier showed a deep ulcer, 1.5cm across in the anterior portion of the stomach. Helicobacter testing was positive at the time and he was treated with eradication therapy. He is now asymptomatic.

According to NICE, which of the following is the most appropriate way to manage him?

Re-endoscopy

Re-endoscopy and repeat H. pylori testing

No further intervention is necessary

He should be treated with long term PPI

PPIs should be continued for a further 6 months

EXP--According to NICE guidelines, A patient with gastric ulcer and H. pylori should receive repeat endoscopy, retesting for H. pylori 6--8 weeks after beginning treatment,depending on the size of the lesion.If the ulcer has healed and he is now H pylori negative, then no further intervention is required

6/ 23-year-old woman presents with worsening shortness of breath. Past medical history of note includes laparoscopic appendicectomy 6 years earlier, complicated by intra-abdominal haemorrhage, laparatomy, multiple organ failure and numerous centralvenous catheterisations. She has suffered multiple admissions over the past 5 years for cardiac failure and has been noted to have pulmonary hypertension on echocardiogram. On examination she is apyrexial, BP 162/90 mmHg, pulse 90/min. A murmur is heard over the left groin.Investigations; Right atrial pressure 15 mmHgSaturation 91% in IVCMean pulmonary artery pressure 38 mmHg

What is the most likely underlying cause?

Congenital AV malformation

Patent ductus arteriosus

ASD

Iatrogenic AV fistula

EXP-central venous catheterisation is a rare cause of iatrogenic AV fistula. This woman has had several attempted central venous catheterisations including potentially via the groin, which has led to a fistula between the IVC andthe iliac artery,with the consequence that right sided circulatory pressures are significantly increased. The treatment of choice is stent repair of the iliac artery which is likely to lead to resolution of her symptoms. Significantly raised right sided cardiac pressures are also seen as a natural rather than iatrogenic phenomenon in patients with significant arterio-venous malformations

7/ 39-year-old woman with a history of manic-depressive disorder visits her GP for review. She is currently treated with lithium therapy. The GP has been monitoring her blood pressure for the last few months; it is 155/105 mmHg in the clinic and he is keento commence pharmacotherapy.

Which of the following agents is likely to carry least risk for her with respect to lithium toxicity?

Bendroflumethiazide

Acetazolamide

Amlodipine

Enalapril

Valsartan

8/ A 32-year-old man presents to the general practitioner after returning from a 1 week holiday in Thailand. He complains of pain on passing urine, and cloudy urine that lookslike pus on occasions. There is also joint pain predominantly affecting the knees and ankles, and itchy eyes. On examination there appears to be a psoriatic-type rash affecting the feet.

Given the likeliest diagnosis, which one of the following treatments would best fit with the management of this condition?

Methotrexate 2.5mg po weekly

Azathioprine

Doxycycline 100 mg bid

Prednisolone 40 mg po daily

Coal tar skin creams

EXP---This man has reactive arthritis, possibly as a result of Chlamydia infection acquired during his recent trip to Thailand. This is exemplified by his presentation with probable uveitis, arthritis, urethritis, and keratoderma blennorrhagica. Appropriate treatment during the acute stage would be doxycycline.

9/ An 18-year-old boy and his father have a diagnosis of tuberous sclerosis. They attend the genetics clinic for mapping of the pattern of inheritance. The paternal grandparents are unaffected by the disease.What is the most likely explanation for this?

Autosomal recessive inheritance

Genetic anticipation

Variable penetrance

Non-paternity

Spontaneous mutation

EXP--The two features which impact significantly on attempts to determine the prevalence of tuberous sclerosis are variable penetrance, and a very high spontaneous mutation rate which makes up 2/3rds of cases. As such it is likely the father represents a new mutation. Tuberous sclerosis follows an autosomal dominant inheritance pattern;genetic anticipation is seen in trinucleotide repeat neurological disorders such as HuntingdonS chorea. As the genetic defects responsible for tuberous sclerosis are further characterised, it is thought that differences in penetrance are associated with different genetic mutations

10/ An 82-year-old woman is admitted to the Emergency department with hypotension, BP 80/60 mmHg, tachycardia with a pulse of 105/min, and probable gram negative sepsis. After 3 litres of fluid resuscitation she is still hypotensive, with a BP of 85/60 mmHg, and her CVP is measured at 14. She is being managed by the ITU outreach team prior to being moved to the unit.Which of the following is the most appropriate next intervention?

Noradrenaline

Adrenaline

Dopamine

Dobutamine

GTN

EXP-----Noradrenaline is the intensivE CARE inotrope of choice in the management of septic shock. Its main action is on alpha-1 receptors leading to a significant increase in blood pressure, there is also some action on beta-1 receptors which leads to an increase in myocardial contractility. Adrenaline is not favoured as it can lead to excessive tachycardia, myocardial ischaemia and rhythm disturbance. Dopamine is associated with increased risk of rhythm disturbance, and dobutamine can lead to excessive tachycardia with hypotension. GTN is obviously not indicated given the systolic is only 85 mmHg

10/ 53-year-old man whose Hb has dropped to 6.2g/dl after a variceal haemorrhage is blood typed for a transfusion. His panel is detailed below;

Anti-A positiveAnti-B negativeAnti-Rh positive

Which of the following answers represents his blood group?

AB+

AB-

B-

B+

O

EXP---The presence of Anti-A antibodies, and anti-rhesus antibodies implies that these antigens are not present in this patient. As such his blood group must be B rhesus negative.

Blood group B- is rare in the caucasian population, making up only approximately 2% of blood groups for the UK, O+ and A+ are the commonest blood groups.

11/ 24-year-old man is admitted with a painful sickle cell crisis. He is given successive doses of iV morphine by the A&E staff and becomes extremely drowsy with a respiratory rate of 8/min. He is given naloxone but then wakes screaming in pain. His BP is elevated at 155/95 mmHg, pulse is 95/min and regular.

Which of the following is the most appropriate next therapeutic option?

Haloperidol

Lorazepam

Morphine

Codeine

ParacetamoL

exp----Naloxone is relatively short acting, but reversal of his opiates has led to significant further pain.

Paracetamol is highly unlikely to be adequate with respect to pain control,

codeine is difficult to titrate, and a weak opiate versus morphine.

Whilst benzodiazepines and haloperidol may have a role in controlling agitation and anxiety, they are not appropriate here.

The most appropriate option is IV up-titration of morphine with careful observation of conscious level and respiratory

12/ A 27-year-old woman who is 32 weeks pregnant with her first child presents with progressively increasing shortness of breath over the past 2-3 weeks. She is now unable to climb the stairs and notices by the end of each day she has bilateral pitting oedema affecting both lower limbs. On examination her BP is 100/60 mmHg, pulse is 90/min and regular. Thereare bilateral basal crackles on auscultation of the chest and a systolic flow murmur.

Investigations;

Hb 12.0 g/dlWCC 8.1 x 109/lPLT 181 x 109/lNa+ 137 mmol/lK+ 4.0 mmol/lCreatinine 90 mol/lμEchocardiography dilated left ventricle, ejection fraction 30%


Aortic stenosis

Ischaemic cardiomyopathy

Mitral regurgitation

Peripartum cardiomyopathy

Hypertrophic obstructive cardiomyopathy

13/ 42-year-old woman presents with pins and needles in her hands and feet. She incidentally describes weight loss and offensive smelling stool. She has a history of small bowel diverticulae and anaemia. She is

a non-smoker and non-drinker. She eats red meat. On examination, the power and tone in her legs are normal. There are exaggerated knee jerks and absent ankle jerks. Joint position and vibration sense are absent below her ankles. The plantar responses are extensor.

Investigation results:

Hb 10.3 g/dl

White blood count (WBC) 5.0 —109أ /l

Platelets 142 109أ— /l

Mean cell volume (MCV) 107 fLBilirubin 32 آµmol/lAlanine aminotransferase (ALT) 22 U/l (5--35)Alkaline phosphatase (ALP) 45 U/l (30--150)Albumin 35 g/L

Blood film Macrocytosis and hypersegmented neutrophilsFerritin 46 آµg/l (4--120)Serum B12 80 ng/l (160--900)Folate 50 آµg/l (2-11)

Schilling test:

Oral labelled vitamin B12 secreted in urine:

Pre intrinsic factor 3%Post intrinsic factor 4%

What is the most likely diagnosis?

Terminal ileal Crohns disease

Chronic pancreatitis

Bacterial overgrowth

Pernicious anaemia

R-Binder deficiency

14/ A 62-year-old woman with long-standing, active rheumatoid arthritis is referred to the emergency medical take as she is unable to mobilise. She has had progressive loss of power and sensation in both upper and lower limbs over the past few weeks, and increasing occipitalpain. On examination there is grade 3/5 weakness affecting both upper and lower limbs, with increased tone and hyperreflexia. There is no sphincter disturbance and vibration sense and proprioception are preserved, although pain and temperature sensation is impaired.Which of the following is the most likely diagnosis?

Cervical cord myelopathy

Atlantoaxial subluxation

Syringomyelia

Spinal stenosis


15/ 76-year-old man with a 10-year history of chronic obstructive pulmonary disease was admitted to hospital with a 2-day history of progressively worsening dyspnoea and a cough productive of mucoid sputum. His wife stated that he is on home oxygen therapy for up to 12 h per day and home nebulisers. He is breathless on minimal exertion and rarely leaves the house. He has several exacerbations per yearrequiring hospital admission and these have become more frequent over the last few years, although he has never required ventilation before. He stopped smoking 2 years ago. On examination he was acutely dyspnoeic with a respiratory rate of 32/min and was using accessory muscles of respiration. He was apyrexial, pulse 120/min and regular, blood pressure 182/92 mmHg. He was able to speak in broken sentences. Auscultation of his chest revealed generalised poor air entry andwidespread expiratory wheeze.

Arterial blood gases (on 24% oxygen via Venturi mask) were:

pH 7.32 pa(O2) 6.2 kPa pa(CO2) 7.2 kPa

His inspired oxygen concentration was increased to 28% and he was treated with intravenous hydrocortisone, salbutamol and ipratropium nebulisers and an aminophylline infusion. After 1 h he had made little improvement and was tiring.

Repeat blood gases on 28% oxygen showed:

pH 7.26 pa(O2) 6.8 kPa pa(CO2) 9.2 kPa

What is the next most appropriate step in management?

Immediate intubation and ventilation

Intravenous doxapram

Bilevel positive airway pressure (BiPAP)

Increase inspired oxygen concentration to 35%

Continuous positive airways pressure (CPAP

EXP---This man is in type 2 respiratory failure due to a severe exacerbation of chronic obstructive pulmonary disease (COPD), and is not improving despite maximal medical therapy. His poor premorbid functional status and lack of an acute precipitating event make him a poor candidate for the intensive therapy unit. Non-invasive ventilation is the best option in this

situation and may be life saving

16/ A 57-year-old woman who has a history of breast cancer, and who underwent mastectomy

some 3 years earlier, presents to the Emergency department with increasing drowsiness and confusion. According to her husband she has been very well since her surgery, but he has noticed her â€œslowing downâ€, and suffering from some unsteadiness on her feet over the ‌past 8-12 weeks. She has lot a small amount of weight and been complaining of some back pain over the past 6 months, which she puts down to arthritis. On examination she is drowsy and mildly confused, with a GCS of 14. There are signs of meningism and she moans about asevere headache. There is no focal neurology.Investigations;

Hb 11.0 g/dl WCC 10.0 x109/l PLT 203 x109/l ESR 74 mm/1st hour Na+ 138 mmol/l K+ 4.3 mmol/l Creatinine 110 micromol/l Albumin 30 g/l ALT 85 U/l ALP 487 U/l Calcium 2.8 mmol/l Glucose 5.2 mmol/l

CSF glucose 2.0 mmol/l CSF protein 0.7 g/l CSF lymphocytosis CSF opening pressure 28cm H2O

What is the most likely cause of her neurological symptoms?

Tuberculous meningitis

Carcinomatous meningitis

Herpes simplex encephalitis

Meningococcal meningitis

Fungal meningitiS

17/ A 72-year-old man presents to the Emergency department with a severe episode of epistaxis. On further questioning it turns out that he has been suffering from nose bleeds, intermittent PR bleeding, headaches and weight loss over the past 6 months. There is a past medical history of hypertension and Type 2 diabetes, but nil else of note. On examination his BP is 115/70 mmHg, pulse is 100/min and regular. He looks pale although you do notice areas of purpura on examination of his skin. He has hepatosplenomegaly.Investigations;

Hb 8.9 g/dl WCC 11.1 x109/l PLT 112 x109/l

ESR 82 mm/1st hour Na+ 137 mmol/l K+ 4.1 mmol/l Creatinine 132 micromol/l ALT 203 U/l IgM raised


Chronic myeloid leukaemia

Waldenstroms macrogammaglobulinaemia

Benign monoclonal gammopathy

Myelodysplasia

Myelofibrosis

18/ 58-year-old man comes to the Emergency department with increasingly severe symptoms of heart failure. He has shortness of breath and pitting oedema to the mid calf. He has completed a third course of combination chemo and radiotherapy for small cell lung cancer some 2 months earlier. On examination his BP is 100/60 mmHg, pulse is 88/min and regular. JVP is elevated. The apex beat is not displaced but is difficult to palpate, and heart sounds are quiet.

Investigations;

Hb 10.9 g/dl WCC 8.9 x109/l PLT 180 x109/l Na+ 138 mmol/l K+ 4.2 mmol/l Creatinine 138 micromol/l ECG Small complexes, no Q waves CXR Globular cardiac enlargement


Ischaemic cardiomyopathy

Chronic pericardial effusion

Cisplatin toxicity

Adriamycin toxicity

Paclitaxel toxicity

19/ A 36-year-old woman with a 15-year history of severe ileo-colonic Crohnâ€™s disease is

admitted for assessment and management of a severe flare-up of her disease. Her symptomsare severe lower abdominal pain, diarrhoea, weight loss and lethargy. She has also recently developed a vesico-colic fistula. She is currently taking mycophenolate mofetil (MMF) which had been controlling her symptoms for the last few months, but was now losing its efficacy. Her treatment history consists of multiple courses of steroids which, when tapered off resultedin severe disease recurrence. She also failed on azathioprine and 6-mercaptopurine and an elemental diet. She had an ileal segmental resection with end-to-end anastomosis 8 years ago. Her blood tests show a normochromic normocytic anaemia, leucocytosis, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and a low albumin.

What is the most appropriate next line as steroid sparing therapy?

Oral ciclosporin

Intravenous infliximab

Total colectomy with ileo-anal pouch formation

Alpha-interferon therapy

Intravenous cyclophosphamide

20/ 54-year-old woman who has a history of SLE comes to the clinic with increasing shortness of breath and a dry cough. She has a history of smoking but gave up some 20 years earlier. Her GP has prescribed a salbutamol inhaler but this has made little difference toher symptoms. Other medication includes hydroxychloroquine for her lupus. On examination her BP is 135/75 mmHg, pulse is 70/min and regular. There is wheeze on auscultation of her chest.

Investigations;

Hb 10.9 g/dlWCC 5.4 x109/lPLT 178 x109/lNa+ 138 mmol/lK+ 4.4 mmol/lCreatinine 134 micromol/lESR 55 mm/1st hourFVC 90% of expectedFEV1/FVC 63%KCO is in the normal range


COPD

Asthma

Bronchiolitis obliterans

Interstitial fibrosis

Hydroxychloroquine related pneumonitis

EXP---Bronchiolitis obliterans (BO) is associated with an obstructive lung disease pattern; however some degree of restriction may also be seen, which accounts for the FVC being slightly reduced at 90%. Whilst BO occurs less frequently than interstitial fibrosis or pleural effusion in the context of SLE, it is still a recognised association. COPD would not be expected, given that she gave up smoking 20 years earlier and symptoms are of recent onset.Late presenting asthma in this context would also be unusual. High resolution CT is an important next step in confirming the diagnosis; unfortunately the results of pharmacological intervention have been poor, and progression to a requirement for lung transplant is usual

21/ 25-year-old woman comes to the office with a 3-day history of lower abdominal pain that is now beginning to radiate to her right flank. She denies nausea, vomiting or diarrhoea but states she feels feverish and is worried that she may have the flu. She has noticed an increase in her urinary frequency. Vital signs are temperature 39.2oC, blood pressure 120/70 mmHg, pulse 95/min, and respiration 16/min. Physical examination shows tenderness in the suprapubic region, hyperactive bowel sounds and no signs of peritoneal irritation or masses. Her right flank is tender to light percussion. The remainder of the physical examination is within normal limits.Some of the laboratory results are:

Urinalysis

Leucocytes +++ Proteinuria + Gram stain Gram-negative bacilli


Acute appendicitis

Acute pyelonephritis

Ovarian torsion

Perinephric abscess

Pelvic inflammatory disease

EXP---This is a typical picture of pyelonephritis. Additional testing such as renal ultrasonography or intravenous pyelography is indicated only if there is suspicion of a complication such as a stone stricture or tumour causing the pyelonephritis. These tests are not necessarily part of routine management of a simple uncomplicated pyelonephritis. If symptoms persist beyond 3 to 5 days of effective treatment an ultrasound or computed tomography (CT) scan of the kidney should be obtained to exclude a perinephric abscess or other drainable collection of fluid

21/ 24-year-old woman presents to the cardiology clinic for review. She has a history of late presenting congenital heart disease, pulmonary hypertension and Eisenmengerâ€™s

syndrome. After not attending two previous appointments, she announces that she has not had a menstrual period for 4 months. On examination her BP is 145/82 mmHg, pulse is 86/min and regular and she looks cyanosed at rest. Her abdomen is consistent with a 20 week pregnancy and an ultrasound scan confirms this. Pulmonary artery pressure at last review wasestimated to be 60 mmHg.Other investigations;

Hb 12.1 g/dl WCC 8.2 x109/l PLT 190 x109/l Na+ 139 mmol/l K 4.3 mmol/l Creatinine 110 micromol/l

Which of the following is the most appropriate next step?

Aspirin

Low molecular weight heparin

Sildenafil

Termination of pregnancy

Advice to continue with no further medication

EXP--Historical advice has been termination of pregnancy where pulmonary hypertension and Eisenmengers pre-dates conception. This advice however has been based on a very limited number of cases and is related largely to increased risk of fatal thromboembolic events around the time of delivery. Use of low molecular weight heparin during pregnancy is not thought to significantly impact on outcomes, although limited trials of PDE5 inhibitors such as sildenafil may be associated with improved maternal and fetal survival

22/ 20-year-old man with a history of recurrent bronchiectasis is admitted with a third episode in the past 9 months. Apparently he has suffered a number of respiratory tract infections over the pastfew years. He takes no regular medication apart from a salbutamol inhaler prescribed by his GP. Onexamination he is pyrexial 38.4oC, pulse is 95/min and regular, BP is 100/60 mmHg. There are coarse crackles to the right mid zone on auscultation.

Investigations;

Hb 13.1 g/dl WCC 15.2 x109/l PLT 203 x109/l Na+ 138 mmol/l K+ 4.3 mmol/l Creatinine 110 micromol/l CRP 175 mg/l IgA 0.3g/l

IgG 3.0g/l

Which of the following is the most important intervention?

Routine immunoglobulin infusions

Splenectomy

Low dose continuous antibiotics

Bone marrow transplant

Postural drainage

23/ A 67-year-old woman has suffered from rheumatoid arthritis for the past 30 years. She is currently managed with methotrexate, low dose prednisolone and regular diclofenac. She presents to the clinic complaining of swollen painful wrists, pitting oedema of her lower limbs, shortness of breath and wheeze. Other history of note includes hypertension for which she takes ramipril and indapamide. On examination her BP is 155/82 mmHg, pulse is 80/min and regular. There is evidence of active synovitis, and pitting oedema to the mid calves.

Investigations;

Hb 10.9 g/dl WCC 10.1 x109/l PLT 187 x109/l Na+ 137 mmol/l K+ 4.1 mmol/l Creatinine 143 micromol/l Albumin 21 g/l ALT 130 U/l ALP 189 U/l Urine protein +++


Inflammatory amyloidosis

Membranous nephritis

Chronic interstitial nephritis

Acute interstitial nephritis

Multiple myeloma

EXP---significant hypoalbuminuria, coupled with proteinuria, raises the possibility of nephrotic syndrome. Multiple myeloma, chronic interstitial nephritis, membranous disease and inflammatory amyloidosis are all possible causes of proteinuria, although the lack of haematuria and evidence of ongoing active rheumatoid point more towards---------- inflammatory amyloidosis. In this case a renal biopsy is optimal

in confirming the diagnosis. Controlling underlying inflammation may slow amyloid progression

24/ 52-year-old woman who has a history of gout and chronic renal impairment comes to the emergency department complaining of an acute flare affecting her right big toe and currently stopping her from mobilising.She couldnâ€™t take a previous medication during her last acute flare because of profuse diarrhoea. She currently takes allopurinol 100mg daily and a range of medications for high blood pressure. Her BP is 152/82 mmHg, pulse is 80/min and regular. Her big toe is red, swollen and painful and she is unable to weight bear on it.Investigations;

Hb 13.5 g/dl WCC 11.2 x109/l PLT 209 x109/l Na+ 138 mmol/l K+ 4.5 mmol/mol Creatinine 167 micromol/mol Serum urate 400 mmol/l (0.19 â€“ 0.36)

Which of the folllowing is the most appropriate way to manage her?

Increased allopurinol

Diclofenac

Prednisolone

Colchicine

Paracetamol

25/ 28-year-old man presents with pain at the base of his neck and pain and weakness affecting his right arm. He had a suspicious mole removed from his right calf some 2 years earlier, but did not follow up on the histology, instead going travelling to the far-east. On examination he looks unwell, his BP is 100/60 mmHg, pulse is 75/min and regular. Cardiovascular and respiratory examination is normal, but he has inguinal and axillary lymphadenopathy, and there is evidence of other abnormal naevi over his torso. He has winging of the right scapula, wasting of the muscles of the upper arm, and sensory loss over the lateral border.Investigations;

Hb 11.0 g/dl WCC 8.9 x109/l PLT 193 x109/l Na+ 138 mmol/l K+ 4.3 mmol/l Creatinine 123 micromol/l ALT 356 U/l ALP 391 U/l


Malignant infiltration of the brachial plexus

Thoracic outlet syndrome

C5/6 disc prolapse

Long thoracic nerve injury

Inflammatory neuritis

EXP----There are many clues here to an underlying diagnosis of malignant melanoma with metastases, namely the failure to follow up on biopsy results, numerous abnormal naevi, liver function tests and lymphadenopathy. Pain control may only be achieved with a combination of opiates and adjunctive agents such as anti-epileptics or tricyclic anti-depressants. The lack of history of injury counts against disc prolapse or long thoracic nerve disruption

26/ 62-year-old man is admitted to the Emergency department with severe chest pain radiating to the back and tingling radiating to both arms. He was playing with his grandson, throwing him up and down when the pain started. He describes this as a tearing pain, of maximal intensity immediately after it began. He has a history of hypertension, chest pain on exertion, and smokes 40cigarettes per day. On examination in the department his BP is 180/100 mmHg, heart sounds are normal and his chest is clear.Investigations;

Hb 12.9 g/dl WCC 9.0 x109/l PLT 201 x109/l Na+ 138 mmol/l K+ 4.0 mmol/l Creatinine 112 micromol/l 12hr troponin <0.05 ECG ischaemic changes in II,V1-V4 CXR reported as no significant abnormalities


Aortic dissection

Acute MI

Muscloskeletal injury

GORD

Pulmonary embolism

27/ A 32-year-old man comes to the Emergency department. He visited the chiropractor the morningbefore admission for a neck manipulation but since then has suffered an increasingly severe

occipital headache and neck pain. He also reports problems with his vision affecting his left eye. There is a past history of hypertension, but nil else of note. On examination his BP is 158/95 mmHg and he looks unwell. He is unable to move his neck and it is held in spasm. He has a left sided horners syndrome, nystagmus and an ataxic gait.Which of the following is the most likely diagnosis?

Sub-arachnoid haemorrhage

Vertebral artery dissection

Carotid artery dissection

Vertebral artery embolism

Cluster headache

28/ 28-year-old warehouse man comes to the clinic complaining of weakness of his right arm and movement of his shoulder blade when he tries to move heavy objects around the building. The weakness has got so bad that he is unable to work at the current time. Apparently he had a crash where he fell from his motorbike a few weeks earlier; although this happened at low speed he did fall onto his outstretched arm. On examination in the clinic there is obvious winging of the scapula when he is asked to push against resistance.

Which of the following is the most likely cause?

Brachial neuritis

C5/C6 disc prolapse

Long thoracic nerve injury


Spondylolisthesis

EXP-----The commonest cause of winging of the scalpula is serratus anterior palsy, which could well be related to long thoracic nerve injury as a result of his motorcycle accident. Brachial neuritis, disc prolapsed, cervical spondylosis and spondylolisthesis would all be associated with pain, not a feature seen here. Physiotherapy to enhance shoulder stability is the initial therapy of choice, although surgery to stabilise the position of the scapula is often required

29/ A 25-year-old woman who is known to have a history of brittle asthma is deteriorating with drowsiness and confusion, despite having been treated with back to back salbutamol nebulisers,

atrovent and hydrocortisone over the last hour. She is normally managed with maximal dose seretide inhalers and monteleukast. On examination her BP is 105/60 mmHg, pulse is 100/min and regular. There is bilateral wheeze and poor air entry on auscultation, and her respiratory rate is 24/min. She is mumbling and unable to answer any questions.Investigations;

pH 7.35 pO2 7.9 kPa pCO2 5.6 kPa Peak flow 140 ml/min


Continue nebulisers

Intubate and ventilate

NIPPV

IV magnesium

IV aminophylline

EXP---This patient is tiring and has a very poor peak flow. She is hypoxic with a CO2 edging towards the upper limit of normal and has a life threatening episode of asthma. As such the best option at this stage is intubation and ventilation

30/ 23-year-old man is admitted with worsening cellulitis of his left lower leg, some 3 days aftersustaining a laceration in a motorcycle accident. On examination he is pyrexial 38.2oC, pulse is95/min and his BP is 110/70 mmHg. There is an 8cm sutured laceration on the lateral aspect of the left calf. The sutures are beginning to burst apart and the edges of the wound are looking black in colour. The area is swollen, intensely painful, and crackles on palpation, and a numberof bullae are forming. Tenderness extends beyond the margins of the cellulitis.Investigations;

Hb 11.9 g/dl WCC 16.8 x109/l PLT 151 x109/l Na+ 137 mmol/l K+ 5.2 mmol/l Creatinine 135 micromol/l Urea 19.2 mmol/l CK 1020 U/l


Deep vein thrombosis

Necrotising fasciitis

Uncomplicated cellulitis

Pyoderma gangrenosum

Compartment syndrome

EXP-- Patients with wounds as a result of trauma, are at risk of NF. It is most likely to be either Type 1 NF due to

polymicrobial infection, or Type 2 NF which is due to group A streptococcus. The diagnosis is a clinical one, the extensive

necrosis and spreading infection seen here is consistent with NF. Urgent surgical debridement is the cornerstone of therapy,

benzylpenicillin, clindamycin and gentamycin is the usual initial antibiotic treatment of choice, although this should of course

be discussed with the hospital microbiologis

31/ A 75-year-old woman is brought to the Emergency department by police after being found by neighbours wandering in the street. The neighbours tell you she has no family, and that she has been looking progressively more unkempt and not looking after her house for the past 6 months. There is a history of diabetes and hypertension but nil else of note. She is incontinent of urine. On examination her BP is 165/95 mmHg, pulse is 80/min and regular. She is able to identify common objects, but recall is poor. She has only sparse speech and seems disinterested in the conversation. There is no significant limb weakness and gait is normal, although she complies poorly with the examination. MMSE 26/30. EEG shows marked slowing in anterior regions bilaterally.Investigations;

Hb 12.9 g/dl WCC 7.2 x109/l PLT 203 x109/l Na+ 137 mmol/l K+ 4.2 mmol/l Creatinine 110 micromol/l HbA1c 66.12 mmol/mol (8.2%)


AlzheimerS disease

Vascular dementia

Frontotemporal dementia

Lewy body dementia

Normal pressure hydrocephalus

EXP--This patient has mild dementia, but the MRI scan demonstrates marked frontotemporal volume loss. The EEG findings are also charcateristic of frontotemporal dementia. Lack of concern and apathy fit well with a frontal lobe dementia pattern, visiospacial skills are relatively preserved, and as seen here, sparse speech is a feature of the condition. Incontinence is a feature of normal pressure hydrocephalus, but the normal gait counts

against NPH as a diagnosis. There is no specific treatment for frontal lobe dementia, although drugs which may worsen / impair memory and higher cerebral function should be discontinued

32/ A 40-year-old man comes to the Emergency department complaining of headache and flushing sensation in his head. He attended the Emergency department some 5 weeks ago having suffered a road traffic accident and a blow to his head, but was discharged after 10hrs. On examination he looks in pain, his BP is 155/82 mmHg, pulse is 90/min and regular. He has pulsatile proptosis and conjunctival chemosis affecting his left eye.


Caverno-carotid fistula

Cavernous sinus thrombosis

Aortocaval fistula

Lymphangioma

Capillary haemangioma

EXP---carotid-cavernous fistula may be spontaneous or traumatic. Seventy to ninety percent of cases are direct (high-flow

shunts in which the carotid artery blood passes directly into the cavernous sinus) and, of these, 75% occur as a result of

trauma. Interventional radiology is the main modality for therapy, aiming for balloon occlusion of the fistula. A cavernous sinus

thrombosis would not normally be associated with pulsatile proptosis. Capillary haemangiomas are usually first diagnosed in

children. Lymphangiomas develop primarily from the lymphatic system, and as such are not pulsatile

33/ 42-year-old man has returned from a caving trip to Eastern Europe some 5 days ago and presents with shortness of breath, a fever and chills. He also has a cough productive of haemoptysis. There is a past history of mild asthma for which he takes a seretide inhaler, but nil else of note. On examination his BP is 110/60 mmHg, pulse is 90/min and regular and he is pyrexial 38.9oC. Auscultation reveals scattered wheeze but nil else of note.

Investigations;

Hb 9.0 g/dl WCC 3.9 x109/l PLT 67 x109/l Na+ 138 mmol/l K+ 4.0 mmol/l Creatinine 132 micromol/l CXR bilateral hilar lymphadenopathy, patchy infiltrates in the lower zones


Tuberculosis

ABPA

Sarcoidosis

Histoplasmosis

Histiocytosis X

EXP--- Histoplasma is fungus known to thrive on bird and bat droppings, and it is highly likely that this man has been

exposed to large amounts of the fungus during his caving expedition.

Acute histoplasmosis presents with cough, fevers, shortness of breath and joint pains. 70-90% of patients with symptoms of

acute infection present with pancytopaenia. Blood, sputum culture, and complement fixing antibody testing are all used in an

attempt to confirm the diagnosis.

Histoplasma is sensitive to fluconazole, itraconazole and amphotericin B.

Histiocytosis X is an eosinophilic granuloma forming autoimmune disease

34/ 22-year-old man is brought to the Emergency department by the police. He was found trying to smash the window of the local department store as he says the televisions in the window are communicating with him and telling him that he is worthless and he should kill himself. He has no past medical history, is unemployed, and lives with his mother. According to his friends his behaviour has deteriorated over the past few years as he has smoked increasing amounts of cannabis. He is agitated, BP is 155/82 mmHg, pulse is 92/min. He refuses to comply with the remainder of the physical exam. You suspect he has schizophrenia.Which of the following is the best first line medication?

Haloperidol

Risperidone

Clozapine

Diazepam

Chlordiazepoxide

EXP---Traditional anti-psychotics such as haloperidol are no longer recommended for initial treatment of schizophrenia.

Atypical anti-psychotics such as risperidone and olanzapine are recommended in their place.

Clozapine is reserved for schizophrenia where the symptoms are resistant to first line therapies,as close monitoring is

required because of the risk of agranulocytosis. Sedatives such as diazepam may be used in addition to atypical anti-

psychotics, but they do not replace them

35/ A 45-year-old man who is treated with risperidone for previous psychotic episodes is found by his wife collapsed in a chair. He was well when she left him at lunchtime to go shopping, and by 5pm he was found unconscious. On examination in the Emergency department his respiratory rate is 8/min, BP is 90/60 mmHg, pulse is 97/min and regular, he is deeply unconscious. O2 saturations are 89%. He is intubated andventilated.


Gastric lavage

Activated charcoal via NG

Naloxone

Sodium bicarbonate

Flumazenil

EXP---all likelihood this patient has taken an overdose of risperidone leading to decreased consciousness. Risperidone is

also with QT prolongation and risk of torsades de pointes VT; as such cardiac monitoring is essential. If overdose has

occurred within 1hr, then gastric lavage can be considered.

Otherwise risperidone does bind to activated charcoal, so delivery of this via the NG is an option. Naloxone and flumazenil

are not of value in improving consciousness in risperidone overdose

36/ A 39-year-old man is referred to the endocrine clinic by his GP for erectile dysfunction. He has suffered from difficulties maintaining his erection during intercourse, and has had an absence of morning erections for at least the past 5 months. He is a non-smoker who drinks 6 units of alcohol/ day.On examination his BP is 135/75 mmHg, pulse is 80/min and regular. There are no murmurs and his chest is clear. Abdominal examination is unremarkable, but you notice a few spider naevi over his upper body.Investigations;

Hb 14.1 g/dl WCC 7.0 x109/l PLT 207 x109/l Na+ 137 mmol/l K+ 4.3 mmol/l Creatinine 103 micromol/l ALT 180 U/l ALP 205 U/l Bilirubin 31 micromol/l Fasting glucose 8.4 mmol/l

Which of the following is the most appropriate next test?

Liver biopsy

Genetic analysis for haemochromatosis

Short synacthen text

Pituitary function testing

Urinary copper estimation

37/ A 28-year-old man is currently undergoing combination chemotherapy for metastatic testicular carcinoma. He has last received a course of chemotherapy some 2 weeks earlier and presents to the Emergency department with worsening shortness of breath. On examination heis apyrexial, his BP is 110/70 mmHg and pulse is 90/min. There are scattered crackles on auscultation throughout both lung fields. O2 saturation is 90% on air.

Investigations;

Hb 12.0 g/dl WCC 4.3 x109/l

PLT 145 x109/l Na+ 138 mmol/l K+ 4.0 mmol/l Creatinine 115 micromol/l CXR Bilateral pulmonary infiltrates Pulmonary function tests Restrictive pattern


Pulmonary embolus

Left ventricular failure

Bacterial pneumonia

Bleomycin related lung toxicity

PCP

38/ 72-year-old man comes to the neurology clinic with his wife for review. He cannot settle at night, continuously having to move his legs around, complaining of burning, tingling sensations. Eventually he has to get up and walk around because heâ€™s just unable to keep still in bed. He has no past medical history of note apart from hypertension which is treated with amlodipine 5mg. On examination his BP is 128/80 mmHg, there are no significant abnormal findings.

Investigations;

Hb 13.1 g/dl WCC 5.2 x109/l PLT 181 x109/l Na+ 138 mmol/l K+ 4.5 mmol/l Creatinine 110 micromol/l Glucose 5.3 mmol/l

Given the likeliest diagnosis, which of the following is the most appropriate treatment?

Quinine

Pramipexole

Diazepam

Cabergoline

Bromocriptine

39/ 78-year-old woman suffers from dysuria after removal of a catheter post left hemi-arthroplasty. The first urine culture demonstrated methicillin-resistant staphylococcus aureus (MRSA), and she was commenced on doxycycline. A repeat sample 48hrs later, sent as symptoms had failed to resolve, showed both S aureus and coliforms.


Change to trimethoprim

Change to ciprofloxacin

Change to vancomycin

Change to coamoxiclav

Change to linezolid

EXP---MRSA and coliforms are usually both sensitive to trimethoprim, therefore the most logical next step is to move to trimethoprim given the mixed result for the second urine culture. Nitrofurantoin is a potential alternative to trimethoprim, and in severe or resistant cases, a glycopeptide such as vancomycin could be used. There is significant coliform resistance to ciprofloxacin

40/ 42-year-old woman presents 10 days after induction chemotherapy for leukaemia with fever, cough anda severe sore throat. On examination she is pyrexial 38.9oC, pulse is 95/min and regular and her BP is 95/50 mmHg. She has coarse crackles throughout both lung fields consistent with pneumonia.

Investigations;

Hb 9.9 g/dl WCC 2.3 x109/l Neut 0.1 x109/l PLT 156 x109/l Na+ 137 mmol/l K+ 5.3 mmol/l Creatinine 132 micromol/l CXR Multiple pulmonary infiltrates with nodule formation BAL Galactomannan positive


Aspergillus fumigatus

Pneumocystis jiroveci

Streptococcus pneumonia

Histoplasma capsulatum

Mycobacterium tuberculosis

EXP -Galactomannans are polysaccharides which are composed of a mannose backbone and galactose side groups.

There are a component of the cell wall of A fuMigatus, which explains the development of an ELISA test for their detection.

Mycobacterium is detected by AAFB staining, culture or and or PCR.

An immunofluorescence test now exists for detection of pneumocystis, and

serum and urine antigen testing is useful for the detection of histoplasmosis

41/ 42-year-old woman is taking ciclosporin for mixed cryoglobulinaemia. She has been in close (face to face) contact with her niece some 2 days earlier and receives a phone call to say the child has developed chicken pox. Antibody testing reveals that she is VZV IgG negative.

What should you do for treatment as a first step?

Oral aciclovir

IV aciclovir

Nothing

Immunoglobulin

VZV vaccination

EXP---This patient is immunocompromised due to the ciclosporin and is antibody negative. As such she requires

prophylaxis against varicella infection. The vaccination is a live vaccine and should thus be avoided in this case. The best

chance of protection for her is with immunoglobulin given within the first 4 days of contact with an infected child. There is less

data in this situation to support the use of aciclovir as prophylaxis

42/ 65-year-old lady with a background history of Type 1 diabetes mellitus (HBA1c 73.77 mmol/mol (8.9%))comes to the clinic for review. She presents with a 6 month history of bilateral leg weakness, tingling and loss of sensation from the knees down. On examination, the patient has bilateral calf muscle weakness, more on the right, than the left. She has loss of propioception and sensation of the left lower limb more thanthe right, bilateral plantar reflexes are down going; bilateral forearm weakness is also present, more on the right than the left. There is also evidence of a partial left 7th nerve palsy. Electrophysiological studies are awaited.Which is the most likely underlying pathology of her neurological problem?

Chronic inflammatory demyelinating polyneuropathy

Diabetic neuropathy

Cervical myelopathy

Syringomyelia

Cervical disc protrusion

EXP----CIDP is thought to be a T cell mediated chronic demyelinating disorder which leads to a mixedpicture of both sensory and motor loss. It is seen most often in the fifth and sixth decades and appearsto have an equal sex distribution. Diabetic neuropathy is most commonly sensory only. Cervical myelopathy and cervical disc protrusion do not lead to facial nerve weakness, and syringomyelia produces sensory loss in a shawl distribution. Immunoglobulin, plasma exchange and a range of second line agents have been used in the management of the condition

43/ 23-year-old student is going to West Africa on a school building project. She is prescribed anti-malarial prophylaxis and suffers a grand mal seizure whilst out with her friends at her leaving party. It turns out that she had a single seizure at the age of 16 but has had no problems since then.

Which of the following agents is most associated with increased risk of seizure?

Chloroquine

Mefloquine

Proguanil

Proguanil plus atovaquone

Chloroquine plus doxycycline

44/ 39-year-old woman with end stage cervical cancer presents with worsening pain. She is taking co-dydramol four times per day and requires 60mg of oral morphine per day to control her back pain. On examination she is alert and orientated, her BP is 135/82 mmHg, pulse is 85/min and regular. There is pain on palpation of her lower back but she is comfortable at rest.

Investigations;

Hb 10.9 g/dl WCC 8.8 x109/l PLT 181 x109/l Na+ 138 mmol/l K+ 5.4 mmol/l Creatinine 210 micromol/l

Which of the following is the most appropriate next step in controlling her pain relief?

Fentanyl patch

Regular slow release morphine

Diclofenac

Gabapentin

Regular immediate release morphine

EXP----Use of morphine is not recommended in renal failure because of accumulation of metabolites. Similarly, diclofenac

is not recommended in renal impairment as it may further worsen creatinine. Gabapentin is a reasonable addition as adjuvant

pain relief, particularly where there is nerve root pain, but that doesnt appear to be the case here. As such the best option is

to regularise her strong opiate use by switching this to a fentanyl patch (fentanyl not being subject to the same risk of

accumulation in moderate renal impairment

45/ 27-year-old woman with poorly controlled epilepsy comes to the Emergency department with drowsiness and confusion, having suffered 3 fits in the past 24hrs. You understand she is treated with sodium valproate and that lamotrigine was added a few days before the rash started. On examination her BP is 100/60 mmHg, pulse is 90/min and regular. She moans incomprehensibly when you try and wake her from sleep. Her rash is consistent with Stevens-Johnson syndrome. She is intubated and ventilated and taken to the ITU.Which of the following is the most important next step in her management?

Stop all anti-epileptics

Plasmapheresis

IV immunoglobulin

IV steroids

IV ciclosporin

46/ A 26-year-old man comes to the Emergency department complaining of ongoing headaches some 4 months after he was treated in A&E for a minor scalp laceration which occurred as a result of being hit with a cricket ball. He was not knocked out at the time and there was no abnormal neurology. He is taking co-codamol 30/500 tablets up to 6 times per day. On examination his BP is 122/72 mmHg, pulse is 70/min and regular. Neurological examination is entirely normal.

What is the next most appropriate management step?

CT Head

Down titrate and stop analgesia

Add diclofenac

Add amitriptyline

Add diazepam

47/ A 45-year-old man is brought to the Emergency department after being pulled from a house fire. He was found by firemen in the lounge, which was filled with smoke from a burning sofa and was brought immediately to the hospital.There is a past history of Type 2 diabetes for which he takes metformin monotherapy. On admission he is agitated and confused. His respiratory rate is elevated at 32/min, he has bilateral wheeze on auscultation of his chest. Pulse is 90/min and regular and his BP is 155/85 mmHg. Satsare 94% on the pulse oximeter.

Investigations;

Hb 13.1 g/dl WCC 9.8 x109/l PLT 203 x109/l

Na+ 137 mmol/l K+ 5.1 mmol/l Creatinine 122 micromol/l pH 7.2 HCO3- 13 mmol/l ECG Anterolateral ST depression


Metformin overdose

Cyanide poisoning

Acute respiratory distress syndrome

Acute asthma

Non ST elevation myocardial infarction

EXP---The picture of metabolic acidosis, with tissue ischaemia, fits best with a diagnosis of cyanide poisoning. It is well known that soft furnishings release cyanide containing fumes when they burn, and this is the likely cause. Lactate concentration greater than 10 mmol/l is strongly suggestive of cyanide poisoning, and serum lactate would be a logical next step in investigating him. Hydroxycobalamin, sodium nitrite and sodium thiosulphate are all possible interventions

48/ 37-year-old woman with a history of asthma comes to the Emergency department with worsening headaches, particularly in the mornings, which she describes as being like â€a ‌permanent hangoverâ€. She has also suffered increasing nausea over the past 2-3 weeks. A ‌history of frequent UTIs in childhood is noted. On examination her BP is 198/110 mmHg, pulse is 86/min and regular. She has retinal haemorrhages bilaterally consistent with severe hypertensive retinopathy. There are no other abnormal findings.Investigations;


Which of the following is the optimal management for her?

IV nitroprusside

IV labetalol

Nifedipine MR

IV GTN

Phentolamine

------In this situation, with a history of asthma, IV beta blockade is ill advised. Additional benefit from using nitroprusside may

come in that it preserves cerebral blood flow even in the presence of a blood pressure reduction.

Oral nifedipine is potentially too gentle an initial measure given the BP and symptoms seen here, and phentolamine is

reserved for the treatment of hypertensive crises associated with phaeochromocytoma. In this case it seems like chronic

reflux nephropathy is a likely cause of her hypertension and renal impairment

49/ 54-year-old man with known alcoholic cirrhosis comes to the Emergency department aftersuffering a massive variceal haemorrhage. Despite colloid replacement he still has a heart rate of 130/min, and is hypotensive at 80/40 mmHg. You have asked for type specific blood, and type A rhesus positive blood arrives, although he is known to be type A rhesus negative.

Which of the following is the best course of action?

Give the blood

Return the units and wait for a full cross matched sample

Transfuse O negative blood

Give further colloid

Transfuse O positive blood

EXP---Rhesus mis-matched transfusions are likely to result in a serious autoimmune haemolytic reaction and are not

advised under any circumstances. Given his state of circulatory collapse, waiting or giving further colloid is also not an option.

As such the best course of action is to give O negative blood in an attempt to stabilise him before moving on to

oesophagogastroduodenoscopy

50/ A 30-year-old man who has a history of manic depression is referred from the psychiatric department. He is found to have abnormal liver function tests. On examination, he is very irritable, dysarthric and ataxic.

His blood tests are as below:

Na+ 133 mmol/l K+ 4.5 mmol/l Urea 14.0 mmol/l Creatinine 220 آµmol/l Bilirubin 45 آµmol/l ALT 70 U/l (5â€“35) ALP 401 U/l (30â€“150) GGT 89 Albumin 33 g/L

Given the likeliest diagnosis, what therapy is he likely to require?

Desferrioxamine

Trientine

Venesection

Genetic analysis

N-acetylcystien

51/ A 68-year-old female smoker comes to the clinic for review. She has increasing problems with poor balance and her relatives have noticed that her speech is becoming increasingly slurred. On examination she has bilateral finger-nose ataxia, bilateral nystagmus and a broad-based gait,. Additional symptoms include polyuria and polydipsia, with nocturia 2-3 times every night. On examination her BP is 132/72 mmHg, pulse is 73/min and regular. Her BMI is 23 and she tells you she has lost 4kg in weight over the past few months.

Investigations;

Hb 12.0 g/dl WCC 7.9 x109/l PLT 200 x109/l Na+ 132 mmol/l K+ 4.3 mmol/l Creatinine 105 micromol/l CXR Changes consistent with COPD

Which of the following is the investigation most likely to confirm the diagnosis?

Mammogram

CT Chest

Calcium

CT head

Skeletal surve

EXP---This patient has symptoms and signs of cerebellar dysfunction. Given her weight loss and additional symptoms a malignant cause could be suspected. Her presentation could be explained by paraneoplastic cerebellar degeneration, which is seen in conjunction with breast cancer, small cell lung cancer, Hodgkins lymphoma, and ovarian carcinoma. Given that the chest x-ray is reported as normal, and we are not presented with symptoms of deteriorating chest disease, lung cancer is less likely than breast cancer. As such a mammogram is the next most appropriate step. The polydipsia and polyuria might be related to hypercalcaemia, which is also seen in association with breast cancer, because of production of PTHrP and/or due to bony metastases

52/ 25-year-old man has been referred to the rheumatology clinic by the local sexual health service for recurrent oral and genital ulceration. He tells you that many of the ulcers take up to3 weeks to heal. Over the past few months he has also suffered from joint pains which have interfered with his work as a sports teacher, night sweats and gradual weight loss. His BP is 110/70 mmHg, pulse is 75/min and regular, there are a number of aphthous ulcers on

examination of the mouth, and 2-3 ulcers in the genital region. You also notice he has erythema nodosum.Investigations;

Hb 10.9 g/dl WCC 10.8 x109/l PLT 172 x109/l ESR 81 mm/1st hour Na+ 137 mmol/l K+ 4.3 mmol/l Creatinine 112 micromol/l

Which of the following would most support a diagnosis of BeCHETs disease?

Leukocytoclastic vasculitis on skin biopsy

Positive pathergy test

Positive Kveim test

Positive anti-phospholipid antibody test

Positive ANCA

53/ A 65-year-old man presents with a history of abdominal and back pain which has worsened over the last 4 months. Most recently he has begun to suffer from increased nausea and over the past week has passed less and less urine. He has a history of hypertension for which he has been treated with a number of medications over the past few years, and arthritis. On examination his BP is 185/90 mmHg, pulse is 95/min and regular. He looks pale and complains of back pain whilst lying on the examination couch.

Investigations;

Hb 9.1 g/dl WCC 9.8 x109/l PLT 201 x109/l ESR 65 mm/1st hour Na+ 138 mmol/l K+ 5.6 mmol/l Creatinine 325 micromol/l ALT 45 U/l ALP 320 U/l Albumin 33 g/l PSA 7 microg/l (<4) Antinuclear antibody positive

Polyclonal hypergammaglobulinaemia is seen and USS renal tract reveals bilateral hydronephrosis

Which of the following is the most likely cause of his renal failure?

Benign prostatic hypertrophy

Multiple myeloma

Transitional cell carcinoma of the bladder

Retroperitoneal fibrosis

Renovascular disease

54/ 53-year-old woman with long standing hypertension comes to the Emergency department with left ventricular failure. She takes a number of medications to control both her blood pressure and pitting oedema of both lower limbs which has developed over the past few weeks. Current therapy includes spironolactone, furosemide, bisoprolol, atorvastatin, irbesartan and doxazosin. On examination her BP is 96/60 mmHg, pulse is 95/min and regular. There are bibasal crackles on auscultation of the chest.

Investigations;


Which of the following medications should be discontinued?

Atorvastatin

Bisoprolol

Furosemide

Spironolactone

Doxazosin

55/ 54-year-old man woke from sleep with palpitations a few hours after returning from a ceremonial dinner at which he drank a bottle and a half of wine. He said these seemed to be very fast and irregular, he felt very light headed and could only get to the bathroom with great difficulty. He reports one previous episode of palpitations which reverted spontaneously after a few minutes sitting in a chair. There is no past medical history of note and he still plays amateur rugby. On examination in the emergency department his pulse is 78/min and regular, BP is 122/72 mmHg. He has no signs of cardiac failure.

Investigations;

Hb 13.4 g/dl WCC 7.9 x109/l PLT 200 x109/l Na+ 138 mmol/l K+ 4.4 mmol/l Creatinine 103 micromol/l ECG Sinus rhythm with no acute changes CXR No cardiomegaly or evidence of heart failure

Which of the following is the most likely cause of his palpitations?

Sinus tachycardia

Atrial fibrillationVentricular tachycardia

Sinus arrhythmia

Paroxysmal SV

56/ A 67-year-old woman presents to the Emergency department with worsening thirst, polyuria and abdominal pain. According to her husband she has been off her food and feeling increasingly unwell for thepast few weeks. On examination she is drowsy and confused. She complains of tenderness on palpation ofher abdomen, but nil else of note. Her BMI is 22.

Investigations;

Hb 10.9 g/dl WCC 8.1 x109/l PLT 181 x109/l Na+ 141 mmol/l K+ 5.1 mmol/l Creatinine 149 micromol/l Ca++ 3.6 mmol/l ALP 384 U/l Albumin 23 g/l PO4- 0.6 mmol/l

You start her on IV fluids; which of the following is the next most appropriate step?

Calcitonin

Pamidronate

Denosumab

IV furosemide

Cinacalce

EXP--IV furosemide use is a little controversial in this setting, and is usually reserved to prevent / treat fluid overload after

re-hydration. It is however of course calciuric. Cinacalcet is usually used in the management of hypercalcaemia related to

hyperparathyroidism as it leads to a reduction in PTH secretion. Denosumab is used to chronically reduce osteoclast activity

in patients with osteoporosis and those with bony metastases. Both calcitonin and pamidronate are effective in reducing

hypercalcaemia, but calcitonin is thought to have a more rapid onset of action, and therefore would be the next step here

57/ 25-year-old woman is referred to the cardiology department with a history of palpitations. Shedescribes these as of sudden onset and termination associated with a feeling of lightheadedness.They have occurred on a couple of occasions while she was running on thetreadmill in the gym and she felt she had to stop. She smokes 10 cigarettes a day and denies

any heavy alcohol use. There is no past medical history and she is on no regular medication.On examination there is a systolic murmur at the left lower sternal edge and a prominent apicalimpulse.The electrocardiogram (ECG) shows deep T wave inversions in leads V3-V5.Which test is the first line investigation to reveal the underlying diagnosis?Echocardiogram24-h ECGExercise ECGMIBI scanThyroid function

1/ mtx tx antidote ……………. ca folinate

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