1-Answer: e) abetalipoproteinaemia. Abetalipoproteinaemia is a disorder in the synthesis of serum lipoproteins containing apolipoprotein B, for example chylomicrons, VLDL and LDL. There is a failure of apoB100 in the liver and apo B48 in enterocytes of the intestinal mucosa. The result is malabsorption of fat soluble vitamins.
2-Answer: b) 261. Serum osmolality is 2 X sodium + Urea + Glucose = 248 + 5 + 8 = 261 mOsmol/Kg. Normal is 280 to 305 hence she has low serum osmolality. An alternative formula is 1.9 x (Na + K) + Ur + Glucose.
3-Answer: e) translocation between the long arm of chromosome 4 (q) and the short arm of chromosome 8 (p). The karyotype 46 XX, t (4;
(q26;p21.3) describes a female with a normal number of chromosomes but a translocation between the long arm of chromosome 4 (q) and the short arm of chromosome 8 (p).
4-Answer: a) finger agnosia.
Parietal lobe signs are:
loss of two point discrimination
dressing and constructional dyspraxia
Gerstmann syndrome includes four features (acalculia, agraphia, finger agnosia, left right disorientation), and is due to a lesion in the dominant hemisphere.
5-Answer: d) ptosis. 3rd nerve palsy leads to ptosis, dilated unreactive pupil and eye looking down and out (due to unopposed superior oblique and abducent nerves. Exopthalmos can be associated (e.g. graves disease) but is not a feature of 3rd nerve palsy
6-Answer: d) subthalamic nucleus. Hemiballismus is caused by a subthalamic nucleus lesion, which is commonly due to an infarct.
7-Answer: b) p53. Ras is an oncogene. Bcl-2 inhibits rather than promotes apoptosis
8-Answer: c) sciatic nerve. The sciatic nerve branches into the tibial nerve and common peroneal nerve. Damage to these branches will cause almost total weakness around the ankle and absent ankle jerk.
9-Answer: c) thoracic sarcoma. The four Ts for mediastinal masses (anterior) are thyroid, thymoma, teratoma and tumour (lymphomas).
10-Answer: e) pernicious anaemia. Achlorhydria (absence of gastric acid secretion) can be caused by immune destruction to the stomach wall, malnutrition and marijuana use. The pentagastrin test is used as a diagnostic aid for evaluation of gastric acid secretory function. It is effective in testing for anacidity (achlorhydria) in patients with suspected pernicious anemia, atrophic gastritis, or gastric carcinoma.
1-Answer: b) pericarditis. Significant outflow tract obstruction, advanced heart block, hypertension > 180 mmHg systolic, and unstable angina are all contraindications towards ETT.
2-Answer: a) simvastatin. A statin is most appropriate. In a patient with vascular disease (CVA or MI), a cholesterol > 5 should be treated. Ezetimide lowers cholesterol by preventing its intestinal absorption through the inhibition of cholesterol transport across the intestinal wall and can be used in conjunction with HMGCoA enzyme inhibitors (i.e. statins).
3-Answer: d) ruptured papillary muscle. Following an MI, ruptured papillary muscle or interventricular septum is most likely to cause the combination of pulmonary oedema and new murmur (either mitral regurgitation or due to VSD).
4-Answer: b) rheumatic fever. This patient has polyarthritis, carditis (2 major criteria), fever and raised inflammatory markers (2 minor criteria). The history is consistent with rheumatic fever (β haemolytic strep Group A) infection.
5-Answer: a) reduction in thromboxane A2 synthesis. Aspirin blocks the synthesis of COX1 and COX2 enzymes. This leads to a reduction in PGG2, PGH2 → TXA2 synthesis↓ leads to → platelet aggregation.
6-Answer: c) myocarditis. Pyrexia, chest pain (pleuritic), raised troponin, T wave changes on the ECG would be suggestive of myocarditis. Pericarditis usually causes saddle shaped ST elevation on ECG. Coxsackie B is the commonest cause. Other causes are HIV, diphtheria, Chagas disease, Lyme disease, SLE and arsenic poisoning.
7-Answer: c) 2:1 Mobitz type II heart block. The first form of second degree heart block, Mobitz type I (Wenkebach) is due to progressive prolongation of PR interval and then missing a beat. Mobitz type II second degree heart block can occur with 2:1 (only 1 QRS is conducted for 2 p waves) or 3:1. In a patient who is compromised with symptoms and hypotension, temporary pacing is indicated.
8-Answer: b) ACE inhibitor, β blocker, aldosterone antagonist. Of all the combinations, ACE inhibitor / angiotensin II blocker with β blocker and aldosterone antagonist (spironolactone) is the most appropriate given the fact that this patient has symptomatic heart failure. Trials have shown that these medications have reduced mortality and also conferred symptomatic benefit.
9-Answer: c) history of diabetes and a tanned complexion. A history of diabetes and bronze / tanned pigmentation suggest haemochromatosis. Liver function tests and iron studies would help to confirm the diagnosis.
10-Answer: b) supraventricular tachycardia. Out of the following options, the most likely rhythm which may cause symptoms are supraventricular tachycardia. The other rhythms may cause palpitations but would be unusual to cause light headedness / presyncope.
1-Answer: A) gastrin levels. Diarrhea and recurrent gastric ulceration is common with Zollinger Ellison syndrome (gastrinoma). There would be demonstrable high fasting plasma gastrin levels. Gastrinomas may occurs as part of a multiple endocrine neoplasia syndrome type 1.
2-Answer: b) B12 deficiency. In chronic pancreatitis, trypsin secretion is reduced. Trypsin is required in the processing of dietary B12 which enables absorption and hence B12 deficiency is the most likely in this case.
3-Answer: e) spontaneous bacterial peritonitis. A white cell count of > 350 mm3 is diagnostic of spontaneous bacterial peritonitis. There is underlying cirrhotic liver disease and this should always be considered related to decompensation.
4-Answer: d) botulinum toxin. Botulinum injections are most effective of all the options for relieving a lower oesophageal sphincter restriction which leads to achalasia. Nifedipine, nitrates or sildenafil can also be used, but are less effective.
5-Answer: c) reassure her that no intervention is required. She is likely to have irritable bowel syndrome from the history and normal investigation. She should be reassured and also recommended to have a high fibre diet.
6-Answer: e) celecoxib. COX 2 inhibitors such as celecoxib are used as analgesics instead of NSAIDS in patients who are at high risk of upper GI dyspepsia or ulceration. However, there remains an increased risk of ulceration, though less so compared to NSAIDS. Misoprostol (prostaglandin analogue) and cimetidine are used in treatment of gastro-oesophageal ulceration.
COX 2 inhibitors have also recently been shown to increase the mortality rate of patients with coronary artery disease by blocking the antithrombotic effects of certain prostaglandins.
7-Answer: b) barium meal and follow through. The likely diagnosis is Crohn's disease and a barium follow through is the best test to confirm this. Behcet's disease and Yersinia colitis can also present with raised inflammatory markers, oral ulceration and right sided abdominal pathology.
8-Answer: E) Liver function tests. The features are suggestive of autoimmune hepatitis. Liver function tests may demonstrated elevated levels of bilirubin, AST and ALT. A liver biopsy may then be warranted.
9-Answer: d) Carcinoid syndrome. Carcinoid syndrome is diagnosed by raised urinary 5-HT levels. A precursor of 5HT, tryptophan is highly metabolised and consequently niacin deficiency (pellagra) occurs.
10-Answer: e) pantoprazole. Proton pump inhibitors such as omeprazole, lansoprazole and pantoprazole are more effective than H2 receptor blockers such as ranitidine, cimetidine or nizatidine. Healing in oesophagitis is beter with a PPI although all of the options can reduce symptoms due to acid reflux.
1-Answer: a) hydrocortisone 10mg mane, 5mg mid day and 5 mg evening and also fludrocortisone 100 μg mane. She has Addison's disease and needs both glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement. Steroid replacement is usually given 10/5/5 mg or 10/5 mg, although this is adjusted with cortisol day curves. Fludrocortisone 100 μg mane should be adequate.
2-Answer: b) adrenal tumour. An adrenal tumour is most likely, with androgen secretion. Virilisation occurs. These are aggressive tumours and the treatment option is surgery or radiotherapy.
3-Answer: a) serum alkaline phosphatase is increased. Serum alkaline phosphatase is usually increased in primary hyperparathyroidism.
Primary hyperparathyroidism does not respond to steroids.
Salt and pepper changes on the skull can be a hallmark.
Gout, rather than arthritis, is worsened by hyperparathyroidism.
High urinary phosphate excretion leads to serum phosphate and a high cAMP in the urine suggests active excretion.
Pepper pot skull
4-Answer: d) 72 hour fast with insulin, C peptide and plasma glucose sent when BM < 4. The diagnosis is likely to be an insulinoma. Hypoglycaemic attacks are likely to be witnessed during a 72 hour fast. Insulin and C peptide levels are high, whilst glucose is low. Sulphonylurea levels are also sent in cases where oral hypoglycaemic drug misuse is suspected.
1-Answer: c) malignancy. A protein of >35 g/L suggests an exudate.
Causes of transudate are:
Congestive heart failure
Caues of exudate are : Infection (Bacterial, viral, or parasitic)
Connective tissue disease
Drug-induced (eg, by amiodarone)
Light's criteria (suggests exudate) is satisfied if
pleural fluid protein/serum protein ratio greater than 0.5
Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6
Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH (a cut-off value of 200 IU,/L was used previously)
2-Answer: d) thoracoscopy and biopsy. This patient probably has a malignant effusion. As he is symptomatic, the best option would be to drain the fluid as well as confirm a diagnosis simultaneously. A video assisted thoracoscopy would help to do this
3-Answer: d) adult respiratory distress syndrome. Respiratory distress syndrome is associated with profound hypoxia and increased vascular permeability (causing a V/Q mismatch). A normal PCWP differentiates the condition from pulmonary oedema. It does not respond to steroids.
4-Answer: d) byssinosis.
Byssinosis is caused by cotton dust, and is commoner among smokers. Immunologically, it is different from farmer’s lung but is more akin to occupational asthma – wheeze occurs after exposure to cotton and hemp.
The condition is typically worse on Mondays when work begins and lung function stabilises throughout the week. The CXR is normal, unlike extrinsic allergic alveolitis, where mottling is seen on CXR (interstitial pneumonitis).
6-Answer: d) silica. Slate workers, stonemasons and miners are exposed to silica dust. Silicosis impairs macrophage function, and in particular, predisposes to TB infection.
7-Answer: e) bronchoscopy. This patient is likely to have TB due to the apical shadowing. In a patient who is unable to expectorate sputum, bronchoscopy with lavage (send for AFB) should be performed to confirm the diagnosis.
8-Answer: d) inhaled corticosteroids.
Diurnal PEFR variation points towards a diagnosis of asthma. Patients who do not respond to B agonists should be treated with inhaled steroids.
9-Answer: b) iv magnesium 2g. According to BTS guidelines, single dose Magnesium of 2g IV should be instituted in cases of acute severe asthma following administration of conventional therapy. Aminophylline is no longer recommended as the second line treatment in most trusts.