1. While on call you are called by a nurse to a patient on the ward complaining of light headedness and palpitations. When you arrive the patient is not conscious but has a patent airway and is breathing with oxygen saturation at 97 per cent. You try to palpate a pulse but are unable to find the radial or carotid. The registrar arrives and after hearing your report of the patient decides to shock the patient who recovers. What is the patient most likely to have been suffering?
Option B is the correct answer. This patient is suffering from a life-threatening ventricular tachyarrhythmia of which there are two types, sustained ventricular tachycardia and ventricular fibrillation. In ventricular fibrillation (B) the patient is pulseless and cardioversion is required. A sustained ventricular tachycardia (C) is usually recognized by cannon ‘a’ waves on JVP and broad QRS complexes if an ECG is available. If stable, patients can be cardioverted with amiodarone, if unstable, electrocardioversion is required. Torsades de pointes (A) presents with irregular QRS complexes and prolonged QT interval, a non-sustained ventricular tachycardia (D) is defined by more than five consecutive heart beats within 30 seconds, while a normal heart ventricular tachycardia (E) is a benign tachyarrhythmia. Answers (A), (D) and (E) are not shockable rhythms
2.A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present?
Option D is the correct answer. Aortic stenosis will first result in left ventricular failure as a result of increased ventricular pressure as the ventricle tries to pump blood across a narrowed valve. Initially the pressure load will cause a backlog of blood into the lungs, resulting in pulmonary oedema – the first sign of which will be bibasal crepitations (D) before enough fluid accumulates as pleural effusions visible on chest x-ray (A). Earlier signs of pulmonary oedema include upper lobe blood diversion and Kerley B lines as fluid infiltrates the interstitium. If the backlog continues back into the right heart, eventually signs of right-sided heart failure will be evident including raised JVP (B) and bilateral pedal oedema (C). Atrial fibrillation (E) may coexist with aortic stenosis, however it is more commonly associated as a result of mitral stenosis as the enlarged atrium disrupts the normal electrical pathways.
3.A 66-year-old woman presents to accident and emergency with a 2-day history of shortness of breath. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also complains of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is:
Option E is the correct answer. This patient is most likely suffering from a pulmonary embolism (E), defined as an occlusion of the pulmonary vasculature by a thrombus causing an area of lung that is ventilated but not perfused. Patients most often complain of shortness of breath, pleuritic chest pain and haemoptysis. Clinical signs can include a pleural rub, coarse crackles and atrial fibrillation. In massive pulmonary embolism there can be a raised JVP, respiratory rate, heart rate and hypotension. The Geneva scoring system (see below) is useful for predicting the risk of a pulmonary embolism: a score of ≤3 (mild), 4–10 (moderate) and ≥11 (high). Muscular strain (A) typically occurs on movement and is not associated with shortness of breath or leg pain and there is usually an indicator of injury or a preceding stressor. Heart failure (B) is unlikely due to the acute presentation of symptoms which tend to occur more insidiously and can be associated with bilateral leg oedema, murmurs, orthopnoea or hepatomegaly, among others. A pneumothorax (C) can present with a similar pleuritic chest pain that occurs in an embolism, however, there is no association with limb pain and a respiratory examination is likely to reveal hyper-resonance. Angina (D) is typically described as a dull or crushing chest pain in the centre of the chest, patients have risk factors such as diabetes, hyperlipidaemia, obesity, smoking and hypertension.
4. You see a 68-year-old man in clinic, with a 40 (cigarette) pack year history, who has been experiencing breathlessness on exertion and a productive cough of white sputum over the last four months. You assess his spirometry results which reveal an FEV1/FVC of 51 per cent with minimal reversibility after a 2-week trial of oral steroids. Cardiological investigations are normal. Which of the following is the most likely diagnosis?
Option B is the correct answer. The patients symptom history coupled with the spirometry results indicate that he has an obstructive defect. Spirometry is typically used to measure functional lung volumes. The ratio of the forced expiratory volume in one second (FEV1) to the forced vital capacity (FVC), provides a reliable approximation of severity of airflow obstruction; the normal being 80 per cent. An FEV1/FVC ratio of less than 80 per cent indicates an obstructive defect seen in COPD and asthma while a ratio of greater than 80 per cent is representative of a restrictive defect seen in lung fibrosis (E). The spirometry results coupled with minimal reversibility points the diagnosis to COPD (B) rather than asthma (A), where reversibility of the FEV1/FVC ratio is usually seen. Chronic bronchitis (D) can be defined as cough productive of sputum for three months of two successive years which does not corroborate with the onset of symptoms. Left ventricular failure (C) is obviously incorrect due to the fact that cardiological tests have been mentioned as normal.
5. Which of the following organisms would typically be found in a patient with atypical community-acquired pneumonia?
Option C is the correct answer. From the list of answers above, H. influenzae (E) and S. pneumoniae (C) are organisms which are usually responsible for community-acquired pneumonia. S. aureus (A) and Pseudomonas spp. (B) are usually found in patients with hospital-acquired pneumonia. L. pneumophilia (D), along with Chlamydia spp. and Mycoplasma pneumoniae, are the atypical pneumonia-causing organisms. A urinary antigen test is routinely used for the detection of Legionella spp. Serological tests can be used for the detection of Mycoplasma and Chlamydia spp. and also Legionella spp.
6. A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of breath presents to you in clinic. On examination, there is reduced air entry and dullness to percussion in the right lung. A pleural tap is performed and the aspirate samples sent for analysis. You are told that the results reveal a protein content of >30 g/L. From the list below, select the most likely diagnosis:
Option A is the correct answer. Pleural effusions can be categorized into transudates and exudates according to their protein content. Transudates (protein content <30 g/L) occur as a result of increased venous pressure (cardiac failure (B), restrictive pericarditis, fluid overload), hypoproteinaemia (cirrhosis (C), nephrotic syndrome (D), malabsorption) hypothyroidism and Meig’s syndrome (E) (right pleural effusion coupled with ovarian fibroma). Exudates occur as a result of increased capillary permeability secondary to infection (pneumonia, tuberculosis), inflammation (pulmonary infarction, rheumatoid arthritis, SLE) or malignancy (bronhogenic carcinoma, secondary metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis). From the history, the most likely answer is bronchogenic carcinoma (A)
7. A 47-year-old woman presents to your clinic with a three-month history of dysphagia. There is no history of drastic weight loss and the patient experiences symptoms when swallowing solids but not liquids. Which of the following is not an obstructive cause of dysphagia?
Option E is the correct answer. Answers A–D are all termed obstructive causes of dysphagia. The causes can be categorized into: • Obstructive • Oesophageal carcinoma • Peptic strictures (D) • Oesophageal web/ring (B) • Gastric carcinoma • Pharyngeal carcinoma (A) • Extrinsic pressure from, for example, lung carcinoma, retrosternal goitre (C) • Oesophageal motility disorders • Achalasia (E) • Systemic sclerosis • Stroke • Myasthenia gravis • Neurological degenerative conditions, e.g. motor neurone disease, Parkinson’s disease • Others • Oesophagitis • Pharyngeal pouch • Oesophageal candidiasis
8. You see a 47-year-old man in clinic with a three-month history of epigastric dull abdominal pain. He states that the pain is worse in the mornings and is relieved after meals. On direct questioning, there is no history of weight loss and the patient’s bowel habits are normal. On examination, his abdomen is soft and experiences moderate discomfort on palpation of the epigastric region. The most likely diagnosis is:
Option C is the correct answer. Although all of the answers may present with abdominal pain, the key to the answer is in the history. Duodenal ulcers (C), which are four times more common than gastric ulcers, classically present with abdominal pain which is usually relieved after meals or drinking milk. Gastric ulcers (A) on the other hand present with abdominal pain which tends to worsen after meals. In either duodenal/gastric ulcers, weight loss may be an associated symptom, but this is usually more common in gastric ulcers. Patients who suffer from GORD (B) usually experience retrosternal discomfort (‘heartburn’) after meals and on lying flat. In addition, abdominal discomfort and pain in patients with gastritis (E) usually occurs after meals. Gastric carcinomas (D) tend to present with abdominal pain and drastic weight loss (e.g. 2–3 stone weight loss in the space of three months).
9. Which of the following is the most common cause of duodenal ulcers?
Option B is the correct answer. The most common causative agent that gives rise to approximately 90 percent of duodenal ulcers is infection with H. pylori (B) (a helical-shaped gram-negative microaerophilic bacterium). The bacteria favours low pH environments and, with the help of its flagella, moves to the epithelial lining of the stomach and duodenum. The bacterium produces ammonia and proteases which break down the epithelial linings of the stomach and duodenal mucosa causing ulceration. Non-steroidal anti-inflammatory drugs (NSAIDs) (A), alcohol abuse (C), chronic corticosteroid therapy (D) and Zollinger–Ellison syndrome (E) (increase in gastrin production, from e.g. a gastrinoma, which stimulates the parietal cells of the stomach to produce excess hydrochloric acid leading to peptic ulceration) are all less common causes of peptic ulceration.
10. A 56-year-old man presents with a 2-week history of diarrhoea which has not settled following an episode of ‘food poisoning’. Which of the following would be the most appropriate investigation?
Option C is the correct option. The most appropriate investigation for this patient would be to obtain a stool sample (C), especially if there is a history of travel. Performing tests such as full blood count (A), urea and electrolytes (B), abdominal x-ray (D) and liver function tests (E) would not change the management of this patient and hence in this scenario would not be indicated. A stool sample would enable the physician to isolate the causative organism (if present), which would consequently determine if antibiotic therapy is required
11. A 16-year-old boy presents with a low-grade fever which started 1 week ago. The patient also reports feeling fatigued and indicates pain in his joints. His parents mention that he has been visiting the toilet more often than usual. A urine dipstick shows trace proteins, while a blood test shows raised eosinophils. The most likely diagnosis is:
Option A is the correct answer. The majority of tubulointerstitial nephritis (A) is due to drug hypersensitivity reactions, most commonly penicillin or non-steroidal anti-inflammatory drugs which are commonly given. Patients typically present with fever, skin rashes and may also have painful joints. Blood results will often have raised eosinophils. Eosinophils are involved in allergic responses, such as asthma and drugs, parasitic infection and also tissue inflammation. Renal failure (B) is the sudden loss of renal function which in the acute phase is reversible, plasma urea and creatinine typically increase due to the loss of filtering function of the kidney and patients tend to be oliguric rather than polyuric. In diabetes (C), although patients would tend to visit the toilet more due to hyperglycaemia causing an osmotic diuresis, other important features would include weight loss, polydipsia and the presence of glucose and possibly ketones on urine dipstick. A UTI (D) is characterized by features that include dysuria, elevated white cell count and raised leukocytes and nitrites in the urine. Reiter’s disease (E) is a sterile synovitis that typically follows an infection and involves the classical triad of urethritis, arthritis and conjunctivitis.
12. A 58-year-old African man presents with pitting oedema of his ankles. He suffers from recently diagnosed hypertension, but is otherwise healthy. Blood results show low albumin and a urine dipstick is positive for protein. The most appropriate initial treatment is:
Option B is the correct answer. This patient has the classic triad of proteinuria, low serum albumin and oedema that occurs in the nephrotic syndrome. This can occur due to a number of disease processes such as diabetes and SLE, as well as those specific to the kidney, including minimal-change nephropathy and focalsegmental glomerulosclerosis. First-line management should include dietary measures to restrict sodium intake and a diuretic (B). Potental diuretics include furosemide which is often required to control any associated severe oedema. High protein diets (A) do not have any benefit to the management of nephritic syndrome, a normal low salt diet should be encouraged. Albumin infusion can be used as adjuncts in patients who are resistant to diuretic therapy but never in isolation as they have transient beneficial effects. Bed rest (E) should also be discouraged in patients since coagulation factors, for example antithrombin, are also lost as part of the proteinuria creating a hypercoagulable state, patients are therefore at risk of thromboembolism, including renal vein thrombosis. Therefore, prophylactic anticoagulation (C) is desirable to protect against hypercoagulation and should always be considered, Angiotensin-converting enzyme (ACE) inhibitors (D) protect against proteinuria by reducing the filtration pressure upon the glomerular capillaries.
13. A 28-year-old woman patient who is 13 weeks pregnant presents for an antenatal clinic appointment. The patient feels embarrassed when asked to provide a urine sample and produces enough for a urine dipstick test only which is positive for leukocytes and nitrites. The patient denies any symptoms. The most appropriate treatment is:
Option D is the correct answer. The treatment of symptomatic and asymptomatic bacteriuria is important to prevent complications in pregnancy. Empiric treatment for common organisms such as Escherichia coli and Proteus should be administered while maintaining safety. Penicillins and cephalosporins, such as cephalexin (D), are safe for use during pregnancy. Ampicillin (E) is no longer recommended due to increasing resistance. Nitrofurantoins are also effective. Trimethoprim (A) is a folic acid antagonist and therefore should be avoided in pregnancy, especially in the first trimester of pregnancy as in this patient. Fluoroquinolones (B) and tetracyclines (C) are also known teratogens and must also be avoided in pregnancy
14. A 38-year-old woman presents to her GP with a 2-week history of dysuria, haematuria and shortness of breath. She suffers from chronic headaches and has been taking ibuprofen in order to treat them. She has a history of cardiovascular disease in the family and a friend recommended she use aspirin to keep healthy. The most appropriate investigation is:
Option E is the correct answer. This patient is most likely suffering from analgesic nephropathy in view of the chronic history of NSAID consumption. Chronic intake can result in papillary necrosis and tubulointerstitial nephritis leading to anaemia, UTIs and haematuria. Diagnosis is made by ultrasound or CT scan (E) alongside this clinical picture. An ultrasound is particularly useful if patients complain of sudden flank pain which can result from sloughed papillae causing urinary obstructions. Antegrade pyelography (D) is used to investigate a potential area of obstruction within the kidney which is not indicated in this case. Retrograde pyelography (A) is conducted to investigate obstructions via a catheter. A renal biopsy (B) would be useful to assess the degree of damage to the kidney but this is not essential as stopping analgesics or replacing them with alternatives, such as paracetamol, can reduce or even improve the condition. An abdominal x-ray alone would not be a useful modality for revealing renal damage in this case (C).
15. A 53-year-old man with HIV suffers a ruptured aortic aneurysm and is rushed into theatre, he undergoes a successful operation and is recovering on the wards in a stable condition. One day after the operation, he becomes oliguric with mildly elevated urea and creatinine. After 1 week, he becomes polyuric with a GFR of 30. The most likely diagnosis is:
Option B is the correct answer. Acute tubular necrosis (B) is most commonly due to renal ischaemia, as in this case, though direct pharmacological toxicity can also be the cause among many others including haemorrhage, diuretics, contrast during radiological procedures and heart failure. The clinical course is dependent on the offending factor and degree of damage but most commonly early oliguria followed by recovery of renal function with an increase in renal output. GFR, however, may remain low due to tubular damage. Full renal capacity is usually regained within 6 weeks of the initial stressor. Haemolytic uraemic syndrome (HUS) (A) defines the acute injury to the kidney from RBC fragmentation which usually originates from thrombosis within arteries. HUS is therefore the triad of microangiopathic haemolysis, thrombocytopenia and acute renal injury. The syndrome of inappropriate anti-diuretic hormone (C) (SIADH) is the result of inappropriately elevated levels of ADH causing the acute retention of water. As a result, there is hyponatraemia and reduced serum osmolality which is not present in this patient. In severe cases, patients can become very agitated and at risk of seizures. HIV nephropathy (D) is a common occurrence in HIV sufferers and can be due to direct HIV infection. Features include nephritic range proteinuria, large kidneys on ultrasound scan and typically collapsing focal segmental glomerulosclerosis on renal biopsy. In this acute case, the impact of renal hypoperfusion is the likely cause of the patient’s presentation. Although this is an example of acute renal failure (E), the specific cause is the most appropriate answer.
16. A 60-year-old man visits his GP complaining of tiredness. He has noticed weight loss over the last six months and irritation of the tip of his penis which appears inflamed on examination. He mentions he has been visiting the toilet more often than usual and feeling thirsty. The most appropriate investigation would be:
Option C is the correct answer. Type 2 diabetes symptoms are usually well recognized, as in this patient, with polyuria and weight loss occurring due to the osmotic diuresis that results from elevated blood glucose. In subacute presentations, more subtle signs include lethargy and opportunistic infections, such as Candida, causing pruritus vulvae in females or penile inflammation (balantis) in males. The criteria for diabetes diagnosis depends on the clinical presentation. In symptomatic patients, a single abnormal glucose reading is adequate and this may be a fasting plasma glucose ≥7.0 mmol/L or as in this case a random plasma glucose (C) of ≥11.1 mmol/L. In asymptomatic presentations, two abnormal readings are required, e.g. two fasting plasma glucose ≥7.0 mmol/L or two random plasma values ≥11.1 mmol/L. Water deprivation (D) is useful in investigating polydipsia for conditions such as diabetes insipidus. An oral glucose tolerance test (A) is only used for borderline cases or diagnosis of gestational diabetes. Other investigations, such as triglyceride (E), cholesterol and glycated haemoglobin (B), can be conducted after diagnosis to monitor the progress of the condition and used as potential risk factors for other conditions.
17. A 42-year-old woman presents with visual disturbances. She reports having double vision which was intermittent initially but has now become much more frequent. In addition, she becomes breathless very easily and experiences palpitations. On examination, raised, painless lesions are observed on the front of her shins and finger clubbing. The most likely diagnosis is:
Option D is the correct answer. Graves’ disease (D) is the most common cause of hyperthyroidism. The condition is due to IgG antibodies binding to the TSH receptor, this in turn causes excess production of thyroid hormone. The antibodies also bind to other areas of the body such as the extraocular muscles leading to gaze abnormalities, the shins causing raised lesions known as ‘pretibial myxoedema’ and rarely the fingers causing clubbing known as ‘thyroid acropachy’. These collective signs are only seen in Graves’ disease, hence it is the only correct answer. De Quervain’s thyroiditis (A) is a transient thyroid state most likely due to a viral infection. The patient usually complains of a fever and painful neck with some signs of hyperthyroidism, such as tachycardia, as well as raised ESR levels. A few weeks later, the patient suffers from transient hypothyroid symptoms before returning to a euthyroid state. Phaeochromocytomas (C) are malignancies of the sympathetic nervous system, 90 per cent arise in the adrenal medulla and produce excess catecholamines. The symptoms of a phaeochromocytoma are often similar to hyperthyroidism and include anxiety, palpitations and headache. However, these symptoms are usually intermittent and the main risk to patients is from cardiovascular compromise. Plummer’s disease (E) is a solitary nodule in the thyroid gland producing excess thyroid hormones. It is usually refractory to antithyroid treatment. A thyroid storm or crisis (B) is a rapid deterioration in patients suffering from hyperthyroidism, often stimulated by a stressor such as infection. Patients present with acute-onset, severe tachycardia, distress and hyperpyrexia.
18. A 54-year-old woman presents to her GP complaining of a change in her breathing sound. She first noticed numbness, particularly in her fingers and toes, three months ago but attributed this to the cold weather. Her partner now reports hearing a high pitched, harsh sound while she is sleeping. Her BMI is 27. While measuring blood pressure, you notice the patient’s wrist flexing. The most likely diagnosis is:
Option B is the correct answer. This patient exhibits many of the signs present in hypocalcaemia (B) including tingling in the fingers and toes and carpopedal spasm. In the latter, occlusion of the brachial artery, which occurs when measuring blood pressure, causes muscle spasming of the hand and forearm (Trosseau’s sign). Other signs include facial muscle twitching when the facial nerve is tapped on the same side (Chvostek’s sign), prolonged QT interval, hyperreflexia and stridor. Hypocalcaemia most commonly arises due to renal failure. DiGeorge syndrome (C) is a congenital condition that arises due to an abnormality at chromosome 22q11 causing malformation of the third and fourth pharyngeal arches. Patients present at a young age with cardiac abnormalities, abnormal facies, cleft palate and hypocalcaemia. Raynaud’s syndrome (E) is characterized by triphasic changes in the peripheral digits, usually the fingers, stressors such as cold temperature causes arterial spasming which reduces the blood flow to the end arteries. Patients will notice their fingers turn white, blue and then red as the blood flow returns. In mild disease, this can be associated with mild tingling while severe disease can cause severe pain and even necrosis. Obstructive sleep apnoea (A) is a disorder of sleep that is characterized by loss of airway patency causing a significant reduction in airflow despite constant breathing effort. This can occur for a number of reasons such as obesity, asthma and hypothyroidism. However, there are not usually any underlying neurological signs. Guillain–Barré syndrome (D) is an immune-mediated disease which usually results following an infection such as cytomegalovirus (CMV) and campylobacter causing a polyneuropathy. The demyelination typically occurs in a symmetrical ascending pattern starting with the distal limbs. Paralysis of the respiratory muscles can occur, requiring emergency treatment, but there are no signs of hypocalcaemia as in the above patient.
19. A 45-year-old Asian man is diagnosed with Cushing’s disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK one year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases of both hands. The most likely diagnosis is:
Option C is the correct answer. Nelson syndrome (C) occurs in patients who undergo bilateral adrenalectomies, the loss of negative feedback over time causes a macroadenoma to form in the pituitary which secretes adrenocorticotropin (ACTH). A spectrum of symptoms may arise due to the effects of serum ACTH, as well as the deficiency in other pituitary hormones. An ectopic tumour secreting ACTH (A) can produce similar symptoms, however they usually originate from oat cell of small cell lung carcinomas which are associated with weight loss rather than headaches and visual disturbances. Iatrogenic steroid side effects (E) would cause symptoms imitating cortisol excess such as striae, bruising, thin skin and weight gain. A prolactinoma (B) can cause some of the symptoms the patient complains of, such as headache and visual disturbances, due to impingement upon surrounding structures. However, symptoms in males does not involve hyperpigmentation and usually include loss of libido, impotence and gynaecomastia. Addison’s disease (D) causes similar symptoms described in the question stem, however the cause of adrenal function loss is due to autoimmune action or infection.
20. A 36-year-old woman presents to the rheumatology outpatient clinic with a two-month history of stiff hands and wrists. She mentions that the pain is particularly bad for the first few hours after waking up and is affecting her work as a dentist. On examination, the wrists, metacarpophalangeal joints and proximal interphalangeal joints are swollen and warm. What is the most likely diagnosis?
Option A is the correct answer. Rheumatoid arthritis (A) is a chronic, systemic inflammatory disease, which produces a symmetrical, deforming polyarthritis. The typical presentation of rheumatoid arthritis is with symmetrical pain and stiffness of the small joints of the hands and feet. Pain is characteristically worse in the morning and improves with exercise. As the disease progresses, it may cause deformity of the affected joints. Less commonly, rheumatoid arthritis may present with a monoarthritis. Diagnosis is made from the presence of articular and extra-articular features characteristic of the disease.
21. A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis?
Option E is the correct answer. Osteoporosis is a loss of the bone mass. It is important to note that the mineralization of the bone is normal. This loss of bone mass means there is an increasing likelihood of fracture with increasing age. Due to the accelerated loss of bone mass following the menopause, elderly women are at a higher risk of osteoporosis than men. There are numerous risk factors for the development of osteoporosis. Among them are Caucasian and Asian ethnic groups, female sex, increasing age, early menopause, smoking, excess alcohol, corticosteroid use, hypogonadism and rheumatoid arthritis. The reduced bone mass of osteoporosis may result in vertebral crush fractures, the majority of which are asymptomatic. The extent of osteoporosis is best investigated with a dual energy x-ray absorptiometry (DEXA) scan (E). This gives a T score, which is the number of standard deviations the patient’s bone mineral density differs from the population average for a young healthy adult. The World Health Organization defines osteoporosis as a T score of −2.5 or greater (i.e. the bone mineral density of more than 2.5 standard deviations below that of the average for a young healthy adult). A T score of between −1.5 and −2.5 is defined as osteopenia. Spinal x-rays (A) are useful to assess vertebral crush fractures but cannot assess extent of osteoporosis. MRI scans (B) are not used to assess osteoporosis, so this answer is incorrect. Full blood count, bone and liver biochemistry tests (C) are not affected by osteoporosis, making this answer incorrect. Vitamin D deficiency may contribute towards the development of osteoporosis but levels (D) cannot assess extent of disease. Treatment options in osteoporosis include use of bisphosphonates, hormone replacement therapy and raloxifene (a selective oestrogen receptor modulator).
22. A 70-year-old woman presents to her GP complaining of severe unilateral headache over the left side of her head. On further questioning, she mentions that she has been having bilateral shoulder and neck pains over the past few weeks. She has also been feeling lethargic. On examination, the left side of her scalp is painful to touch. What is the most likely diagnosis?
Option E is the correct answer. This is a relatively straightforward question. Giant cell arteritis (E) is a large vessel vasulitis, which occurs in association with polymyalgia rheumatica. Features of giant cell arteritis include severe headaches, which are usually unilateral and involve the temporal region with associated scalp tenderness. There may also be jaw claudication on eating. Involvement of the ophthalmic arteries may result in visual loss, which may be permanent if the condition is untreated. Polyarteritis nodosa (A) is a medium-sized vessel vasculitis, which may affect a number of organs. However, headache is not a feature, making this the incorrect answer. Polymyositis (B) presents with proximal muscle weakness, resembling polymyalgia rheumatica. Again, headache is not a feature making this answer wrong. Hypothyroidism (C) can result in proximal muscle weakness but does not cause unilateral headache, making this answer incorrect. The presentation of migraine (D) is variable and includes unilateral headache, with or without aura. However, the presence of scalp tenderness and features of polymyalgia rheumatica make giant cell arteritis a more likely option.
23. A 30-year-old Afro-Carribean woman presents to accident and emergency with a1-week history of progressive shortness of breath and fever. On further questioning, she mentions that her hands have been painful and stiff over the past few months and she has been having recurrent mouth ulcers. Chest x-ray confirms bilateral pleural effusions and blood tests reveal a raised ESR and a normal CRP. What is the most likely diagnosis?
Option A is the correct answer. SLE is a multisystem, inflammatory disorder which is nine times more common in women than men. It is also more common in people of AfroCarribean origin and peak age of onset is usually 20–40 years of age. Multiple genetic and aetiological factors have been associated with the development of this disease. SLE has an extremely variable presentation, with clinical features usually caused by underlying vasculitis. These include polarthritis (the most common clinical feature, often a symmetrical small joint polyarthritis similar to that seen in early RA), photosensitive rashes (characteristic erythematous rash over malar eminences, sparing the nasolabial folds), mouth ulcers, serositis (affecting pleura or pericardium) or renal disease (usually nephrotic syndrome of renal failure due to underlying glomerulonephritis). The features presented in this case are, therefore, most suggestive of SLE (A) as the diagnosis. The raised ESR and CRP should also identify SLE as the correct answer. Systemic sclerosis (B) can be localized or diffuse and does not characteristically cause mouth ulcers, pleural effusions or a raised ESR. Sjögren’s (C) is a syndrome of dry eyes and dry mouth. It can be a primary syndrome or occur secondary to other autoimmune diseases. While it is associated with athralgia, the pleural effusion, mouth ulcers and blood results make this diagnosis unikely. Discoid lupus (D) is a variant of SLE where skin involvement is the only feature. Therefore, this is the incorrect answer. Beçhet’s disease (E) usually manifests with oral ulceration. However, the peripheral polyarthritis, pleural effusuions and blood results (in Beçhet’s both ESR and CRP may be elevated) make this the incorrect answer in this case.
24. A 66-year-old woman complains of stiffness and weakness climbing stairs. She has a history of hypertension and diet-controlled type 2 diabetes. On examination, there is mild upper arm weakness, hip flexion is 4−/5 bilaterally, with bilateral wasting and flickers of fasciculations in the right quadriceps. Knee extension is 4/5. Dorsiflexion and plantar flexion are strong. Brisk knee and ankle reflexes are elicited, as well as a positive Hoffman’s and Babinski’s sign. Sensory examination and cranial nerves are normal. Her BM is 8.9, her pulse is regular and her blood pressure is 178/97. What is the most likely diagnosis?
Option D is the correct answer. This woman presents with upper (brisk reflexes, upgoing plantar) and lower (fasciculations) motor neurone signs. Motor neurone disease (MND) (D) presents with mixed upper and lower motor neurone signs and importantly no sensory involvement. In this case, there is involvement of two regions (arms and legs). Bulbar signs, such as tongue wasting and fasciculation, often help make the diagnosis. Myositis (C) affects the muscle, resulting in tenderness, wasting and fasciculation but no upper motor neurone (UMN) signs. Although the patient is diabetic, neuropathies (B) result in lower motor neurone (LMN) signs only. These may be motor and/or sensory. Typically, diabetes results in a peripheral neuropathy, most commonly sensory. The proximal distribution of weakness would be in keeping with myasthenia (A), but not the UMN signs. There is no mention of fatigability, which is a key feature. MS (E) in this age group is less common and an inflammatory disorder of the central nervous system would not result in LMN signs.
25. A 23-year-old man is stabbed in the neck. Once stabilized, his MRI shows a right hemisection of the cord at C6. What is the expected result of this injury?
Option B is the correct answer. Hemisection of the cord is also known as Brown–Séquard syndrome. This results in ipsilateral paralysis and loss of light touch and vibration sensation and contralateral loss in pain and temperature below the point of the lesion. The spinothalamic tracts cross at the level of the cord, so sensation to pain and temperature is lost in the contralateral limbs (B). C3, 4, 5 keep the diaphragm alive (A), so breathing should be preserved. As the right corticospinal tract has been severed, the right, ipsilateral hand would be paralysed (C) as well as the right leg. The left dorsal columns carry light touch fibres from the left limb (D). They have been unaffected by the injury. C6 is responsible for the biceps reflex and would be lost (E). Reflexes distal to the lesion would be brisk.
26. A 19-year-old woman collapses at a concert and is witnessed to have a tonic-clonic seizure lasting 2 minutes. When the paramedics arrive and ask her questions, she mumbles but no-one can understand what she is saying. Only when the paramedic applies pressure to her nailbed does she open her eyes and reach out with her other hand to rub her nail and then push him away. What is her Glasgow Coma Scale (GCS)?
Option D is the correct answer. The GCS is frequently used to assess level of consciousness. The lowest score is 3, the highest 15. A score of 8 or below is classified as coma. GCS is assessed by evaluating eye (1–4), verbal (1–5) and motor (1–6) response. Clinically, it is best to assess for the highest possible score and work down. So, if a patient is not opening their eyes spontaneously, assess whether they respond to verbal command and only then to pain. In this case, E = 2 (responds to pain), V = 2 (incomprehensible sounds), M = 5 (localizes to pain), giving this patient a GCS of 9/15. It is important to carefully monitor her GCS, like most measurements a trend is more useful than a one-off assessment
27. A 79-year-old man is admitted with left hemiparesis. CT reveals a middle cerebral artery infarct. What is his most significant risk factor for stroke?
Option A is the correct answer. The three most important risk factors for stroke are hypertension, hypertension and hypertension (A)! INTERSTROKE, a recent large case–control study evaluating risk factors for stroke, has shown that ten risk factors are associated with 90 per cent of the risk of stroke and that of these modifiable risk factors, hypertension is the most important for all stroke subtypes and is a particularly dangerous risk factor for intracerebral haemorrhage. Other risk factors include smoking (B), lipids (E) and diabetes (D) which promote atherosclerosis. Poor diet, lack of regular activity and increased waist–hip ratio are as significant risk factors as smoking. Unmodifiable risk factors include increasing age (by far the most significant), male sex, family history (C) and ethnicity (higher in Blacks and Asians). Patients in atrial fibrillation have an annual stroke risk of 5 per cent. This can be lowered to 1 per cent by anticoagulating with warfarin, aiming for an international normalized ratio (INR) of between 2 and 3 (avoid confusion with aspirin which is an antiplatelet). Stroke is the third most common cause of death in England (after heart disease and cancer) and is more often disabling than fatal, so primary and secondary prevention are crucial
28. A 42-year-old woman presents with ataxia. Gadolinium-enhanced MRI reveals multiple subcortical white matter lesions as well as enhancing lesions in the cerebellum and spinal cord. She is diagnosed with MS. Two months later she develops optic neuritis. What feature is associated with a milder disease course?
Option C is the answer. In this woman’s case, all of the features except her gender (C) point to a more aggressive disease course. Although it is close to impossible to predict an individual patient's outcome, features of a better prognosis include onset under 25 years (A), optic neuritis or sensory, rather than cerebellar symptoms on initial presentation (B), a long interval (>1 year) between relapses (D) and few lesions on MRI (E). Full recovery from relapses is also a positive feature. Progressive MS carries a poorer prognosis compared to relapsing–remitting MS.
29. A 71-year-old man with atrial fibrillation is seen in clinic following an episode of syncope. He describes getting a poor night’s sleep and, as he got out of bed in the morning, feeling dizzy for a couple of seconds before the lights dimmed around him. He was woken a couple of seconds later by his wife who had witnessed the event. She says he went pale and fell to the floor and his arms and legs jerked. After waking, he was shaken but was ‘back to normal’ a few minutes after the event. His medication includes aspirin, atenolol and frusemide. What is the most likely diagnosis?
Option B is the correct answer. This man most likely experienced an episode of orthostatic or postural hypotension (B) where syncope occurs as a result of reduced cerebral perfusion as the patient moves from lying to standing. Symptoms are similar to vasovagal in that the patient may become pale and describe ‘the lights or sound dimming’. Perfusion is restored after the patient collapses and unconsciousness lasts no more than seconds or a couple of minutes with full recovery. However, vasovagal epsiodes (A) can be brought on by sleep or food deprivation, hot or emotional environments, Valsalva manoeuvre (such as straining) and are not as closely related to position. Syncope while lying down is more suggestive of cardiac syncope or seizure activity. It is important to rule out cardiac causes of syncope (C) which may be heralded by chest pain or palpitations. Arrhythmias or aortic stenosis may be the underlying cause. TIAs (D) are a very rare cause of syncope. Seizures (E) may be triggered by lack of sleep. They may be heralded by an aura, typically visual or olfactory. There may be urinary incontinence, tonic-clonic movements, tongue-biting and cyanosis during the event. However, jerky movements may occur in syncope of any cause. This alone does not equate to a seizure.
30. A 69-year-old man presents to clinic with a six-month history of progressive lower back pain which radiates down to his buttock. He found the pain was exacerbated while taking his daily morning walk and noticed that it eased going uphill but worsened downhill. He stopped his daily walks as a result and he now walks only slowly to the shops when he needs to, taking breaks to sit down and ease the pain. He has a history of hypertension, diabetes and prostatic hyperplasia. What is the diagnosis?
Option C is the correct answer. This man gives a good history of spinal claudication (C), lower back pain and sciatica on walking. The pain worsens when the spine is extended (walking, especially downhill, and improves when flexed, going uphill, sitting). It is caused by narrowing of the spinal canal as a result of spondylosis (degenerative disease). Intermittent claudication from peripheral vascular disease (A) can be similar in timing, worse on walking and relieved by rest, but the pain comes from ischaemic muscles, typically calf or buttock, and has no relation to the incline. There is nothing to suggest osteoporotic fracture (B), and in addition, his sex is protective for osteoporosis. Sciatica (D) presents as sharp pain shooting down the posterior leg and occurs as a result of impingement of the nerve roots forming the sciatic nerve. It is a symptom rather than a diagnosis. Metastatic bone disease (E) could result in spinal stenosis or sciatica but in itself does not explain the patient’s exact symptoms and there is nothing else to suggest malignancy in the stem such as constitutional symptoms or a nodular prostate.