PLAB FOR ALL DOCTORS

mock PLAB 1

2005-03-15T05:58:00.000-08:00

MOCK EXAM CHINNI

1. Theme Headaches: selection of Diagnostic testsSelect the SINGLE most suitable investigative procedure from the list of options below.

Options:
A. Skull x-ray
B. Toxoplasma serology
C. Intraocular pressure
D. Lumber Puncture
E. Mental state examination
F. Electroencephalogram
G. Nasendoscopy
H. Fundoscope
I. Magnetic resonance imaging of Cervical spine
J. Computed tomography scan of brain
K. Visual fields
L. Erythrocyte sedimentation rate
M. Cartoid arteriography
N. Temporal artery biopsy1.

1. A 33-year-old woman reports a generalized headache to be like a tight band around her head. The headache is not relieved by paracetamol. She has had difficulty in sleeping and has recently lost weight

2. A 74-year-old woman complains of a right-sided headache that is worsened when she brushes her hair. She's been unwell for a number of months with aching muscles.
3. A 34-year-old man looks pale and complains of a headache, photophobia and a sudden reduction in visual acuity
4. A 15 year-old boy, who is recovering from a bilateral parotitis, complains of drowsiness and a generalised headache. On examination his CT scan is normal.
5. A 57-year-old man complains of severe headaches that become worse when he lay down. On examination you find bilateral papilloedema.

2. Theme Diagnosis of acute vomiting in childrenSelect the SINGLE diagnosis for each child's symptoms from the list of diagnosis below. Options: A. Overfeeding B. Acute appendicitis C. Cyclical vomiting D. Meningitis E. Duodenal atresia F. Gastroenteritis G. Pyloric stensosis H. Whooping cough I. Urinary tract infection J. Gastro-oesophageal reflux K. Pancreatitis L. Mesenteric adenitis M. Psychogenic vomiting N. Meconium ileus 6. An eight-year-old girl has vomited all fluids for the last 24 hours. The vomit is not bile stained and her abdomen is now soft and non-tender. She shows signs of moderate dehydration and has had two similar attacks of vomiting this year.7. A six-week-old male infant has suffered projectile vomiting, after each feed, for the last 2 weeks. He is now lethargic, dehydrated and tachypnoeic 8. A 12-week-old developmentally normal, thriving baby boy vomits after every feed. A is bottle fed at 260 ml/kg/day.9. A breast fed, three day-old baby boy vomits after each feed. An Abdominal x-ray showed a "double-bubble"10. A four-month-old baby has persistent vomiting, that on occasions is bloody. The baby is thriving but cries during the incidents of vomiting. 3. Theme Drug Prescription in PregnancySelect the SINGLE most appropriate Rx for each patient from the list of drugs below. Options: A. Aspirin B. Insulin C. Reduce Glibenclamide D. Warfarin and Aspirin E. Lisinopril F. Glicazide G. Continue Carbamazepine H. Bendrofluazide I. Acamprosate J. Paracetamol K. Heparin and Aspirin L. Prednisone M. Methyldopa N. Increase Glibenclamide O. Carbamezepine with 5mg/day Folate 11. A 27-year-old woman is undergoing treatment with Carbamazepine with very good results. She has missed two periods and has a pregnancy test that is positive. 12. A 39-year-old diabetic, being treated with Glibenclamide (10mg/day) and whose blood glucose control is good, has missed a period and asks for a pregnancy test. She tests positive 13. The blood pressure of a 34-year-old woman in her 31-week of pregnancy reads 150/100mmHg. She has not complained. 14. A pregnant 41-year-old woman has stiffness and chronic pain in her left knee. On examination she's found to have Osteoarthritis 15. The tests of a pregnant 34-year-old woman, who has previously had two-second trimester miscarriages, show positive for anti-cardiolipin antibodies and Lupus anticoagulant at 11 weeks of pregnancy. 16. A pregnant 41-year-old woman has stiffness and chronic pain in her left knee. On examination she's found to have Osteoarthritis.4. Theme Diagnosis of sudden visual lossOptions: A Cataract B Central retinal artery occlusion C Acute glaucoma D Cerebral embolism E Cerebral haemorrhage F Chronic (simple) glaucoma G Hypertensive encephalopathy H Polymyalgia rheumatica I Retinal detachment J Temporal arteritis K UveitisChoose the single most likely diagnosis from the above list of options.17. A 40 year-old lady has reccurrent episodes of an acutely painful red eye with reduced vision.18. A 70-year-old smoker suddenly notices markedly reduced vision in one eye. He cannot read any letter on the visual acuty chart, but can count fingers. The fundus looks pale. 19. An 90-year-old woman notices sudden increased visual impairment. She is found to have homonymous hemianopia20. A 45-year-old lady complains of sudden loss of vision in one eye. She describes the incident like a curtain coming down21. A 80-year-old lady has had a painful scalp and headache for three weeks and is generally unwell. She presents with an acute onset of blindness in the left eye.5. Theme Causes of pneumoniaOptions: A Chlamydia psittaci B Staphylococcus aureus C Streptococcus pneumoniae D Mycoplasma pneumoniae E Legionella pneumoniae F Mycoplasma tuberculosis G Haemophilus influenzae H Chlamydia trachomatis I Pneumocystis cariniiChoose the single, most likely causative agent, from the list of options above. 22. A young male homosexual with kaposi's sarcoma complains of a dry cough associated with increasing breathlessness.23. A 22-year-old girl who works in a pet shop complains of fever, a dry cough associated with increasing breathlessness 24. A 30-year-old woman, has just returned from a holiday in Cyprus. She complains of dry cough, fever and general malaise. A chest x-ray shows patchy consolidation.25. A 56-year-old smoker with chronic obstructive airway disease develops a fever. He reports bringing up green phlegm. 26. A 40-year-old homeless alcoholic presents with a chronic productive cough. He reports 3 episodes of seeing red streaks in the sputum. Chest x-ray shows a cavitating lesion in the right lower zone 7. Theme Diagnosis of weight loss Options: A Starvation B Malabsorption C Anorexia nervosa D Depression E Hyperthyroidism F Atrophic gastritis G DementiaChoose the single most likely diagnosis from the above list of options. 27. An elderly man with alcoholic liver disease is found to be wasted. 28. A 50-year-old man presents to A&E with a 4 month history od diarrhoea, weight loss and palpitations. On examination, there no significant findings. 29. A 37-year-old company executive has just had a company merger. She now complains of weight loss, and early morning wakeness. 30. A 21-year-old girl presents to her GP before her forthcoming A-level exams, complaining of ammenorrhea. She has lost 10kg over the last 3 months.7. Theme Diagnosis of Infections Options: A Pseudomonas Aeruginosa B E.Coli C Staphylococcus aureus D Proteus mirabilis E Streptococcus viridans F Chlamydia trachomatic G Chlamydia psittaci H Trichomonas vaginalis I Neisseria Gonorrhoea J Neisseria Meningitidis K Haemophilus Influenzae Choose the most likely causative organism, from the list of options above.31. A 25-year-old man presents with a swelling in his right axilla. Aspiration yields yellowish-green pus. 32. A 32-year-old man presents with a fever, dyspnoea and palpitations. On auscultation, a pansystolic murmur is heard in the tricuspid area. He was previously healthy. 33. A 5-year-old boy who has started school presents with a high fever, vomiting, headache and a stiff neck. 34. A 10-year-old Nigerian boy presents with a 3-month history of a purulent eye discharge and increased lacrimation. His 16-year-old brother has a similar condition. 35. A 20-year old woman presents with a subacute onset of lower abdominal pain associated with frequency and dysuria. 8. Theme: Hormonal disease Options: A Cortisol B Adrenocorticotrophic hormone(ACTH) C Growth hormone D Calcitonin E Somatostatin F Thyroxine G Parathyroid hormone H Insulin I Adrenaline J Thyroid stimulating hormone(TSH) K Serotonin L Glucagon M AldosteroneChoose the single most likely hormone involved from the list of options above.36. A 20 year old known diabetic is brought to A&E unconscious. He has up-going plantar reflexes. 37. A 38-year-old man with an enlarged right adrenal gland and normal left gland presents with weakness. Na+=140mmol/L K+=2.5mmol/L. 38. A 35 year old man complains of polyuria, excessive drinking of water, associated with excessive thirst. 39. A 35-year-old woman with polyuria presents with a one month history of palpitations and diarrhoea. 40. An obese 34 year old woman is found to have a 'moon face', a blood pressure of 145/95mmHg and raised blood glucose. (Cortisol)9. Theme Principles of the dutes of a doctor registered with the General Medical Council Options: A Make the care of your patient your first concern B Treat every patient politely and consideraly C Respect patients dignity and privacy D Listen to patients and respect their views E Give patients information in a way they can understand F Respect the right of patients to be fully involved in decisions about their care G Keep your professional knowledge and skills up to date H Recognise the limits of your professional competence I Be honest and trustworthy J Respect and protect confidential information K Make sure that your personal beliefs do not prejudice your patients' care L Act quickly to protect patients from risk if you have good reason to believe that your colleague may not be fit to practise M Avoid abusing your position as a doctor N Work with colleagues in the ways that best serve patients' interests Choose the single most appropriate principle from the list of options.41. A 23-year-old Indian woman requests a female doctor to perform a pelvic exam. 42. A 55-year-old man who is being admitted for a total knee replacement states that he is a Jehovah's witness and therefore refuses any blood products. 43. A 16-year-old girl informs you that she may be pragnant, and her parents are unaware. 44. A 28-year-old man is offered the choice of whether he would like to receive interferon injections for multiple sclerosis 45. A -65- year-old diabetic sees you for a neurological option and asks if you would renew his insulin prescription as a favour 46. There is a lunch-time teaching session, but a patient on the ward is experiencing chest pain. 47. Your patient reports feeling of depression. You seek a psychiatric opinion. 48. You asked a patient to undress to examine the abdomen. You remember to cover the patient's groin 49. You are asked to examine a patient at his bedside. You remember to pull the curtain around the bed to ensure privacy. 50. You see an overworked colleague struggle with his duties. You intervene and offer assistance 10. Theme Diagnosis of abdominal pain Options: A Acute appendicitis B Diverticular disease C Abdominal aortic aneurysm D Perforated peptic ulcer E Crohn's disease F Ulcerative colitis G Acute pancreatitis H Chronic active hepatitis I Acute viral hepatitis J Pseudo-obstruction K Acute cholecystitis L Acute diverticulitisChoose the single most likely diagnosis from the above list of options.51. An 80-year old lady with stable angina presents with massive abdominal distension 10 days following a total hip replacement. 52. A 55-year-old man presents with left-sided colicky iliac fossa pain, change in bowel habits and, rectal bleeding. A thickened mass is palpated in the region of the sigmoid colon. His full blood count is normal. 53. A 50-year-old man presents with severe epigastric pain radiating to the back. He is noted to have some bruising in the flanks54. A 40 year old lady presents with anorexia, abdominal pain, and increasing jaundice. She is asthmatic and takes methyldopa for hypertension. 55. A 25-year-old man presents with colicky periumbilical pain, which shifts th the right iliac fossa, fever, and loss of appetite. 11. Theme Diagnosis of Joint pain Options: A Gout B Pseudogout C Osteoarthritis D Infective arthritis E Psoriatric arthropathy F Ankylosing spondylitis G Juvenile chronic arthritis H Rheumatoid artritis I Reiter's syndrome J Felty's syndrome K Osteogenesis imperfecta Choose the single most likely diagnosis from the list of options above. 56. A 30 year old homosexual male is found to have a markedly swollen knee of one month duration and a temperature of 38 C. He says the knee has only recently become painful and also admitted to losing weight. He had no other complains apart from a 2-month history of cough, which he attributed to his heavy smoking. 57. A 36-year-old lady presents with swollen knee joint. She says they feel stiff, especially in the morning. On examination, she is found to be pyrexic with ulcers on both her legs and marked hyperpigmentation. Hb 9g/dl, WBC, platelets are decreased and with a serum albumin of 20g/L. 58. A 45 year old obese man presented with a painful and swollen ankle. The symptoms had started gradually in the previous month. Joint fluid aspiration was done and positively birefringent crystals were found. The patient drinks alcohol but doesn't smoke. 59. A 15-year-old boy complains of temporal-mandibular joint pain for three months. On examination, he has micrognathia, loss neck extension and unequal lengths of the lower limbs. He is rheumatoid factor negative. 12. Theme Diagnosis of Arrhythmias Options: A Atrial flutter B Atrial fibrillation C Ventricular tachycardia D Ventricular extrasystoles (ectopics) E Heart block F Sinus tachycardia G Sinus bradycardia H Supraventricular tachycardia I Blood loss J Wenckebach's phenomenon Choose the single most likely diagnosis from the list of options above.60. A 65-year-old man, post myocardial infarction is found to have a regular pulse, with a rate of 50 beats/min. 61. A 50-year-old man with palpitations is treated with a carotid massage. He now has no other complaints62. Following a road traffic accident, a 25 year old man is brought to the A&E. He is found to have a pulse rate of 120 beats/min and Blood pressure of 90/50 mmHg 63. A 65-year old man is found to have an irregular pulse, with a rate of 110 beats/min 64. A 23 year old footballer is examined by his GP and found to have a pulse rate of 50 beats/min. He is otherwise well. 65. A 50 year old man, post myucardial infarction in ITU is found to have a pounding heart beat which then disappeared spontaneously. The patient remains conscious. 13. Theme Immediate investigations of the unconscious patient. Options: A Arterial blood gases B Blood carbondioxide C Blood culture D Blood glucose E Blood paracetamol F Blood salicyclate level G Chest x-ray H Computed tomography scan I Electrocardiogram (ECG) J Lumbar puncture K Serum osmolality L Skull x-ray M TemperatureChoose the single most discriminating investigation from the above list of options. 66. A 28 year old woman is brought to the A&E unconscious (GCS=7) On initial examination, her pulse rate is 110 beats/min, Sa02 95% on air, BM(glucose) 4.5. A purpuric rash is noted on both her arms. 67. A 47 year old female is brought to the A&E unconscious (GCS=7). On initial examination, her pulse rate is 110 beats/min. Sa02 100% on air, BM(glucose) 4.3. 68. A 45 year old man is brought to the A&E unconscious (GCS=7). On initial examination his pulse rate is 90beats/min, BM(glucose)5.3, Sa02 97% on air. He smells of alcohol and there are no external signs of injury. 69. A 45 year old woman is brought to the A&E unconsious (GCS=7). On initial examination, her pulse rate is 80 beats/min, she is sweating and has a SaO2 of 98% on air. 70. A 45-year-old woman is brought to the A&E unconscious (GCS=7). On examination her pulse rate is 110 beats/min, temperature normal, BM(glucose) 4.6. She was found with an empty bottle of antidepressant (Dothiepin) 13. Theme Management of heart failure. Options: A ACE inhibitors B Digoxin C Aortic valve replacement D Thiazide diuretics E Heart transplant F IV furosemide G Nitrates (oral) H Nitrates (IV) I Thiamine (IV) J Pericardiocentesis Choose the single most appropriate management strategy from the list of options above. 71. A 15-year-old boy is examined and found to have severe congestive cardiac failure. 72. A 40-year-old man with cardiac failure is found to have a palpable thrill in the right second intercostal space, which radiates to the neck. 73. A 50-year-old man with suspected heart failure has a blood pressure of 90/60 mmHg and pulse rate of 110 beats/min. Chest x-ray ahows globular heart. 74. A 50-year-old suspected alcoholic has biventricular cardiac failure. He has deranged liver function tests. 75. A 60-year-old female in cardiac failure wants long term treatment for her conditions. Echocardiography shows global hypokinesia and loss of contractility 14. Theme Investigation and management of scrotal swellings Options: A Ultrasound scan of scrotum B Surgical exploration C Reassurance D Aspiration E Mid stream urine for microscopy and/or culture F Biopsy G Analgesia H Droppler ultrasound of scrotum I Computed tomography (CT) scan of scrotum J Clotting studies K Urethral swab L Antibiotics M Urine cytology N HerniotomyChoose the single most appropriate management strategy from the above list of options.76. A 12-year-old boy presents with a tender, red swollen scrotum. He has already been given analgeasia by his general practitioner. 77. A young boy with acute lymphoblastic leukaemia is given chemotherapy. He now develops a right testicular swelling. 78. A 70-year-old man comes in to have his right testicular hydrocele aspirated. A ady after the procedure, he develops a scrotal swelling on the right. 79. A baby girl born at 28 weeks gestation is found to have a right swollen scrotum 80. A 16-year-old boy presents with unilateral scrotal swelling. On examination a bluish, soft and non-tender compressible mass is found. The child is otherwise well. 81. A 6-year-old boy presents with bilateral scrotal swelling. He had suffered from mumps two week prior to presentation82. A 13-year-old boy presents with bilateral pain and testicular swelling, after cycling 15. Options: A Angiography B Bronchoscopy C Colle's fracture D Dental treatment of a cardiac patient E Dislocated shoulder F Emergency appendicectomy G Heart valve replacement H Sigmoid colectomy I Splenectomy J Thyroidectomy Choose the single most likely indication from the above list of options. 83. One dose of metronidazole at induction of anaesthesia.84. Long term oral penicillin and immunisation against pneumococcal infection. 85. Clear fluids by mouth and two sachets of sodium picosulphate on the day before the operation plus broad-spectrum intravenous antibiotics at induction 86. Clear fluids by mouth and two sachets of sodium picosulphate on the day before the operation plus broad-spectrum intravenous antibiotics at induction 87. A 3g sachet of amoxycillin one hour before the procedure. 16. Theme: Causes of headache Options: A Meningitis B Migraine headache C Cluster headache D Tension headache E Subarachnoid haemorrhage F Sinusitis G Benign intracranial hypertension H Cervical spondylosis I Giant-cell arteritis J Otitis madia K-Transient ischaemic attackChoose the single most likely cause from the above list of options. 88. A 35-year-old obese female presents with headache and diplopia. On examination, she has papilloedema. She is alert with no focal symptoms and signs.)89. A 65-year-old female presents with bitemporal headache, unilateral blurry vision, and pain on combing her hair. Her ESR is elevated 90. A 10-year-old boy presents with fever, headache, left eye pain, and swelling. He described his vision as blurry. He has recently recovered from a cold. 91. A 45-year-old man presents with severe pain around his right eye, with eyelid swelling lasting 20 minutes. He has had several attacks during the past weeks. The attacks are worse at night. 92. A 25-year-old female presents with episodes of unilateral throbbing headache, nausea, and vormiting. She states that it is aggravated by light. The episodes seem to occur prior to her menstruation. Options: A Ruptured bronchus B Ruptured aorta C Ruptured oesophagus D Tension pneumothorax E Cardiac tamponade F Blood transfusion G Oral analgesia H Morphine(IV) I Strap chest J Ruptured sleep K ImmobilisationChoose the most likely diagnosis/management strategy from the list of options above.93. A 17-year-old boy with multiple fractures is taken for open reduction. His pulse rate = 120 beats/min BP=100/60 mmHg. 94. A 47-year-old man is involved in a road traffic accident. Chest x-ray shows atransverse fracture of the sternum. He is otherwise well. 95. A 47-year-old man is involved in a road traffic accident. Chest x-ray shows atransverse fracture of the sternum. He is otherwise well. 96. A 35-year-old man is brought to the A&E with a haemothorax. Bilateral chest drainage is done, but his condition fails to improve. 97. A 12-year-old boy was involved in a fight in which he received a kick to his chest. He presents the following day with chest pain and is found to have 3 fractured ribs. 98. A 45-year-old man who has a seat belt is involved in a high-speed car accident. On x-ray, a 'widened' mediastinum is seen

Answers to mock test 1. Mental state examination2. ESR3. Carotid arteriography4. Lumbar Puncture5. CT Scan Brain6. Cyclical vomiting7. Pyloric stenosis8. Overfeeding9. Duodenal atresia10. GE Reflux11. Carbamezepine with 5mg/day Folate12. INSULIN13. Methyldopa14. Paracetamol15. Aspirin16. Paracetamol17. Uveitis18. Central Retinal Artery Occlusion19. Cerebral embolism20. Retinal detachment21. Temporal arteritis22. Pneumocystis carinii23. Chlamydia psittaci24. Legionella pneumonia25. Streptococcus pneumonia26. Mycoplasma tuberculosis27. Malabsorption28. Hyperthyroidism29. Depression30. Depression31. Staphylococcus aureus32. Staphylococcus aureus33. Neisseria meningitides34. Staphylococcus aureus35. Chlamydia trachomatis36. Insulin37. Aldosterone38. Parathyroid hormone39. Thyroxine40. Cortisol41. listen to patients and respect their views42. Make sure that your personal beliefs do not prejudice your patient's care43. Respect and protect confidential information44. Respect the right of patients to be fully involved in decisions about their care45. Recognise the limits of your professional competence46. Make the care of your patient your first concern47. Work with colleagues in the ways that best serve patient's interests48. Respect patients dignity and privacy49. Respect patients dignity and privacy50. Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practice51. Pseudo-obstruction52. Diverticular disease53. Acute pancreatitis54. Chronic active hepatitis55. Acute appendicitis56. Infective arthritis57. Felty's syndrome58. Pseudogout59. Juvenile chronic arthritis60. Sinus bradycardia61. Supraventricular tachycardia62. Blood loss63. Atrial fibrillation64. Sinus bradycardia65. Ventricular extrasystoles66. Lumbar puncture67. Blood culture68. CT SCAN69. Blood Glucose70. ECG71. Digoxin72. Aortic valve replacement73. Pericardiocentesis74. IV Thiamine75. Heart transplant76. Mid stream urine for microscopy and/or culture77. Biopsy78. Surgical exploration79. Herniotomy80. Aspiration81. Reassurance82. Surgical exploration83. Emergency Appendicectomy84. Splenectomy85. Sigmoid colectomy86. Heart valve replacement87. Dental treatment of a cardiac patient88. Benign intracranial hypertension89. Giant cell arteritis90. Sinusitis91. Cluster headache92. Migraine headache93. Blood transfusion94. Oral analgesia95. Immobilization96. Ruptured aorta97. Oral analgesia98. Ruptured aorta

another experience

2004-11-13T02:10:00.000-08:00

Well here are the stations.... i reached royal free by 8:45 am went in at 9 ... all of us were assembled in a room,breifed by showing a VDO and then we all stood in a line like school children,marched to the clinical skills lab, since my surname starts wth an A there fore my first station was Sation no 1.............. here goes

1) I/V CANNULATION FOR DRUG ADMINISTRATION: i was shaking while redaing my task for 1 minute....bt then things went well i was already in non sterile gloves, the venlflon was different b/c the stopper was in a separate pack so it took me a while finding it i just cudnt understand what was waht... did everything then got blodd first time i put in the cannula, then threw the needle in the sharps bin but the stopper wudnt go in i tried but it cudnt and the maniquin was bleeding like hell, i asked the examiner and he tried but he also cudnt put it in so he told suppose its done take it out, so i didand threw it in the sharps bin cleaned up and thanked the examenr....... dunno what i will get

2)ASTHAMATIC PT BEING DISCHARGED, ADVICE ABOUT MEDICATION: when i went in did the grips then saw one ventolin,one beclotide inhalers and prednisolone tablets...when i picked up the ventolin inhaler to tell the pt about he started smiling...i thot i did something wrong... bt continued told him about it... it had 2 puffs written on it but not the dose , so told him take it as prescribed by ur dr, then the same wth beclotide and the predinisolone tabs when i told him 6 tabs(as was written in the staion) he said" u must be joking Dr , that doesnt seem right", i told it is and its written in ur notes.. after finishing i noticed a discharge paper under the medication and realized the dose wud have been mentioned on them so i told the examiner ideally i shud have read the thing b4 talking to the pt.

3)EXAMINE THE UPPER ABDOMEN, PT WITH RUQ PAIN: Grips, asked permission, straight forward started wth inspection from the foot end, murphy's sign was positive palpated the spleen, wanted to do rebound tnde3rness but examiner stopped me, asked my diagnosis Acute Cholecystitis, 2 D/D Acute Pancreatits and Hepatits, then asked for the liver span i said i didnt percuss for it and i cannot palpate the lower edge b/c he is teneder, thank you u can sit down.

4)BP: very co-operative old patient although it mentioned diastolic method but i still did palpatory,sitting and standing.i just cudnt hear the systolic heart sound so said im not sure wud like a senior to help me out.

5)ALCOHOL DEPENDANCE-RAISED MCV TALK TO HER ABOUT ALCOHOL: Well the pt was nice, expressionless examiner, went wth the cage history she worked at a wine bar at 5 whine glasses and then 3-4 strong stuff at night, take one glass forst thing in the morning to steady her nerves.... then she said she wanted to quit but didnt know how.... so told her abot alchol anonymous, associations, website and certain medications which my seniors will talk to you about then thanked her and time was up

6)DYSKARIOSIS( CIN)IS THE RESULT OF A CERVICAL SMERA TALK TO THE PATIENT ABOUT COLPOSCOPY AND BIOPSY: she was a great actor, really looked anxious told her what her reults were and that IT IS NOT CANCER, bt my consultant will do this procedure explained whta it is and told herr to bring extra tmpons and come wth some who drives u back the same day, will have no pain but discomfort might have bleeding and discharge for a few days and abstain fron sex for a week, she was worried she can get pregnant again,it shudnt be a problem, then she was worried about the treatment told i cant tell her lets the results of the biopsy come out then my seniors will decide about it, told her about website and gave her leaflets, thanked her and sked if she had any other query.

7)CHILD CPR, 6 YEAR OLD WHO IS CYANOSED: examiner was a very nice lady, although she didnt say much and asked me to sit down after i activated the system in 1 minute then we chatted for the rest of the time

REST drank 2 glasses of water and tried to hear what the station was, it was otoscopy

9)OTOSCOPY-EXAMINE THE EAR OF THIS PATIENT: went in told the examiner i wud do all that grips theing if this was a real pt, explain the procedure and take a verbal consent, the did inspection, looked for mastodoits and tragul tenderness, the before opening the otoscope put a disposible plastic cover he asked why we use it ,i told hin so that we dont tranfer infection from one pt to the other he said GOOD (wow), the did the otscopy cudnt understand whats in it but the only thing i cud get was hyperaemiv tympanic membrane. asked me to do rinnies and webers test and how to interpret that. when i told him normail is air conduction is better than bone conduction and this is called Rinnies Positive.... he said good again. this was the best staion i had

10)PHONE CONVERSATION- MOM WORRIED ABOUT 18 MONTH OLD CHILD WITH DIARRHOEA FOR 24 HRS SHE ALS HAS IT, CHILD WAS ADMITTED 6 MONTHS BACK ALSO FOR DIARRHOEA AND WAS GIVEN I/V FLUIDS.: Picked up the phone asked about consistency, type and amount... had only passed 3 stoold in small amount were watery... no fever.... ruled our dehydration, ruled out meningitis(jst to be on the safe side), when i asked her about the soft spot she didnt know what it is and it took me 1 minute to explain what it was , then she said it was hard,of course it was the baby is 18 months, told her not to worry contact GP and give ORS in water, if signs of dehydration occur the come to A&E immediatley. after putting the phone down jst remeber that i didnt ask for blood, mucus and flushing stools....but then time was over. Thank you dr.

11)BREAKING BAD NEWS-HUSBAND DIGNOSED WITH MESOTHELIOMA COUNSEL WIFE.LIFE EXPPECTANCY 6 MONTHS well started of by telling reports are out and im afraid they are not good, she said whats wrong then i said it CANCER. she looked down and i had my hands on my tissue just ready bt she didnt cry(DAMN)she said how he is jst a builder , i told her about its association wthasbestos and all,the she said we wre planning so much then she looked down again, then i said do u need anny body else , wud u like a glass of water(u see we were both engrossed in high class acting, i was about to shed tears for her)she said no thank you. but when will he die dr, i said we can only presume rt now and its different for every pt its very subjective but we were planning to go to austrailia in 6 months, i told look if his health allows and he can walk about then u can surely go but he will be facing hard time now and we will try to make his life as comfortable as possible.... she wanted to take him home i said f9 as soon as my seniors discharge hima nd then u can take care of him at home wth associations helping u, McMillan nurses, meals on wheels... gave her associations address and phone and websites and all.

12)GCS AND NEUROLOGICAL EXAMINATION IN AN UNCONCIUOS PATIENT: did the gcs wrong first got 7 bt examiner told me to do it againa dn the it was 9, started wth neuro exam thot of doing lower limbs only bt then started wth upper limb did tone then reflexes nothing else... the the same wth lower limb, examiner asked me not to do babinski's...the he said anything else.. i was quite for a moment and the said pupil relex he said to it quick, direct and consensual in bothe the eyes, asked if teh pupils were dilated i said didnt know.

13)PRIMARY SURVEY( INITIAL ASSESMENT); man this was a bad station... well from the beging examiner kept telling me no time dr be quick when i put the cervical collar back and wanted to send him for BP,ECG, Cannula etc he said u dont have time dr be quick we do that later, went thro the ches and abdomen, while auscultating for gut sounds the examiner told me no bleeding or bruising in the perineum, i took of my steth cause i cudnt hear him , then i said i wud like to expose the pelvis and genitilia, he said what did i jst tell u dr no BLEEDING OR BRUISING in the perineum be quick... so i skipped the pelvis , but he cudnt raise both his legs and lower limbs are f9 so i told the examiner there cud be a pelvic fracture and then he said"Well u didnt look at the Pelvis, Did U"... time ran out and so did my courage to go on. bt by the grace of god i forgot about the station and conitinued

14)FEMALE WITH PALPITATIONS, TAKE HISTORY AND ADVISE well she was sitting on the edge of the seat, kept on moving througfh out the history, ruled out hypertyroidism, heart disease, MI,rhematic fever, or medication no + family history, but she used to dring 12 cups of coffee every day for them past many years and she at been working a stress full job but job has been stressfull for the past 20 years. so said that i think coffee is the cause bt i wud still like my seniors to have a look and rule out if u have anyother mediacl condition. she said coffee is her life line she cannot quit i told not abstain from coffe but to jst decrease the quntity of cups and see if palpitations are controlled, slowly decrease cpffee intake.

15)MALE CATHETRIZATION: it was assumed u are gloved i went in the examiner wanted to shake my hands but i didnt b/c i was gloved, i dont remeber if i said i wanted a chaperone or want to ensure privacy or if it was already written in the station that these things are done.... os god help me... started cleaning there were 5-6 cotton swabs only cleaned it put drapping sheet ,then put in lignocain, then catheter attached the urine bag,forgot to take the drapping sheet off.

16)PILOT-OBESE PT HIS WISDOM TOOTH WAS NOT EXTRACTED B/C THEY DIDNT WANT TO GIVE HIM ANESTHESIA. TAKE HISTORY AND ADVICE. well there was really a fat bloke there, didnt understand what to ask so just asked about hypothyroidism, cushings(if on any medication) family hx fathr was also really bigno past illness or co morbids + no family history, he asked he wanted to loose weight , i told him we will get u in touch wth te dietecian she will tell how control ur diet and we will also ask u to do and excercise program.... he came close tome and asked well dr i heard there are some medicines which help u, i said im not sure but will ask my seniors to help u out but remeber the natural way is the best way. thanked him. chatted wth the eaminer on how pilot station are choosen to come in the exam.

AND THT WAS IT FINISHED, but as i left the area i felt i forgot one thing or the other in all the stations, and my primary survey was a disaster.... so please pray for me guys i hope i pass, please pray for me.

MRCP 1

2004-09-21T04:34:00.000-07:00

Basic Sciences Pastest

1.A 76-year-old patient is admitted to the acute admission unit with septic shock. Pulse is 106 and BP 90/40 mmHg. Urinary catheterisation produces 75 ml of concentrated urine. Which of the following principles applies to the choice of an appropriate intravenous fluid for resuscitation?
A Certain intravenous solutions, which would be hypo-osmolar, have dextrose added to ensure they are iso-osmolar <>Hartmann’s solution contains sodium, potassium, chloride, calcium and lactate. It is not possible to store bicarbonate in solution with calcium; instead lactate is used which is metabolised to bicarbonate by the liver. A major disadvantage of crystalloid solutions is that relatively large volumes have to be infused to restore an intravascular volume deficit (the 3:1 replacement rule). The normal colloid oncotic pressure is 25 mmHg. The routine use of albumin is not indicated in resuscitation and may be harmful in some groups of patients.
2.Which of the following is associated with hereditary angio-oedema?
A Low levels of C1 inhibitor <>This disorder is due to low levels of the C1 inhibitor of the complement system and is one of the commonest complement deficiencies. Low levels of the C1 inhibitor allow C1 to act on C4 and C2. This in turn produces kinin-like products that cause the angio-oedema. Low levels of C4 are found during an attack. C3 levels are normal. Membrane-attack complex deficiencies leave patients particularly susceptible to neisserial infection. In a few cases C1 inhibitor levels are normal but defective. The skin lesions are not itchy, unlike allergic urticaria. Painful intestinal involvement can occur. Triggers include stress, infection and menstruation. Danazol may be used in treatment. Acquired C1 inhibitor deficiency may be associated with lymphoproliferative disease and infection.
Which of the following takes place during inspiration?
A The diaphragm drops by 10 cm during normal breathing
B A negative pressure of 1–3 mmHg is created <>During normal breathing the diaphragm may drop 1 cm, creating a pressure drop of 1–3 mmHg and an air intake of 500 ml. During strenuous exercise the diaphragm may drop 10 cm, producing a pressure drop of 100 mmHg and an air intake of 3000 ml. During expiration the rib cage recoils, the abdominal muscles contract and the accessory muscles relax.
Which of the following is not typically a cause of hypercalcaemia?
A Hyperparathyroidism
B Hypothyroidism <>Two of commonest causes of hypercalcaemia in the western world are primary hyperparathyroidism and malignancy. In primary hyperparathyroidism there is excess production of parathyroid hormone (PTH); although usually from a benign adenoma, this sometimes results from hyperplasia of the parathyroid glands and, in rare cases, a carcinoma. Thyrotoxicosis can cause hypercalcaemia as well as osteoporosis. The milk–alkali syndrome can occur in patients who suffer from dyspepsia and drink milk and alkali-containing antacids, which may reduce the renal excretion of calcium. Around one-fifth of those with sarcoid have increased calcium levels. Various mechanisms cause raised hypercalcaemia of malignancy.
Which of the following is the initial treatment of choice for the hyponatraemia in the majority of patients with the syndrome of inappropriate [secretion of] ADH (antidiuretic hormone, vasopressin)?
A Intravenous infusion of hypertonic saline
B Intravenous infusion of isotonic saline
C Oral demeclocycline
D Oral frusemide
E Restriction of water intake <>The t-test does not require data to be exactly normally distributed in order for it to be applied, the test being robust. The approximately symmetrical distribution will be adequate to ensure that the test is valid. Option A would not be chosen because a non-parametric test would give less power. Option B is incorrect as the data is not paired and this also applies to Option C. Option E would be a valid analysis to undertake but it would have the major disadvantage that its power would be far less than Option D.
A 38-year-old woman with type-1 diabetes reports at her regular clinic review that she has been experiencing frequent episodes of hypoglycaemia during the previous 6 months, despite reducing her overall dose of insulin by almost 50%. Her Hb A1c in the clinic is 5.6%, having been 6.8 % a year previously. She also says she has lost some weight and that her periods are becoming scanty and irregular, and wonders if she is having an early menopause. Gonadotrophin concentrations are in the normal early follicular range. What is the most likely cause of the reduction in her insulin requirement?
A Addison’s disease
B Hypopituitarism Correct answer
C Increased exercise
D Spontaneous regression of diabetes
E Weight loss

>>Type-1 diabetes is irreversible. Exercise, weight loss and decreased production of counter-regulatory hormones can all result in decreased insulin requirements. The latter can occur with Addison’s disease (resulting in a decreased secretion of cortisol) and hypopituitarism (decreased secretion of growth hormone and cortisol). Autoimmune Addison’s disease occurs more frequently in patients with type-1 diabetes than in non-diabetic subjects, as does autoimmune ovarian failure. However, the evidence of decreasing ovarian function without an increase in gonadotrophin concentrations makes hypopituitarism the most likely cause here. The lower limit of detection in many gonadotrophin assays includes the lower limit of the normal follicular range, so that frankly low concentrations, such as may occur in hypopituitarism, may not be distinguishable from low–normal values.
In a cross-over trial comparing two drugs to treat children suffering from enuresis, the number of dry nights was recorded in each of two 28-day periods of treatment. Which of the following strategies for analysis is the most appropriate?
A Construct a contingency table with the number of dry nights forming the columns, and the treatments forming the rows, and apply a Chi-squared test
B For each child, identify the treatment producing the greater number of dry nights, and apply an appropriate test of significance to test the null hypothesis that the proportion of ‘preferences’ for each treatment is the same
C Apply a paired t-test if the differences in the number of dry nights are approximately symmetrical, otherwise apply a Wilcoxon Signed Rank Sum Test Correct answer
D Apply a non-parametric test to compare the distribution of the number of dry nights for the two treatments
E Calculate the correlation coefficient between the number of dry nights on each treatment, and test for a significant correlation

>>In a cross-over trial it would be sensible to allow for the possibility of an order effect in the data, but none of the options allows for this. The answers are therefore not perfect for the question posed but the best answer is C. If there is no order effect, this would be a good method of analysing the data. Option A ignores the pairing and would therefore be a poor method of analysis. Option B is a reasonable approach but, because it is compressing the data, would be less efficient than option C. Option D ignores the pairing and should not be chosen for that reason. Option E would not answer the relevant question as correlation between the responses to the two treatments is of no interest here.
A 16-year-old girl presents with primary amenorrhoea. On examination, her height is 145 cm and weight 45 kg. What is the most likely diagnosis?
A Crohn’s disease
B Cystic fibrosis
C McCune–Albright syndrome
D Iron deficiency anaemia
E Turner’s syndrome Correct answer
>>Crohn’s disease and cystic fibrosis are associated with slowing of growth but not primary amenorrhoea. In polyostotic fibrous dysplasia (McCune–Albright syndrome), precocious puberty causes premature closure of the epiphyses and short stature but menstruation is not affected. Chromosomal analysis will establish the diagnosis of true Turner’s syndrome (45 XO). Mosaic forms of Turner’s syndrome may not have these features.
In a randomised controlled trial of treatments for heart failure in which the primary end-point is death, which is the most important of the following?
A To have an independent Data Monitoring and Ethics Committee to review the data as it accumulates <>Option B is a classical mistake to make where the data is tested repeatedly without taking into account the multiple testing of the data that is implied. Option C gets round this problem, but to suggest that the trial would only be stopped on this basis is inappropriate as other factors, such as intolerable adverse effects of treatment, would also need to be considered, as would results from other newly published studies. It is considered good practice for the Trial Steering Committee to be unaware of the results as the trial progresses, and therefore D is wrong. Option E sounds plausible but is an unusual restriction and is indeed undesirable. Many patients may die within the first 3 months of treatment and therefore this option would be inappropriate.
Only IgE-mediated allergic reactions can be formally tested by skinprick testing. Adverse reactions to which of the following substances can be tested in this manner?
A Morphine
B Radiocontrast media
C Scombrotoxins Your answer
D Colloid plasma expanders
E Latex Correct answer
Latex can induce allergy through IgE bound to mast cells. All the others induce histamine release via their direct effects on mast cells, except for scombroid fish poisoning which is related to the heat-stable toxin in tuna/mackerel/mahi mahi, etc.
A 54-year-old Afro–Caribbean man consults his family doctor because of the chest discomfort he first noticed 4 days ago after a session digging in his garden, but which he says is now resolving. He has previously been well, but is being treated with a statin for hypercholesterolaemia, and a thiazide and a calcium-channel antagonist for hypertension. Serum creatine kinase activity is 512 U/l (normal up to 150 U/l); serum troponin-T concentration is normal. What is the most likely explanation for the elevated creatine kinase?
A Myocardial infarction
B Racial variant Correct answer
C Recent exercise
D Statin treatment
E Thiazide treatment

>>Myocardial infarction is excluded by the normal troponin concentration, and the creatine kinase would have been expected to have fallen to normal 4 days after an MI, as would an elevated CK due to exercise. Thiazides are not reported as increasing CK activity, but moderate increases occur in some patients on statin treatment. Black people frequently have CK activities up to three times the normal levels seen in Caucasians.
A young man is admitted to the emergency room unconscious and hyperventilating. His breath smells of alcohol. Which of the following findings would suggest a specific cause for his condition?
A Blood glucose concentration of 12 mmol/l
B Ketonuria
C Metabolic acidosis
D Serum calcium concentration (corrected) 1.62 mmol/l Correct answer
E Serum sodium concentration 131 mol/l

>>Patients with diabetic ketoacidosis sometimes have only moderately elevated blood glucose concentrations, but mild hyperglycaemia can occur in any stressed patient. Ketosis can occur in DKA, alcoholic ketoacidosis and with prolonged fasting. Many drugs can cause metabolic acidosis. Mild hyponatraemia is also a non-specific finding. Severe hypocalcaemia, particularly in this clinical context, is highly suggestive of poisoning with ethylene glycol. This is oxidised to various organic acids, including oxalic acid, which combines with calcium to produce insoluble calcium oxalate: oxalate crystals are often present in the urine. The only other poison that causes hypocalcaemia is hydrofluoric acid.
In a randomised, controlled, parallel group trial to compare two treatments for lowering blood pressure, comparison of the mean ages at the time of randomisation shows an average difference of 3 years between the two treatments. A t-test shows that the difference is highly significant (P <>>Imbalance in a baseline variable will inevitably sometimes occur in well-conducted, randomised controlled trials. Under such circumstances the approach described in option B is a sensible one to choose. Option A is plausible, but good practice would not allow what might be an important difference in baseline variables to be simply ignored. The imbalance may be a nuisance in interpretation but it certainly does not invalidate the trial, so C is incorrect. Option D sounds like ‘being wise after the event’ and adopting this approach would ensure balance by age. However, it may not be of great importance in relation to response to treatment, and therefore it would not always be sensible to stratify by age as suggested in D. Option E is undoubtedly the worst of the five answers.
Immunological investigations in a patient with renal disease are important in the diagnostic work-up, which of the following statements is correct?
A Henoch–Schonlein purpura is associated with IgG in the mesangium
B SLE is typically associated with sparse deposits of IgG and complement in the glomeruli
C C3 nephritic factor is associated with mesangiocapillary glomerulonephritis type I
D Minimal-change glomerulonephritis is associated with hypocomplementaemia
E Antiglomerular basement-membrane antibodies are associated with Goodpasture’s disease Correct answer

>>Minimal-change glomerulonephritis is not associated with complement activation. C3 nephritic factor is associated with mesangiocapillary glomerulonephritis type 2, not type 1. SLE nephritis is an immune complex problem; hence deposits of IgG and complement are prolific. Henoch–Schonlein purpura is typically associated with IgA in the mesangium. Hence immunological examination of both a blood and renal biopsy will help to define the underlying process.
If the prevalence of Rett syndrome is 1 per 10,000 and a genetic screening test applied in infancy has a sensitivity of 90% and a specificity of 99.99%, then
A The positive predictive value is less than 50% and the negative predictive value is greater than 99.99% Correct answer
B The positive predictive value is less than 50% and the negative predictive value is less than 99.99%
C The positive predictive value is greater than 50% and the negative predictive value is greater than 99.99%
D The positive predictive value is greater than 50% and the negative predictive value is less than 99.99%
E The positive predictive value and the negative predictive value cannot both be calculated

>>.To see this, tabulate the expected numbers in a population, which, to make the numbers easier, we will take as 1,000,000:
Test positive Test negative Total
Rett 90 10 100
Non-Rett ~100 ~999,800 999,900
Total 190 999,810 1,000,000
We form the column of totals first from the prevalence of Rett syndrome, and then use the sensitivity applied to the first row and specificity applied to the second row to obtain the tabulated numbers (we actually expect 99.99+ tests in the non-Rett population). The positive predictive value is therefore 90/190 (<> 99.99%).
In patients with systemic lupus erythematosus which of the following statements is correct?
A Only 50% of patients have anti-dsDNA antibodies Correct answer
B Patients with anti-dsDNA antibodies are less likely to have renal disease
C 10% of patients can be antinuclear antibody-negative
D Ro positivity is associated with Raynaud’s disease
E Griseofulvin should be avoided in patients with SLE

>>Only 50% of patients with SLE will have anti-double stranded DNA antibodies at some point during their illness. Patients with anti-dsDNA antibodies are more likely to have renal disease. Less than 5% of patients with lupus are ANA-negative. Drugs that induce lupus do not need to be avoided in the idiopathic type of lupus.
In Duchenne’s muscular dystrophy, which of the following statements applies?
A Serum creatinine kinase is elevated in 30% of cases
B Exon deletion or duplication in the dystrophin gene occurs in 60% of patients Correct answer
C Prenatal diagnosis involves analysis of restriction fragment length polymorphisms (RFLPs)
D The genetic defect affects mainly skeletal muscle
E 50% of male fetuses are affected

>>Duchenne’s muscular dystrophy is an X-linked recessive disorder in which affected boys develop progressive weakness of the limb-girdle muscles. Most muscular tissues, including cardiac tissues, are involved. An abnormally high creatinine kinase level is found in all these patients. Since 60% of patients have an exon deletion or duplication in the dystrophin gene, this can be tested directly without the need for analysis of RFLPs.
Which of the following statements is true about the matrix metalloproteinases, which play a major role in pathological processes, including rheumatoid arthritis, periodontitis, vascular disease as well as tumour invasion and metastasis?
A All are controlled by specific tissue stimulators of the metalloproteinases
B All contain an iron atom
C Each is involved in the synthesis of at least one component of the extracellular matrix, basement membrane proteins and bioactive mediators
D All are secreted as a proenzyme, which in each case is activated by cleavage of defined glycoprotein sequences
E All share sequence homologies Correct answer

>>The matrix metalloproteinases (MMPs) are a family of 24 proteolytic enzymes that share common characteristics. All are inhibited by specific tissue inhibitors of the metalloproteinases (TIMPS). All contain a zinc atom. Each is involved in the degradation of at least one component of the extracellular matrix and of basement membrane proteins and bioactive mediators. All are secreted as a proenzyme, which in each case is activated by cleavage of defined peptide sequences. All are involved in normal remodelling processes, such as embryonic development, postpartum involution of the uterus, bone and growth-plate remodelling, ovulation and wound healing. A range of MMP inhibitors is currently under development for the treatment of solid tumours.
Which one of the following groups is arranged as nominal scale data?
A Hot/cold Correct answer
B Hot/hotter/hottest
C 81–90/91–100/101–110 °C
D 271–280/281–290/291–300 kelvin
E None

>>Data always comes in one of the four scales of measurement:
Nominal Data is divided into qualitative groups, such as hot/cold, with no implication of order.
Ordinal Data is placed in an order (hot/hotter/hottest), although the absolute levels are unknown and no conclusion can be made about the size of the interval.
Interval Data is placed in an order; and the exact value of the measurement is given, usually in measured quantities (81–90/91–100/101–110 °C). However, the ratios of the values are not absolute, eg 100 °C is not twice as cold as 50 °C because 0°C does not imply a complete absence of heat. In other words, an absolute zero is not defined.
Ratio Here, there is an absolute zero and the ratio between the values is meaningful, eg 271–280/281–290/291–300 kelvin.
Nitric oxide is derived from
A Cyclic GMP
B Endothelium-derived relaxing factor
C GTN
D l-Arginine Correct answer
E Nitrous oxide
>>Nitric oxide (NO), which used to be known as ‘endothelium-derived relaxing factor’, is a local cellular messenger. It is derived from l-arginine (an amino acid) by nitric oxide synthase. Its actions increase the levels of intracellular cGMP (cyclic guanosine monophosphate), which has effects depending on which cell it is acting upon. These include modulation of vascular tone (hence the therapeutic use of glyceryl trinitrate, a synthetic compound) and memory. NO has also been implicated in septic shock, adult respiratory distress syndrome (ARDS) and inflammation. Nitrous oxide, also known as ‘laughing gas’, is often used in obstetrics and trauma for pain relief.
In a parallel group trial, which of the following claims for randomisation is the most appropriate?
A It guarantees that all variables are well balanced across the treatment groups prior to treatment
B Any differences in response found between the treatment groups must be due to the treatments rather than chance
C It prevents systematic differences between the treatment groups at baseline Correct answer
D It results in a simplified analysis of the trial
E It ensures that an equal number of patients receive each treatment

>>The purpose of randomisation is to prevent systematic differences between treatment groups, so option C is the correct answer. Although we will often get good balance across the treatment groups, unfortunately randomisation does not guarantee this, so option A is incorrect. Even if randomisation is undertaken in a trial, this does not guarantee that differences in response found between the treatment groups must be due to the treatment. We may still be unlucky and find a false-positive result, so B is incorrect. We may hope that randomisation leads to a simplified analysis of the trial compared to any other option but it is not the primary objective, so D would not be the answer of choice. Finally, randomisation can be used to ensure an equal number of patients receive each treatment; however, in some trials we will deliberately wish to have a randomisation ratio such as 3:2, so randomisation does not imply equal numbers on each treatment and E is incorrect.
Granuloma is seen in which of the following conditions?
A Syphilis Correct answer
B Typhoid
C Cholera
D Amoebiasis
E Shigellosis
>>A granuloma is a collection of macrophages: giant cells as a nidus of chronic inflammation. The centre may necrotise to form caseation, classically in tuberculosis. There is a long list of infective and immunological conditions where a granulomatous response may be seen, including tertiary syphilis, sarcoidosis and Crohn’s and Wegener’s granulomatosis.
A group of 400 male asthmatics attending a hospital out-patient clinic had their forced vital capacity (FVC) assessed at the start and end of a 5-year period. The mean annual reduction in FVC was 60 ml and the standard error of the mean annual reduction in FVC was 4 ml. Which of the following statements is the most appropriate?
A 95% of patients had reductions in FVC between 260 ml and 340 ml over a 5-year period
B Almost all patients had a lower FVC at the end of the study, compared with their level at the beginning
C 95% confidence limits for the mean annual reduction in FVC are approximately 52 ml and 68 ml Correct answer
D 95% confidence limits for the mean annual reduction in FVC are approximately 56 ml and 64 ml
E Calculation of confidence intervals requires that the data are normally distributed

>>The 95% confidence limits will be the mean plus or minus two standard errors as given in this answer. Option D is incorrect because the limits given correspond to the mean plus or minus one standard error. The statement E is not a necessary condition for the calculation of confidence intervals. Option A relates to the distribution of individuals within the population, whereas the standard error has been calculated for a parameter that is the mean. Option B looks convincing, but back-calculating from the standard error of the mean to the standard deviation within the population shows that the standard deviation is 80 ml, and therefore an appreciable proportion of patients will have increased their FVC.
The results of a statistical study were expressed as follows: R = +0.67, p <> 0.05. Which of the following options applies?
A A negative R-value indicates an inverse association
B R stands for standard coefficient
C A positive R-value indicates association Correct answer
D This study indicates there is a strong association
E p <> 0.05 is significant

>>R stands for correlation coefficient. A negative R-value indicates a lack of association. In this study, the R-value is positive, indicating association. However, this association does not seem to be statistically significant as the p-value is greater than 0.05. P-values <>>She has congenital adrenal hyperplasia (CAH). During the first months of life, adrenal metabolism changes to the adult pattern. The most common type of CAH is 21-hydroxylase deficiency (autosomal-recessive) affecting around 1 in 10,000 Caucasians. As a result, cortisol levels are low and therefore trigger ACTH release and adrenal hyperplasia. Salt-losing crises can occur with very low cortisol levels. Progesterone cannot be metabolised as the enzyme deficiency increases the manufacture of 17a-hydroxyprogesterone and androgens, which then cause virilisation/precocious sexual development. Late-onset disease can be due to partial enzyme deficiency. 11b-Hydroxylase deficiencies can lead to hypertension.
In a randomised controlled trial to compare two drugs (A and B) for the secondary prevention of myocardial infarction, in the first year there were five deaths in 100 patients treated with drug A and ten deaths in 100 patients treated with drug B. The results are reported as X2 = 1.15, P = 0.28. Which of the following statements is most appropriate?
A There is a 28% probability that the death rate with drug A is lower at one year than the death rate with drug B
B There is a 28% probability that the null hypothesis of equal drug effects is true Your answer
C The null hypothesis of equal drug effects has not been disproved Correct answer
D The two drugs may be considered equivalent
E A larger trial would have given statistically significant results

>>The basis of tests of significance is such that statements expressed as a 28% probability of something happening are simply not within the scope of the methods, so A and B are incorrect. The fact that the differences are non-significant does not imply equivalence between the drugs, and therefore option D is incorrect. A larger trial may or may not have given statistically significant results and therefore option E is also incorrect.
Which of the following definitely excludes antibody deficiency?
A Normal serum immunoglobulins
B Good IgG antibody responses to immunisations Correct answer
C The presence of existing antibody responses to past infections
D Normal IgG subclasses
E Normal peripheral blood lymphocyte subpopulations

>>Normal immunoglobulins, including subclasses, do not exclude antibody deficiency. Hence in patients with a good history of recurrent (proven) bacterial infections, responses to Haemophilus influenzae, Pneumococcus spp. and tetanus toxoid should all be assessed, as should postimmunisation responses if required. Antibodies to past infections and haemagglutinins can be helpful in assessing a patient.
A 42-year-old man consulted his family doctor because of a 2–3 month history of lethargy and feeling generally unwell. The history was otherwise unremarkable. His urine tested positive for glucose, and a random venous plasma glucose concentration was 8.3 mmol/l. The family doctor arranged an oral glucose tolerance test: glucose concentration at baseline 5.6 mmol/l, 9.3 mmol/l at 120 minutes. Which of the following statements is correct?
A Diabetes could have been diagnosed on the random glucose value alone
B The combination of the random glucose and glycosuria are diagnostic of diabetes
C The result of the OGTT confirms a diagnosis of diabetes
D The result of the OGTT indicates impaired glucose tolerance Correct answer
E The result of the OGTT indicates that he is at increased risk of microvascular disease

>>The combination of a fasting venous plasma glucose concentration of <>>Remembering that around two-thirds of values lie within 1 SD of the mean, one-third will therefore lie outside 1 SD, and half of these (one-sixth) will be less than 1 SD below the mean (ie < 6 =" 15"> 86 mmHg. For A, around 53 (two-thirds) will be between 68 mmHg and 80 mmHg. Although on average half will be below the mean and half above, it is unlikely that exactly 40 will be so, making B incorrect. As 90 mmHg is 2.67 SDs above the mean, values > 90 mmHg will be relatively uncommon (around 0.5%). It is therefore quite possible that nobody will have a DBP > 90 mmHg, but there is still an appreciable chance that someone in the group will be > 90 mmHg, so D is less appropriate than C. Option E corresponds to one-third being above 80 mmHg, whereas the correct fraction is one-sixth.
The gene for which of the following disorders is correctly paired with the stated chromosome?
A Duchenne muscular dystrophy: X chromosome Correct answer
B Haemophilia A: Chromosome 11
C Variegate porphyria: X chromosome
D Cystic fibrosis: Chromosome 1
E Hereditray heamochromatosis : Chromosome 7

>>The gene for variegate porphyria (the PPOX gene) has been located to chromosome 1. It has an autosomal-dominant pattern of inheritance. Hereditary haemochromatosis is an autosomal-dominant disorder with variable penetrance, and results from a mutation of the HFE gene located on chromosome 6. This encodes a transport protein found in the duodenum. 77.5% of patients have two copies of the C282Y mutation, 4% have one copy, while 6.5% have one or two copies of a different mutation, H63D. Cystic fibrosis is caused by a mutation of the CFTR gene, which is normally found on chromosome 7. Haemophilia, Duchenne and Becker forms of muscular dystrophy are all X-linked recessive conditions.
A 24-year-old, unconscious man is admitted to A&E. No history is available. The results of arterial blood gas analysis are: [H+] 80 nmol/l (pH 7.1), p(CO2) 7.0 kPa, p(O2) 8.2 kPa, [HCO3–] 17.1 mmol/l. These results indicate which one of the following acid–base disturbances?
A Metabolic acidosis with respiratory compensation
B Mixed metabolic and respiratory acidosis Correct answer
C Respiratory acidosis
D Respiratory acidosis with metabolic alkalosis
E Uncompensated metabolic acidosis

>>The high hydrogen-ion concentration (low pH) indicates acidosis. The elevated p(CO2) indicates a respiratory component; in compensated metabolic acidosis, p(CO2) is reduced; in an uncompensated metabolic acidosis (a very unusual situation, since the respiratory response to a metabolic acidosis is usually a rapid one), it would be normal. The hydrogen-ion concentration is too low to be accounted for by a respiratory acidosis alone: there must therefore be a metabolic acidosis in addition (as the low bicarbonate concentration also indicates).
Which of the following adverse food reactions is mediated by IgE-dependent mechanisms and hence can be ascertained by skinprick testing?
A Monosodium glutamate in Chinese food
B Scombroid fish poisoning
C Sulphites on prepacked salads .
D Salicylate-induced urticaria
E Kiwi fruit Correct answer
>>Kiwi fruit is a member of the latex-associated foods and adverse reactions to this fruit are mediated by IgE. All the others are examples of food intolerance, so that detailed history-taking is essential to making the correct diagnosis. Scombroid-fish poisoning causes immediate diffuse redness, diarrhoea and vomiting following the consumption of fish such as tuna, mackerel and mahi mahi. Monosodium glutamate causes abdominal bloating and vomiting – the so-called ‘Chinese restaurant syndrome’. Sulphites on prepacked salads causing asthma is called the ‘Salad-bar syndrome’.
A patient on enteral nutrition develops constipation. What could explain the underlying clinical physiology?
A Hyperosmolar feed
B Bacterial contamination
C Low feed temperature
D Inadequate fluid replacement Correct answer
E Reduced intestinal absorptive capacity

>>Hyperosmolar feed, bacterial contamination, low feed temperature, too rapid or irregular administration, lactose intolerance, reduced intestinal absorptive capacity can all explain diarrhoea.
In relation to the nutritional physiology of patients, which of the following would represent appropriate nitrogen requirements (g N/kg per day) and calorie requirements (kcal/kg per day)?
A Reduced food intake: nitrogen requirement 0.3 g N/kg per day, calorie requirement 35 kcal/kg per day
B Moderate injury: nitrogen requirement 0.15 g N/kg per day, calorie requirement 25 kcal/kg per day
C Moderate sepsis: nitrogen requirement 0.3 g N/kg per day, calorie requirement 15 kcal/kg per day
D Severe injury: nitrogen requirement 0.3 g N/kg per day, calorie requirement 35 kcal/kg per day Correct answer
E Severe sepsis: nitrogen requirement 0.2 g N/kg/day, calorie requirement 15 kcal/kg/day

>>Usual ranges for:
reduced food intake: nitrogen requirement 0.15–0.2 g N/kg per day calorie requirement 25–30 kcal/kg per day
moderate injury/sepsis: nitrogen requirement 0.2–0.3 g N/kg per day calorie requirement 30–35 kcal/kg per day
severe injury/sepsis: nitrogen requirement 0.3–0.35 g N/kg per day calorie requirement 35–40 kcal/kg per day

Which of the following statements pertains to a resting neurone?
A It is uncharged
B It is depolarised .
C It is negatively charged externally
D It is positively charged externally Correct answer
E It is unable to conduct impulses

>>In its resting state, the inside of a neurone is rich in chloride ions and a lesser amount of potassium ions. The outside of the neurone is rich in sodium ions. The net result is that the neurone is polarised, ie negative on the inside and positive on the outside. This is called the ‘resting potential’. When stimulated, the permeability of the neurone changes, allowing sodium from the extracellular fluid to flood into the neurone and potassium to move out. This depolarisation causes the generation of an action potential.
Which of the following is a feature of the early asthma response?
A Multiple myeloma
B Eosinophils are particularly important
C Attraction of phagocytes is predominant
D Mast-cell degranulation is seen in response to the B-cell production of IgE Correct answer
E Usually resolves spontaneously after 6–8 hours

>>The early asthmatic response (EAR) is an episode of bronchoconstriction peaking 10–20 minutes after exposure to the provoking agent and resolving spontaneously after 1–2 hours. The first inflammatory step is the appearance of an antigen (eg pollen) in the lung that stimulates an immune response. Initial exposure to the antigen stimulates B cells to produce IgE antibodies, which attack antigens and become attached to the surface of mast cells by high-affinity FceRI receptors. When present, antigens will attach themselves to antibodies, forming antigen–antibody complexes on the surface of the mast cell. These complexes cause the mast cell to degranulate, releasing a range of inflammatory mediators, including histamine, cytokines, prostaglandins and leukotrienes with bronchoconstrictor effects. The antigen is also presented to T cells via epithelial cells and macrophages. The late asthmatic response (LAR) occurs between 3 and 5 hours after an initial response to an allergen. Eosinophils are particularly important and attraction of phagocytes is predominant. It usually resolves spontaneously after 6–8 hours.
Which of the following statements is most consistent with the Crigler–Najjar syndrome?
A Autosomally inherited, severe conjugated hyperbilirubinaemia
B Autosomally inherited, severe unconjugated hyperbilirubinaemia Correct answer
C Autosomal-recessive, mild unconjugated hyperbilirubinaemia
D X-linked, severe conjugated hyperbilirubinaemia
E X-linked, severe unconjugated hyperbilirubinaemia

>>This is a rare syndrome that can either be autosomal-recessive (type 1) or autosomal-dominant (type 2). Severe unconjugated hyperbilirubinaemia results from an absence (type 1) or decrease (type 2) of glucuronyl transferase. As, in effect, it is a prehepatic problem, liver histology is normal. Only those with the type-2 disease can survive to adulthood. There is no available treatment except liver transplantation.
Which of the following diseases is correctly matched to the immunodeficiency?
A Ataxia–telangiectasia – absent NBT (neutrophil nitroblue tetrazolium) reduction
B Bruton’s disease – impaired phagocytosis
C Chronic granulomatous disease (CGD) – hypogammaglobulinaemia
D Chédiak–Higashi – reduced IgA levels
E DiGeorge syndrome – absent T-cell function Correct answer

>>Ataxia–telangiectasia presents in childhood with cerebellar ataxia, impaired cell-mediated immunity and productions of antibody. It is an autosomal-recessive condition. Bruton’s disease is an X-linked hypogammaglobulinaemia due to absent mature B cells. Recurrent pyogenic infections occur once maternal antibody levels fall. CGD (chronic granulomatous disease) is caused by a failure of intracellular killing (no respiratory burst). There are various types. Screening is by the nitroblue tetrazolium (NBT) test. Chédiak–Higashi is a disorder affecting neutrophil chemotaxis and is inherited as an autosomal-recessive. DiGeorge syndrome consists of hypoparathyroidism (hypocalcaemic convulsions in newborns), cardiac anomalies, abnormal facies and absent T-cell function (impaired cell-mediated immunity). In this condition the third and fourth branchial arches, and therefore the thymus and parathyroid, fail to develop. As a result, cardiac outflow tract anomalies occur (interrupted aortic arch, truncus arteriosus and teratology of Fallot).
In patients with severe oral and genital ulceration, therapy with agents having clinically significant anti-TNF-a activity can be beneficial, which of the following is used for this indication?
A Cyclophosphamide
B Dapsone
C Methotrexate
D Pentoxifylline .
E Thalidomide Correct answer
>>Both methotrexate and pentoxifylline have weak anti-TNF activity, but thalidomide has clinically significant effects. The problems with thalidomide therapy include a potentially irreversible neuropathy, teratogenesis, drowsiness, constipation and weight gain. Thalidomide and its derivatives are also used in the management of leprosy, HIV, myeloma and melanoma.
Which of the following statements is true concerning immunity to bacteria?
A Antibodies to secreted bacterial products play no protective role
B Bacteria opsonised by antibodies and complement are more effectively phagocytosed than those opsonised by antibodies alone Correct answer
C Humoral rather than cellular immunity is predominant in protection against all types of bacteria Your answer
D Phagocytes cannot engulf bacteria in the absence of antibodies
E Endotoxin induces shock mainly through the activation of T cells

>>Antibodies such as those to cholera, diphtheria and tetanus toxin can play a major role in protective immunity in these infections. Cellular immunity is essential in protection against intracellular bacteria, eg mycobacteria. Phagocytes interact directly but weakly with bacteria, or strongly if they are complement-opsonised. Endotoxin activates macrophages by binding to CD14.
Which of the following statements is true in the epidemiology of a1-antitrypsin deficiency?
A Smoking is not a major risk factor
B There is an increased incidence of hyper-reactive airways in adult life
C It is an autosomal dominant disorder with low penetrance
D The disorder is an indication for liver transplantation in a child Correct answer
E Most cases present during the neonatal period

>>a1-antitrypsin deficiency is an autosomal recessive disorder. Emphysema results from the uncontrolled action of the proteases on the lung tissue. There is accelerated age-related decline in FEV1, which is exacerbated by smoking. Smoking is the greatest risk factor for the development of panacinar emphysema in adults with a1-antitrypsin deficiency. In non-smokers this may never develop or occur later in life. Jaundice and cirrhosis occur because the hepatocytes are unable to secrete the protein. Progressive liver damage in an infant in the neonatal period is an indication for liver transplant.
Which of the following neoplasms responds to specific tyrosine kinase inhibitors?
A Gastrointestinal stromal tumours Correct answer
B Acute myeloid leukaemia
C Chronic lymphoid leukaemia
D Acute lymphoid leukaemia
E Multiple myeloma

>>Specific tyrosine kinase inhibitors were developed after it was recognised that the Philadelphia chromosome (translocation 9:22) was associated with bcl–abl tyrosine kinase overexpression. STI571, later known as iniminitab mesylate (Gleevec), was therefore designed to treat chronic myeloid leukaemia, but it was also found to be effective in gastrointestinal stromal tumours (GIST) – previously known as leiomyosarcoma.
A patient undergoes respiratory function tests. Which of the following are normal readings for a 70-kg man?
A Peak expiratory flow of 376 l/min
B Total lung capacity of 3.5 litres
C Functional residual capacity of 3.5 litres
D Tidal volume of 250 ml .
E Inspiratory reserve volume of 2 litres Correct answer
>>Normal readings for such a patient would be:
peak expiratory flow 520–700 l/min
total lung capacity 5–6.5 litres
functional residual capacity 2–3 litres
tidal volume 500–700 ml
A 25-year-old patient presents with anaemia and jaundice. A blood film shows polychromasia, bite cells, reticulocytosis and Heinz bodies. What is the most probable diagnosis?
A Haemolytic uraemic syndrome
B Autoimmune haemolytic anaemia
C Glucose-6-phosphate dehydrogenase deficiency Correct answer
D Hereditary spherocytosis
E Paroxysmal nocturnal haemoglobinuria

>>The blood picture, caused by haemolysis, is consistent with G6PD deficiency. Glucose-6-phosphate dehydrogenase deficiency is the commonest red cell enzyme defect. Inheritance is sex-linked and the disease is common in Africa, the Mediterranean and the Middle and Far East. The majority are asymptomatic until there is an oxidative crisis precipitated by drugs (eg primaquin, sulfonamides, ciprofloxacin, quinidine, probenecid), fava bean ingestion or illness. Reticulocytosis is common and indicates active erythropoiesis. The presence of Heinz bodies is characteristic of G6PD deficiency. In hereditary spherocytosis, the red blood cells are usually spherical in shape. This is an autosomal dominant red cell membrane defect where the RBCs are osmotically fragile. Splenomegaly is common. Blood film shows spherocytes. Hereditary elliptocytosis has the same clinical features as hereditary spherocytosis with the presence of elliptocytic red cells on the blood film.
Which is the most characteristic feature of an ogive?
A The first percentile has 99% of the observations in the ordered set below it
B The first decile is equal to the 90th percentile and has 10% of the observations in the ordered set below it
C The mean is equal to the 50th percentile
D The range is the difference between the 1st and 99th percentiles
E The interquartile range lies between the first and third quartiles Correct answer

>>The first percentile has 99% of the observations in the ordered set above it, not below it. The first decile is equal to the 10th percentile (not the 90th percentile), although it does have 10% of the ordered observations below it. The median is equal to the 50th percentile. The range is the difference between the largest and smallest observations.
Which of the following is true concerning complement activation?
A IgG and IgE are the main antibody classes involved in classical pathway activation
B C1q binds to the Fab regions of antigen-complexed IgG antibodies
C The alternative, but not the classical C3, convertase enzyme involves C3b Correct answer
D Elevated serum C3dg is a good marker of complement activation
E The membrane-attack complex involves polymerisation of C7

>>IgG and IgM are the main antibody classes that activate the classical pathway. C1q binds to the Fc rather than the Fab fragment that binds antibody (Fc, crystallisable fragment; Fab antigen-binding fragment). It is C9 that polymerises in the membrane-attack complex. Clotting of blood can lead to complement activation, and hence complement conversion products must be measured on plasma and not serum.
Genomic imprinting is seen in which of the following conditions?
A Neurofibromatosis
B Prader–Willi syndrome Correct answer
C Huntington’s chorea .
D Hurler’s syndrome
E Marfan’s syndrome

>>The term 'genomic imprinting' refers to the dependence of phenotype on whether the gene deletion is inherited from the mother or father. Neurofibromatosis is an autosomal-dominant disorder with 95% penetrance. The gene is located on chromosome 17. Prader–Willi syndrome is a result of a paternal deletion of a gene on chromosome 15; Angelman syndrome results if the same gene is deleted from the maternal side. In both syndromes, 3–5% of cases are a result of uniparental disomy (both chromosomes from the same parent). Huntington’s chorea is a result of a triplet codon repeat. There is a 35–90 repeat segment of CAG nucleotides on chromosome 4p 16.3. It is rare in childhood, presenting later in adult life with dementia, chorea and rigidity. Hurler’s syndrome (type I) is an autosomal-recessive disorder occurring due to a defect in chromosome 4p. Marfan’s syndrome is an autosomal-dominant disorder affecting chromosome 15q.
In an adult patient with cirrhosis, which of the following findings is the most reliably diagnostic of hereditary haemochromatosis as the cause?
A Liver biopsy Correct answer
B Serum ferritin concentration
C Serum iron concentration
D Serum total iron-binding capacity
E Transferrin saturation

>>In hereditary haemochromatosis (HH), the excess iron is primarily found in parenchymal cells, whereas with secondary iron overload, accumulation tends to be in Kupffer cells. Liver biopsy can demonstrate this, allows assessment of liver damage and is of prognostic value. Serum ferritin concentrations are almost always markedly elevated, but elevations can occur in any inflammatory condition (including other liver diseases). Serum iron concentration is normal in approximately 25% of patients with HH and can be elevated in healthy individuals or people with secondary iron overload. Total iron-binding capacity reflects the transferrin concentration, which is usually normal in haemochromatosis. Moreover, although transferrin saturation is typically high in HH, it can also be increased in other iron overload conditions and in liver disease. Molecular genetic analysis and demonstration of homozygosity for the C282Y mutation, or of compound heterozygosity for C282Y and H63D, can detect asymptomatic individuals at risk of developing clinical haemochromatosis.
The clinical significance of antinuclear antibodies (ANAs) is associated with which of the following situations/conditions?
A Ankylosing spondylitis
B Primary antiphospholipid antibody syndrome (APL)
C Chronic fatigue syndrome
D Women over 40 years of age Correct answer
E Myasthenia gravis

>>Younger women often have low-titred ANAs, and the titres increase with age. ANA positivity with APL suggests secondary APL, ie in association with a connective tissue disease. ANAs are not typically associated with the other options.
Antibodies to which of the following are most frequently present in the serum of patients with type-1 diabetes at diagnosis?
A Cocksackievirus
B Glucagon
C Insulin
D Islet cells Correct answer
E Rubella

>>Islet-cell antibodies (usually directed against glutamic acid decarboxylase, GAD) are present in the serum of the majority of patients with type-1 diabetes at the time of diagnosis, although the titre usually declines rapidly thereafter, and they persist in only 10–15% of patients. Antibodies to insulin may develop during treatment, although less frequently now than when animal insulin preparations were widely used. The presence of antibodies to cocksackievirus in children developing type-1 diabetes has been suggested to imply a causal relationship between infection and the development of diabetes. There is an association between congenital rubella and type-1 diabetes, but the basis of the association is unclear.
The oxygen–haemoglobin dissociation curve is shifted to the left by which of the following factors?
A Rise in pH Correct answer
B Rise in 2,3-DPG (2,3-diphosphoglycerate)
C Rise in plasma temperature
D Rise in blood CO2 content
E Fall in plasma bicarbonate concentration
>>All the above shift the dissociation curve to the right, with the exception of a rise in pH.
Which one of the following features in an adult patient presenting with porphyrinuria would most suggest lead poisoning rather than acute intermittent porphyria as a cause?
A Abdominal pain
B Anaemia Correct answer
C Foot drop
D Hypertension
E Seizures

>>Abdominal pain, motor neuropathies and seizures can be features of both lead poisoning and acute intermittent porphyria (although encephalopathy is more common in lead poisoning in children than in adults). Autonomic neuropathy in acute intermittent porphyria can cause hypertension but this is not a feature of lead poisoning. Anaemia occurs only in lead poisoning: it is due to inhibition of ferrocheletase (the activity of this enzyme is normal in AIP) and a decrease in red cell lifespan. This is also a result of enzyme inhibition (pyrimidine 5'-nucleotidase) leading to the accumulation of pyrimidine nucleotides in red cells, which in turn reduces the stability of the cell membrane (and is seen on a blood film as basophilic stippling).
Concerning monoclonal free light chains, which of the following statements is true?
A They are usually found in association with Waldenstrom’s macroglobulinaemia
B They are commonly found in the serum of myeloma patients with normal renal function
C They are found in isolation in 20–30% of cases of myeloma Correct answer
D They are not associated with IgE- or IgD-secreting myelomas
E They are rarely associated with renal tubular damage

>>Light chains are toxic to renal tubules. They are uncommon in association with Waldenstrom’s macroglobulinaemia, and not found in the serum of patients with myeloma because they are cleared rapidly in those with normal renal function. All patients with light chains in their serum without IgG, IgM or IgA paraproteins should be checked for IgE and IgD. Both blood and urine must be sent to the laboratory in the search for paraproteins, since 20–30% of cases will be missed if only blood is sent. But the diagnostic clue is often the finding of low levels of the non-paraprotein classes of immunoglobulin as the malignant clone in myeloma suppresses the normal production of immunoglobulins.
A trial was conducted to look for coagulation abnormalities in patients with tuberculosis. Serum fibrinogen levels were taken as a criterion to diagnose coagulation abnormalities. The subjects were divided into three groups – those without tuberculosis, those with pulmonary tuberculosis and those with disseminated fulminant tuberculosis. The mean fibrinogen level was calculated for each group of patients and compared for significant difference between the groups. Which of the following tests would be ideal for this measurement?
A Chi-square test
B Student’s t test
C Regression analysis
D ANOVA Correct answer
E Pearson test

>>The appropriateness of a test to examine a statistical problem depends upon the scale of measurement (nominal, ordinal, interval, ratio) and the type of question being asked. The Chi-square test is used for nominal data to find out if there is a significant difference between the proportion of observations falling in each group – for example, comparing the proportion of children developing measles between a group receiving a new measles vaccine and a group not given the vaccine. The Student’s t test is used to compare one or two means, whereas ANOVA (analysis of variance) is used for more than two means, as in this scenario. The Pearson test is used to assess the correlation (strength of association) between two variables, whereas regression techniques are used to predict the value of one variable based on the other.
In a positively skewed distribution:
A Mean increases, median remains the same, mode increases
B Mean remains the same, median remains the same, mode increases
C Mean increases, median increases, mode increases
D Mean remains the same, median remains the same, mode remains the same
E Mean increases, median increases, mode remains the same Correct answer

>>A positively skewed distribution would have a relatively small number of very large values. Imagine a normal distribution to which a few observations with large values are added. This would produce a positive skew. The mean is the measure of the central tendency that is most sensitive to extreme scores. The mode is uninfluenced by the small number of extreme values as it only indicates the value that occurs most frequently in the distribution. The opposite events would occur in a negatively skewed distribution.
Which of the following is true concerning immunity to viruses?
A IgA can offer protection at mucosal surfaces Correct answer
B Cytotoxic T cells are activated before natural killer cells during the course of infection
C Viruses stimulate the non-immune cells that they infect to produce interferon-g
D Non-enveloped viruses are susceptible to damage by complement
E Influenza virus can avoid antibody recognition by mutational changes in its nucleocapsid proteins

>>Natural killer cells are activated faster than cytotoxic T cells. Infected non-immune cells produce interferon-a and - b, whereas interferon-g is produced by T cells. Influenza virus mutates its surface neuraminidase and haemagglutinin to avoid antibody recognition. Enveloped viruses are susceptible to complement attack.
In a patient with chronic hyponatraemia (sodium concentration 112 mmol/l), which of the following findings would most suggest a diagnosis of the syndrome of inappropriate [secretion of] antidiuretic hormone (SIADH)?
A Normal cortisol response to ACTH
B Plasma albumin concentration 28 g/l
C Plasma osmolality 248 mOsmol/kg
D Urinary osmolality 350 mOsmol/kg Correct answer
E Urinary sodium concentration <>>The most significant finding is that the urine is concentrated relative to plasma. This is inappropriate, in that a low plasma osmolality should suppress ADH secretion and lead to the formation of a maximally dilute urine. The low plasma osmolality reflects the hyponatraemia, since sodium is the principal determinant of extracellular fluid osmolality. A low urine sodium excretion would suggest extrarenal sodium depletion as a cause of hyponatraemia. Addison’s disease, another cause of chronic hyponatraemia, is excluded by the cortisol response to ACTH, as it should be before SIADH is diagnosed. The low plasma albumin concentration could just reflect dilution of the plasma by the excess water, but it could also suggest chronic liver disease, another cause of chronic hyponatraemia.
In the design of a randomised controlled trial, to what does the ‘power of the study’ refer?
A The size of treatment difference that the trial can be expected to detect
B The probability of rejecting the null hypothesis that the treatments have the same effect
C The chance that a clinically significant difference will be observed
D The probability of a type-2 error
E The probability of a statistically significant treatment effect if the true treatment difference is at a prespecified level Correct answer

>>It uses a specified size of treatment difference, but A is not correct. Option B would become correct if it was extended to say ‘when there is a prespecified treatment difference’, but is incorrect as it stands. C looks plausible, but the difference being specified in the power calculation might not correspond to a clinically significant difference (the difference might be set higher) so C is incorrect. Power is often defined as 1 minus the probability of a type-2 error, so D is wrong.
Regarding the clinical physiology of the adrenal gland in Cushing’s disease, which of the following pertains?
A The zona glomerulosa of the cortex is predominantly responsible for sex steroid production
B The zona fasciculata is predominantly controlled by ACTH and is often hypertrophied Correct answer
C The zona reticularis is predominantly responsible for mineralocorticoid production
D About 15% of glucocorticoid production takes place in the adrenal medulla
E The zona fasciculata is primarily responsible for mineralocorticoid production

>>The zona glomerulosa of the cortex is predominantly responsible for mineralocorticoid production, the zona fasciculata for glucocorticoid production and the zona reticularis for sex corticoid production. The adrenal medulla originates from the neural crest and hence there is almost complete demarcation of function, with the medulla being responsible for the production of catecholamine-related compounds.
Which of the following statements is most appropriate regarding the relative risk of a disease?
A Always lies between zero and one
B Is always positive Correct answer
C Measures the increased (or decreased) risk of the factor when the individual has the disease
D Measures the risk of the disease in the population
E Takes the value zero when the risk is equally likely in those exposed and unexposed to the factor of interest

>>The relative risk is always positive, but it can take a value that is greater than one. It measures the increased (> 1) or decreased (< 1) risk of the disease if the factor is present compared to when it is absent and is the ratio of two risks in the population. The relative risk takes the value one (unity) when the risks in those with and without the factor are equal.

trauma survey

2004-09-21T04:26:00.000-07:00

A Step-by-Step Procedure for Trauma Resuscitation

1. Notification by Prehospital Personnel: The receiving emergency department should be informed about:Airway patencyPulse and respirationsLevel of consciousnessImmobilizationMechanism of injury and blood loss at the sceneAnatomic sites of apparent injury
2. Preparation for Receiving the Trauma VictimAssign tasks to team membersCheck and prepare vital equipmentSummon surgical consultant and other team members not present

>>>3. Primary Survey: The most immediately lethal injuries are taken care of as they are identified.AirwayClear airway: chin lift, suction, finger sweepProtect airwayDepressed level of consciousness of bleeding, tracheal intubation without neck movementSurgical airwayBreathingVentilate with 100% oxygenCheck thorax and neckDeviated tracheaTension pneumothorax (intervention—needle decompression)Chest wounds and chest wall motionSucking chest wound (intervention—occlusive dressing)Neck and chest crepitationMultiple broken ribsFractured sternumPneumothoraxListen for breath soundsCorrect tracheal tube placement?Hemopneumothorax?Chest tube(s)—38-FrCollect blood for autotransfusionCirculationApply pressure to sites of external exsanguinationAssure that two large-bore IVs establishedBegin with rapid infusion of warm crystalloid solutionIf arm sites unavailable, insert a large central line or perform a saphenous cutdown at the ankleAssess for blood volume statusRadial and carotid pulse, BP determinationJugular venous fillingQuality of heart tonesBeck triad present?Pericardiocentesis or echocardiogramDecompress tamponadePericardiocentesisThoracotomy with pericardiotomyHypovolemiaAfter 2 L of crystalloid begin blood infusion if still hypovolemic; in children use two 20-mL/kg boluses then 10-mL/kg blood boluses if still unstableNear-term pregnant patient—place roll under right hipDisabilityBrief neurologic examinationPupil size and reactivityLimb movementGlasgow Coma ScaleExposureCompletely disrobe the patientLogroll to inspect backContinuing resuscitationMonitor fluid administrationConsider central line for CVP monitoringUse fetal heart rate as indicator in pregnant womenRecord all events

>>>4. Secondary Survey: A thorough search for injuries is carried out in order to set further priorities.Trauma series x-rays: lateral cervical spine, supine chest, AP pelvisHead-to-toe examination looking and feeling; quickly bring problems under control as they are discoveredScalp wound bleeding controlled with Raney clipsHemotympanum?Facial stability?Epistaxis tamponaded with balloons if severeAvulsed teeth, broken jaw?Penetrating injuries?Abdominal distention and tenderness?Pelvic stability?Perineal laceration/hematoma?Urethral meatus blood?Rectal examination for tone, blood, and prostate positionBimanual vaginal examinationPeripheral pulsesDeformities, open fracturesReflexes, sensationLarge gastric tube ≥18-Fr insertedFoley catheter insertedBlood?Pregnancy testLogroll the patient to feel and see the back, flanks, and buttocks if not already doneSplint unstable fractures/dislocationsAssure that tetanus prophylaxis is givenConsult with surgeon regarding further tests or immediate need for surgery or preferred IV medications; consider:Emergency thoracotomy to provide aortic compression of cross-clampingAortogram or upright chest x-ray to rule out ruptured aortaCystogram if pelvic fracture present or blood in urineIVP or enhanced CT scan of the abdomenFAST or diagnostic peritoneal lavageHead CT scanIV mannitol for neurologic decompensationIV steroids for possible spinal cord injuryIV antibiotics for possible ruptured abdominal viscusIV antibiotics for perineal, vaginal, or rectal lacerationsPelvic arteriogram and embolization for pelvic hemorrhage

Mistakes done by plabber during part II exam

2004-08-18T14:18:00.000-07:00

>>>mine were 1)test tumor-here it was completely my fault1(it was my 1st station)had no idea what it was except i thought it was a teratoma since the pt was 25 yrs old.didnt dare to mention that.said will do tests and get back and ask senior to get back.(expected an 'e' infact)but got a 'd' no. 1 2)thyroid exam-well here he asked me was it hypo/hyperthyroid even after i said that i couldnt appreciate anything but dummy me in that tense atmosphere i said hyper!!! 'd' no. 2 3)tel convers-this was the 1st time i saw an obs chart and couldnt make out the BP readings and didnt know how much of colloids to administer. 'd' no. 3 4)idiopathic epilepsy-here i missed something and i think that its the recovery position that i forgot to mention since she was asked me twice that 'anything else' etc...inspite of telling her all that supervised swimming as soon as i went in i said that i understand that ur daughter has epilepsy and asked what her concerns were and she asked me 4-5 qns of waht r mentioned in books like swimming,cycling,discos,picnics etc... then she asked at the time of attack what to do? i said remove her from danger do not try to hold or stop her fitting even if she bites her tongue coz if a fit has to happen it has to happen. she asked if her daughter can have children later in life and lead a normal life i said im not sure but will fix u up for an appointment with the consultant.(think i should have said that it was normal)anywayz... but there was 1 think she asked me twice i.e. "anything else doc,anything else" i couldnt answer her so i said no. 'd' no. 4 5)this was the biggest shock of them all the mother of diabetic child take history...i took the history and said the dd's were DI,DM(im not sure but i think i did the blunder of saying CF also in the dd's ... 'd' no. 5 6. was able to put 1 suture only properly but the 2nd one was 1/2 way thru then bell rang. 7. venepuncture too the examiner said that the vein is thrombosed so i had to do once more then bell rang so i told all the sharps bin stuff etc... 8. BP. managed only palpatory and sitting. got 'c' in stations 6, 7 & 8 where i could have got a d.

>>Here are my mistakes: 1.Bp: i was very slow..wanted to avoid any tricks like improper cuff, loose connections etc, and spent too much time on rapport etc..so didnt get time to take bp properly..had to leave in a hurry without removing the cuff or thanking patient..( d) 2.Cervical smear: was slow here also..too much time on explaining the procedure.Also fumbled a lot with the gloves..confused regarding correct size.then i thought i had to do it in sterile manner..and spent a lot of time..but it is only a clean procrdure..not sterile..in the end had to run with the speculum still in the vagina (d) 3.Knee examination..lack of practice probably..they had a woman with a skirt up to her knees.and the question said dont undress unnecessarily..and that got me confused.couldnt complte special tests..and had no findings to discuss with examiner.I mumbled something about a mild effusion ..shouldnt have done that..i was just confabulating( d) 4.Ophthalmoscopy;dont know what happened..i got all the findings right..but i think i fumbled a bit with the procedure.especially while switching from one eye to another.and i didnt mention the macula..the examiner asked me abt it..i said no idea..will call senior.(d)

>> made similar mistakes. 1) diabetic child take history from mom. cud not reach the diagnosis, completely misread the q. 2)fundiscopy. examiner asked me macula twice and asked mw to try againn. i said i cant see anythin in macula 3)bp.. was slow left the cuff on and without thanking the pt. 40telephonic conv. forgot abc in post operativce collapse. did not mention about blood transfusion also 5) epilepsy...i sail dont drive for 1 yr. i was wrong here

>> passed plab on my 2nd attemp .I did make several mistakes the first time and took enough care not to repeat them again but this exam is a pure test of nerves.Presence of mind is very very imp, its very imp to be relaxed or appear relaxed.I know its difficult but that is the clue to pass. Here are the mistakes i made and what I experienced on my 2nd attemp.Its very difficult to say everything at a time so will do it in bits 1- pcm poisoning the osce said do not take further mental hist its very imp to ask a few q's before saying what u r going to do to help her u know she's taken pcm tab, so comfirm that how many? how long has it been did she take any more since the time did she take anything else, any other tab with it any alcohol-how much any side effects etc how is she gen feeling its quite imp to say that you will need to admit her to be able to treat her. tell her of compl of pcm tell her about management very imp explain pcm treatment graph tell her ur senior will also come and check her out ask if she would like to tell you why she did it would she like to talk to somebody else, perhaps a senior colleague make sure u tell her the psych. nurse will come down to see her any questions?? very imp to ask pts isf they have any concerns thats the rough idea,you have to elaborate on it.The 1st time i had it I just told her I would admit her and didnt ask her anything and didnt mention about psych. ref or my senior colleague coming to examine her etc, also did not discuss the treatment graph. next time had the station again , so did evrything this is all of my experience , others are more than welcome to add anything to it. 2--i had tel conv about post op pt on the 2nd attemp.I thought i had messed it up but cant tell you guys if i passed that or not since i have passed the exam now here are a few pointers the examiner kept asking me diff diagnosis , i totally messed it up becoz i went blank and told him i am sorry i didnt know.i mumbled a lot.its very imp not to mumble and speak very clearly and louly.the examiner seemed a bit annoyed as well since he said this is a tel conv and i cant hear u, well, i could hradly her him but couldnt tell him that its very imp to say i am sorry i dont know but will find out about this rather than mumble anything else other q's asked were what are you going to do with the pt what do you think has caused dec bp and inc pulse how much fliuds to give etc is it an emergency its also very imp to read the chart and tell all your findings this is where a clin attachment helps 3-acute pain on rt side in a lady.take hist from my experience it seemed very imp to take past med hist .i had a flash of the marking sheet where there were marks given for past med hist. the lady had gall stones hist, always had dull pain on the rt side which was more severe now,she will not tell you about the dull pain she's always had , you have to ask her about all that and the acute pain and if she doesnt say she;s had gall stones have to ask her apart from taking family hist. 4-thyroid examn its quite imp to mention the status after examn becoz the examiner asked me that to say after examining pt if he was hypo/euthy/hyperth if you are not sure about ur findings say ur not sure ,say what u think it is but are not sure so will ask senior colleague. this is very imp becoz then it gives the impression that u r a safe doc, thats what they want. this is gen guidelines for all examinations i gave the exam on 12th aug so if anybody has any queries about that exam , i will be happy to help.i think its a great idea to just put in ur mistakes , tahst how evrybody else will learn to avoid those.this forum has helped me a lot, its time i gave something back, so i will be happy to help with any queries since my memory is still fresh , might forget a few things in a couple of months time about my experience of the exam.good luck to eerybody else, will keep posting a few things now and then.

>>2.one of my friend got pcm station, saying talk to the pt.who has taken pcm.. dont take psych. hst. he told her how they will treat her n all the management.then she told i am being discharged and why r u telling me this.it is possibly post pcm-discharge advice, if this is the case how would u respond. 3.how to manage a child abuse station. ill anser 2&3 quest. in my next post, meanwhile post ur ideas,.

>>did many mistakes in my exam but took Ds where I thought I would pass and passed in the critical stations: 1/ blood pressure: did everything right but the examiner was very very grim and when I told him that the sitting is 145/90 and he said: WHAT? and I repeated because I was dead sure. then I carried on and finished (standing was 120/80). I tought that's a D and the whole station was the starter of my downhill (because I lost my confidence). the irony is that I got an A in this station. I really hated the examiner for this. bottom line: don't lose confidence no matter what. 2/ LA conselling: thought I was fine but I wasn't, answered most of the questions and told him will answer the rest after I check but apparently that wasn't good enough. he had needle phobia and I forgot to tell that we would use nitrous oxide for this. D 3/ diabetic feet exam: didn't finish in time and also didn't check beyond the tibia for vibration although it was lost. D 4/ secondary survey: the case was femur fracture but this one was after the blood pressure station immediatly ,so I didn't bother to examine the chest and the abdomen, crazy huh? all because of the previous station. D 5/ patient with terminal illness, consel his daughter: again I thought I did well but not enough. I answered all the questions and mentioned the pain killing unit and the nurses but I didn't tell her how much he had left when she asked (as everybody told us to say!) and yet I got a D. this one I really don't understand. anyone with an opinion on this one. 6/ spacer: I didn't know that we should demonstrate the actual process to the patient, otherwise I did and tell everything, I only found out when I received the result. D

>>good that u got A in bp but from what i remember bp should be measured to nearest 2 decimal.(sorry if iam wrong) for local anasthesia it is not NO, but emla cream, its a local topical anaesthetic, its is applied and should wait for some time and then proceed with the needle( same if a child has to be put a canula, put some emla cream) you have to tell the advantages between local and general anasthesia.if the patient says can i have some one to talk to during the oper.say yes ull have a named nurse by ur side and u can talk to her. if u still feel nervous u can tell the doc and he will give u sedative , sed. puts u to sleep but it will not compl. knock u off unlike g.an

>>there is a thread by plab27(my plab notes) detailing how to handle various qsts. i apreciate his effort,i have read only two topics in that 1.16 year old wt loss 2. breast examination. i have found some mistakes in those two.i am not trying to be critical, thats why i am posting in this thread, had i done this in that thread he might think i am over scrutinizing take it negatively 1.wt loss in a 16 year. the pt is usually very very unco-operative and very temtermental the r made to act like that cos the real anorexia pts r like that cos they dont know that they have a problem (no insight). so they will never say oh yes doc i am loosing wt. these days and iam really worried.-if she says like that u can happily say that it is not anor.(99%sure) but usually the pt reacts quite sharply and starts scolding u or be rash with u. so when u enter the cubicle intro. urself as a plab candidate (unless given on the card where ur working)tell her that "i understand u mother brought u here and she is worried that u r loosing wt recently" usually reaction from the pt " no iam not loosing wt. my mother is stupid lady" and all the abusives she can think of at that time. then u say u look very angry n upset about ur mother can u tell me why r u so angry with her(english people want u to empathise and reflect their feelings back), then the pt will say she always complains that i am loosing wt. and ia m not eating properly bla.. bla... now u say so what do u think about that ( now the ice is broken) she says i am not thin in fact i think i am very fat(no insight-AN),and what does ur friends think r say about ur wt.evn they r stupid people like my mom. so u say ur fat do u do anything to get rid of that fat, yes i exercise. follow the format in jyothi kulkarni. belive me it is not such an easy case to handle in real life also. some time the pt might say the moment u enter n inttro. urself , htat she wants to go home .. say to her u look to be in a hurry can i ask u why u wanted to go home... if she still answers rudely say that u look very angry cvan u tell me why ur angry.. (pl. note : i donot say that is the 100% best aproach, there r many ways of handling this station. but i know only like this) 2.breast examination. the most important points in any examination is after intro, priv, etc.. 1.exposure 2 . position of the pt for that examination.(for eg.. in resp. st. u have to examin the pt by sitting him on the stool.n the only chair-stools will not b kept in osce-in the room , the examiner put his coat on it. u have to ask for it then he will remove and give u the chair) so in breast exam. while palpating u have to make her lie down compl. or at 45deg. with the hand on the examining side under her head. i have failed in this just coz of that. otherwise i thout i did wonderfully n i was very confident. i did every thing . the point is breast tissue has to be palpated against the chest wall for any masses.arm under the head to palpate the axillary tail.

>>if its the dial one for bp as in guy's , you have to request the examiner to hold it for u in standing position becoz then you will be able to correctly make out what the reading is otherwise its difficult to see, anyway, I could do only sitiing bp and was dpoing standing when the bell rang so I told her I couldnt take the standing reading reading becoz of the 40 sec bell , she said it was alright i had the sitting BP.eVEN IF YOU HAVENT HAD THE TIME TO START MEASURING BP IN STANDING YOU HAVE TO ATLEAST MENTION IT TO THE EXAMINER WHAT YOU WOULD DO.

>> thoght this thresd is over n evrybody forgot. good to c this again.the pilot station of diazepam is very simple.ull be given diazepam amp. or a bottle and ull be asked to make a preparation of particular strength.ull have saline r st.water. as simple as that, a bit of maths n comonsense is need. dont try to think that they cant give such a simple station and worry unnescerly. other recent pilot stations- 1.recent wt gain in a 55 year old lady. 2.do an IM injection in the buttock. suturing ur cleaning method might be wrong,insted of saline it would be better to say the cleaning solution provided for me(dont we usually clean with antiseptic lotion , say betadine). u should start cleaning with one swab with the cleaning solution at the apex(in V cut) and run it along one side on the line of cut,throw it in the clin. waste bin take another swab follow the same on other line. then take another swab and starting on the line of cut paralel to it clean away from the cut never do the other way or bring it back or do with the samw swab on the other line.( imagine V to be two lines meeting at one point)now do the same with other cut line.now put the first knot on the apex, then the next knot on either of the end point,doesnt matter which end. there is one silly trick here,(not every examiner does this) the examiner will as usual give hand shake to u, but u must be consious to tell that u r gowned and glowed and canot shake hands, if he says ok its alright and still offers the hand give the hand shake but tell him ill do it with sterile precautions. as rightly pointed out never touch the needle with hand, and always say i am putting the needle on the sterile drape.- then sharps bin , pain killers, light dressing if nesc. n antibiotics if nesc. as already said.

>>H-P 2 its hard luck that u have got E.we ll never know the exact reasons(unfortunatly) there is one more thjing one should say as the area is naesthetised ill check if it is working by putting pressure with forceps.

>>if the quetion says the area is cleaned draped n anaesthetised, just say as the wound is cleaned ansth. n draped n i am gowned n glowed i am continuing with the procedure. ill ask my asst. to open the suture pack(outer cover, u should not do it) and put ii in the tray.ull respond according to the question. as per ur question,, say ill give some local anaesthetic along the skin tag and infiltrate the area n wait for some time for it to act.most of the times the question is clear n if u know the sequence u can respond accordingly, ur task is to put two sutures in 5mins.i dont think we can anaesthetise before cleaning.

>>I failed the exam in aug in the foll stations 1) catheterisation - gloved and sterile do we have to check identity? I did't with one hand holding the penis ,I had dificulty meking a center hole in the drape ,lost 2 mins there and was abt to introduce ,time was over - E 2) abdomen exam - upper abd only .so did not examine genitalia .also forgot back .No general examination .Got some finding in abd ? liver -D 3) coma - Motor . To pain the actor was withdrawing his hand a little and slightly pronating .so I thought it was decerebrate rigidity ,eas this the mistake?. Did reflexes and pupils .-D 4)Breaking bad news - I had said the life span will definitely decrease! I did not say abt the mc millan nurses -D 5)primary survey - actor with collar . told abt cervial stabilisation .Opened mth ,no obstruction .did not mention abt airways etc .rest as taught .Had pain on pelvic spring test - D. can anyone point out the mistakes so that i can rectify in future. I thought i shall fail in canula .did not get blood . but did checking identity , explaining procedure ,tourniquet release ,sharps bin .The stopper fell down and i told I'll get a new one and close.

>>Hi friends, I took exam 8months back and I did few mistakes rather blunders when I took the first time .BIMANUAL EXAMN-I did everything right, but never realised until the end that I was wearing glove on only one hand. The same in PREXAMN. 'cos this is how we used to do back home. I got D in both. It seems to be veeeery silly and serious blunder isn't it. But this is what plab all about.[/i][/quote]

>>hi all... my mistakes: 1- in bp i did not write the reading. 2- in panic attack i did not ask about depression. 3-in primary survey i did not ask to put canula though i did every thing else. can any one comment on my mistakes...and what the possible score?

>>i think you will not have any problem with the bp station if you have done verything else right. definitely above c. panic attack about depression. thats too ok i feel. above c. but think you should have asked to put canula. definitely c or above. any more comments from others. i stand open to suggestions

>>thank you ... i would like to ask in cervical smear: if the cervix normal and you used the spatula..would that be considered fatal mistake?

>>gud pm. I was fortunate enough to pass the IELTS, PLAB 1 and PLAB 2 this year. It took me 13 months to finish all these 3 exams and currently I got a post as SHO (trauma and orthopedics) which I will be starting February 4, 2004. When I first came here in UK, I was lost. I did think of coming back home but I was glad I did not. My advise to all of you doctors preparing for the plab test is to be very patient, study and practice. I did self- review and did not attend any review classes. The only thing I'm very thankful of is this FORUM. this forum taught me what to expect in the IELTS, PLAB 1 and 2 and that's why I just studied what this forum is talking about. remember that in PLAB 1, almost 80% of what came out during my exams were found in this forum and to be honest I could have failed without this forum. As to the plab 2, majority of what came out was also found in this forum.Here's the breakdown. Pilot station- elderly female patient with rheumatoid arthritis on medications. Px is asking everything about RA. Exam proper: 1. CPR- adult (manequin) 2. Venesection- anemic patient came in with blood request for FBC(you have the option to use a vaccutainer or a syringe) 3. Suturing of a clean wound (at least 3, study anything, antibiotic prophylaxis? tetanus prophylaxis? follow-up, suture removal, dressing) 4. Digital rectal examination of a 60 year-old male with hematuria BPH VS PROSTATIC CA 5. Complete physical examination of a patient with Frozen shoulder, give diagnosis, work-ups to be done, differentials, management 6. Complete chest PE of a very fat 50 year-old female presenting with dyspnea- true patient- CHF? 7. BP measurement- standing and sitting- true patient presenting with dizziness when patient suddenly stands-up 32 year-old fat female 8. Hx taking- 45 year-old female who came in because of hemoptysis give differential diagnosis,(px had history of working in a shipyard for 20 years) 9. Hx taking- depressed unemployed separated 55 year-old male who smashed his car (PE and diagnostics normal), counselling if have time left 10. Counselling- mother asking everything about her child with seizure disorder(watching TV, cycling, swimming, which is better shower or bath tub?, etc..) 11. Management of a pregnant patient with pre-eclamcia(patient wanted to go home, daughter alone in the house, husband working until late night) 12. Patient's mother worried child have meninggitis 13. TELEPHONE conversation with your registrar about an obstructed patient(abdominal pain, vomiting, labs and PE points towards obstruction secondary to an incarcerated inguinal hernia)- u should interpret the lab results, discuss Hx and PE and management I'm so sorry but I cant remember the remaining two stations. If you'll ask me why I remembered these 14 stations? Yes, It's because I've read it here in this FORUM. Don't be depressed, discouraged, or even lose patience because in due time I know you will pass too.Hoping for all the best. Good luck and God Bless. I hope I have given something in return from the FORUM which helped me a lot.

>>hi, i wrote my plab2 on nov 11., i could not make through., bcoz i got 2 E and 1D. 1. BP- though this is asimple station., i was unable to screw the appararus and i asked for help to the examiner ., she said she cant help ., i could not get the reading., so i got E 2.-asthma discharge.in this i told him abt all the things to mention during discharge ., but the thing is tht we must take the discharge sheet some where in the station.,i dint find it., i should have asked for the sheet ., but i didnt ., so i got E 3.pediatric h/o.. in this i came to a conclusion from what the mother told to be DM., so gave the DD as DM and DI., but i got D..

>>hi got five d's .just because of little nervousness.was in need of just one more c. 1.hoarseness hisotry& dd: here i hadn't given sufficient diff. diagnosis,didn't ask the patient whether he is comfortable or not. 2.bp very sad to read that i got c in that cos thats the easiest station to pass.got d in this cos fiddled with the instrument,and was not comfortable myself. 3.primary survey:practised it a lot but i don't know why i just went blank when everything examiner was saying normal.pelvic fracture was there after patient made winking face when i touched his pelvis. i said i would like to call orthopaedician ,examiner said he is in op.theatre,what you will do.i said pelvic compression test(goshhhhh) (failed cos no bp meauring,no fluids no oxygen.those five minutes man they are the real thing only those matter,what you are saying after that or thinking before them doesn't matter. 4.iv cannulation:failed cos spilled the blood when didn't open the torniquet. but i threw the needle in the sharp's bin.......hahaha 5.history of night sweats and hot flushes:failed cos was not looking into patient's eyes and in end told that what we would do.(goshhhhhh ) i was there to take only history....that one minute is more important then those five minutes. to pass just make the formats of all stations ,try to remember that format in that one minute and apply that format in those five minutes.you would pass.may god pass me also next time.

>>appeared in plab-2 on 11th of decemebr, and coiuldn't get through. i failed in following station. 1- telophonic conversation about diarrhoea and councilling of mother.i took a detailed history, and it seemed to be viral gatroenteritis. then i asked about dehydration status. i dont know wheter we can ask about findings of dehydration like dry tongue, depressed fontele, bla .bla. but i asked all these things . she said normal , i think this was a mistake. then she asked me about the treatment, t told her about oral rehydration. she askd me where she could get that , i told her from chemist's shop with out presciption. i asked her whether she had any other question. she saod no . i thanked her. i dont know why i got i D in this station. 2- this station was about breaking bad news. i was a bit confused. i started from admission. like mr. james was admitted with chet pain and coughing ,we did an x-ray which sowed an opacity on lung covering (pleura) than we got a ct which confirmed an abnomal area on lung covering, under ct guidance we took a piece of tissue from that area and sent it for examination under microscope. the repeort came back today.and i am afraid mrs.james i have no good news for u . i stopped here. she eager to listen about the report. i told her the report shows that mr. james got mesothelioma. and let me tell u what mesothelima is. i told her clearly that mesothelioma is cancer of covering of lungs. she asked me whether i was sure about the report . i assured her that the consulatant has double checked it. she started crying at this point. i requested her to compose herself and offerd her tissues and asked her whetehr she needs someone to be with her. she said no and i continued telling her about management, i told her that about multidisciplinery approach. ( radiotherapy, chemotherapy, pain clinic) she asked whether it can be cured or not . i told her it cannot be cured but we shall be trying to make him more comfortable by giving him pain killers. draining fluid from his chest if gets that . she aked me what else can be done . i repeated the same( it was a mistake , i coild have tell her about mcmaolon nurse which i didn't) she asked me why her husband. i told her that this is difficult question, but i asked what was his husband's profession.she told me that he has been working as a builder( i was blank again , i coild have told her about relation of mesothelioma and silicon)and at this the bell rang. i shall tell about other four station in next mail . please tell me about my mistakes as i have to appear again in june.[/b]

>>hi guys just got my result for plab2 i took on feb 17 at the gmc got D in 5 stations i got this result a wk after getting my pass result for jan 2004 mrcp part1 i feel absolutely awful here r my mistakes 1. cpr of cyanosed adult in a hospital ward while giving the rescue breaths during the 1st breath the chest didnt rise. i saw that and extended the head a little bit more and gave 1 breath and the chest rose adequately. now instead of giving 1 more effective breath i proceeded with the rest of the cpr thinking that the examiner wouldnt have noticed. this one mistake has cost me dearly since as far as i remember i did everything else correctly 2.suturing of a clw in forearm wound anaesthetised but not cleaned clean the wound and put 2 sutures cleaning the wound picked up the swabs with my gloved hand instead of a sponge forceps forgot to mention abt looking for foreign bodies my hands were trembling a lot and with a lot of clumsiness picked up the needle with forceps and needle holder was able to put only one suture 30s bell rang and i threw the needle in the sharps bin i knew that i was going to get atleast a D in this station 3.asthma counselling of a 20 something male abt to be discharged explain abt medications he asked abt side effects of inhaled steroids said u might get thrush in ur mouth what to do abt that i said go to ur gp he will give u some medications?! rinsing the mouth after using the reliever didnt say that also didnt look for a discharge sheet which is supposed to be kept in this station D again 4. MMSE of a confused old man wasnt able to complete the station but i dont know of anybody who has. i asked the rt questions completed around 25 pts when the bell rang left abruptly without thanking the patient and talking to the examiner may be this made it D instead of C but still i think this was a bit unfair 5.telephonic conversation with the mother of a 5yr old child who has ear infection gp prescribed antibiotics mother not happy wants to talk to a hospital dr the woman said the child was having high fever and was lethargic asked her if the child had a stiff neck- no(here forgot to ask for rash) then i thought it was sepsis and i asked her to bring the child to the hospital immediately as the infection cld have spread to the blood and asked her to bring the child to the hosp as we have to see the child do some inv and give stronger iv antibiotics she asked shld i do something do tepid sponging and give a tab paracetamol( shld ve said syrup or kid tab) then she said ive other children to look after and my husband is coming after 2 hrs i will ask social services to look after the child she said ok before i cld ask her phone no and address to send the ambulance she said thank u and i also said thank u and put down the phone

>>I really do not understand How I passed this exam but I did. Just go through my stations, except for few rest all stations I performed horribly and I could have performed far better than this but even than they passed me . This is a MIRACLE fOR ME HONESTLY I was in the first batch in the morning. My first station was Explaining Asthma medicine to a young adult. It was written dont tell him about the inhaler technique. I picked up the Ventolin inhaler and looked at the discharge slip and was written use PRN. I didnt knew what PRN meant but told him that this is a reliever and you use it only when you have an attack of breathlessness and I asked himyou know how to use he saidyes. I also told him if you feel you are in need os this medicine more than twicea day go back to your gp. Didnt tell him any thing about side effect. Than I picked up the steroid inhaler told him this is a steroid and it is a preventer and you have to se it regularly donrtstop unless you are told to. I looked at the discharge slip and told him to take 4 puffs in the morning and evening at the same time and rinse your mouth. Didnt tell any thing about any side effect. Than picked up the deltacortril tablets and told him these are steroids and help in relievibg acute stage. However I looked in the discharge slip and told him to take 6 tablets in the morning and definitely stop after five days as was written in the slip. Dint tell about any side effect. I asked him than did you understand all what I said or you want me to repeat or any question in your mind. He asked me you are giving me two types of steroid I have been told that you gain weight and have many other side effect. I told him ther are many but you are using it for a short while and so dont worry. I aslo told him do you want me to tell you about the side effects if used for long term but you may get scare. He said I dont want to know I thanked him and the examiner. 2) Suture. I was trembling when I went in and did not put any drap or even did not clean the wound .Was unable to complete even one suture bell rang left the needle on the table and went away without thanking. 3) BP. Did not had any problem completed as per protocal and wrote the readings and especially thanked the beautiful lady over there 4)I/V Cannula. Di not identify the patient from the tag though mentioned that I would greet and idetify and bla bla. Open the cannula and threw the stopper also as using that kind for the first time. Managed to get in but when removing stellate I told the examiner I have dropped the stopper. He asked me what will you do now and do it. I was confused any how I remove the cannule and dropped it in the normal bin and flushed it with saline kept the syringe there and opened another cannula and took tke stopper and fixed it dropped it in the sharp bin now ansd realised what I did before so mentioned to the examiner about my previous mistake. Di not thank and left hurriedly 5)AIDS Counselling. I was not prepared and didnt knew what to say. I took a bit of history and the task said counsel him so that he can make an informed consent. So his history was clear I asked him why do you want to take this test. I said all rubbish ther didnt let him speak a word and in the end forgot to take a consent from him 6) CPR no problem over here. But I kept me eyes on the chest wehther it is inflating or not . After one minute I was stopped by the examiner 7)Management of MI and Pulmonary oedema. I identified the ECG well and like every other person narrated the treatment of simple MI with doses and contraindication of thrombolysis. He said what would you look for in diabetic I answered prolifarative retinopathy.Than he showed me an x-ray it was pulmonary oedema. He asked me to pick up three medicines for it. I picked up B Blocker ( which was contra indicated as his chest was wheezy written in the sheet but I forgot) picked up frosemide he asked me dose I straight awy said 80 mg not realising in sheet his bp was 100/70. I picked up ACE inhibitor and he said what dose, I realised I picked up the wrong medicine so I kept quiet and the bell rang so messed up all here 8)MMS MAN RATHER DEMENTIC. He was very talkative didnt let me ask questions but I kept my cool and every time before asking a question I listened to his answers patiently and requested permission that can I ask you some more also . I managed to ask 18 questions bell rang . I thanked him and told the examiner that although I have been unable to complete but for sure he has an evidence of dementia as he answered only 10 correctly. I this station I never interrupted him 9)Telephonic conversation Was easy on taking history she told me there is no fever no headache or neck problem or shying away from light no vomitting or diarrhoe but in the end I ask for any rash she said yes so than tumbler test was positive. She told me that she would come sfter two hours but I told her do not pannic but we need to see the child soon she made many excuses but I told her give me your address I am sending ambulance. She also asked for tepid sponging or any thing else at home but I said no you have to come now 10)Child with lethargy and had cold one week back. I thought it is meningitis, but no fever headache neck pains, no rash,I thought of encephalitis, but no fits, any thing. I thought pneumonia but no cough or breathlessnes. So than I thought to complete the protocol of history and asked about jabs, developmental and than family history and asked generally about DM, IHD,HTN etc and suddenly I thought about IDDM and again asked her for bed wetting loss of weight and poly uria and poly dypsia all were positive so just before the bell rang I managed to reah the diagnosis and told to the examiner 11)Mannikin P/V. I did every thing right chaperone ,consent etc, technique also good and felt the uterus on bi-manual examination over the symphysis pubis. Di not do the cervical excitation test and when he asked any abnormality I knew it was a bulky uterus but told the examiner every thing is normal 12)Manikin. P/R no problem here 13)Tahe history of 40 years with diarrhoea. I started with blood and mucous he said yes. So I thought this is inflammatory bowel I asked about travel history, anal conditions,depression, irritable bowel, asked about arthritis scleritis but he said no. Asked about weight loss he said yes. Took family history but did not took colon cancer history though he told me he was a smoker and drink also. Did not took h/o for diet, antibiotics,and many other things. Bell rang I said inflammatory bowel disease ,examiner asked any thing else i did not say any thing not even mentioned colonic cancer though he gave me history of weight loss 14)Person with episodes on unconsciousness. Youn boy I asked about the witness he said my girl friend but she told me every thing. I stated off and immediately came to know it was a tonic-clonic fit. I left it there and starte asking about th e hypoglycaemia, arrythmia, colour change of face and ict mass lesion took family history personal history all in detail . Than came back to epilepsy asked whether he fells floppy or rigid he said rigid, and about twitching also he said yes also about aura which was ther. Di NOT ASK ABOUT TONGUE BITE, FROTHING, IN-CONTINENCE tO URINE OR STOOLS, bell rang thanked him and told the examiner that this is epilepsy I would like to investigate. Two rest stations. Honestly I thought I would fail I had no hope to pass. Di d very bad in four stations and performed bad in another 2-3 stations

>> did Ped CPR perfectly right.....but called Crash Team at wrong hour 2.Did not open touniqette-But spilling of blood is due to thousands of pricks at the same site!!!!!!................................. 3.Fundoscopy held fundoscope in right hand and tried to look with left eye into left eye of the patient.....played with tools......ha ha ..ha 4.In ectopic pregnacy counselling.............did something stupid though overall did well. 5.In Diabetic foot exam.....time ran out.................. 6.In knee exam started with injured knee but soon realised I am going wrong. 7.forgot to offer leaflet in herniorapphy counselling 8.In BP station.....could not hear a thing...time ran out...could not do standing. 9.Tried to push and rotate speculum while doing cervical smear.......it was nothing less than a sexual assualt with dummy.................

>>In BP measurement during standing do v have to lift the manometer?wht if it is aneroid type(needle)or mercury type?(wht v use?) in ybes they told tht the arm shud be at heart level and the bp apparatus shud be at eye level,u can stoop and c!!!i stooped and saw!!and got a D!! Sorry to hear abt the Bp station. ..Actually what u have said is right...i.e. the arm shud b at the level of the heart (i.e. the 2nd intercostal space) and the BP apparatus shud b at the level of the eye, esp. so if its the mercury one to avoid the roleux error. But if its the aneroid one, it should not really affect whether its on the table or the eye level 'coz there 's no such thing as to cause an error in the reading! Unless you r unable to see properly in the apparatus when the patient is standing ( especially so if u r too tall and the table is short )when I think for convenience sake, one can request the patient to hold it for u if he's alright and not feeling giddy..I really fail to understand why they gave u a D? R u sure U did not do any other mistake? One of my friends said later on that she was not sure if she told the correct BP! And she too could not understand why she got a D ? Please feel free to send ur suggestions ........its really frightening if they r giving a D for not lifting the anaroid BP app. ! I am taking the exam in April..and wd appreciate ur valuable suggestions...... -------------------------------------------------------------------------------- well i shall give u a word by word recap of wht happened.., i went in grips and then asked if bp taken before he tells no i explain the procedure get consent tell him i may have to take more than once and in standing position too..,i take bp in sitting it is 124/90 i did palpatory method before it.., was around same thing..,then asked him to stand up..,i told him am holding him and to tell me when he feels dizzy..,(some say i shudve told sit down immediately when u feel dizzy!!) the examiner was also standing along with me..,(an indian examiner who r becoming more dreadful stock of late!!they r fast gaining reputation to be more like the old ones back home whom v know very well during our mbbs medicine finals!!)i just stooped while keeping the arm at heart level., i cudnt get the reading in standing position cos i wasnt applying the stethoscope with pressure..,then i started to repeat when the time went off.., i stopped and told him amnt able to take the standing bp i want to repeat it again as the stethoscope slipped and the sitting bp was 124/90 the patient was very co-operative helping me to tie the cuff..,there were no different sized cuffs..,just one and the adult one..,the examiner never saw me or replied anything.., some of my friends who did the same day too cudnt do the standing bp they told they shall do it ideally and blah blah..,and got a pass..,whereas another one who fumbled failed..,maybe i too was judged to be fumbling..,whtsoever..,it wudntve happened if i wasnt shaking tht much!!i never realised i was under tht much stress!! so its upto u to judge fm my experience and come to ur conclusion.., i really dont knw where i went wrong exactly maybe the whole!! do suggest wht better cud be done n trouble shoot for others to know as well.., regards

>>1.Well I made some mistakes in procedures and now cannot forget them even in dreams..............next time it's going to be PERFECT EXAM.................... 2.Was slow in physical exam stations 3.Communication....................all very well done 4.Was overconfident contrary to most PLAB candidates 5.Did not attend any course................ooooooops

>>the following was the experience of a fellow plabber who didnt get through 1- telophonic conversation about diarrhoea and councilling of mother.i took a detailed history, and it seemed to be viral gatroenteritis. then i asked about dehydration status. i dont know wheter we can ask about findings of dehydration like dry tongue, depressed fontele, bla .bla. but i asked all these things . she said normal , i think this was a mistake. then she asked me about the treatment, t told her about oral rehydration. she askd me where she could get that , i told her from chemist's shop with out presciption. i asked her whether she had any other question. she saod no . i thanked her. i dont know why i got i D in this station. i would like to know what could he have done to prevent a D in this station.

BOF

2004-08-18T14:07:00.000-07:00

BOF 1 A 68-year-old female patient is seen on the ward. She complains of severe pain in her right eye. There is blurring of vision and she feels nauseated and has vomited several times. Earlier in the day she has undergone colonoscopy for evaluation of her long-standing Crohn's disease. The endoscopist has made a comment that the examination was difficult. What is the likely cause of her painful red eye?

a) Anterior uveitis
b) Acute conjunctivitis
c) Episcleritis
d) Sub-conjunctival haemorrhage
e) Acute angle closure glaucoma

Answer e) Anticholinergic agents are sometimes used during endoscopy to cause smooth muscle relaxation to aid examination when difficulty is encountered. These agents cause pupillary dilatation thus precipitating acute angle closure glaucoma in susceptible patients. In patients with a history of glaucoma, glucagon is used instead of anticholinergics.

BOF 2 The surgical registrar on duty calls you up to ask for advice. A 24-year-old female patient was admitted under their care the previous night and underwent a diagnostic laparoscopy for investigation of abdominal pain. The examination was normal, the pain has subsided and the plan is to discharge the patient. The patient is a tourist and wants to travel back to her home country. He would like to know how soon after laparoscopy a patient might undertake an airline flight. What would your reply be?

a) Immediately
b) After one week
c) After five days
d) 48 hours
e) Ten days

Answer: d) Modern aircraft normally cruise at between 35,000 to 43,000 feet. As this environment would be non-physiological, the aircraft cabin is pressurised to a maximum cabin altitude of 8,000 feet. This reduced atmospheric pressure would cause gas in body cavities to expand by 30-40%. Hence, air travel should be delayed for 48 hours after laparoscopy to allow all gas to be absorbed.

BOF: 3 A 55-year-old male is admitted as an emergency with severe abdominal pain. He smokes 30 cigarettes a day and takes approximately 30 units of alcohol per week but admits to exceeding this amount sometimes. He also complains of sudden deterioration in vision. Ophthalmoscopy shows multiple micro infarcts (cotton wool spots). What investigation would best confirm your diagnosis and guide treatment?

a) Upper GI endoscopy
b) E.R.C.P.
c) Blood glucose
d) Mesenteric angiogram
e) CT scan abdomen

Answer: e)Ischaemic retinopathy, which causes retinal oedema and micro infarcts, causes acute visual loss. This is a complication of acute pancreatitis. CT scanning will be useful in diagnosis and evaluation of pancreatitis

BOF: 4 A patient has been transferred to your ward from the coronary care unit. He has suffered an uncomplicated myocardial infarct 3 days ago and at the moment he has no problems. He is a tourist and wishes to travel back home as soon as possible. How soon after an uncomplicated myocardial infarct may a patient undertake air travel safely?

a) 10 days
b) 48 hours
c) 72 hours
d) 14 days
e) 21 days

Answer: a) A patient should be fit to fly 10 days after an uncomplicated myocardial infarct.

BOF: 5A 32-year-old female patient has had multiple resections of the bowel on account of recurrent Crohn's disease. This has resulted in intestinal failure and she is dependent on home parenteral nutrition. She has a Broviac catheter inserted for central venous access. She presents with fever accompanied by chills and rigors.
No physical signs are demonstrable. Cultures taken both centrally and peripherally demonstrate the presence of methicillin-sensitive Staphylococcus aureus.
Your next course of action would be

a) Treatment with intravenous vancomycin for 14 days followed by repeat cultures
b) Treatment with intravenous teicoplanin for 14 days followed by repeat cultures
c) Determine the antibiotic sensitivity prior to commencing antibiotic treatment
d) Do not use the intravenous line until the infection has been successfully eradicated.
e) Remove the intravenous line

Answer e) One of the main complications of parenteral nutrition is infection of the central line. Educating the patient and carers may reduce this. However, line infections do occur and infection with Staphylococcus aureus and Candida are indications for line removal.

BOF: 6 A 76-year-old male has been admitted to your ward following a stroke that has resulted in a left hemiplegia. He is a mild diabetic and is hypertensive but both these conditions are well controlled. Seven days after admission the patient develops fever, tachycardia and tachypnoea. On auscultation of his chest crepitations are heard over both lung bases. Chest X-ray demonstrates bilateral basal pulmonary infiltrates. Your decision regarding empirical antibiotic treatment for this condition will be based on the assumption that the most likely causative organisms would be

a) Methicillin-resistant Staphylococcus aureus
b) Methicillin-sensitive Staphylococcus aureus
c) Pneumococcus
d) Gram-negative organisms
e) Legionella

Answer d) The diagnosis in this patient is most likely to be hospital-acquired pneumonia. After taking appropriate cultures, the patient should be started on antibiotics.Gram-negative organisms are the most likely cause of hospital-acquired pneumonia. Pneumococci are seldom isolated from culture and the most common gram-positive organism that causes hospital-acquired pneumonia is Staphylococcus aureus, particularly MRSA

BOF: 7 A soldier returns from training in Belize. He has developed an ulcer on his right leg that has failed to heal despite treatment with antibiotics and daily dressings. Skin biopsy from the edge of the lesion has been examined histologically and amastigotes have been detected.
Your next course of action would be.

a) Leave the lesion alone and await spontaneous healing.
b) Freeze the lesion with liquid nitrogen
c) Treat the patient with a twenty-day course of sodium stibogluconate
d) Surgical excision
e) Intralesional injection of sodium stibogluconate

Answer c) Amastigotes (LD) bodies seen on biopsy suggest the diagnosis of Leshmaniasis. Cutaneous leishmaniasis may be divided into that of the Old World (Africa, Mediterranean, Afghanistan) and cutaneous leishmaniasis of the New World (Central and South America). Cutaneous leishmaniasis of the Old World heals in 4-18 months leaving a scar. No serious sequelae occur. It may be left alone. It could be frozen with liquid nitrogen. A pentavalent antimonial such as sodium stibogluconate may be administered intralesionally. Cutaneous leishmaniasis of the New World runs a more protracted course. Without treatment the ulcers may persist for years. Some of the patients may develop the mucocutaneous form where the infection spreads from the skin the nasopharyngeal mucosa and this leads to progressive destruction of the nose and pharynx. New World cutaneous leishmaniasis should be treated and the drug used is sodium stibogluconate.

BOF: 8 One of your patients suffers from a cardiac arrhythmia that gives rise to syncope. He continues to drive despite you having made all reasonable efforts to explain to him that this is unsafe. Your response should be

a) It is the legal obligation of the patient to inform the authorities of his disability; hence you are not obliged to take any further action
b) As the patient has a right to confidentiality you may not take the matter any further
c) Inform the police
d) Inform the next of kin or the driving authority
e) Inform the patient's solicitor

Answer: d) In such a situation your duty to society overrides any right of an individual to confidentiality. The ultimate responsibility is yours and you have to inform the next of kin or the driver licensing authority.

BOF: 9 A 26-year-old male has returned from a backpacking trip to India. It is a week since arriving back in Britain. He has had fever for two weeks and has been treated with an antibiotic for a few days whilst in India. He does not know the name of the drug used.On examination he is febrile, has a few rose spots on his abdomen and splenomegaly.What source is the most likely to provide a positive culture in view of the fact that he has been exposed to antibiotics?

a) Blood
b) Rose spots
c) Bile
d) Urine
e) Bone marrow

Answer: e) In typhoid fever, positive cultures may be obtained from blood, bone marrow, urine, faeces, rose spots and bile.Bile has a high concentration of bacteria and the method of culturing it is by using a duodenal string capsule to obtain intestinal fluid. Bone marrow gives a good yield on culture and may provide culture even after antibiotic treatment has been commenced.

BOF: 10 A fifty-year-old patient attending the hypertension clinic has refractory hypertension. Random aldosterone: plasma renin activity has shown a ratio of greater than 750. In order to differentiate the underlying cause of primary aldosteronism, demonstrated in this patient, you arrange for the patient to have aldosterone: plasma renin activity measured in the morning (at 8 a.m.) with the patient in the supine position and again at noon with the patient in the erect position. This test helps to differentiate the causes of primary hyperaldosteronism because

a) ACTH suppresses aldosterone secretion in adrenal adenoma
b) ACTH has no effect on glucocorticoid suppressible hyperaldosteronism
c) Erect posture increases plasma aldosterone in adrenal hyperplasia
d) ACTH levels are higher at noon
e) The supine position increases aldosterone secretion in glucocorticoid suppressible hyperaldosteronism.

Answer: c)In primary aldosteronism, the aldosterone: PRA (plasma renin activity) ratio is greater than 750.
The causes of primary aldosteronism are
• An aldosterone producing adenoma (Conn's syndrome)
• Bilateral adrenal hyperplasia
• Glucocorticoid suppressible hyperaldosteronism
• Adrenal carcinoma (rare)
• Unilateral hyperplasia (rare)

By measuring aldosterone: PRA ratio at 8a.m. in the supine position and at noon in the erect position one may differentiate between these conditions. Posture has an effect on aldosterone levels in adrenal hyperplasia. Erect posture increases plasma aldosterone. ACTH produces a marked effect in patients with glucocorticoid suppressible hyperaldosteronism.It increases aldosterone levels.ACTH has no effect in adrenal hyperplasia ACTH has only a small effect on adrenal adenoma At 8a.m. ACTH levels are higher than at noon.

BOF: 11 A 32-year-old male has returned from a holiday in Gambia six weeks ago.He presents with fever, chills and rigors and on clinical examination is found to have an enlarged spleen. Initial thin film examination for malarial parasites is negative.You are aware that local experience and expertise in diagnosing malaria is not dequate.As the clinical suspicion of malaria is very high in this patient, what would your next course of action be?

a) Repeat the thin film examination in 48 hours
b) Do a thick film examination
c) Do a dipstick assay of Plasmodium Lactate dehydrogenase (pLDH)
d) Give empirical treatment for malaria
e) Repeat thick and thin films in 72 hours

Answer: c)In patients with malaria, examination of a thin film is useful for making the diagnosis of the particular type of malaria and assessing the degree of parasitaemia. However, this depends on local expertise.If an initial film is negative it is best to repeat the test in 12 hours and then again in 24 hours if still negative.Thin films are more sensitive than thick films but this depends on the expertise of the person performing the examination.Dipstick assay is available for detection of all four types of malaria.The assay can differentiate between P.falciparum and P.vivax The test is an antigen detection system for Plasmodium Lactate Dehydrogenase (pLDH) p LDH is an abundant intracellular enzyme produced by malarial parasites. The dipstick is coated with monoclonal antibodies against this intracellular metabolic enzyme pLDH.The test is effective, sensitive and may be performed rapidly.It has almost the same sensitivity as examination of a thick film by an expert. It should be used as a supplement to thin film examination where expertise is lacking.

BOF: 12 A 60-year-old male is admitted with a history of acute on chronic breathlessness. He has been a longstanding smoker. On examination, he is breathless at rest with pursed lip breathing, use of accessory muscles of respiration and a barrel shaped chest. He is not oedematous.Which of the following physical signs will allow you to infer that on chest X-ray hyper inflated lung fields will be seen?

a) Determining respiratory movements
b) Vocal fremitus
c) Percussion
d) Auscultation of breath sounds
e) Vocal resonance

Answer:c) Absence or reduction of dullness over the praecordium (cardiac dullness) or reduction of dullness over the right lower chest (liver dullness) will allow you to infer that on chest X-ray the lung fields will be hyper inflated.

BOF: 13 A 56-year-old male presents with pain in the lower back. The pain has a girdle like distribution beginning in the lower back and radiating to the lower bdomen. He has not been on any drugs. The patient is hypertensive but there are no other physical signs of note. Investigations reveal a normocytic normochromic anaemia, raised erythrocyte sedimentation rate and C-reactive protein. Renal function is impaired. Ultrasound scanning reveals bilateral hydronephrosis. Which of the following investigations is most likely to give you the diagnosis?

a) Intravenous urogram
b) Retrograde urogram
c) Isotope renogram
d) Computerised tomogram of abdomen
e) Renal biopsy

Answer: d) The patient has idiopathic retroperitoneal fibrosis (peri-aortitis).This is a condition in which the ureters become embedded in dense fibrous tissue, usually at the junction of the middle and lower thirds of the ureters.This results in unilateral or bilateral ureteric obstruction.CT scanning will show a peri-aortic mass.Histological confirmation is obtained by CT guided biopsy or laparotomy.

BOF: 14 A 54-year-old male has a longstanding cough productive of sputum and breathlessness on exertion. The breathlessness increases following upper respiratory tract infections. He has been smoking 20 cigarettes a day over a period of 30 years.On examination, there is no clubbing the patient is breathless with use of accessory muscles and resting activation of the abdominal muscles. The chest is barrel shaped and cardiac dullness is reduced. Breath sounds are reduced on auscultation and a few rhonchi are audible.In your assessment of the patient which one of the following is known to be a predictor of mortality?

a) The degree of breathlessness
b) The presence of pursed lip breathing
c) The body mass index (BMI)
d) Spirometry
e) Blood gas analysis

Answer: c) The patient has chronic obstructive pulmonary disease.A low body mass index is a known predictor of mortality in patients with chronic obstructive pulmonary disease. A change in BMI with treatment suggests a better prognosis.Ankle swelling is also an important prognostic feature. This is because ankle swelling suggests the development of right ventricular failure.

BOF: 15 A 54-year-old male with known chronic obstructive pulmonary disease is breathless on minimal exertion and is almost incapacitated by this. Chest X-ray has demonstrated the presence of large emphysematous bullae. In this patient you would arrange a CT scan of his chest for the following reason.

a) To exclude a co-existent lung cancer
b) To exclude co-existent heart failure
c) To document the presence of bronchiectasis
d) To determine the distribution of the emphysema
e) To detect co-existent pulmonary emboli

Answer: d) This patient has incapacitating chronic obstructive pulmonary disease and has emphysematous bullae.This patient will be considered for lung volume reduction surgery.The distribution of the emphysema is an important variable when lung olume reduction surgery is being considered

BOF: 16 A 63-year-old male presents with a history of itching after he has a hot shower. There are no other clinical features of note. He has no significant past illnesses and is not taking any medication. Which of the following investigations is most likely to lead you to a diagnosis?

a) Alkaline phosphatase levels
b) Blood urea and electrolytes
c) Thyroid stimulating hormone levels
d) The fasting blood glucose levels
e) A Full Blood Count

Answer: e) Aquagenic pruritus is caused by the slow release of histamine when the skin is exposed to water.The slow rate of release of histamine gives a sufficient concentration to cause itch but is insufficient to cause visible vascular changes. Aquagenic pruritus is a feature of Polycythaemia Rubra Vera but may also occur in conditions such as Hodgkin's disease and myeloid metaplasia.Out of the choices given, the full blood count will pick up this haematological condition, which is the most likely cause of this type of pruritus in a male in this age group.Remember that Aquagenic pruritus may precede the development of Polycythaemia Rubra Vera by several years.

BOF: 17 A 25 year old male who is known to have insulin dependent diabetes mellitus presents with nausea, vomiting and abdominal pain. He has a tachycardia, a postural drop in blood pressure. He is hyperglycaemic and has ketonuria. The clinical feature that will help differentiate abdominal pain due to diabetic ketoacidosis from a surgical emergency is:

a) Postural hypotension
b) The presence of diarrhoea
c) Abdominal pain preceding the onset of vomiting
d) Vomiting preceding the onset of abdominal pain
e) Colicky pain in the right iliac fossa

Answer: d)Abdominal pain may be a feature of diabetic ketoacidosis. It is usually a dull, persistent discomfort centred on the umbilicus. If vomiting precedes the onset of abdominal pain it is more likely to be due to ketoacidosis than to be a surgical mergency.

BOF: 18 Inferior extension of a pituitary tumour may result in

a) Ethmoid sinusitis
b) Sphenoid sinusitis
c) Damage to the maxillary division of the trigeminal nerve
d) Sixth nerve palsy
e) Quadrantic hemianopia

Answer: b)The inferior relationship of the pituitary is the sphenoid sinus and rarely inferior extension of a pituitary tumour may result in sphenoid sinusitis.

BOF:19 An obese 45-year-old female is referred to the clinic by her general ractitioner as she has been found to have a raised alanine aminotransferase level. She is not on any medication and does not take alcohol. On examination she is obese. In this patient you would expect:

a) Type 2 diabetes mellitus
b) Insulin resistance
c) Hyperlipidaemia
d) Acanthosis nigricans
e) Hepato-splenomegaly

Answer: b) This patient has non-alcoholic fatty liver disease. The metabolic abnormalities leading to accumulation of lipid within hepatocytes are poorly understood but one of the most reproducible features in the development of this process is insulin resistance. Type 2 diabetes mellitus and hyperlipidaemia frequently co-exist with this condition but not necessarily.Acanthosis nigricans is a feature of non-alcoholic fatty liver in children. Hepatomegaly is a common finding but not hepato-splenomegaly.

BOF: 20 A 45-year-old female being treated for rheumatoid arthritis is admitted complaining of breathlessness on exertion. She is found to have a Haemoglobin level of 8.5 g/dl with a MCV of 102. The white cell count and platelets are normal.The anaemia is most likely to be due to:

a) Treatment with Diclofenac
b) Treatment with methotrexate
c) Anaemia of chronic disease
d) Treatment with penicillamine
e) Felty’s syndrome

Answer: d) Treatment with non-steroidal anti-inflammatory drugs would result in anaemia as a consequence of gastro-intestinal haemorrhage. This would cause a microcytic hypochromic anaemia if chronic or normocytic normochromic anaemia if acute. Methotrexate treatment would result in marrow aplasia and a pancytopaenia Anaemia of chronic disease would result in normocytic normochromic anaemia. In Felty’s syndrome the patient would be neutropaenic.Treatment with penicillamine could result in haemolytic anaemia with macrocytosis.

BOF: 21 A 33-year-old female who has had multiple resections of the small bowel has been left with 90 cms of jejunum anastamosed to the colon. She is maintained on a diet high in polysaccharides and manages well on this diet. She is admitted to the ward with ataxia, blurred vision, ophthalmoplegia and nystagmus.The likely cause of this complication is

a) Thiamine deficiency
b) Vitamin B 12 deficiency
c) Magnesium deficiency
d) L (+) lactic acidosis
e) D (-) Lactic acidosis

Answer: e) In patients with a short small bowel and an intact colon, energy is absorbed from the colon by bacterial fermentation of polysaccharides to short chain fatty acid, which can be absorbed by the colonocytes. In rare instances mono and oligosaccharides may be metabolised to D (-) lactic acid by abnormal bacteria. The normal lactic acid produced by man is L (+) lactic acid. Absorption of D (-) lactic acid results in ataxia, blurred vision, ophthalmoplegia and nystagmus. Treatment is with broad-spectrum antibiotics such as neomycin or vancomycin, thiamine and a change in diet to one high in polysaccharides and low in mono and oligosaccharides.

BOF: 22 A 28-year-old male presents with a painful swollen knee. He feels generally unwell and has fever. He has a psoriasiform rash on his glans penis and he also complains of low backache. Six weeks previously he has had a self-limiting episode of diarrhoea.In this patient

a) Prompt treatment will reduce the chance of recurrence
b) High dose steroids should be used without delay
c) Prolonged antibiotic treatment will prevent the disease becoming chronic
d) If the disease becomes chronic sulphasalazine and methotrexate are useful second line agents
e) He has a greater than 50 % chance of developing erosive disease or spondylitis

Answer: d) This patient has developed reactive arthritis. If possible athrocenetesis should be preformed to exclude septic arthritis. Prednisolone does help to control symptoms in active disease but is not the drug of first choice. Non-steroidal anti-inflammatory drugs should be used. Antibiotics should be used if active infection is demonstrated but prolonged therapy is of no benefit. More than 50 % of patients will experience further episodes. Sulphasalazine and methotrexate are useful second line agents if the disease becomes chronic. About 15 % of patients go on to develop erosive disease or spondylitis.

BOF: 23 A 35-year-old female presents with a mutilating arthritis of the hands with associated pitting of the nails.In treating this patient

a) Sulphasalazine is unlikely to be effective
b) Methotrexate is unlikely to be effective
c) Antimalarials are best avoided
d) Tumour necrosis factor alpha antagonists are not effective
e) Oral corticosteroids should be the drugs of first choice as they help the nail condition as well

Answer: c) The patient has psoriatic arthropathy. Treatment is usually with non-steroidal anti-inflammatory drugs although there is a risk of worsening the psoriasis. Sulphasalazine and methotrexate are useful in this condition. Tumour necrosis factor alpha antagonists are effective but are expensive to use. Steroids are seldom needed and may provoke worsening of the psoriases on withdrawal. Antimalarials are best avoided as they can cause an acute psoriatic skin reaction.

BOF: 24 A 45-year-old male presents with a sudden onset of pain and swelling of the metatarso-phalangeal joint of the right big toe. In this patient

a) A normal serum uric acid concentration excludes the diagnosis of gout
b) The x-ray changes would be characteristic
c) Synovial fluid analysis should be delayed to allow crystals to aggregate and become easier to visualise
d) Fever, leucocytosis and elevated ESR would suggest septic arthritis
e) The first attack is seldom associated with residual disability

Answer: e) In an acute attack of gout serum uric acid is raised in only about 60 % of patients. Similar x-ray changes may occur in inflammatory and degenerative arthritis. Synovial fluid analysis should be undertaken immediately following aspiration of joint fluid. The characteristic changes being the demonstration of needle shaped negatively birefringent crystals of mono-sodium urate in synovial fluid neutrophils by polarizing light microscopy. A raised ESR fever and leucocytosis can accompany very acute attacks of gout and do not necessarily indicate sepsis. The first attack of gout is seldom associated with residual disability.

BOF: 25 A sixty five year old male who is on treatment for chronic heart failure with diuretics, angiotensin converting enzyme inhibitors, beta-blockers and spironolactone presents with sudden onset of pain and swelling of the metatarso-phalangeal joint of his right big toe. Aspiration of the joint demonstrates crystals of monosodium urate.
In this patient:

a) Moderate doses of aspirin would be beneficial
b) Non-steroidal anti-inflammatory digs would be the drugs of first choice
c) Highly selective cyclooxygenase 2 inhibitor should be used
d) Colchicine would be the best choice
e) Parenteral colchicine may be safely used to counter nausea and diarrhoea

Answer: d) Aspirin unless used in high doses causes uric acid retention. Non-steroidal anti-inflammatory drugs would be contraindicated in view of the heart failure. Highly selective COX 2 inhibitors may not be used with co-existing heart failure. Intravenous colchicine is potentially hazardous.

BOF: 26 A 50-year-old female presents with a sudden onset occipital headache followed by a decreased level of consciousness. On examination she has neck tiffness and a positive Kernig’s sign. CT scanning shows blood in the sub-arachnoid and intraventricular space. The patient improves initially but 10 days following admission her level of consciousness begins to deteriorate. The next step in management would be:

a) Decompression by lumbar puncture
b) Lumbar puncture followed by high dose broad spectrum antibiotics until cultures are available
c) High dose dexamethasone
d) CT scan followed by a ventricular jugular shunt
e) Cisternal puncture for decompression

Answer: d) The patient has had a sub-arachnoid haemorrhage. Deterioration coming on after an initial improvement is most likely due to the development of secondary hydrocephalus due to blockage of CSF flow by blood. The management would be CT scan to confirm the diagnosis followed by a procedure to drain CSF.

BOF: 27 A 60-year-old female presents with a severe left-sided temporal headache. The temporal artery is tender, pulsation is lost and the overlying skin is erythematous. The E.S.R. is 80 mm in the first hour. In this patient:

a) A short course of high dose steroid should be prescribed
b) The E.S.R. is not a reliable guide to use when reducing the dosage of steroids
c) The headache subsides within hours of commencing the patient on high dose steroid
d) Lifelong steroid treatment will be required
e) As steroids may be harmful in elderly patients, treatment should be delayed until the results of temporal artery biopsy are available

Answer: c) The patient has temporal arteritis. The diagnosis is confirmed by biopsy but in view of the serious complications that may occur treatment with high-dose steroids should be started immediately. Reduction of steroid dosage is guided by the fall in the E.S.R. but the duration of treatment would be several months to years.

BOF: 28 A 30-year-old female presents with a history of weakness and fatigability of the ocular, bulbar and limb muscles. On examination she has bilateral ptosis and extra-ocular muscle weakness. Reflexes are preserved, there is no muscle wasting. The Edrophonium test is positive. In this patient

a) Thymectomy has no long term benefit
b) If a thymoma is present the muscle weakness would improve
c) In non-thymoma patients improvement will be seen in 60 % of patients
d) The prognosis is worse as the patient is under 40 years of age
e) Thymectomy should not be performed if the patient has positive receptor antibodies

Answer: c)In myasthenia gravis thymectomy offers long-term benefits. It improves the prognosis in patients below 40 years, in those with positive receptor antibodies and in those who have had the disease for less than 10 years. Following thymectomy 60 % of non-thymoma patients will improve. In thymoma although surgery is necessary as the tumour is potentially malignant, the myasthenia is unlikely to improve.

BOF: 29 A 70-year-old male is referred by his general practitioner as he has had a stroke. On examination the patient has left sided complete third nerve palsy with a contralateral hemiplegia. The lesion is likely to be in the:

a) The pons
b) The medulla
c) The mid-brain at the level of the inferior colliculus
d) The mid-brain at the level of the superior colliculus
e) The thalamus

Answer: d) The lesion involves the mid-brain at the level of the superior colliculus damaging the third nerve nucleus and the cerebral peduncles.

BOF: 30 A 30-year-old male presents with a chronic cough productive of copious amounts of thick yellow sputum and occasional haemoptysis. He also complains of bad breath and recurrent episodes of fever. On examination he has clubbing and on auscultation over the lung bases coarse crepitations are heard. The test that would identify the cause of his condition would be:

a) Sweat electrolytes
b) Sinus x-ray
c) Bronchoscopy
d) High resolution CT scanning
e) Bronchography

Answer: d) The patient has bronchiectasis. High resolution CT scanning would be the investigation of choice. It would show bronchial dilatation and wall thickening.

BOF: 31 A 30-year-old female presents with fatigue, weight loss, red, painful tender nodules over her shins and breathlessness. The chest X-ray shows bilateral hilar lymphadenopathy. Investigations show that she has hypercalcaemia.The cause of the hypercalcaemia is:

a) Increased parathyroid hormone production in the lungs
b) A high serum ACE causing increased hydroxylation of 25 hydroxycholecalciferol to 1,25 dihydroxycholecalciferol in the kidney
c) Alpha hydroxylation of 25 hydroxycholecalciferol to 1, 25 dihydroxycholecalciferol by macrophages in the lung
d) Lytic lesions in the bones
e) Hyperventilation

Answer: c) The patient has sarcoidosis. In this condition alpha hydroxylation of 25 hydroxycholecalciferol to 1,25 dihydroxycholecalciferol takes place in sarcoid macrophages in the lungs. This increases levels of calcitriol in the blood and results in hypercalcaemia.

BOF: 32 A 65-year-old male presents with a chronic cough. He is a heavy smoker of over 40 cigarettes a day. CXR shows a peripheral right-sided lesion, which on CT guided lung biopsy, is shown to be squamous carcinoma. No regional lymph nodes are involved. Lung function tests show a FEV1 of less than 1.5 litres. The treatment most likely to benefit this patient would be:

a) Surgery
b) Chemotherapy
c) High dose radiotherapy
d) Combination chemotherapy and radiotherapy
e) Combination chemotherapy and surgery

Answer: c) A FEV1 of less than 1.5 litres is not compatible with an active life following surgery. High dose radiotherapy can produce good results and is the treatment of choice in patients with poor lung function.

BOF: 33 A 45-year-old male homeless alcoholic has been referred to the medical ward after being brought in to casualty. He has a chronic cough productive of sputum, loss of weight, and night sweats. On examination he is unkempt and emaciated. His trachea is deviated to the left and there are crepitations over the apex of the left lung. CXR shows fibrosis and cavitation in the left apex. The investigation most likely to confirm the diagnosis would be

a) Sputum examination for acid and alcohol fast bacilli
b) High resolution CT scan
c) Fibreoptic bronchoscopy
d) Mantoux test
e) Gastric washings

Answer: a) The patient has a productive cough. The chances are that AAFB will be identified in these specimens. If sputum were not produced bronchoscopy would be preferred to gastric washings.

BOF: 34 A fifty –five year old male presents with a history of anorexia, nausea and vomiting and abdominal pain. His skin is pigmented with pigmentation of palmar creases and sun exposed areas. He has a few patches of vitiligo. His blood pressure is low and there is a postural drop. In this patient the blood urea and electrolytes are likely to show the following

a) Decreased Na, Decreased K, Normal Urea
b) Decreased Na, Increased K, Increased Urea
c) Decreased Na, Increased K Normal Urea
d) Increased Na, Decreased K, Increased Urea
e) Decreased Na, Decreased K, Increased Urea

Answer: b) The patient has Addison’s disease. The Na will be low with and increase in K and increase in blood urea.

BOF: 35 A sixty-year-old female presents with a history of palpitations and swelling in the neck. On examination of the pulse there is atrial fibrillation and in the neck there is a large multinodular goitre. In this patient which one of the following are likely

a) Eye signs are common
b) Eye signs are rare
c) Spontaneous remission is likely
d) Long term antithyroid drugs are effective in controlling symptoms
e) Thyroxine will help to reduce the size of the goitre

Answer: b) This patient has toxic multinodular goitre. In this condition eye signs are rare unlike Grave’s disease. Spontaneous remission is rare. Antithyroid drugs will increase the size of the goitre and are only used as a temporary measure prior to definitive treatment. Thyroxine will not reduce the size of the goitre.

BOF: 36 A sixty-year-old female presents with a history of nausea, lethargy and depression.Her skin is pigmented and there is vitiligo. Her blood pressure is low and there is a postural drop. In this patient which one of the following are true

a) Eosinopaenia is a feature
b) The ESR is decreased
c) Hyperglycaemia is a feature
d) The heart size is small
e) Hypokalaemia would occur

Answer: d) The patient has Addison’s disease. In this condition the heart size is small. The eosinophil count may be elevated, the ESR may be high, hypoglycaemia may be a feature, and hypokalaemia would be a feature.

BOF: 37 A sixty-year-old man presents with a history of increased sweating. He also complains of headaches.On examination the patient has large hands and the facial features are exaggerated with large nose, prominent jaw and thick lips.In this patient which of the following may be used as a screening test

a) Growth hormone level
b) Glucose Tolerance Test
c) Prolactin level
d) Plasma Insulin-like Growth Factor levels
e) Serum calcium

Answer: d) The patient has acromegaly. Plasma Insulin-like Growth Factor may be used as a screening test.

BOF: 38 A fifty-five year old man is admitted with a history of fatigue, weight loss and jaundice. His alcohol intake is sixty units a week. On examination he has clubbing, Dupuytren’s contracture, palmar erythema, flapping tremor, parotid enlargement, spider naevi, gynaecomastia, hepatosplenomegaly.Which of the following signs is indicative of a poor prognosis:

a) Clubbing
b) Parotid Enlargement
c) Gynaecomastia
d) Flapping Tremor
e) Splenomegaly

Answer: d) The patient has alcoholic liver disease with clinical evidence of cirrhosis. The features of a poor prognosis are hepatic encephalopathy, low serum albumin concentration, and low serum sodium and prolonged prothrombin time.

BOF: 39 A sixty-year-old man who is known to have ischaemic heart disease is admitted with a history of sudden onset abdominal pain, followed by watery diarrhoea and subsequent profuse rectal bleeding. The likely diagnosis is

a) Small bowel infarction
b) Large bowel infarction
c) Volvulus of the sigmoid colon
d) Colon cancer with intussusception
e) Ulcerative colitis

Answer: b) The history of pain flowed by diarrhoea and bleeding per rectum in a patient with known macro vascular disease is typical of large bowel infarction, which occurs in the region of the splenic flexure.

BOF: 40 A thirty five year old female has had a right hemicolectomy and resection of 30 cms of terminal ileum for ileocaecal Crohn’s disease. She has persistent diarrhoea, which is not explosive. She does not have abdominal pain, bloating, or loss of weight. Investigations have failed to demonstrate evidence of recurrent Crohn’s disease. Treatment that would relieve symptoms and give a clue to the underlying diagnosis would be:

a) Loperamide
b) Steroids
c) Cyclical antibiotics
d) Cholestyramine
e) Tricyclic antidepressants

Answer: d) The patient has had resection of the terminal ileum and the cause of the diarrhoea is likely to be Bile Acid Malabsorption (BAM). Treatment with a Bile Acid Sequestrants such as Cholestyramine would relieve symptoms and point to the diagnosis.

BOF: 41 A thirty four year old female presents with a deep vein thrombosis. She has a history of weight loss, recurrent mouth ulcers and chronic diarrhoea with the passage of a bulky stool, which is difficult to flush away. She has a macrocytic anaemia.The underlying biochemical abnormality that would explain the DVT would be:

a) Vitamin B 12 deficiency
b) Folic acid deficiency
c) Iron deficiency
d) Protein S deficiency
e) Protein C deficiency

Answer: b) The patient has coeliac disease. In coeliac disease folic acid deficiency with resultant hyper-homocystinaemia increases the tendency to thromboembolic phenomena.

BOF: 42 A twenty seven year old female presents with a rash. The rash consists of erythematous plaques, excoriations, and vesicles some of which have ruptured leaving a crust.She also complains of diarrhoea with the passage of a bulky stool, which is difficult to flush away. In this patient:

a) The rash responds rapidly to a gluten free diet
b) The rash responds slowly to treatment with Dapsone
c) The rash responds rapidly to treatment with Dapsone
d) Doxycycline is the drug of choice
e) Oral Steroids should be commenced immediately

Answer: c) The patient has dermatitis herpetiformis, which is associated with coeliac disease. The rash responds within a few hours to treatment with dapsone.

BOF: 43 A twenty four year old female who is known to have ulcerative colitis presents with an ulcer above the medial malleolus. This is large has a necrotic base and the edges are undermined. In this patient:

a) Immediate treatment should be with broad spectrum antibiotics
b) High dose steroids should be used in the first instance
c) Surgery is the first line treatment of the ulcer
d) Treatment of the colitis with high dose mesalazine preparation will cause the ulcer to heal
e) Colectomy is indicated

Answer: b) The patient has pyoderma gangrenosum complicating ulcerative colitis. The initial treatment should be with high dose steroids.

BOF: 44 A 50-year-old male presents with oral ulceration, and flaccid blisters on the skin especially the trunk. The blisters are sore but not itchy and they rapidly denude leaving weeping, erythematous erosions. Gentle sliding pressure on the blisters makes them extend. In this condition:

a) Low dose steroids are effective in controlling formation of new blisters
b) Local steroids are effective in controlling the disease
c) Long term tetracycline is effective treatment
d) Gold may be effective therapy in steroid resistant patients
e) Dapsone is effective on controlling the disease

Answer: d) The patient has pemphigus vulgaris. The physical sign described is Nikolsky's sign( extension of the blister with pressure). In pemphigus vulgaris high dose steroids may be needed to prevent formation of new blisters. Azathioprine and methotrexate may be needed to reduce the dose of steroids. Gold may be effective in steroid resistant patients.

BOF: 45 In patients with cystic fibrosis a FEV1 of less than 30 % would predict

a) 80% of patients would be infected with Pseudomonas aeroginosa
b) 60% would develop a digestive tract malignancy
c) 80 % would develop a variceal haemorrhage
d) 50 % would be dead within two years
e) 60 % would respond to treatment with high dose ibuprofen

Answer: d)In patients with cystic fibrosis a FEV1 of less than 30 % would predict 50 % mortality within two years.

BOF: 46 In lung cancer which of the following features would suggest response to cytotoxic chemotherapy

a) Horner’ syndrome
b) Wasting of small muscles of hand
c) Ectopic ACTH syndrome
d) Bone metastases
e) Pleural effusion

Answer: c) In small cell lung cancer the ectopic ACTH syndrome may occur. Small cell lung cancer responds to cytotoxic chemotherapy.

BOF: 47 Which one of the following auscultatory signs is confirmatory for bronchial breathing?

a) Aegophony
b) Whispering pectoriloquy
c) Increased vocal resonance
d) Coarse crepitations
e) Fine crepitations

Answer: b) Whispering pectoriloquy is the confirmatory sign for bronchial breathing

BOF: 48 A 24-year-old male presents with sudden onset left sided pleuritic chest pain and difficulty in breathing. On examination he is distressed, tachypnoeic and has tracheal displacement to the right together with a hyper-resonant percussion note on the left side with absent breath sounds on the left. In this patient:

a) The lung will spontaneously expand within one week
b) Immediate insertion of an intercostal drainage tube is required
c) Aspiration of the pneumothorax should be undertaken in the first instance
d) Surgical pleurodesis will be required
e) Chemical pleurodesis will be required

Answer: c) Treatment of a complete pneumothorax would be initial aspiration. This is less painful, leads to a shorter duration of admission, reduces the need for leurectomy, there is no increase in recurrence rate at one year.

BOF: 49 In a man the commonest presentation of prolactinoma is with:

a) Galactorrhoea
b) Gynaecomastia
c) Impotence
d) Adiposity
e) Apathy

Answer: c) In men with prolactinoma the commonest of the features mentioned above is impotence. Approximately 8% of men presenting with sexual dysfunction have hyperprolactinaemia.

BOF: 50 An elderly female is admitted with loss of consciousness. She is hypothermic, has a bradycardia, evidence of cardiac failure, hypoventilation, hypoglycaemia and hyponatraemia. In this condition one of the treatment strategies would be:

a) Thyroxine 1000 micrograms by slow intravenous infusion every 8 hours
b) Prednisolone 60 mgs orally
c) Oral thyroxine 125 micrograms daily
d) Oral thyroxine 25 micrograms daily
e) Hydrocortisone 100 mgs iv 8 hourly

Answer: e) The patient has myxoedema coma. Hydrocortisone 100 mgs iv 8 hourly should be used to protect against the possibility of associated adrenocortical deficiency.

Title: Hypothyroidism
Aetiology: Primary Hypothyroidism
Congenital thyroid agenesis, thyroid maldescent, dyshormonogenesis
Traumatic post-thyroidectomy hypothyroidism or following radioiodine therapy
Inflammatory Hashimoto’s thyroiditis, lymphocytic thyroiditis, Riedl’s fibrosing thyroiditis
Metabolic iodine deficiency or excess
Drugs anti-thyroid drugs, lithium, amiodarone

Secondary Hypothyroidism
Panhypopituitarism
Isolated TSH deficiency almost never occurs

Clinical Features:
History:
E&M:
Tiredness
Weight gain
Cold intolerance
GIT:
Anorexia
Constipation
RAG:
Menorrhagia, oligomenorrhoea
Loss of libido
Examination:
E&M:
Increased weight
Goitre
IS:
Dry, coarse skin
Peaches and cream complexion
Dry, brittle hair
Loss of eyebrows
CVS:
Cold peripheries
Hypertension
Heart failure
Pericardial effusion
RS:
Hoarse voice
HS:
Anaemia
CNS:
Poor memory
Depression
Psychosis
Coma
Deafness
Ataxia
Carpal tunnel syndrome
Proximal myopathy
Increased ankle jerk relaxation time
Investigations:
TSH levels:
Increased
T4 level:
Decreased
Management:
Drugs: Replacement with thyroxine

BOF: 51 The commonest clinical manifestation of primary hyperparathyroidism is:

a) Renal stone disease
b) Bone disease
c) Peptic ulceration
d) Constipation
e) Polyuria

Answer: a) Renal stone disease occurs in 50 % of patients.

BOF: 52 A 50-year-old female has been referred for investigation of abnormal liver function tests. On examination she is obese with mainly truncal obesity, with a moon face and a buffalo hump shaped deposit of fat across her shoulders. Her face is plethoric and there are numerous telangiectasia. The abdomen is protuberant and there are striae. In this patient:

a) The biochemical abnormalities do not return to normal with abstinence
b) There is little relationship between the degree of liver damage and the plasma cortisol levels
c) Urinary 17 – hydroxycorticosteroid levels are suppressed
d) Plasma cortisol levels are suppressed
e) Plasma ACTH levels are elevated

Answer: b) The patient has alcoholic pseudocushings. There is little relationship between the degree of liver damage and the plasma cortisol levels

BOF: 53 A 50-year-old man presents with malaise, weight loss, diarrhoea and pain in the joints. He is pigmented, has clubbing and lymphadenopathy. He has ascites and ophthalmoplegia. Investigations show him to be anaemic. ECG shows a right bundle branch block and paracentesis abdominis reveals chylous ascites. The investigation most likely to give a diagnosis would be:

a) Lumbar puncture
b) CT head
c) Ascitic fluid cytology
d) Small bowel biopsy
e) Transoesphageal echocardiography

Answer: d) The patient has Whipple’s disease, which is diagnosed by the emonstration of multiple macrophages in the lamina propria and the presence of rod shaped bacteria both within and without the abnormal macrophages.

Title: Whipple’s Disease
Definition: A rare multisystem disease caused by Trophyrema whippelli
Aetiology: Infection by Trophyrema whippelli
Clinical Features:
Affects males > females
Usually middle aged
History:
E&M:
Weight loss
Fever
RS:
Cough
Pleuritic chest pain
GIT:
Diarrhoea
Steatorrhoea
Abdominal pain
CNS:
Insomnia, Hyperphagia, Polydypsia (Hypothalamic syndrome)
LMS:
Arthritis
Examination:
E&M: Loss of weight , Fever
IS:
Clubbing
CVS:
Endocarditis, Cardiomyopathy, Cardiac conduction defects, Coronary arteritis, Pericarditis
RS:
Pleurisy, Pulmonary infiltrates
GIT:
Chylous or serous ascites
HS:
Lymphadenopathy
CNS:
Scotoma, Ophthalmoplegia, Uveitis, Papilloedema
Meningitis
LMS:
Migratory non-deforming seronegative arthritis predominantly affecting the peripheral joints

Investigations:
FBC: anaemia
Endoscopy: Small bowel biopsy
Tissue Diagnosis: Large, foamy PAS positive macrophages in the lamina propria
Management:
Drugs:
Penicillin and streptomycin for 2 weeks followed by:
Tetracycline for 1 year
Prognosis:
Untreated it is eventually fatal

BOF: 54 A 32-year-old female who is known to have Crohn’s disease presents with increased frequency of micturition. She is demonstrated to have sterile pyuria. The lesion is likely to be:

a) Left colonic
b) Colo-vesical fistula
c) Terminal ileal
d) Recto-vesical fistula
e) Vesico-vaginal fistula

Answer: c) Crohn’s disease of the terminal ileum or left colon may involve the right ureter and result in sterile pyuria

Title: Crohn’s disease
Definition: A chronic inflammatory condition of unknown aetiology that may affect any part of the bowel from mouth to anus
Aetiology:
Unknown
Contributory factors:
Family history
Smoking
Clinical Features:
Commonly affects young adults
History:
E&M:
Loss of weight
Fever
GIT:
Mouth ulcers
Anorexia
Vomiting
Abdominal pain
Diarrhoea
Bleeding and mucous per rectum
Perianal discharge
KUB:
Dysuria and frequency due to ureteric involvement
Oxalate stones
Amyloidosis
Hydronephrosis (ureteric involvement)
Rectovesical fistulae
Examination:
E&M:
Fever
Sweats
Loss of weight
IS:
Clubbing
Erythema nodosum
CVS:
Tachycardia
GIT:
Mouth ulcers
Glossitis
Tenderness over affected bowel
Abdominal mass
Anal skin tags
Anal fissures
Perianal Fistulae
RAG:
Colovaginal, rectovaginal fistulae
HS:
Anaemia
LMS:
Enteropathic arthritis
Osteoporosis
Psoas abscess

Investigations:
FBC: Anaemia: iron deficiency, B12 deficiency, folate deficiency
Biochemistry: Hypokalaemia: diarrhoea
Albumin: decreased
ALT, alkaline phosphatase: increased
Mg, Zn, Se: may be deficient
Urine: Sterile pyuria (ureteric involvement)
Imaging:
Plain X-ray:
Intestinal obstruction
Suggestion of mass
Mucosal oedema and ulceration in colitis
CT scan: Image masses, inflammatory disease of the bowel
MRI:
Image fistulae
Small bowel imaging
Barium Studies: Small bowel studies would show ileo-caecal involvement (barium follow through or small bowel enema)
Barium enema
Nuclear Medicine:
Labeled white cell scan:
Localises inflammatory lesions
Endoscopy: Upper and lower GI endoscopy would show lesions and allow biopsies for histological conformation
Surgery:
Diagnostic laparoscopy or laparotomy
Tissue Diagnosis:
Histological conformation
Management:
Drugs:
Induction of Remission:
Steroids
Antibiotics (ciprofloxacin, metronidazole)
Infliximab
5 Amonosalicylic acid preparations
Maintenance of Remission:
5 Amonosalicylic acid preparations
Azathioprine
Methotrexate
Thalidomide
Infliximab
Surgery:
Induction of remission in localised disease
Management of complications
Lifestyle Adjustments:
Smoking:
Stop smoking
Diet:
Supplementation
Induction of remission and maintenance of remission with elemental diet, Modulen
Staffing:
Dietician regarding nutritional supplementation
Equipment:
Pumps for nutritional therapy

BOF: 55 A 30-year-old male presents with several weeks history of blood and mucous diarrhoea. He has a frequency of bowel movement of 8 times during the day and has to wake up 3 times at night to have a bowel movement. Unprepared flexible sigmoidoscopy shows an inflamed colonic mucosa. A feature that will show that this patient has disease affecting the right colon would be:

a) Serum albumin level of less than 30 g /l
b) CRP of greater than 100
c) Thumb printing on plain abdominal x-ray
d) Distended loops of small bowel
e) A tachycardia of greater than 100 per minute

Answer: d) The patient has ulcerative colitis . The presence of distended small bowel loops would suggest incompetence of the ileo-caecal valve indicating right colonic involvement.

BOF: 56 A 20-year-old male presents with bleeding oesophageal varices. On examination he has Kayser- Fleischer rings in the cornea. The inheritance of this disorder is:

a) Autosomal dominant
b) Autosomal recessive
c) X-linked recessive
d) X-linked dominant
e) Polygenic inheritance

Answer: b) This patient has Wilson’s disease, which is inherited in an autosomal recessive fashion due to a mutation on the long arm of chromosome 13

BOF: 57 A 35-year-old female presents with acute severe abdominal pain associated with tachycardia, hypotension and tachypnoea. The finding of a raised serum amylase in this patient:

a) Is diagnostic of acute pancreatitis
b) Makes ectopic pregnancy less likely
c) Makes diabetic ketoacidosis less likely
d) Could indicate a perforated duodenal ulcer
e) Makes mesenteric ischaemia less likely

Answer: d) A raised serum amylase may occur in all these conditions

BOF: 58 In primary sclerosing cholangitis:

a) There is clear female predominance
b) It is associated with Crohn’s colitis but not with ulcerative colitis
c) The liver biopsy features are diagnostic
d) Colectomy prevents the progression of the disease
e) Ursodexoycholic acid improves clinical symptoms and reduces the level of cholestatic enzyme markers

Answer: e) Ursodexoycholic acid improves clinical symptoms and reduces biochemical evidence of cholestasis but no effect on morbidity and mortality has been demonstrated.

BOF: 59 In psoriatic arthropathy:

a) There is a strong relationship between the skin changes and the severity and extent of arthritis
b) There is a close relationship between the onset of nail dystrophy and arthritis
c) Nail dystrophy is more common in patients with the spinal form of arthritis
d) Longitudinal ridging of the nails is diagnostic of psoriatic arthropathy
e) Acute anterior uveitis is common in patients with the mutilating form of psoriatic arthropathy

Answer: b)There is poor correlation between the skin changes and the arthritis although there is closer relationship between nail changes and arthritis. Nail dystrophy is common in those with distal interphalangeal joint involvement. Longitudinal ridging is not a specific associated feature of psoriatic arthropathy. Anterior uveitis is associated with sacroiliitis.

BOF: 60 In polymyalgia rheumatica:

a) The disease is common in those over 80 years of age
b) A dramatic onset is unusual
c) The onset is more common in the pelvic girdle
d) Morning stiffness is not a common feature
e) Anorexia and weight loss are features

Answer: e) Polymyalgia rheumatica is common between 60 and 70 years. It is seldom seen before 45 or after 80. The onset is often dramatic. Immobility is most severe on waking and may persist for hours. Anorexia and weight loss may be striking.

BOF: 61 An elderly lady has features of osteoporosis. She appears to have lost height due to osteoporotic collapse of the vertebrae but she does not know what her former height was. Which measurement will give an indication of her former height?

a) Length of manubrium sterni
b) Distance between the costal margin and the iliac crest
c) Diameter of the rib cage
d) Waist measurement
e) Arm span

Answer: e) In an adult the arm span and height are approximately equal. In osteoporotic collapse of the vertebrae, the arm span becomes greater than the height.

Title: Osteoporosis
Definition: A disorder characterised by loss of bone mass per unit volume with deterioration of its micro-architecture. This results in increased fragility of bone and an increased risk of fracture.
Aetiology:
The risk factors for osteoporosis are:
Internal Factors
Increasing age
Female gender
Caucasian or Asian race
Family history of osteoporosis
External Factors
Dietary factors such as a low calcium intake
Systemic Factors
Conditions affecting the:
RAG secondary amenorrhoea, primary hypogonadism, premature menopause
E&M acromegaly, hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, diabetes mellitus
KUS chronic renal failure
LMS rheumatoid arthritis, prolonged immobilisation
GIT nutritional failure, inflammatory bowel disease
Drugs steroid therapy
Toxins cigarettes, alcohol
Surgery organ transplantation
Clinical Features:
In osteoporosis the only cause of symptoms is fracture. The usual sites involved are:
Spine
Colles’ fracture
Fracture neck of femur
History:
LMS:
Pain , deformity
Examination:
GIT:
Abdominal protuberance
LMS:
Loss of height, kyphosis
Dinner fork deformity in Colles’ fracture
External rotation, shortening and decreased movement of limb in fracture neck of femur
Investigations:
Imaging:
Plain X- Ray decreased bone density, reduced cortical thickness, wedge collapse of vertebrae, “codfish” vertebrae
DEXA (dual x- ray absorptiometry) provides a T score, which reflects fracture risk
Management:
Drugs:
Bisphosphonates
Hormone replacement therapy
SERM (selective oestrogen receptor modulator)
Androgens (hypogonadal men)
Calcium and vitamin D (elderly)
Lifestyle Adjustments:
Diet increased calcium and vitamin D
Exercise increase physical activity
Smoking cessation

BOF: 62 In osteoporotic collapse of the vertebra:

a) The absence of precipitating stress makes it less likely
b) The absence of severe pain will make the diagnosis less likely
c) The pain is very well localised and the absence of this symptom will exclude the diagnosis
d) The vertebrae are tender to percussion and the absence of this sign will exclude the diagnosis
e) Frequently occurs without symptoms

Answer: e) Osteoporotic collapse of the vertebrae frequently occurs without symptoms

BOF: 63 The three main sites at which osteoporotic fractures occur are:

a) Vertebrae, pelvis, femoral neck,
b) Vertebrae, femoral neck, forearm
c) Vertebrae, forearm, pelvis
d) Vertebrae, femoral neck, humerus
e) Vertebrae, forearm, ribs

Answer: b) The commonest sites of osteoporotic fracture are vertebrae, femoral neck, forearm

BOF: 64 In contrast to other forms of osteoporosis, steroid induced osteoporosis affects the:

a) Skull
b) Forearm
c) Vertebrae
d) Pelvis
e) Femoral neck

Answer: a) Osteoporosis is thought not to affect the skull except in steroid induced osteoporosis.

BOF: 65 A 45-year-old female is admitted with a subarachnoid haemorrhage. She initially, makes satisfactory progress but 5 days later her level of consciousness begins to deteriorate. The most likely cause of the deterioration is:

a) Bacterial meningitis complicating lumbar puncture
b) Cerebral abscess
c) Coning of the medulla
d) Acute hydrocephalus
e) Dural sinus thrombosis

Answer: d) Organised blood in the subarachnoid space may cause obstruction to the flow of cerebrospinal fluid and result in hydrocephalus.

BOF: 66 A 67-year-old man presents with a history of falls. He has difficulty in reading and coming down stairs. He has dysarthria, and akinesia and rigidity can be demonstrated. Power of the muscles is normal, reflexes are brisk. What physical sign will help to make the diagnosis?

a) Jaw jerk
b) Romberg’s sign
c) Tandem walking
d) Eye movements
e) Plantar response

Answer: d)

BOF: 67 A 25-year-old female has recently had a forceps delivery. She complains of pain in the groin and on examination she has weakness of adduction and internal rotation of the hip. There is sensory impairment over the medial aspect of the thigh. The affected nerve is the:

a) Femoral nerve
b) Sciatic nerve
c) Lateral cutaneous nerve of the thigh
d) Tibial nerve
e) Obturator nerve

Answer: e) The obturator nerve supplies gracilis, adductor longus and brevis, adductor magnus, obturator externus and the skin over the lateral aspect of the thigh.

BOF: 68 A 20-year-old male presents with wasting and weakness of the muscles of the pelvic girdle. There is evidence of generalised muscular hypertrophy. His maternal grandfather had a similar disorder. The mode of inheritance is

a) Autosomal dominant
b) Autosomal recessive
c) X-linked recessive
d) Polygenic inheritance
e) X-liked dominant

Answer: c) The patient has benign x-liked muscular dystrophy (Becker type)

BOF: 69 Myotonia aggravated by cold is a feature of:

a) Myotonia dystrophica
b) Myotonia congenita
c) Chondrodystrophic myotonia
d) Paramyotonia
e) Hypothyroidism

Answer: d) Myotonia appearing on exposure to cold occurs in Paramyotonia. Chondrodystrophic myotonia causes choking on cold drinks.

BOF: 70 In myasthenia gravis the tendon reflexes are:

a) Brisk
b) Absent
c) Depressed
d) Delayed
e) Pendular

Answer: a) In myasthenia gravis the tendon reflexes are characteristically brisk. If the reflexes are depressed or absent one should think of Eaton-Lambert syndrome.

BOF: 71 A 25-year-old male who is known to have ankylosing spondylitis presents with a painful, aching, photophobic red eye. Examination shows cells floating in the anterior chamber and precipitated on the back of the cornea. In this patient treatment should be commenced with:

a) High dose oral steroids
b) Broad spectrum antibiotics
c) Local steroids
d) Local steroids and dilator
e) Local steroids and a constrictor

Answer: d) The patient has anterior uveitis. Treatment should be with local steroids and a dilator to break adhesions to the lens and allow the iris to remain mobile.

BOF: 72 In diabetes mellitus eye complications that do not result in visual impairment are:

a) Cataract
b) Lipaemia retinalis
c) Rubeosis iridis
d) Retinal vein occlusion
e) Diabetic retinopathy

Answer: b) Lipaemia retinalis is seen in association with hypertriglyceridaemia and reverses with metabolic control. All other complications impair vision. Rubeosis iridis can result in glaucoma by neovascularistion of the drainage channels of the aqueous in the anterior chamber.

BOF: 73 A 27 year old female presents with abdominal pain, weight loss, diarrhoea and mouth ulcers. On clinical examination apart from mouth ulcers no abnormality is detected. Full blood count reveals normocytic normochromic anaemia, inflammatory markers are raised, and biochemical investigation reveals a raised alkaline phosphatase. Barium follow through shows terminal ileal inflammatory disease. In this patient long term remission may be maintained by the use of:

a) Low dose prednisolone
b) Mesalazine
c) Azathioprine
d) Infliximab
e) Elemental diet

Answer: c) The patient has Crohn’s disease. Induction of remission of Crohn’s disease may be achieved by the use of steroids, elemental diet, surgery or Infliximab. Mesalazine may maintain remission if induction has been achieved by surgery and if an 8-week course of metronidazole is administered. In other cases the most useful drug to maintain remission is azathioprine.

BOF: 74 An 80-year-old man has had a stroke and has a poor swallow. He keeps pulling his nasogastric tube out and is not adequately nourished. He develops diarrhoea. Stools were examined and show the presence of Clostridium difficile toxin. He has not been treated with antibiotics. In this patient the next course of action should be:

a) Arrange a colonoscopy
b) Arrange a barium enema
c) Treat with metronidazole
d) Treat with Loperamide
e) Treat with Cholestyramine

Answer: c) Infection with Clostridium difficile is usually established upon exposure to antibiotics. However, it may also occur in debilitated patients who have not been exposed to antibiotics.

BOF: 75 A 50-year-old male presents with haematemesis and melaena. He gives a history of alcohol abuse of several years duration. On examination he has bilateral parotid enlargement, spider naevi, Dupuytren’s contracture, jaundice and ascites. Whilst awaiting endoscopy the initial management of this patient should be:

a) Administration of intravenous pantoprazole
b) Administer terlipressin
c) Insert a Sengstaken tube
d) Nasogastric tube and aspiration to decompress the stomach
e) Administer sucralfate

Answer: b) The patient has clinical evidence of cirrhosis of the liver (features of portal hypertension and features of hepatocellular failure). The likely cause of the haematemesis and melaena is bleeding oesophageal varices. Until endoscopy and definitive treatment one should attempt to reduce portal venous pressure with terlipressin.

BOF: 76 The cardinal manifestation of acute hepatic failure is:

a) Jaundice
b) Prolonged prothrombin time
c) Hepatic encephalopathy
d) Ascites
e) Elevated ALT

Answer: c) Cerebral disturbance (hepatic encephalopathy) is the cardinal manifestation of acute hepatic failure.

BOF: 77 A 45-year-old female who is known to have autoimmune hepatitis, which has progressed to cirrhosis of the liver documented on liver biopsy, complains of breathlessness. The breathlessness is better when she lies down and gets worse when she is upright. Her arterial oxygen saturation is reduced on standing. The condition that this patient suffers from is an:

a) Indication for treatment with carvedilol
b) Indication for treatment digoxin
c) Indication for liver transplantation
d) Indication for home oxygen treatment
e) Indication for oral beta agonists

Answer: c) Breathlessness on standing relieved by lying down (platypnoea) together with decreased arterial oxygen saturation on standing (orhtodeoxia) are features of the hepato-pulmonary syndrome which is an indication for liver transplantation.

BOF: 78 A 26-year-old female who has been on the contraceptive pill presents with abdominal pain and distension of 5 days duration. On examination she has no stigmata of chronic liver disease. She has distended veins over the anterior abdominal wall with flow of blood in a caudal to cephalic direction .She also has ascites, an enlarged tender liver with absent hepato-jugular reflux. Her lower limbs are oedematous. In this patient the oedema of the lower limbs is due to:

a) Hypoalbuminaemia
b) Hepato-renal syndrome
a) Inferior vena cava thrombosis
b) Portal venous thrombosis
c) Lymphatic obstruction

Answer: c) Budd-Chiari syndrome is thrombosis of the hepatic veins. Lower limb oedema could occur due to associated thrombosis of the inferior vena cava.

BOF: 79 A 40-year-old male presents with a history of intermittent, but slowly progressive dysphagia for both solids and liquids. He experiences pain on swallowing and has regurgitation of food swallowed several hours earlier. He has no heartburn but has anorexia and weight loss. Ba swallow demonstrates proximal dilatation of the oesophagus and failure of relaxation of the lower oesophageal sphincter. In this patient good medium to long term relief of symptoms may be obtained by:

a) Oesophageal myotomy
b) Amyl nitrite
c) Amlodipine
d) Intrasphincteric botulinum toxin
e) Oesophageal bouginage

Answer: a) The patient has achalasia of the cardia, which is a functional obstruction at the lower oesophageal sphincter caused by a failure of relaxation. Oesophageal myotomy (Heller’s operation) and balloon dilatation give good medium to long-term results. Bouginage is not used. Drug therapy does not achieve medium to long-term relief.

BOF: 80 A 22-year-old female of Irish descent has been admitted under the care of the surgeons with a history of abdominal pain. They have concluded that the patient has non-specific abdominal pain, which they define as abdominal pain that cannot be treated by an operation. No abnormality has been detected clinically or by routine investigation. They wish to discharge the patient but would welcome your opinion. You agree to see the patient in clinic following discharge but request that they perform an investigation prior to discharge. This investigation would be:

a) B12 and folate levels
b) Urine for porphyrins
c) ANCA screen
d) Mesenteric angiogram
e) Anti gliaden and anti endomysial antibodies

Answer: e) Coeliac disease presents with abdominal pain and a coeliac screen would be a good screening test for this condition.

BOF: 81 A 55-year-old Caucasian male presents with a 2-year history of arthritis, fever, recurrent cough and chest pain. He has been feeling generally unwell. Recently he has developed diarrhoea (steatorrhoea), abdominal pain and weight loss.On examination he is pigmented, there is finger clubbing and lymphadenopathy. On auscultation of the heart a pan-systolic murmur is heard.Which of the following investigations would confirm your clinical diagnosis?

a) ECHO
b) Blood cultures
c) Lymph node biopsy
d) Small bowel biopsy
e) Mesenteric angiogram

Answer: d)The patient has Whipple’s disease, which may be confirmed by small bowel biopsy. Small bowel biopsy will show large, foamy PAS positive macrophages in the lamina propria.

BOF: 82 A 35-year-old male intravenous drug abuser presents to his GP with a complaint of severe fatigue and a blistering eruption on the sun exposed areas of his skin. He also abuses alcohol consuming between 30-40 units a week. The GP carries out blood test and refers him for investigation of abnormal liver function tests.
In this patient:

a) Combination therapy will induce a response in 90% of patients
b) Development of cirrhosis does not preclude a good response to treatment
c) If the patient develops cirrhosis he has an 80-90% chance of developing hepatocellular carcinoma.
d) Without treatment end stage liver failure will develop in 2-3 years
e) In patients without cirrhosis, combination therapy induces a response in 45% of patients

Answer: e) The patient has hepatitis C with associated porphyria cutanea tarda. Significant liver disease develops in 20-30 % of patients who have necro-inflammatory disease. The process takes 20-30 years. Development of cirrhosis results in a poor response to combination therapy (Interferon and ribavarin) although the newer PEGylated interferons yield a better virological response. Once cirrhosis is established the incidence of hepatocellular cancer is 1.5-2 % per year.

BOF: 83 A 50-year-old male has been seen by his GP who has made a diagnosis of diabetes mellitus. On routine investigation he has been noted to have abnormal liver function tests. The GP refers him to the clinic querying non-alcoholic fatty liver disease. On examination he is pigmented, there is loss of body hair, gynaecomastia, testicular atrophy, and an arthropathy of his knee joints.In this patient treatment of the underlying condition will:

a) Increase the severity of the diabetes mellitus
b) Increase the size of the liver
c) Reverse any changes of cirrhosis
d) Only results in decrease in malaise and decreases liver size
e) Improves 5- year survival rate

Answer: e) The patient has haemochromatosis. Venesection is the best method of depleting body iron stores. It decreases the severity of diabetes mellitus and results in a general improvement in malaise and decreases liver size. The changes of cirrhosis are not reversible. Five-year survival has improved from 4.4 years in 1935 to 89% in 1969.

BOF: 84 A 40-year-old female presents with hepatitis. She also has arthralgia and autoimmune thyroid disease. Investigations reveal high serum transaminases, increase in total globulin and smooth muscle antibodies are positive.Where treatment of this condition is concerned:

a) Steroids are contraindicated as they increase the risk of osteoporosis
b) Steroids reduce the enzyme levels and decrease jaundice but are of no long term benefit
c) Steroids improve survival rate, but do not prevent development of cirrhosis
d) Steroids should be used continuously for 4 years
e) Azathioprine is as effective as steroids and can be used instead of steroids in older females

Answer:c) The patient has autoimmune hepatitis. In this condition response to steroids is excellent and improves five-year survival but does not prevent development of cirrhosis. Azathioprine is an useful adjunct to steroids and allows a lower dose of steroids to be used and thus reduces the risk of osteoporosis. If the disease is inactive for 2 years steroids may be cautiously withdrawn. Relapse is common (60-80 %) and necessitates reintroduction of steroids.

BOF: 85 A 50-year-old female presents with weakness of her left upper limb, which developed overnight. She says she fell asleep on a chair. On examination there is weakness of extension of her left elbow, a wrist drop and absent sensation over the first interosseus space of her left hand on the dorsal aspect. The lesion is in the:

a) Ulnar nerve at the elbow
b) Musculocutaneous nerve
c) Radial nerve in the spiral groove
d) Radial nerve in the axilla
e) Upper brachial plexus

Answer: d) The weakness of extension of the elbow indicates weakness of the triceps hence the lesion should be in the axilla. Lesions of the radial nerve in the spiral groove spare the triceps.

BOF: 86 A 32-year-old female who has had surgery on her cervical spine following a car accident presents with sudden onset of left-sided weakness. The weakness developed when she looked up whilst bending to pick up an object. On examination she has a hemiplegia affecting the left face arm and leg. She also has unilateral internuclear ophthalmoplegia with failure of adduction to the left and nystagmus to the left. She also has early papilloedema. In this patient MRI shows:

a) Right mid brain infarct
b) Left mid brain infarct
c) Right pontine infarct
d) Left pontine infarct
e) Lateral medullary syndrome

Answer: a) The patient has unilateral internuclear ophthalmoplegia. The side of the lesion is the side of the failure of adduction not the side of the nystagmus. This localises the lesion to the right medial longitudinal fasiculus. To cause weakness of face arm and leg the lesion must be above the pons.

BOF: 87 A 32-year-old female who has had surgery on her cervical spine following a car accident presents with sudden onset of left-sided weakness. The weakness developed when she looked up whilst bending to pick up an object. On examination she has a hemiplegia affecting the left face arm and leg. She also has unilateral internuclear ophthalmoplegia with failure of adduction to the left and nystagmus to the left. She also has early papilloedema. In this patient the papilloedema is due to:

a) Obstruction of the foramen of Magendie
b) Obstruction of the foramen of Luschka
c) Obstruction of the aqueduct of Sylvius
d) Obstruction of the foramen of Monro
e) Obstruction of the foramen of Morgagni

Answer: c) The aqueduct of the midbrain (the aqueduct of Sylvius) runs in the tegmentum of the midbrain and joins the third and fourth ventricles. Oedema around the midbrain infarct would have compressed the aqueduct and resulted in obstructive hydrocephalus and papilloedema.

BOF 88 A 57-year-old female who is known to have rheumatoid arthritis has been on penicillamine for treatment of her condition. She presents with oedema, proteinuria, hypoalbuminaemia and her serum cholesterol levels are elevated. In this patient renal biopsy:

a) Is indicated as she may have developed a vasculitis
b) Is indicated to decide if she needs steroids and immunosuppression
c) Should be performed in order to demonstrate minimal change nephropathy as this will respond to steroids
d) Is indicated to look for amyloidosis
e) Is not indicated

Answer: e) The patient has nephrotic syndrome. In patients on drugs such as penicillamine it is best to stop the drugs and assess response first, rather than proceed to renal biopsy. In nephrotic syndrome, renal biopsy is not indicated in: Young children, especially males, with a highly selective protein leak, no hypertension, no red cells or red cell casts in the urine Long standing insulin dependent diabetes mellitus with associated retinopathy or neuropathy as here the most likely diagnosis is diabetic nephropathy Patients on drugs, which should be stopped first
Title: Nephrotic Syndrome
Definition: The nephrotic syndrome consists of heavy proteinuria, hypoalbuminaemia and oedema. Hypercholesterolaemia is almost always present.
Aetiology:
Glomerulonephritis
Systemic vasculitides especially systemic lupus erythematosus
Diabetic nephropathy
Amyloidosis
Drugs: penicillamine, captopril, gold
Allergies
Clinical Features:
History:
KUS:
Swelling of the body
Frothy urine
Examination:
CVS
Venous thrombosis occurs due to:
Loss of factors such as antithrombin
Increased production of fibrinogen
KUS:
Oedema
Investigations:
Urine:
Proteinuria
24-hour urinary protein more than 3-5 gram daily
Selective protein clearance
Selective: minimal change nephropathy, early diabetes, amyloid
Unselective leak: in severe glomerulonephritis
Blood:
Serum albumin less than 30 g/dl
Serum electrophoresis: reduced serum albumin with an increase in alpha and beta globulin
Tissue Diagnosis:
Renal biopsy is indicated to see if the cause is a steroid sensitive lesion
Management:
Drugs:
Diuretics
Steroids
Cyclophosphamide
Cyclosporin
Vaccines:
Pneumococcal vaccine should be given, as sepsis is common in the nephrotic syndrome
Lifestyle Adjustments:
Diet high protein diet

BOF: 89 A 60-year-old male with uncomplicated stable alcoholic cirrhosis presents with severe breathlessness on exertion. On examination he was found to be anaemic and jaundiced. He has splenomegaly. His Hb is 8 gm/dl with normal MCV. WBC and platelet count are normal. There is no evidence of blood loss. Iron studies and red cell folate assay are normal. What is the most likely explanation for his anaemia?

a) Burr cell anaemia
b) Paroxysmal cold haemoglobinuria
c) Autoimmune haemolytic anaemia
d) Spur cell anaemia
e) Hypersplenism

Answer: d) Spur cell anaemia should be suspected when the anaemia is more severe than is observed in otherwise uncomplicated cirrhosis. Splenomegaly is always present. The RBC are irregularly shaped with multiple spicules. The surface membrane of a spur cell contains 50 – 70% excess cholesterol. Spur cells are distinguished from regularly spaced crenated RBC (Burr cells), which are present in some patients with uraemia. It is not hypersplenism because his white cells and platelets are normal.

BOF: 90 Which of the following conditions is most likely to be associated with Paroxysmal Cold Haemoglobinuria

a) Mycoplasma infection
b) Lymphoma
c) Systemic lupus erythematosus
d) Tertiary syphilis
e) Chronic lymphocytic leukaemia

Answer: d) This is a rare disorder now. It was more frequent when tertiary syphilis was prevalent. Now most cases are either secondary to a viral infection (measles and mumps in children) or are autoimmune. Paroxysmal Cold Haemoglobinuria results from the formation of the Donath-Landsteiner antibody, an IgG antibody that is directed against the P antigen. This can induce complement-mediated lysis. Attacks are precipitated by exposure to cold and are associated with haemoglobinemia and haemoglobinuria.

BOF: 91 A 40-year-old male was admitted with sudden onset headache and generalised tonic-clonic convulsion. MRI scan and subsequent MRI venography revealed sagittal sinus thrombosis. He recently recovered from an episode of aplastic anaemia. Investigation reveals anaemia with reticulocytosis. What is the most likely diagnosis?

a) Homocystinuria
b) Thrombotic thrombocytopaenic purpura
c) Paroxysmal Cold Haemoglobinuria
d) Paroxysmal Nocturnal Haemoglobinuria
e) Thalassaemia

Answer: d) Paroxysmal Nocturnal Haemoglobinuria (PNH) is an intracorpuscular defect acquired at the stem cell level. Three common manifestations are haemolytic anaemia, venous thrombosis and deficient haematopoiesis. Granulocytopaenia and thrombocytopaenia are common and reflect deficient haematopoiesis. Clinical haemoglobinuria is intermittent in most patients and never occurs in some, but haemosiderinuria is usually present. Venous thrombosis is a common complication of patients of European origin. Thrombosis can occur in cerebral venous sinuses and is a common cause of death in a patient with PNH.
Title: Paroxysmal Nocturnal Haemoglobinuria
Definition: A rare acquired red cell defect in which a clone of red cells is particularly sensitive to destruction by activated complement
Clinical Features:
History:
HS:
Breathlessness
GIT:
Recurrent abdominal pains
KUS:
Voiding of dark urine in the night or in the morning on waking
Examination:
CVS:
Venous thrombosis, which may be unusual such as Budd-Chiari syndrome, mesenteric vein thrombosis, cerebral vein thrombosis
Investigations:
Blood:
Anaemia
Thrombocytopaenia and neutropaenia may also occur
Flow Cytometric Analysis with anti CD 55 and anti CD 59. This has replaced Ham’s test
Tissue Diagnosis:
Bone marrow may be hypoplastic
Management:
Support:
Blood transfusion
Drugs:
Long term anticoagulation
Immunosuppression with antilymphocyte globulin or cyclosporin for bone marrow failure
Bone marrow transplantation
Prognosis:
PNH may transform into aplastic anaemia or acute leukaemia

BOF: 92 Thrombocytosis does not occur in:

a) Essential Thrombocytosis
b) Systemic Lupus Erythematosus
c) Inflammatory Bowel Disease
d) Acute Myeloid Leukaemia
e) Hyposplenism

Answer: d) Acute Myeloid Leukaemia (AML) causes thrombocytopaenia. Chronic Myeloid Leukaemia can cause thrombocytosis. Idiopathic sideroblastic anaemia and Myelodysplasia can cause thrombocytosis. Essential thrombocytosis is a clonal disorder of unknown aetiology and manifests clinically by the overproduction of platelets. It is often identified incidentally. Patients with Essential Thrombocytosis do have haemorrhagic and thrombotic tendencies

BOF: 93 Which of the following statements is not true about Waldenstrom’s Macroglobulinaemia?

a) Hypercalcaemia is common
b) Renal disease is not common
c) Peripheral neuropathy is not uncommon
d) Hepatosplenomegaly can occur
e) Lymphadenopathy is not uncommon

Answer: a) Waldenstrom’s Macroglobulinaemia is a malignancy of lymphoplasmacytoid cells. The disease is associated with lymphadenopathy, epatosplenomegaly and the hyperviscosity syndrome. The disease involves the bone marrow, but doesn’t ause lytic bone lesions or hypercalcaemia. IgM paraprotein has got very little excretion hrough urine because of its size. Therefore renal disease is not
common.

BOF: 94 Alopecia is not a feature of:

a) Secondary Syphilis
b) Hypothyroidism
c) Hypopituitarism
d) Hyperthyroidism
e) Hypoparathyroidism

Answer: e) Other systemic diseases that cause alopecia are lupus erythematosus, deficiencies of protein/iron/zinc/biotin, HIV infection

BOF: 95 Hyperpigmentation is not a manifestation of:

a) Addison’s disease
b) Vitamin B12 deficiency
c) Pellagra
d) Whipple’s disease
e) Systemic Lupus Erythematosus

Answer: e) Scleroderma can cause hyperpigmentation. Other conditions causing pigmentation are Nelson syndrome, Porphyria Cutanea Tarda, Haemochromatosis, Folate deficiency, Malabsorption, Biliary Cirrhosis, Eosinophilia-myalgia syndrome and POEMS syndrome.

BOF: 96 The following statements about Dermatitis Herpetiformis is false:

a) Papulovesicular lesions over the extensor surfaces are common
b) The rash is non-pruritic
c) Almost all patients have associated sub-clinical gluten-sensitive enteropathy
d) IgA is deposited in the skin
e) Increased incidence of thyroid abnormalities are found

Answer: b) Dermatitis Herpetiformis is intensely pruritic. Most patients with dermatitis herpetiformis do not report overt gastrointestinal symptoms or laboratory evidence of malabsorption. They also have increased incidence of thyroid abnormalities, achlorhydria, atrophic gastritis and antigastric parietal cell antibody. Dapsone is the initial treatment with institution of a gluten free diet.

BOF: 97 A 55-year-old male presents with acute bilateral visual loss. Both the optic discs are swollen and a central scotoma is detected. In further investigation of the cause of this condition the following blood levels are not required:

a) Ethylene glycol
b) Thiamine
c) Vit.B12
d) Folate
e) Vitamin A

Answer:e) The diagnosis is Toxic Optic Neuropathy. This can happen from exposure to ethambutol, methyl alcohol, ethylene glycol or carbon monoxide. Deficiency states induced either by starvation, malabsorption or alcoholism can lead to insidious visual loss. Thiamine, vitamin B12 and folate level should be checked in any patient with unexplained bilateral central scotoma and optic pallor

BOF: 98 Which of the following is not a clinical sequel of rhabdomyolysis:

a) Hypovolaemia
b) Metabolic alkalosis
c) Hyperkalaemia
d) Acute renal failure
e) Disseminated intravascular coagulation

Answer: b)Metabolic acidosis occurs in rhabdomyolysis due to release of cellular phosphate and sulphate.

Cardiovascular System ::

a) Mitral Stenosis
b) Mitral regurgitation
c) Mitral valve prolapse
d) Mitral valve replacement
e) Aortic stenosis
f) Aortic sclerosis
g) Aortic regurgitation
h) Aortic valve replacement
i) Pulmonary stenosis
j) Pulmonary regurgitation
k) Tricuspid stenosis
l) Tricuspid regurgitation
m) Infective endocarditis
n) Atrial septal defect
o) Ventricular septal defect
p) Patent ductus arteriosus
q) Coarctation of the aorta
r) Eisenmenger syndrome
s) Fallot’s tetralogy
t) Right ventricular failure
u) Left ventricular failure
v) Congestive cardiac failure

Patient 1 An elderly female /Height 1.56 m /Weight 54 kg /Comfortable in bed / Dowager’s hump /No malar flush /No clubbing /No splinter haemorrhages /Pulse 60 beats per minute, regular rhythm, small volume, slow rising, no collapse, no Bisferiens pulse, no radio-radial or radio-femoral delay
JVP not raised
Carotid pulse slow rising
Apex beat 5 LICS anterior axillary line, heaving, no thrill
Heart Sounds S1 normal S2 soft
Harsh ejection systolic murmur best heard in the aortic area radiating to the neck
Marked kyphosis
No sacral oedema
Lung bases clear

Answer: e) Aortic Stenosis ….The slow rising pulse suggests aortic outflow obstruction. The heaving apex suggests that the ventricle is contracting against resistance and is therefore stenotic rather than sclerotic.The displacement of the apex beat would suggest left ventricular dilatation and hence aortic regurgitation but this is not a true displacement of the left ventricle but is an apparent displacement as the patient has osteoporosis (marked kyphosis, dowager’s hump) and contraction of the ribcage.

Patient 2 The patient is a 75-year-old male who is 1.54 m tall and his weight is 55 kg. He appears comfortable at rest.
No pallor, no cyanosis.
No clubbing, no splinter haemorrhages. Peripheries are warm. Pulse rate 80 beats per minute, large volume, normal character (no collapse, no Bisferiens) no radio-radial or radio-femoral delay. Brachial artery is normal and there is no brachio-radial delay.
JVP not elevated carotid pulses are normal. Trachea is in the midline.
No deformity of the chest, no praecordial deformity or pulsation. Apex beat 5 LICS, MCL, normal character, no thrills. Heart sounds normal. There is a systolic murmur best heard in the aortic area although it is also heard well at the apex.
On asking the patient to sit up and lean forward a thrill is palpable at the 2 RICS just lateral to the sternum. A soft blowing early diastolic murmur is now heard at the left sternal edge.
No abnormality of the spine, no sacral oedema, lungs clear.
On auscultation of the femoral arteries no femoral thud or pistol shot is heard but a systolic bruit is heard when the artery is lightly compressed with the bell of the stethoscope.

Answer: e) Aortic Stenosis g) Aortic Regurgitation

Patient 3 The patient is a 43-year-old Caucasian male. He appears to be dyspnoeic and is propped up in bed. He is 1.77 metres tall and his weight is 72 kgs. His arm span measures1.82 metres. The lower segment of his body measures 91.44 cms. His skin appears pigmented.
His face is narrow and long and on examination of his mouth he has a high arched palate.
His hands appear long and his fingers are long and narrow. There is no clubbing, no splinter haemorrhages. There is no nail bed pulsation.
His pulse rate is 100 beats per minute, the rhythm is regular. The volume of the pulse is large and on raising the patient’ arms a collapsing pulse is felt. There is no Bisferiens pulse. There is no radio- radial or radio-femoral delay.
There is a sinuous pulsation in the neck which can be obliterated by pressure at the root of the neck and which increases when pressure is applied over the liver. There is no other visible pulsation. The trachea is in the midline.
His respiratory rate is 24 breaths per minute.
There is a depression at the lower end of the sternum. No praecordial pulsations are seen. The apex beat is at the sixth left intercostal space in the anterior axillary line. Normal character. No thrills are palpable.
On auscultation a third heart sound is audible at the apex of the heart. There is a pan-systolic murmur at the left sternal edge and this murmur does not radiate.
On asking the patient to sit up, lean forward and hold the breath in expiration, a short ejection systolic murmur and a short early diastolic murmur are heard at the left sternal edge.
The lungs are clear.
On auscultation over the femoral arteries a thud may be heard in systole and when the artery is lightly compressed with the bell of the stethoscope a systolic and diastolic bruit are heard.
The patient has bilateral ankle oedema.

Answer: g) Aortic Regurgitation l) Tricuspid regurgitation v) Congestive cardiac failure The patient also has features of Marfan's syndrome

Patient 4 A 78-year-old male. He is comfortable at rest. He is 1.77 m tall and weighs 78 kgs. He has no icterus and there is no pallor.
He has no clubbing there are no splinter haemorrhages.
His pulse rate is 80 beats per minute, regular rhythm, the pulse volume is large and a collapse can be detected. No bisferiens pulse. No brachio-radial delay. No radio-radial or radio-femoral delay.
The JVP is not elevated and the carotid pulses are normal. The trachea is in the midline.
No respiratory distress, no deformity of the chest. The apex beat is palpable in the sixth left intercostal space at the anterior axillary line. It is thrusting in nature. The first heart sound is not palpable. No thrills are palpable. Heart sounds are in dual rhythm. The first heart sound is of normal intensity and so is the second. There is an ejection systolic murmur at the aortic area and the left sternal edge and a blowing early diastolic murmur at the left sternal edge, best heard with the patient leaning forward and holding his breath in expiation. The ejection systolic murmur does not radiate to the neck. A rumbling mid-diastolic murmur is audible just medial to the apex of the heart.
The lungs are clear.
On auscultation over the femoral arteries a systolic bruit is audible on light compression with the stethoscope. No diastolic bruit, no pistol shot, no femoral thud.

Answer: g) Aortic Regurgitation …The patient does not have mixed aortic valve disease because there is no bisferiens pulse, no thrill, no radiation of the murmur to the patient’s neck. The mid-diastolic murmur is an Austin-Flint murmur. It is not due to mitral stenosis because the patient is in sinus rhythm, no parasternal heave, the first heart sound is not palpable and not loud, no opening snap, no pre-systolic accentuation .

Abdominal Examination

a) Hepatomegaly
b) Splenomegaly
c) Portal hypertension
d) Acute Hepatocellular failure
e) Chronic hepatocellular failure
f) Cirrhosis of the liver
g) Polycystic kidneys
h) Transplanted kidney
i) Renal carcinoma
j) Crohn’s mass
k) Carcinoma colon
l) Aortic aneurysm
m) Para-aortic lymphadenopathy
n) Ascites
o) Renal bruit
p) Hepatic bruit
q) Venous hum
r) Alcohol abuse

Patient 1 The patient is a 40-year-old Caucasian male. He is not well dressed. His spectacles are broken and held together with sticking plaster. His height is 1.77 m and his weight is 85 kg. His skin looks deeply pigmented.
His sclera is icteric. His hair is overgrown and not well groomed. There are several small telangiectasiae over his malar region. He has a full beard and moustache. There is no parotid enlargement.
He does not have leuconychia; there is no palmar erythema. He does have Dupuytren’s contracture. The peripheral circulation appears adequate; pulse rate 90 beats per minute regular, no collapse. No tremor or flapping tremor.
His JVP is not raised.
No spider naevi. He has hair on his chest. No gynaecomastia.
The abdomen is distended but the distension appears asymmetrical with the right hypochondrium being unduly prominent. No distended abdominal veins. The abdominal wall moves normally with respiration and there is no visible peristalsis.
There is a lump in the right hypochondrium. It has a well-defined edge, smooth surface, non-tender. It is not possible to get above the lump. There are no other masses.
Percussion note over the lump is dull and the dullness continues to the 5th right intercostal space mid clavicular line. No flank dullness, no dullness in the suprapubic region.
Normal bowel sounds no bruits.

Answer: a) Hepatomegaly d) Acute Hepatocellular failure r) Alcohol abuse

The unkempt appearance, broken spectacles and Dupuytren’s contracture would suggest the aetiology is alcohol abuse.
Jaundice suggests acute hepatocellular failure.
The lump in the right hypochondrium is an enlarged liver.
Does the patient have cirrhosis of the liver?
No, there is no clinical evidence of chronic hepatocellular failure nor is there evidence of portal hypertension.

BOF 99 Which one of the following tumours, in advanced stages, is not poorly responsive to chemotherapy?

a) Pancreatic carcinoma
b) Hypernephroma
c) Gall Bladder carcinoma
d) Ovarian carcinoma
e) Non-small cell lung carcinoma

Answer d) Other cancers that are poorly responsive to chemotherapy are thyroid carcinoma, carcinoma of vulva, colorectal carcinoma, prostate carcinoma, melanoma and hepatocellular carcinoma

BOF: 99 A 55-year-old male presents with acute bilateral visual loss. Both the optic discs are swollen and a central scotoma is detected. In further investigation of the cause of this condition the following blood levels are not required:

a) Ethylene glycol
b) Thiamine
c) Vit.B12
d) Folate
e) Vitamin A

Answer: e) The diagnosis is Toxic Optic Neuropathy. This can happen from exposure to ethambutol, methyl alcohol, ethylene glycol or carbon monoxide. Deficiency states induced either by starvation, malabsorption or alcoholism can lead to insidious visual loss. Thiamine, vitamin B12 and folate level should be checked in any patient with unexplained bilateral central scotoma and optic pallor

Respiratory System
a) Chronic bronchitis
b) Emphysema
c) Fibrosing alveolitis
d) Bronchiectasis
e) Consolidation
f) Collapse
g) Cavitation
h) Pulmonary fibrosis
i) Lobectomy
j) Pneumonectcomy
k) Lung abscess
l) Bronchial carcinoma
m) Pleural effusion
n) Empyema
o) Pleural thickening
p) Pneumothorax
q) Superior vena cava obstruction
r) Cor pulmonale
s) Horner’s syndrome
t) T1 lesion
u) Pancoast’s syndrome

Patient 1 A 70-year-old male who looks unwell and distressed. His height is 1.65 m and his weight is 60 kg.
He has flaring of his alae nasi but there is no polycythaemia or cyanosis.
He has clubbing of his fingers and tar staining of his fingers. There is no hypertrophic pulmonary osteoarthropathy.
His JVP is not elevated; the trachea is in the midline.
The respiratory rate is 26 per minute. The apex beat is difficult to palpate. Respiratory movements are diminished at the left base. Vocal fremitus is reduced at the left base. Percussion note is dull at the left base (stony dullness). Breath sounds are diminished at the left base and there is a patch of bronchial breathing (confirmed by whispering pectoriloquy) around the inferior angle of the scapula. Vocal resonance is diminished at the left base and around the level of the inferior angle of the scapula aegophony can be heard (just below the area at which bronchial breathing can be heard).

Answer: e) Consolidation / f) Collapse
m) Pleural effusion
l) Bronchial Carcinoma
The patient has a collapse/consolidation with overlying pleural effusion in the left lung. It is likely to be a bronchial carcinoma in view of the clubbing, tar staining and the fact that the trachea is not displaced despite the effusion.

Patient 2 The patient is a 65-year-old lady. Her height is 1.54 m and her weight is 50 kg. She appears breathless on minimal exertion. There is an oxygen mask lying on the cupboard by her bedside.
Her alae nasi flare with respiration, there is no polycythaemia or cyanosis.
Her nails are not clubbed. No peripheral cyanosis is observed. Her hands are warm to touch, the radial pulse rate is 90 beats per minute and regular and there is no tremor or flapping tremor.
Her JVP is elevated 5 cms above the manubriosternal angle, both a and v waves can be seen and there is no dominant wave. The trachea is in the midline.
Her respiratory rate is 28 per minute. The apex beat is at the 5 LICS lateral to the MCL. Respiratory movements are equal on the two sides. Vocal fremitus is equal on the two sides. Percussion note is normal and cardiac and liver dullness are not decreased.
Breath sounds are vesicular and equal on the two sides, vocal resonance is normal and equal on the two sides. Fine late inspiratory crepitations are heard at the lung bases.
The second heart sound is loud and split, the split varying normally with respiration.

Answer:
c) Cryptogenic Fibrosing Alveolitis
r) Cor pulmonale
A thin elderly lady who is breathless at rest and has fine late inspiratory crepitations at the lung bases is most likely to be suffering from fibrosing alveolitis. The loud, split P2
suggests pulmonary hypertension and the elevated JVP in association with elevation of
both a and v waves suggests right heart failure
The patient’s chest x-ray showed an enlarged boot-shaped heart with dilated pulmonary arteries.

Patient 3 The patient is a 75-year-old male. His height is 1.67 m weight is 68 kg.
He appears breathless on minimal exertion and there is an oxygen mask by his side.
His left eyelid appears drooping and his left pupil is constricted. There is no polycythaemia or central cyanosis.
His fingers are clubbed. There is wasting of all the small muscles of his left hand. His pulse rate is 90 beats per minute and regular. There is no tremor nor is there a flapping tremor.
His JVP is not raised. The trachea is deviated to the left. He has bilateral cervical lymphadenopathy and the lymph nodes in the supraclavicular region are firm and matted.
The respiratory rate is 26 per minute. The apex beat is in the 6 LICS anterior axillary line. Respiratory movements are decreased at the right base. Vocal fremitus is decreased at the right base. Percussion note is stony dull at the right base. Breath sounds are diminished at the right base and vocal resonance is decreased at the right base.

Answer:
m) Pleural effusion
l) Bronchial Carcinoma
s) Horner’s syndrome
t) T1 lesion
The clubbing and right-sided pleural effusion suggests a bronchial malignancy with effusion. The Horner’s syndrome and T 1 lesion are due to cervical lymphadenopathy rather than a left apical bronchial cancer.

Eyes
a) Glaucoma
b) Optic atrophy
c) Papilloedema
d) Papillitis
e) Central retinal vein thrombosis
f) Central retinal artery occlusion
g) Branch retinal artery occlusion
h) Angioid streaks
i) Myelinated nerve fibres
j) Diabetic retinopathy (Background)
k) Diabetic retinopathy (preproliferative)
l) Diabetic retinopathy (proliferative)
m) Hypertensive retinopathy (grade 1)
n) Hypertensive retinopathy (grade 2)
o) Hypertensive retinopathy (grade 3)
p) Hypertensive retinopathy (grade 4)
q) Acute choroiditis
r) Chronic choroiditis
s) Drusen
t) Age related macular degeneration
u) Retinitis pigmentosa
v) Retinal detachment
w) Laser burns
x) Vitreous haemorrhage
y) Asteroid hyalosis
z) Synchysis scintillans
aa) Subhyaloid haemorrhage

Patient 1 A 45-year-old female. Pale disc with decreased blood vessels crossing the disc. Black pigment (similar to bone corpuscles) seen scattered throughout the retina.

Answer:
b) Optic atrophy
u) Retinitis pigmentosa
Retinitis pigmentosa causes consecutive optic atrophy.

Patient 2 A 70-year-old female. She has drooping of her right eyelid. Her right iris is blue in colour and the left iris is brown. The right pupil is smaller than the left.

Answer: b) Horner’s syndrome ..She has heterochromia iridis. This is congenital Horner’s syndrome

Patient 3 A 70-year-old male. On examination of the fundus the disc appears pale. On more detailed inspection the optic cup is deep (like a well) and the blood vessels appear to climb out of this deepened cup. The rest of the fundus is normal.

Answer: a) Glaucoma

Skin
a) Ehlers-Danlos syndrome
b) Pseudoxanthoma elasticum
c) Neurofibromatosis
d) Systemic sclerosis
e) Peutz-Jeghers syndrome
f) Osler-Rendu-Weber syndrome
g) Sturge-Weber syndrome
h) Neurofibromatosis
i) Tuberose sclerosis
j) Systemic sclerosis
k) Psoriasis
l) Lichen planus
m) Lupus pernio
n) Lupus vulgaris
o) Erythema nodosum
p) Dermatitis herpetiformis
q) Necrobiosis lipoidica diabeticorum
r) Pretibial myxoedema
s) Acanthosis nigricans

Patient 1 The patient is a 50-year-old female. Her height is 1.6 m weight 58 kg. Her nose is beak like and there are multiple telangiectasiae over her face. Her mouth appears small and rounded. Her hands look small and the fingers are thin and tapered. The skin over the fingers is taut.

Answer: d) Systemic sclerosis

Patient 2 The patient is a 60-year-old male. He is 1.65 metres tall and his weight is 65 kg. There are multiple fleshy papules and nodules distributed all over his body. In his iris there are a few deeply pigmented lesions. On his trunk there are several pigmented macules and in his axilla there are several smaller pigmented macules.

Answer: h) Neurofibromatosis

Patient 3 The patient is a 60-year-old male. He has multiple red plaques with silvery scales on his scalp, over his elbows and over the lower limbs. On examination of his hands there is a flexion deformity of the terminal interphalangeal joints (mallet finger) of his right and left index and fourth fingers.

Answer: k) Psoriasis

Endocrine
a) Acromegaly
b) Nelson’s syndrome
c) Hypopituitarism
d) Hypothyroidism
e) Hyperthyroidism
f) Goitre
g) Pseudohypoparathyroidism
h) Cushing’s syndrome
i) Addison’s disease

Patient 1 The patient is a 45-year-old female. She is 1.6 m tall and her weight is 85 kg. Her face looks plump but the skin is not oily and she does not have acne.Her hands look normal. The circumference of the upper limbs appears disproportionate to the torso. Over her forearms and upper arms there are multiple erythematous papules and pustules. There is a pad of fat just below her neck posteriorly. Her abdomen shows a midline surgical scar and there is a large fatty apron. No striae. Her lower limbs appear narrow in comparison to her torso.

Answer: h) Cushing's Syndrome

Patient 2 The patient is a 75-year-old Caucasian male. He is 1.67 m tall and his weight is 66 kg. His skin is pigmented. There is pigmentation of his buccal mucosa and the skin creases of his palms are pigmented. His nipples and areola are deeply pigmented. The abdomen does not show any scars and on turning the patient no scars are seen at the back.

Answer: i) Addison's Disease

Patient 3 The patient is a young female. She is quite short (4 foot 11 inches or 1.49 m). She is plump and her face appears rounded (chubby). On examination of her hands her 4th and 5th fingers are short and when she makes a fist it appears that the 4th and 5th metacarpals are short.

Answer: g) Pseudohypoparathyroidism

Patient 4 The patient is a middle aged female. She is about 1.62 m tall and is overweight. She is seated comfortably in a chair. On examination of her eyes there is proptosis, lid retraction and exophthalmos. The conjunctiva is oedematous. On testing eye movements one may detect lid lag and on extremes of eye movement the patient complains of double vision. On examination of her hands there is no tremor pulse rate 80 beats per minute and regular.On examination of the neck there is no goitre.

Answer: f) Thyroid (Grave’s) ophthalmopathy She is euthyroid

Locomotor System
a) Rheumatoid arthritis
b) Psoriatic arthropathy
c) Systemic lupus erythematosus
d) Enteropathic arthritis
e) Ankylosing spondylitis
f) Gout
g) Osteoarthritis
h) Paget’s disease
i) Polymyositis

Patient 1 The patient is a 35-year-old male. He is 1.72m tall and his weight is 75 kg. He appears stooped and when asked to back up against a wall his occiput does not reach the wall. There is loss of the lumbar lordosis and he has a kyphosis. His abdomen is protuberant. All spinal movements are decreased.

Answer: e) Ankylosing Spondylitis

Title: Ankylosing Spondylitis
Definition: Ankylosing spondylitis is a systemic rheumatic disorder that is characterised by inflammation of the axial skeleton and the large peripheral joints.
Aetiology:
Related to the incidence of HLA-B 27
Clinical Features:
History:
More frequent in men. Milder disease in women.
Age of presentation 20- 40 years.
E&M:
Low-grade fever
Weight loss
GIT:
Anorexia
LMS:
Pain and stiffness in the back
Worse in the morning, relieved by activity
Examination:
E&M:
Weight loss
CVS:
Aortic incompetence
Angina
Pericarditis
Conduction defects
RS:
Apical fibrosis and cavitation
CNS:
Anterior uveitis
Radiculitis
Sciatica
Vertebral fracture, subluxation
Cauda equina syndrome
LMS:
Loss of lumbar lordosis
Kyphosis
Decreased spinal movements
Costochondritis
Peripheral joint involvement asymmetrical large joints
Investigations:
Blood:
ESR, CRP mildly elevated
HLA-B27 positive supporting evidence
X-Ray:
Sacroiliitis
Squaring of vertebrae, demineralisation, ligamentous calcification, bamboo spine ultimately
Management:
Drugs:
NSAIDS for pain
Sulphasalazine and methotrexate may help peripheral arthritis
Physiotherapy:
Spinal and chest exercise
Prognosis:
Good prognosis with pain relief and exercise

BOF: 101 A 75-year-old male presents with lethargy and dizziness on standing. He gives a history of having had treatment for tuberculosis when he was young. On examination he looks underweight, his skin is pigmented and there is pigmentation of his buccal mucosa and pigmentation of the palmar creases. His nipples and areola are pigmented. There is no vitiligo. His blood pressure is 120/70 lying down and 90/60 on standing. His blood urea 10.3 mmol/L, Na 120 mmol/L, K 5.9 mmol/L Which of the following investigations is most likely to identify the aetiology of his condition?

a) 0900 ACTH level
b) Short synacthen test
c) Abdominal X-ray
d) Long ACTH stimulation test
e) Serum aldosterone /plasma renin activity

Answer: c) The patient has Addison’s disease. With the history of tuberculosis the likely aetiology is tuberculosis of the adrenal gland and this may result in calcified adrenals.

Title: Addison’s Disease
Aetiology: Inflammation
The cause of inflammation of the adrenal gland may be:
Autoimmune which could be:
• Sporadic
• Polyglandular deficiency type 1 (Addison’s disease, chronic mucocutaneous candidiasis, dental enamel hypoplasia, alopecia, primary gonadal failure)
• Polyglandular deficiency type 2 (Addison’s disease, primary hypothyroidism, primary hypogonadism, insulin-dependent diabetes mellitus, pernicious anaemia, vitiligo)
Inflammation of the adrenal gland may also occur in tuberculosis, sarcoidosis, fungal infections, cytomegalovirus infection, AIDS
Trauma bilateral adrenalectomy
Neoplasia secondary deposits, lymphoma
Vascular Lesions meningococcal septicaemia, adrenal haemorrhage, adrenal vein thrombosis
Degenerative adrenoleucodystrophy, adrenomyeloneuropathy
Metabolic haemochromatosis
Interstitial Infiltration amyloidosis
Clinical Features:
Females > Males
History:
E&M:
Weight loss
Malaise
Weakness
Fever
CVS:
Syncope due to postural hypotension
GIT:
Anorexia
Nausea and vomiting
Abdominal pain
Diarrhoea
RAG:
Impotence
Amenorrhoea
CNS:
Depression
Confusion
LMS:
Joint pains
Back pain
Myalgia
Examination:
E&M:
Decreased weight
Wasting
Salt and water loss
IS:
Buccal pigmentation
Pigmentation of palmar creases, scars
Vitiligo (autoimmune)
Loss of body hair
CVS:
Postural hypotension
Investigations:
Blood:
Hyponatraemia, hyperkalaemia, increased urea
Blood glucose low
Cortisol levels low
Short synacthen test: impaired response
0900 ACTH level: increased
Adrenal antibodies + in autoimmune adrenalitis
Serum aldosterone is decreased with increased plasma renin activity
CXR:
Tuberculosis
Abdominal X-ray:
Calcified adrenals

Management:
Drugs:
Replacement
Glucocorticoid:
Hydrocortisone, prednisolone, dexamethasone
Mineralocorticoid
Fludrocortisone

BOF: 102 A 60-year-old female is admitted with a history of syncopal episodes and breathlessness of one-week duration. No history of immobilisation or recent travel. On examination she looks distressed her conjunctiva and tongue are pale. Her pulse rate is 120 beats per minute, blood pressure 90/60, JVP elevated 5 cms. Respiratory rate 26 per minute, apex 5 LICS MCL heart sounds triple rhythm, soft systolic murmur at the left sternal edge. Lungs clear. HB 13.5 g/dL Blood gases pH 7.46 Pa CO2 3.2 kPa, Pa O2 7.7 kPa The next step in management of this patient is:

a) Immediate thrombolysis followed by an ECHO to confirm the diagnosis
b) Immediate thrombolysis followed by computerised tomographic pulmonary angiography (CTPA) to confirm the diagnosis
c) Immediate thrombolysis followed by ventilation perfusion scan to confirm the diagnosis
d) Urgent CT pulmonary angiography followed by thrombolysis
e) Full dose fragmin followed by ventilation perfusion scan

Answer: d) The clinical features in this patient suggest massive central pulmonary embolus. It is best to obtain an urgent CT PA or ECHO prior to thrombolysis. In a cardiac arrest or peri-arrest situation it may be justifiable to thrombolyse the patient and confirm the diagnosis by CTPA or ECHO if the patient survives.

BOF: 103 A 52-year-old female presents with numbness and weakness of her upper and lower limbs. She developed asthma at the age of 50 and her general practitioner treated her with steroids and antibiotics approximately one month prior to the onset of these symptoms. On examination she looks unwell. She has palpable purpura over her face and over her elbows and knees.On neurological examination she has a left sided wrist drop and there is weakness of dorsiflexion of her right hallux and weakness of dorsiflexion of her right foot. Sensation is impaired over the dorsum of her right foot.
Lungs are clear. CXR is normal
Hb 10.9 g/dL MCV 88 fl
WBC 23,000 10 9 /l
Eosinophils 12%
ANCA negative
In this patient abdominal pain could be due to:

a) Pancreatic infarction
b) Gall bladder infarction
c) Vasculitis of the gastrointestinal tract
d) Renal infarction
e) Splenic infarction

Answer: c) The patient has Churg-Strauss syndrome. The diagnosis may be made on the basis of late onset asthma, vasculitic rash and mononeuritis multiplex.ANCA is positive in approximately 60 % of the patients hence a negative ANCA does not rule out the diagnosis. In this condition vasculitis of the gastrointestinal tract may result in mass lesions that cause intestinal obstruction.

BOF: 104 A 45-year-old female presents with an 8-week history of diarrhoea with no blood or mucous, colicky abdominal pain, vomiting and loss of weight of 10 kgs. She has a history of appendicetomy and has fibromyalgia for which she has been on Diclofenac SR 75 mgs b.d. On examination she was afebrile and looked pale. The abdomen was diffusely tender but soft. Bowel sounds were normal and rectal examination was normal. Investigations showed: Hb 7.5 g/dL, MCV 70 fl CRP 235, coeliac screen negative LFTs normal, urea and electrolytes normal Colonoscopy revealed several webs with superficial ulceration in the ascending colon. Biopsies from these areas showed non-specific inflammation. In this patient, the most important aspect of treatment is:

a) Discontinue Diclofenac
b) Treat with Steroids
c) Treat with Mesalazine
d) Treat with Azathioprine
e) Treat with Ciprofloxacin

Answer: a) The patient has non-steroidal anti-inflammatory drug colopathy. This can occur after short or long term treatment with NSAIDS. These patients should be warned against any further use if NSAIDS.

BOF: 105 A 30-year-old female is under investigation for excessive weight gain. She is 1.62 m tall and weighs 80 kgs. She has central obesity with abdominal striae. She is hirsute. A dexamethasone suppression test has been performed and the results are as follows: Cortisol levels nmol/L Dexamethasone
Day 0 0900 990 8mgs
Day 1 0900 320 8mgs
Day 2 0900 130
The patient has:

a) Cushing’s disease
b) Adrenal tumour
c) Bronchial carcinoma
d) Simple obesity
e) Polycystic ovarian syndrome

Answer: a) In the dexamethasone suppression test normal individuals suppress cortisol levels to < 50 nmol/L 90 % of patients with pituitary dependent disease suppress production of cortisol to < 50 % of that on day 0 on day +2 Failure of suppression suggests ectopic ACTH production or adrenal tumour

Title: Cushing’s Syndrome
Definition: Cushing’s syndrome is condition caused by increased free circulating glucocorticoid
Aetiology:
ACTH dependent
Pituitary dependent (Cushing’s disease)
Ectopic ACTH producing tumours
Non-ACTH dependent
Adrenal adenoma
Adrenal carcinoma
Exogenous steroid
Clinical Features:
History:
E&M:
Weight gain
Growth arrest in children
KUS:
Polyuria, polydypsia
RAG:
Loss of libido
Amenorrhoea, oligomenorrhoea
CNS:
Insomnia, depression, muscular weakness
LMS:
Backache
Examination:
E&M:
Central obesity
Buffalo hump
Moon face
IS:
Hirsutism, frontal balding
Pigmentation
Thin skin
Skin infections
Poor wound healing
Striae
Bruising, plethora
CVS:
Hypertension
Oedema

CNS:
Proximal muscle weakness
LMS:
Osteoporosis
Fractures (vertebra and ribs)

Investigations:
Confirm Cushing’s
48 hour low dose dexamethasone suppression test
24 hour urinary free cortisol
Loss of circadian rhythm of cortisol secretion
Determine Cause
Adrenal CT or MRI
Pituitary MRI
High dose dexamethasone suppression test
Plasma ACTH levels
CRH test
CXR

Management:
Drugs:
Metyrapone
Ketoconazole
Aminoglutethimide
Trilostane
Chemotherapy for ACTH secreting tumours
Surgery:
Pituitary Dependent
Trans-Sphenoidal removal of pituitary tumour
Bilateral adrenalectomy (Cushing’s disease) as a last resort
Adrenal adenoma
Resection
Adrenal carcinoma
Resection or debulking
ACTH secreting tumours
Resection if possible
Radiotherapy:
Pituitary irradiation
Irradiation of ACTH secreting tumours

BOF: 106 A 14-year-old male has had a cardiac catheterisation to document the diagnosis of an abnormality of his heart. The results are as follows: Chamber Pressure in mm Hg % Oxygen saturation Superior vena cave 68 Inferior vena cave 64
Right atrium 10 82 Right ventricle 25/0 81 Pulmonary artery 25/10 81
Left atrium 10 96 Left ventricle 110/0 95 FemoralArtery 110/50 95
In this patient, on auscultation of the heart one may hear:

a) Loud single second heart sound
b) Soft single second heart sound
c) Fixed splitting of the second heart sound
d) Reversed splitting of the second heart sound
e) Varying split of the second heart sound

Answer: c) The patient has an atrial septal defect. In this condition fixed splitting of the second heart sound occurs.

BOF: 107 A 45-year-old female presents with backache. She has had a thyroidectomy for thyrotoxicosis 18 months previously. She is a vegan. Her blood results are as follows:
Hb 10.0 g/dL
Ca 1.8 mmol/L
PO4 0.72 mmol/L
Alkaline phosphatase 200 U/L
Albumin 36 g/L
Urea 6.5 mmol/L
Sodium 140 mmol/L
Potassium 3.8 mmol/L
The test that will define this patient’s condition is:

a) PTH level
b) Serum 25-hydroxy vitamin D3 level
c) Urinary calcium excretion
d) Urinary phosphate excretion
e) Iliac crest biopsy

Answer: b) The patient has osteomalacia with secondary hyperparathyroidism causing low phosphate levels.

BOF: 108 A 14-year-old male, a recent immigrant to the country is been investigated for a murmur. On examination he is in sinus rhythm, he has a loud pan systolic murmur best heard at the left sternal edge and a mid-diastolic murmur best heard at the apex. The first heart sound is not loud; there is no opening snap and no pre-systolic accentuation of the diastolic murmur.
Cardiac catheterisation results are as follows:

Chamber Pressure (mm Hg) % Oxygen saturation
Superior vena cava 66
Inferior vena cava 68
Right atrium 3.5 67
Right ventricle 35/0 80
Pulmonary artery 35/10 81
Left ventricle 100/0 96
In this patient the mid-diastolic murmur is due to:

a) Increased flow across the mitral valve
b) Increased flow across the tricuspid valve
c) Mitral stenosis
d) Tricuspid stenosis
e) Lutembacher’s syndrome

Answer: a) The patient has a ventricular septal defect. This can be deduced from the step up in oxygen saturation at the level of the right ventricle due to the left to right shunt at this level. This causes increased flow into the left atrium and this causes a flow murmur in mid-diastole. Stenosis of the mitral valve would result in a loud first heart sound, opening snap and presystolic accentuation of the murmur. Tricuspid stenosis would have caused a high pressure in the right atrium. Lutembacher’s syndrome is a combination of atrial septal defect and mitral stenosis.

BOF: 109 A 60-year-old male is under investigation for weakness of his legs, pigmentation of the skin, hypertension and glycosuria.
Results of serum cortisol estimations are;
0900 1170 nmol/l
2400 1100 nmol/l
After 48 hours of dexamethasone 8 mgs daily:
0900 1030 nmol/l
In further investigation of this patient the test most likely to identify the cause of his condition is:

a) MRI head
b) CT scan head
c) Perimetry to define visual fields
d) Chest x- ray
e) ACTH levels

Answer: d) The patient has Cushing’s syndrome with failure to suppress cortisol levels with dexamethasone. This will indicate either an adrenal tumour or an ectopic source of ACTH. Out of the list provided the most likely investigation that will determine the cause of the lesion is CXR

BOF: 110 A 31-year-old female presents with a severe headache, which woke her up from sleep at approximately 3 a.m. She has never had a headache like this before. She had a mastoidectomy several years ago. She has no other symptoms and was otherwise well; she is not pregnant and was on no drugs in particular she was not on hormonal contraception. She had not undertaken any severe exercise. On examination she was afebrile, conscious and alert. On examination of the optic fundus the cup of the optic disc was filled and the medial margins of the disc were blurred. No other CNS abnormality in particular no neck stiffness. Examination of the other systems did not reveal any abnormality. A CT scan was reported as normal by the duty radiology registrar, Full Blood Count was normal. In this patient the investigation that is likely to lead to a diagnosis is:

a) MR venogram
b) Lumbar puncture
c) Vitamin A level
d) Cisternal puncture
e) E.S.R.

Answer: a) The patient has sagittal sinus thrombosis. This can be secondary to Thrombophilia, which may be primary or secondary to diseases such as nephrotic syndrome, paroxysmal nocturnal haemoglobinuria. It can also occur in pregnancy and in patients taking hormonal contraception. Dehydration is another cause. It may be secondary to sinusitis and mastoiditis or it may be idiopathic.

In this patient the treatment of choice would be:

a) Heparin
b) Steroids
c) Vitamin A
d) Acetazolamide
e) Repeated lumbar puncture

Answer: a) Sagittal sinus thrombosis is beat treated with heparin. There are reports in the literature of successful thrombolysis by local instillation of thrombolysis.

BOF: 111 A young female who is short, plump and has a rounded facies has the following haematology and biochemical profile:
Hb 12.8 g/dl
Serum Calcium 1.62 mmol/l
Serum Phosphate 2.9 mmol/l
Creatinine 44 micromoles/l
Albumin 38 g/l
Which radiological abnormality is likely in this patient?

a) Defective mineralisation of the pelvis
b) Looser’s zones
c) Nephrocalcinosis
d) Subperiosteal erosions in the middle or terminal phalanges of the hands
e) Short fourth and fifth metacarpals

Answer: e) The patient has pseudohypoparathyroidism, which is associated with short metacarpal bones Looser’s zone are linear areas of low density surrounded by sclerotic borders. This and defective mineralisation of the pelvis are x-ray features of osteomalacia. Nephrocalcinosis and subperiosteal erosions occur in hyperparathyroidism

BOF: 112 A 60 year old male presents with backache and discomfort in his pelvis. He is a widower and lives alone in a small flat.
Investigations are as follows:
Serum calcium 1.9 mmol/l
Serum phosphate 0.6 mmol/l
Alkaline phosphatase 140 U/l
Urea 5.5 mmol/l
Albumin 36 g/l
In this patient the following x-ray changes are likely:

a) Calcification of the basal ganglia
b) Pseudofractures of the pubic rami
c) Osteoporosis circumscripta
d) Rounded lytic lesions in the skull
e) Nephrocalcinosis

Answer: b) The patient has osteomalacia. The x-ray feature that may occur in this condition is pseudofracture of the pubic rami.Calcification of the basal ganglia is a feature of hypoparathyroidism. Osteoporosis circumscripta refers to a front of resorbing bone in the skull. It occurs in Paget’s disease of bone. Rounded lytic lesions in the skull occur in myeloma. Nephrocalcinosis is a feature of hyperparathyroidism.

BOF: 113 A 74-year-old male who is known to have ischaemic heart disease and has had a myocardial infarction presents with breathlessness. His extremities are cold and clammy; his pulse rate is 120 beats per minute, blood pressure 80/40. JVP elevated, heart sounds triple rhythm, crepitations are heard in both bases.
Investigations show:
pH 7.24
Pa O2 8.5 kPa
Pa CO2 4.4 kPa
Blood lactate 5.9 mmol/l
Urine pH 5.2
Urine osmolarity 320mmol/l
Blood glucose 8.6 mmol/l
In this patient the abnormal acid-base balance is due to:

a) Aspirin overdose
b) D-lactic acidosis
c) Type A L-lactic acidosis
d) Type B L-lactic acidosis
e) Diabetic ketoacidosis

Answer: c) Type A L-lactic acidosis occurs when excess lactic acid is formed by anaerobic metabolism. Type B L-lactic acidosis is due to decreased hepatic lactate metabolism caused by insulin deficiency, drugs such as biguanides, haematological malignancies, enzyme deficiencies. D-lactic acidosis is caused by bacterial fermentation in the gut in the short bowel syndrome.

BOF: 114 A 56-year-old female presents with a history of increasing tiredness. On examination there is pigmentation of her skin creases and buccal mucosa. Her blood pressure is 90/50.
Investigations are as follows:
Blood urea 8.4 mmol/l
Na 130 mmol/l
Potassium 6.1 mmol/l
Chloride 96 mmol/l
Bicarbonate 23 mmol/l
Which of the following tests will confirm the diagnosis?

a) Random cortisol measurement
b) Short ACTH stimulation test
c) Long ACTH stimulation test
d) 0900 Plasma ACTH level and cortisol measurement
e) Abdominal x-ray

Answer: d) This patient has Addison’s disease. A high 0900 h plasma ACTH level with low or normal cortisol will confirm the diagnosis of primary hypoadrenalism The short ACTH (synacthen) test would show that the adrenal gland is not responding to ACTH. This may be due to primary hypoadrenalism or secondary to adrenal suppression by steroids or ACTH deficiency. Hence it will not confirm the diagnosis. She does not have adrenal suppression by steroids or ACTH deficiency as her skin creases and buccal mucosa are pigmented. Hence, a long ACTH stimulation test is not the answer.

BOF: 115 A young female has the following somatic features:
Short stature, round face, short neck, short fourth and fifth metacarpals and metatarsals
Her investigations are as follows:
Serum calcium 2.2 mmol/l
Serum phosphate 1.2 mmol/l
Alkaline phosphatase 100 U/L
Urea 4.0 mmol/L
Creatinine 90 mmol/L
The diagnosis is:

a) Pseudohypoparathyroidism
b) Hypoparathyroidism
c) Rickets
d) Vitamin D resistant rickets
e) Pseudopseudohypoparathyroidism

Answer: e) This patient has the somatic features of pseudohypoparathyroidism but biochemistry is normal indicating pseudopseudohypoparathyroidism

BOF: 116 A 50-year-old male who is known to have chronic bronchitis presented to the accident and emergency department. After initial treatment he was sent up to the ward. His blood gases on admission to the ward were as follows:
pH 7.22
PaO2 14.4 kPa
PaCO2 18.8 kPa
The physical sign that alerted the examining clinician to this condition was:

a) Tachycardia
b) Pulsus paradoxus
c) Flapping tremor
d) Elevated JVP
e) Fourth heart sound

Answer: c) A flapping tremor is indicative of hypercapnia

BOF: 117 A 35-year-old female has been on treatment for depression. She complains of constipation. Her blood results are as follows:
Serum calcium 2.77 mmol/l
TSH 20 mU/l
Which drug is responsible for these features?

a) Amitryptiline
b) Fluoxetine
c) Venlafaxine
d) Mirtazepine
e) Lithium

Answer: e) Lithium can causes hypercalcaemia and hypothyroidism. Lithium can increase serum calcium, reduce serum phosphorous, and increase PTH 10-15 % patients will develop slightly elevated Ca and PTH within 4 weeks of starting treatment with lithium. These values may reverse within one week of lithium discontinuation

Short note on ECG

2004-08-18T13:57:00.000-07:00

ECG. Look at the ECG and say it is a 12 lead Ecg and date and time and name of the pt. etc. Comment on the rate-divide 300 by the no. of big squires per R-R interval. rythm- take a piece of paper, mark 3 R waves and slide them and see whether they are equal. Now your rate and rythm are okey. Then look at the ST segment. Only think about the elevation. Inf.MI-2,3,aVF. anteroseptal-V1-4. Anterolateral-V4-6,1,aVL. I don't think they will ask you post. MI.

Vacutainer............Hand

2004-07-23T07:45:00.000-07:00

Vacutainer – hand
Script for the Clinical Skills Video Series: May 2003.

Start by introducing yourself to the patient and gain consent to take a blood sample.

Prepare your equipment so that you will have everything you need:

Wash your hands thoroughly before returning to the patient.

Identify the patient verbally and using the ID bracelet and then check the identification on the request form.

Collect your equipment. Put on your gloves and apply the tourniquet to the lower arm.

Palpate the veins to distinguish structures and select an appropriate vein.

Clean the area with an alcohol swab and allow to dry for 30 seconds.
While it is drying, prepare the syringes and needle.

Check that the seal is not broken before twisting to remove the outer cover. Then fit the needle cover tube to the needle that will pierce the vacutainer.

Open the butterfly,… remove the bung,… and join that to the end of the connector.

Unsheath the needle on the butterfly and fold the butterfly wings up. Hold these to insert the needle.

Stretch the skin over the back of the hand and insert the needle with a quick sharp scratch and then into the vein. Flatten the butterfly wings down onto the back of the hand. You should see the flashback of the blood coming up into the tube.

Take a vacutainer and push it into the needle cover tube, so piercing the end of the vacutainer and allowing the blood to fill the container. Ensure that you hold the lipped edges of the needle cover and apply pressure to the end of the vacutainer.

If you need another sample, hold the needle steady while you unclick the first vacutainer and click the second into place.

Once the second vacutainer is full take it out from the needle cover. Then remove the tourniquet. Finally cover the needle with a pad as you remove the needle from the skin. Do not apply pressure until the needle has been withdrawn.

Immediately place the needle in the sharps bin and apply pressure to the site for up to two minutes or until it has stopped bleeding.
Once it has stopped bleeding, then you can apply a plaster.

The vacutainers are self sealing. However make sure the identifying material is entered onto the syringe cases. Then put the syringes with the request form and make sure you take all your equipment and the sharps bin away with you when you leave the patient.

Vacutainer............antecubital

2004-07-23T07:44:00.000-07:00

Vacutainer – antecubital
Script for the Clinical Skills Video Series: May 2003.

Always start by introducing yourself to the patient and gaining consent to take a blood sample.

Prepare your equipment so that you will have everything you need – see the web page link for full details.

Wash your hands thoroughly before returning to the patient.

Identify the patient verbally and using the ID bracelet and then check the identification on the request form.

Collect your equipment and put on your gloves.

Apply the tourniquet to the upper arm. Palpate the veins to distinguish structures and select an appropriate vein.

Clean the area with an alcohol swab and allow to dry for 30 seconds. While it is drying, you can prepare the needle. .

Check that the seal is not broken before twisting to remove the outer cover. Then fit the needle cover tube to the needle that will pierce the vacutainer.

Unsheath the other end of the needle and ensure that the bevel is down.

Stretch the skin over the vein with the thumb of one hand. Insert the needle with a quick sharp scratch and then into the vein at between 30 and 45 degrees.

Take a vacutainer and push it into the needle cover tube, so piercing the end of the vacutainer and allowing the blood to fill the container. Ensure that you hold the lipped edges of the needle cover and push on the end of the vacutainer, so that you do not push the needle further into the patient’s arm.

If you need another sample, hold the needle steady while you unclick the first vacutainer and click the second into place.

Once the second vacutainer is full take it out from the needle cover. Then remove the tourniquet. Finally cover the needle with a pad as you remove the needle from the skin. Do not apply pressure until the needle has been withdrawn.

Immediately place the needle in the sharps bin and apply pressure to the site on the arm for up to two minutes or until it has stopped bleeding.

Once it has stopped bleeding, then you can apply a plaster.

The vacutainers are self sealing. However make sure the identifying material is entered onto the syringe cases. Then put the syringes with the request form and make sure you take all your equipment and the sharps bin away with you when you leave the patient.

Monovette...........hand

2004-07-23T07:43:00.000-07:00

Monovette – hand

Script for the Clinical Skills Video Series: May 2003.

Start by introducing yourself to the patient and gain consent to take a blood sample.

Prepare your equipment so that you will have everything you need:

Wash your hands thoroughly before returning to the patient.

Identify the patient verbally and using the ID bracelet and then check the identification on the request form.

Collect your equipment. Put on your gloves and apply the tourniquet to the lower arm.

Palpate the veins to distinguish structures and select an appropriate vein.

Clean the area with an alcohol swab and allow to dry for 30 seconds.

While it is drying, prepare the syringes and needle.

First remove the connector from its outer packaging and fit it to the first syringe, ensuring that you turn the connector, clicking it into place rather like a light bulb fitting. Then open the butterfly,… remove the bung,… and join that to the end of the connector … and there you have the full monovette system.

The first sample tube is always used without vacuuming it first. Follow-on samples can be vacuumed in advance if desired.

Fold the butterfly wings up and hold these to insert the needle.

Stretch the skin over the back of the hand and insert the needle with a quick sharp scratch and then into the vein. Flatten the butterfly wings down onto the back of the hand. You should see the flashback of the blood coming up into the tube.

Draw the plunger of the syringe back steadily to withdraw blood.

If you need another sample, hold the needle steady while you unclick the first syringe and click the second into place.

Once the second syringe is full remove the syringe. Then remove the tourniquet. Finally cover the needle with a pad as you remove the needle from the skin. Do not apply pressure until the needle has been withdrawn.

Immediately place the needle in the sharps bin and apply pressure to the site for up to two minutes or until it has stopped bleeding.

Once it has stopped bleeding, then you can apply a plaster.

Ensure the plungers on the syringes are clicked back into place, then break off the plungers to leave sealed samples of blood.

Make sure the identifying material is entered onto the syringe cases. Then put the syringes with the request form and make sure you take all your equipment and the sharps bin away with you when you leave the patient.

Venepuncture.............

2004-07-23T07:36:00.000-07:00

venepuncture: equipment
·                  Sharps bin
·                  Toppers
·                  Tourniquet
·                  Appropriate syringes for the test or tests required
·                  Appropriate sized needle
·                  Sterile alcohol wipe
·                  Plaster
·                  A container to put them all in and
·                  Gloves
extract from the Practical Skills Log Book

Introduces self, gains consent and co-operation

Can name the most frequently used veins for venepuncture

Assembles the appropriate equipment

Identifies patient verbally and using ID bracelet, checks identification on request form and against patient's ID bracelet

Washes hands and wears gloves

Ensures patient is comfortable and assesses venous access on both arms aware of risk factors and reasons (names 3 reasons why some veins may not be used)

Applies tourniquet

Palpates veins to distinguish structures

Massages vein and lightly taps with finger

Cleans area with alcohol swab and waits 30 seconds or until the area is dry

Anchors the veins

Uses collection system correctly and fills tubes required

Releases tourniquet

Applies sterile swab to insertion site and removes needle

Applies pressure to site for 2 minutes or asks patient to do so

Disposes of sharps safely

Monovette – antecubital
Script for the Clinical Skills Video Series: May 2003.

Start by introducing yourself to the patient and gain consent to take a blood sample.

Prepare your equipment so that you will have everything you need:
Sharps bin
Toppers
Tourniquet
Appropriate syringes for the test or tests required
Appropriate sized needle
Sterile alcohol wipe
Plaster
A container to put them all in and
Gloves

Wash your hands thoroughly before returning to the patient with all the equipment

Identify the patient verbally and using the ID bracelet and then check the identification on the request form.

Put on your gloves and apply the tourniquet to the upper arm.

Palpate the veins to distinguish structures and select an appropriate vein.

Clean the area with an alcohol swab and allow to dry for 30 seconds or until dry.

While it is drying, prepare the syringes and needle.

Remove the needle from its outer packaging and fit to the first syringe, ensuring that you turn the needle, clicking it into place rather like a light bulb fitting.

The first sample tube is always used without vacuum. Follow-on samples can be vacuumed if desired.

Unsheath the needle and ensure that the bevel is down.

Stretch the skin over the vein with the thumb of one hand. Insert the needle with a quick sharp scratch and then into the vein at between 30 and 45 degrees.

If you need another sample, hold the needle steady while you unclick the first syringe and click the second into place.

Once the second syringe is full remove the syringe. Then remove the tourniquet. Finally cover the needle with a pad as you remove the needle from the skin. Do not apply pressure until the needle has been withdrawn.

Immediately place the needle in the sharps bin and apply pressure to the site on the arm for up to two minutes or until it has stopped bleeding.

Once it has stopped bleeding, then you can apply a plaster.

Ensure the plungers on the syringes are clicked back into place, then break off the plunger to leave a sealed sample of blood.

Make sure the identifying material is entered onto the syringe cases. Then put the syringes with the request form and make sure you take all your equipment and the sharps bin away with you when you leave the patient.

CBCU: May 2003.

Cannulation

2004-07-23T07:32:00.000-07:00

equipment needed to perform cannulation
·                  Sharps bin
·                  Toppers
·                  Tourniquet
·                  Cannula
·                  IV300
·                  Sterile alcohol wipe
·                  Plaster
·                  A container to put them all in and
·                  Gloves
tips from clinicians:
Helen Smith, Consultant Anaesthetist, Addenbrookes:
"In order to cannulate a vein you need to be able to feel or see the vein, preferably both. Allowing time for the tourniquet to produce dilated veins helps enormously, also asking the patient to perform a tight squeezing action of the hand several times as well as placing the limb below the level of the heart aid venous dilatation.
Preventing the vein moving on cannulation. This is prevented by the use of skin traction and where possible placing the cannula where two veins drain into a single vein.
Make sure you let the injection site dry after cleaning. Most pain at cannulation is due to non-evaporated alcohol entering the wound.
Insert the needle thro the skin above the vein at an angle of 25-35 degrees. Once thro the skin lower the cannula so it is almost flush with the skin and continue to push along the direction of the vein until you feel a loss of resistance as the cannula enters the vein. Blood will appear in the hub of the cannula – flash back. At this point elevate the tip of the cannula so that it is pointing upwards – this prevents the cannula from moving out the back wall of the vein, a very common mistake. With the cannula in this position, gently advance the cannula further along the line of the vein to be certain the cannula tip is securely inside the lumen of the vein. Maintain skin traction as you slide the cannula over the needle into the vein. Stop applying skin traction and release the tourniquet."

extract from the practical skills log book...................>>

Introduces self, gains consent and co-operation

Prepares tray for cannulation to include cannula, steret, IV 3000, flush (saline not water) 5 ml syringe, tourniquet

Identifies patient verbally and using ID bracelet

Positions arm/checks and selects suitable vein

Washes hands and wears gloves

Places tourniquet on arm, cleans skin with alcohol wipe (steret) and waits 30 seconds or until the area is dry

Holds cannula correctly with the bevel at the top

Passes the cannula into the vein at an angle of 25-35 degrees and observes for flash back

Gently advances the cannula a few millimetres beyond the point of flash back

Slides the cannula over the needle maintaining traction to the skin

Releases tourniquet

Removes the needle and places cap onto cannula. Secures and flushes cannula.

Cannulation Script
Script for the Clinical Skills Video Series: May 2003.

Introduce yourself to the patient, gain consent and explain the cannulation procedure.

Wash your hands thoroughly and then assemble the equipment you will need. … Klaud is showing some of the items required here including the IV3000 which will cover the cannula. See the Equipment list for the full details of items.

When you return to the patient, check their identity with their patient card and ID bracelet.

Apply a tourniquet 3-5 inches below the antecubital fossa , ensuring that the arterial flow is not impaired. Put on protective gloves.

Palpate the veins and find a vein which is near the surface and springy to the touch. It should be away from a joint.

Clean the site with a sterile alcohol based swab for at least 30 seconds and leave to air dry for a further 30 seconds. Most pain at cannulation is due to non-evaporated alcohol entering the wound.

Unwrap the cannula and, holding the skin taut one with hand, insert the cannula through the skin above the vein at an angle of 25-35 degrees. Once through the skin lower the cannula so that it is almost flush with the skin and continue to push along the direction of the vein until you feel a loss of resistance as the cannula enters the vein. Blood will appear in the hub of the cannula – the ‘flash back’.

Gently advance the cannula further along the line of the vein to be certain the cannula tip is securely inside the lumen of the vein.

Maintain skin traction as you slide the cannula over the needle into the vein.

Stop applying skin traction and release the tourniquet.

Remove bung from the end of the cannula, if you have not chosen to remove it earlier. While holding the cannula steady, compress the tip (to prevent blood flowing out) and carefully withdraw the needle.

Place the needle in the sharps container and re-attach the bung to the cannula.

Apply the IV3000 over the ‘wings’ of the cannula to hold it securely in place.

Then flush the cannula through with sodium chloride, checking that it is within the expiry date.

Apply a clean bandage to the site and clear everything away when you leave the patient.

Basic Life Support

2004-07-23T07:26:00.000-07:00

Basic Life support………………….

things to remember............
Make sure the person ringing for help remembers:

- the number to call
- to describe accurately where help should be sent

some of the FAQs from the Resuscitation Council Website

Why has the ratio of chest compressions to ventilations changed from 5:1 to 15:2?

The most important reason is that more compressions can be given each minute with a ratio of 15:2 than they can with a ratio of 5:1. Circulating blood volume in this situation is likely to be directly proportional to the number of compressions, assuming compression rate and quality stay the same. Also, when chest compressions are performed during cardiac arrest the coronary perfusion pressure rises progressively. With each pause for ventilation the perfusion pressure falls rapidly. It then takes several further compressions before the previous level of brain and coronary perfusion is re-established.

Why has the mouth to mouth ventilation volume for adults increased to 700-1,000ml per breath?

The 1998 ERC guidelines recommended that each breath of mouth to mouth ventilation should deliver between 400ml and 600ml whilst the American Heart Association Guidelines recommended a volume of between 800ml and 1,200ml. A lower volume decreases the risk of gastric inflation but without oxygen supplementation may result in suboptimal oxygenation. As a compromise it is recommended that for adult resuscitation each rescue breath (without supplemental oxygen) should deliver a volume of 10ml/kg which approximates to 700 -1,000ml for an average male adult. This should be delivered slowly (over 2 seconds) and the rescuer should take a deep breath before each ventilation to optimise the oxygen concentration in the expired air. In practice, there is no change in the BLS guidelines since the instruction "Blow... to make (the victim's) chest rise as in normal breathing" is the same.

In the sequence of actions for BLS why has the assessment of the victims airway for obstruction changed?

The change is really one of uniformity. During the ILCOR 1992-1997 discussions there was a 50:50 split between those who wanted to check the mouth first, and those who wanted to check breathing first. There was no science available, but anecdotally there is no difference in outcome between these two approaches.

How much movement would you expect to see in a patient with respiratory arrest?

There is no single answer to this, as it depends on the individual and the circumstances of cardiopulmonary arrest. The concern is that the victim in respiratory arrest alone would receive chest compressions despite the presence of a spontaneous circulation. Without the provision of artificial ventilation, a victim in respiratory arrest will develop cardiac arrest rapidly. Outside hospital, the discovery of a victim in respiratory arrest alone is comparatively rare. The risks associated with chest compressions in a victim with spontaneous circulation are small. Much greater harm would result if, as a result of the incorrect detection of a pulse, chest compressions were withheld from the victim of true cardiorespiratory arrest.

What harm can I do by doing chest compressions?

Injury can result from chest compressions, especially if the hands are positioned too low on the sternum because of the risk of rupture of the liver. With good technique it is unlikely that any serious injury will occur. However, the overwhelming message is that, on balance of risks, less harm is done by giving chest compression to a victim with a circulation, than withholding them from one in cardiac arrest.

The Guidelines state that a single rescuer will have to decide whether to start resuscitation or go for help first and that if the likely cause of unconsciousness is trauma, drowning, choking, drug or alcohol intoxication or if the victim is a child, the rescuer should perform resuscitation for about one minute before going for help. When training lay people in basic life support should they be taught these exceptions?

The majority of cases of sudden cardiac arrest in adults are due to ventricular fibrillation, and the Resuscitation Council (UK) therefore teaches that the emergency medical services should be called as soon as a victim is found not to be breathing. If, however, the primary cause of unconsciousness is respiratory arrest, there is potential benefit in performing some CPR before leaving the victim, since restoration of breathing or prevention of cardiac arrest may result. For this reason, a list of the most likely causes of respiratory arrest is included in the guidelines. Skill acquisition and retention in resuscitation training has been increasingly recognised as a problem, particularly for lay persons when BLS courses are, of necessity, short. Where possible, the Guidelines have been simplified to aid learning, but a balance has to be struck between ensuring that course participants remember the basic management of cardiac arrest, and teaching additional procedures for less common situations. The BLS/AED Subcommittee of the Resuscitation Council (UK) accepts the established concept that it may be beneficial to give some resuscitation before leaving to obtain help for the victim of primary respiratory arrest. It recognises, however, that this applies to relatively few cases of cardiopulmonary collapse and only when the rescuer is on his or her own. The potential advantages of including these exceptions in BLS training are outweighed by the well-proven disadvantage of having to teach additional steps in the BLS sequence. For these reasons, the Subcommittee recommends that the list of exceptions should not be taught on adult basic life support courses. It is recognised, however, that trainers will at times have to respond to specific training needs. The exceptions should be included in courses for specific target groups, such as paediatric life support and lifeguard training.
extract from the practical skills log book.................>>

Aware of the Resuscitation (UK) Guidelines

Establishes and maintain a person's airway and provide artificial respiration when required

Competently provide external cardiac massage

Recognise why people suffer a respiratory / cardiac arrest

Blood pressure measurement

2004-07-23T07:18:00.000-07:00

equipment required for taking blood pressure·
Sterets ·
Stethoscope ·
Blood Pressure Gauge ·
Pen or pencil and
patient notes or notepad

tips from clinicians>>

It is sometimes advisable to take the blood pressure in both arms, particularly if the blood pressure appears to be raised.Blood pressure should also be measured in the standing position in patients whose symptoms or drug regimes may be associated with a dis-proportionate postural fall. This would include, for example, diabetic patients with autonomic neuropathy.

extract from the practical skills log book.....................>>

Introduces self, gains consent and co-operation

Chooses correct sized cuff and places the cuff on correctly.

Correct position of arm (antecubital fossa in line with heart).

Feels radial/brachial pulse.

Inflates cuff and notes when pulse can no longer be felt then releases cuff.

Places stethoscope over the brachial artery on the medial aspect of the antecubital fossa using diaphragm side.

Inflates cuff to 20-30mm Hg above level noted previously and drops the column slowly.

Listens and records correctly korokoff sounds.

>>>

Check you have all the equipment you require – a blood pressure monitor and a stethoscope. Klaud demonstrates how the cuff will be pumped up and releasing the pressure.

Introduce yourself to the patient and ask the following questions:

Have they had their blood pressure taken before? If not, explain the procedure.
Have they taken exercise, drunk tea or coffee or been smoking in the last 30 minutes?

Ask the patient to roll up their sleeve and ensure that the sleeve is not too tight around the upper arm.

Wrap the cuff around the upper arm. Warn the patient of minor discomfort caused by inflation and deflation of the cuff and tell the patient that the measurements may be repeated several times.

The centre of the cuff bladder should be positioned over the artery. The cuff should fit firmly and be comfortably secured. The lower edge of the bladder should be 2-3 centimetres above the point of the maximum pulsation of the brachial artery.

The arm should be horizontal and supported at the level of the heart otherwise you could over-estimate or under-estimate the blood pressure levels.

Klaud first estimates the blood pressure by using the radial pulse. With your fingers on the pulse, inflate the cuff until the pulsation disappears. Then deflate the cuff. The point of disappearance represents the approximate systolic blood pressure. This avoids under-estimation of systolic blood pressure when there is an oscultatory gap.

In this case the systolic estimate was 112.

Then palpate for the brachial artery and place the stethoscope gently over the artery at the point of maximal pulsation. Do not press too firmly or the dystolic pressure may be under-estimated.

Inflate the cuff to 30 millimetres above the systolic blood pressure as estimated by palpation. Then reduce the pressure at 2-3 millimetres per second. The point at which repetitive clear tapping sounds appear for at least two consecutive beats give the systolic blood pressure. You can see the pattern clearly from the sound wave picture.

The point where the repetitive sounds finally disappear gives the dystolic blood pressure.
For clarity both measurements should be taken to the nearest two millimetres.
In this case the blood pressure was 110 over 80.

Where blood pressure is 140 over 90 millimetres on the first reading, it is suggested that a second reading should be taken. At least one minute should elapse between readings.

Past OSCE stations

2004-07-22T14:32:00.000-07:00

Past OSCE stations..............
History Taking:
1.Haematuria History & discuss Management Plan with the patient.
2.A female Pt with abdominal pain. Umbilical pain radiated to right iliac fossa and the patient has mild fever and had regular periods one week back.
3. LOC take history: TIA
4. Amenorhea: Anorexia nervosa
5.Fever and brathlessnes for 3 days in a young man.
6.Child with cold for ten days drinking lots of water: DM
7.Postpartum depression.
8.A male, 55, no smoker, chest pain, left sided, 18 hrs duration ECG normal. hx suggested pleuritic pain, but did not exclude unstable angina because atypical pain with both parents died from heart problems at their 60's
9.Severeheadache, photophobia, history and management (offer analgesia)
10.A young lady with a 7 month infant and swollen left leg (# of femur): physical abuse
11.Dysphagia+/-dyspepsia..w/wo h/o smoking
12.Asthma attack
13.Thyrotoxicosis: young girl w wt. Loss, sweating, palpitations.
14. 56 lady w ur. Incontinence: past deliveries forceps and prolonged labour.
15.Man with rectal Bleeding father dies of bowel Ca. Works in an antique shop.
16.Symptom of alcohol excess.
17.9mnth old child with fit.
18.Pt. With cough, pleuritic chest pain: take history and give DD.
19.pt with a painful snuff box: xray shows clear fracture…give diff diagnosis.
20.Lady with pain in LIF, (EP)
21.Lady with RUQ pain radating to back(gall stones with infection)
22.A nurse with a constipated patient who is on codeine for vertebral pain, has swelling in lower abdomen also.Take history.
23.50lady with hemoptysis of 1 week.
24.lady 28 rs, 38wks pregnant w pre-eclampsia, protein +++in urine and 160mmhg systolic: Take history and discuss management.
25.Lady with fever
26.Men with chest pain on exertion:had endoscopy and triple treatment.
27.Man 50 with h/o fall w LOC of 2 mins, a bruise on head, bar owner..talk to him
28.History from a woman whose child has been screaming for the last ten hrs (intususseption)
29.Young woman with lower abdominal pain(cystitis)
30.Bleeding PV: history and investigations.
31.man with delusion thinks his wife is having an affair : take history and give diagnosis.
32.Panic attack/agarophobia:take hx
33.Plumber with cough and sputum.
34.Numbness/paraesthesia in right hand for few mnths. Take hx (carpal tunnel synd
35.Hoarseness.
36.Subarachnoid Hemorhage.Hx & Mx
37.Macroscopic hematuria.
38.Peripheral vascular disease:intermittent claudication.
39.Whiplash injury, depressed patient…take history.
40.First episode of wheezing:exercise induced asthma
41.Dysphasia
42.Food poisoning: Hx & Mx
43.Young man with cough and wheeze since last night.started 3 mnths ago when he had a cold: take hx.:classic asthma
44.Headache giant cell arteritis.
45.Father worried of child not well who had a cold few days ago. Take hx.
46.Wt. Gain history taking:; hypothyroidism
47.Take hx of risk factors for TIA.
48.SOB: take hx.
49.Premature menopause: take hx
50.Young guy with delusions of persecution : hx and counselling.
51.Antepartum hemorhage in 32 weeks pregnant ; hx and Mx discussion with pt.
52.Hx of dizziness and tell D/D
53.Baby blues (Hx or counselling)
54.Hx of Scrotal Swelling
55.Neonatal Jaundice (hx /counselling)
56.Ear Pain
57.Generalized Lymphadenopathy
58.Total Hip Replacement
59.Total Knee Replacement
60.DM with Joint swelling
61.Hemetemesis
62.Pain at waking after 50 yards
63.Prostatism
64.PPH
65.Menorhagia
66.Post viral fatigue syndrome
67.Ruptured spleen
68.Red Eye.

Counselling
1.Mesothelioma. Break the bad news to wife
2. Mother worried about son having meningitis but who is diagnosed to have URTI.
3. Ovarian Cystectomy : open surgery/pffanisteil incision - dermoid cyst.
4.Man with cluster headache, diagnosed to have Migraine 5 yrs back, CT normal …wants MRI : counsel.
5.Neonatal jaundice: physical examination normal
6.Morphine advice /side effects (2). Patient complains of side effects and says pain is not controlled by morphine 30mg PO BID
7.Epilepsy advice
8.A man, 75, fever 38°C, pain, dribbling stream, pr shows enlargement of prostate, smooth. discuss management. Prostatitis advice: BPH: do US scrotum
9.Post partum hemorhage.
10.Asthma medicine advise.
11.lady with RA: problem w sleep:husband passed away 6mnths ago
12.Testicular lump
13.Pre discharge advice to MI pt. W drugs side effects.
14.Amitryptyline side effects, addiction , driving
15.emergency endoscopy of patient with melana and hematemesis.
16.HRT side effects and benefits.
17.Child with irritable hip: pre discharge advise to mother.
18.Scrotal swelling
19.lady passed dark stools: take history: D/D: analgesic gastropathy,bleeding diathesis.
20.Hernioraphy under LA: anxious patient,/explain local anesthesia pre operatively.
21.Breaking bad news to wife of patient with pleural Ca nd previous asbestos exposure.
22.Counselling of mather of a child with post viral myalgia.
23.HIV counselling : patient wants to move with his new girl friend and u want her to be tested.
24.Women worried of STD(not of HIV), /men had unprotected sex.
25.Drug addiction: heroine and cocaine
26.CIN3 counselling
27.Men with RTA depressed, unemployed for ten months.
28.Ankle swelling discuss management:no history allowed.
29.Antidepressant drug counselling
30.Missed abortion: prepare for D&C and break the news.
31.Gonorrhea counselling
32.Pre eclampsia for CS: talk to husband.,
33. Child taken ten OCPs: counsel mother (worried about immature puberty which cannot be initiated with single dosage)
34.Discus management with patient with ankle injury who has no fracture on xray.
Discuss management
35.Sterilisation
36.Mother whose child had RTA: spleen injury and fracture femur.
37.talk to patient with hyperemesis gravidarum
38.Talk to parent about appendicectomy
39.pain relief for hernia..previous hernia.
40.Incessant cry investigation normal: worried mother
41.Explain right hemicolectomy w midline laparotomy w primary anastomosis.
42.PID: counselling at dismissal.consequences.
43.Further pain managaement of terminally ill Ca patient already on morphine
44.Life style modifications at post MI discharge
45.Colposcopy: dyscariasis
46.Child abuse: fracture femur/swollen thigh in neonate/7mnth…single mother w boyfriend.:learn how to break the diagnosis of NAI.
47.Complications of meningococemia:discuss with mother.Answer if she can see the child.(ans: this is a communicable disease nd child is in isolation,so only can see through the glass window)
48.Pat with Hypetn, has high cholesterol: has been given three medicines: aspirin, simvastatin and enalapril: discuss these drugs.no BNF provided.
49.Pt w ectopic wants to go home coz she has a four yr old at home: counsel to stay.
50.Patient with toe operation discovered to have high MCV: discuss and take alcohol history.
51.Minocycline and its side effects.
52.BPH: TURP counselling
53.Carbamazepine,
54.Acne : consult about treatment and side effects.
55.Stroke
56.Consititutional anemia:hx and counsel
57.Co-codermol.
58.talk to pt with secodaries whose morphine dose has been changed:allay her anxieties.
59.talk to female pt whose parents are worried that she has lost wt(anorexia nervosa)
60.talk to female pt who has not had periods for the last nine mnths.
61.talk to pregnant female with high BP.
62.Hysterectomy.
63.Pre-eclamptic mother who refuses admision: convince.
64.Post splenectomy
65.Post nephrectomy
66.mother of a child who has swollowed a coin.
67.Pain management in labour
68.Palpitations counselling
69.Midazolam
70.Chronic back pain.
71.Stress incontinence and detrusor instability
72.Testicular tumour
73.d/d of distended abdomen post hemicolectomy(hypokalemia,int obs, reactionary hemorhage)
74.Talk to 45 yrs old who has undergone mastectomy and axillary nodes excision.
75.Heart failure : counselling pre discharge
76.Patient who had a heart attack six weeks ago with LV dysfunction, ankle edema,and shortness of breath on exertion, explain about condition and explain management, and life style.
77.Tota Hip replacement
78.Total Knee replacement

Examinations
1.DM type 1 Pt. examine the motor and sensory
2.Pilot station: it was a patient with Hodgkin’s lymphoma and I was suppposed to do lymphoreticular system examination!!!!!!!!! I didn’t know that it’s a pilot. Oh my goodness!!!!!!!!!!!!!!! I approached, inspected for clubbing, jaundice, masses, scars, and sinuses bla bla bla. Then I palpated lymph nodes and told that I would palpate the inguinal nodes also, the examiner said suppose it is done. Then I did abdominal examination to feel for hepatomegaly and splenomegaly
3.Hip Examination: Pt. With osteoarthritis
4.Arterial examination of legs, inspection/palpation.
5.Knee examination : pain worse on kneeling and walking on rough ground:examine appropriate to history./knee injury while playing football.
6.Breast examination
7. Mental state examination: suicide risk
8.Elbow examination
9.Pt with Scaphoid francture: examination.fell on outstrected hand
10.diabetic leg examination. / sciatica leg examination.
11.RUQ pain: Murphy postive: confirm history and make specific examination.
12.CHD focused exam
13.Back examination: Pt with sciatica
14.Resp system.+ peak flow meter use
15.Pt. In coma :examine CNS
16. Cranial nerves.
17. Lady with dizziness: examine with otoscope nd tunning fork./ slide CSOM
18.Lady with PCM poisoning, physically stable: Assess mental status and risk of suicide
19. Lady with postpartum depression : mental examination.
20.Secondary survey of a guy who fell from ladder.
21.Primary survey
22.Examine upper abdomen and give DD: pt with pain.
23.Sensory system of alcoholic 60yr lady./ sensory and motor exam in alcoholic.
24.Assess GCS of semi conscious patient: not allowed to remove clothes.
25.Thyroid examination
26.Examine CVS./esp for heart failure.
27.Talk to patient and do cognitive examination.
28.Assess memory, concentration and orientation in a pt brought by husband who does not dress well, has bad memory and not her usual self.
29.Young man with possible fracture of hand.perform examinationand explain management to patient.
30.Assesment in neck injury.
31.Primary survey: pelvic pain
32.Secondary survery, head and neck done…start with chest.
33.Lumbar spine examination and neurological examination.
34.Mini mental state examination
35.Lymphoreticular system examination
36.Mini Mental State Examination of Alcohol

Procedures
1.Paediatric CPR.
2.Cannulation/
blood drawing/venepuncture.(sometimes name on bracelt and form different..check it out)"
3.BP (medium cuffs, aneuroid app need to be lifted))
4. Cervical Smear
5. Cauterisation.
6.Adult CPRexaminer asked me what is the specific area that we should,nt press)ans xiphisternum. When is it dangerous to do Chest compression?ans: rib fracture., To call crash team??
7.PR : palpate prostate
8.Suturing
9.Ophthalmoscopy
10.Bimanual vaginal examination.
11.Blood drawing for anemic patient
12.BP of lady who feels dizzy when got up./postural hypotension
13.IV infusion
14.BP by Diastolic method.
15.Fundoscopy.
16.CPR in cyanosed patient
17.Blood for cross matching
18.BLS
19.Otoscopy ..grommet was inside.
20.Do otoscopy and other tests in elderly patient with hearing loss.
23.Vacutainer

Others
1.Management of MI, examiner showed CXR
and ECG and some medicines."
2.Rt. Hemicolectomy: phone call to consultant.Patient drowsy after hemicolectomy viotals given.
3.Difference between frequency and polyuria
4.Menorhagia- Fibroids.
5.Take consent from parents of a young boy for appendicectomy
6.72 yrs old lady with bowel obstruction: ABXR prepared: talk to consultant on phone.
7. Postop internal abdominal bleeding : talk to consultant.
8.Phone conversation with mother of 18mnth old child with diarhea who had similar episode in past and was admitted for IVF: child had 3 times diarhea otherwise fine: give advise(diarolite soln)
9.Discussion with examiner of diabetic ketoacidosis.patient semi cons, nausea, vomiting, left lower lobe pneumonia with consilidation on Xray.
10.Take patients consent for surgery who is worried for pain and has had previous wound infection in past surgery.
11.(DKA, HONK) 25 year person on insulin who took last two doses, presents with coma. The examiner asks questions, initial management, DDx, RBS=43 mmol/l, K=2.5 mmol/l, urine ketone bodies +++ (now what? management), WBC=18*10^9, (ans =Infection .) Shows an X -Ray-l/s lobar pnumonia. M=what antibiotic
12.Phone with parent of child who was give Abac by a GP.
13.talk to registrar about a woman with intestinal obstruction due to strangulated hernia. X ray displayed and vitals provided.
14.Consent for postmortem / include removal and storage of certain organs(PE)
15.Talk with examiner about diagnosis: CXR, ECG, choose 3 appropriate drugs of 10
16.Acute chest pain with Xray: Cardiac failure: drug management chose four drugs to administer in A&E.
17.Questions on organsisms of pneumonia.
18.Stress incontinence treatment options.
19.Dysmenorhea: treatment options.
20.Ectopic pregnancy : treatment
21.Paracatamol poisoning, 15 tab 12 hrs ago..what to do next: do not take psychiatric history.
22.Scaphoid fracture: right type of POP cast and Rx asked.
23.Phone call to registrar: what progress u made after admitting pt with strangulated hernia.
24.Disc compression and symptoms per level.
25.Postmortem consent of daugther whose mother died 2 days post op hysterectomy.
26.Earache , drowsy: phone.
27.Discuss with examinor cause of collapse six hrs after surgery.
28.Midazolam Solution IV infusion, How much normal saline to be added to give 1ml/hr wt:40kg, dose :20ug/kg/hr
29.Prepare morphine for a child 3 kg at rate of 1 ml / hr dose is 20ug/kg/hr and 1 amp =1ml=10mg morphine
30.Why beta blockers are contraindicated in patient of MI with HF, COPD, Pulm edema or bradycardia?
31.Calculate dose of pethidine for 24 hrs , 10kg wt, 1ml=0.5mg pethidine
32.Fentanyl Dosage

feedback from examiners on Candidates from GMC website

2004-07-22T14:30:00.000-07:00

General Feedback from Examiners on Candidates’ Performance in the OSCE

Feedback from examiners has shown up trends in the way candidates perform some tasks and the following information may be useful to you:

Examiners have observed that candidates do not always listen to the patients’ responses. These candidates concentrate on asking a series of questions rather than really listening to what the patient has to say and responding accordingly. They produce set phrases intended to indicate empathy and understanding but do not actually demonstrate these qualities by their responses and behaviour. It is important to help patients to be able to express what they want to say. These comments apply not only to communication stations such as breaking bad news or explaining treatment, but also to other stations with a communication element within them. In history taking, for example, these skills are important in eliciting the information that you need and when you are giving information, in checking understanding.

Examiners have noticed that candidates have particular difficulty with psychiatric stations. Being able to assess suicidal risk, for example, is a very important skill in the UK.

In the practical stations, it is important to consider preparation, technique and the safety of the patient and others. When reflecting on your performance, do not think about your technique alone.

When doing clinical examinations it is important to go through all the steps properly. Examiners have observed that some candidates display evidence of rote learning with no understanding.

In emergency management, examiners have noticed that candidates do not always know the correct protocols. It is necessary not only to be familiar with these to pass these stations but also to know how to perform them effectively.

Of course, you may not have failed these types of stations and I recognise that it must be frustrating for you not to be able to obtain feedback on your own performance. However, without detailed comments from the examiner, which cannot be given in the time available, it is not possible to indicate how you lost marks.

I hope some of the general comments may be of help to you in preparing for any future OSCE exams.

dose calculation

2004-07-22T14:11:00.000-07:00

dose calculation>>>>
Let's consider a problem: 3 kg child to be given morphine @ 20mcg/kg/hr
for 24 hours at 1 ml/hr. 1 ml ampoule of morphine=0.5 mg morphine

Child is 3 kg. So, 20 X 3 = 60 mcg is required per hour. You have to prepare for 24 hours. Therefore, 60 X 24 = 1440 mcg is required per day. Now, 1ml = 0.5mg morphine = 500 mcg You require 1440 mcg. Therefore, You require (1440/500) = 2.88ml of the drug Next, You have to prepare a dose to give @ 1 ml/hr for 24 hours. That means, you have to make 24ml solution, which should contain 2.88ml
morphine. Which is 24 - 2.88 = 21.12ml. So, the Final Answer is:
You add 21.12ml of Normal Saline to 2.88ml of morphine to make 24ml of
solution to go @ 1ml/hr.

Question no: 1 Calculate the dose of Morphine in a 4 kg baby at 25 microgram/kg/hour. 1 ampoule contains 1 ml solution having 1 mg of Morphine. How much Normal Saline need to be added to run at a rate of 1 ml per hour for 24 hour?[/b] Answer: Tell the examiner: “ I shall check the expiry date of Morphine and Normal Saline at first.”
Calculation: Dose of Morphine= 25 microgram/kg/hr Weight of baby= 4 kg Amount of morphine required = 25X4 =100 microgram/hr So, in 24 hours total amount of Morphine required= 100X24 =2400 microgram In the ampoule, 1 ml= 1 mg or, 1000 microgram Morphine Now, 1000 microgram Morphine is present in 1 ml So, 1 microgram Morphine is present in 1/1000 ml So, 2400 microgram Morphine is present in 1X2400/1000 ml= 2.4 ml Now, Morphine solution is to be run at a rate of 1 ml per hour for 24 hour. So, total amount required to be given in 24 hours = 1X24= 24 ml Hence, amount of Normal saline to be added= 24-2.4 ml= 21.6 ml
Ans. Amount of Normal saline to be added is 21.6 ml.
Tell the examiner: “Finally, I shall write the concentration, rate of flow on the syringe and should sign it. I have also to check it with a colleague.”

Question no: 2 Calculate the dose of Midazolam to be given by I/V infusion for 24 hours. Weight 40 kg. Dose 20microgram/hour. 1 ampoule contains 1 ml solution having 1 mg of Midazolam. How much Normal Saline need to be added to run at a rate of 1 ml per hour for 24 hour? Answer:
Tell the examiner: “ I shall check the expiry date of Midazolam and Normal Saline at first.” Calculation: Dose of Midazolam = 20 microgram/kg/hr Weight of baby= 40 kg Amount of Midazolam required = 20X40 =800 microgram/hr So, in 24 hours total amount of Midazolam required= 800X24 =19200 microgram In the ampoule, 1 ml= 1 mg or, 1000 microgram Midazolam Now, 1000 microgram Midazolam is present in 1 ml So, 1 microgram Midazolam is present in 1/1000 ml So, 19200 microgram Midazolam is present in 1X19200/1000 ml= 19.2 ml Now, Midazolam solution is to be run at a rate of 1 ml per hour for 24 hour. So, total amount required to be given in 24 hours = 1X24= 24 ml Hence, amount of Normal saline to be added= 24-19.2 ml= 4.8 ml
Ans. Amount of Normal saline to be added is 4.8 ml. Tell the examiner: “Finally, I shall write the concentration, rate of flow on the syringe and should sign it. I have also to check it with a colleague.”

Question no: 3 Dose calculation for Fentanyl and you had to calculate dilution volume for 24 hours if given at a rate of 1 ml per hour and the ampoule come in the strength of 0.5 mg/ml. Weight is 25 kg and the dose was 4 microgram/kg/hour. Answer: Tell the examiner: “ I shall check the expiry date of Fentanyl and Normal Saline at first.” Calculation: Dose of Fentanyl = 4 microgram/kg/hr Weight of baby= 25 kg Amount of Fentanyl required = 25X4 =100 microgram/hr So, in 24 hours total amount of Fentanyl required= 100X24 =2400 microgram In the ampoule, 1 ml= 0.5 mg or, 500 microgram Fentanyl Now, 500 microgram Fentanyl is present in 1 ml So, 1 microgram Fentanyl is present in 1/500 ml So, 2400 microgram Fentanyl is present in 1X2400/500 ml= 4.8 ml Now, Fentanyl solution is to be run at a rate of 1 ml per hour for 24 hour. So, total amount required to be given in 24 hours = 1X24= 24 ml Hence, amount of Normal saline to be added= 24-4.8 ml= 19.2 ml
Ans. Amount of Normal saline to be added is 19.2 ml. Tell the examiner: “Finally, I shall write the concentration, rate of flow on the syringe and should sign it. I have also to check it with a colleague.”

Question no: 4 (double dilution method) Dose calculation for Morphine in child weighing 3 kg. Dose is 20 microgram/kg/hour and you are given 1 ml ampoule containing 10 mg of Morphine. Use 0.9% Normal Saline if required for dilution. A calculator, paper and pen are provided. Answer: Tell the examiner: “ I shall check the expiry date of Morphine and Normal Saline at first.” Calculation: Dose of Morphine=20 microgram/kg/hour Weight=3 kg Amount of Morphine required=3X20=60 microgram/hour In 1 ampoule, 1 ml contains 10 mg or, 10,000 microgram of Morphine So, 0.6 ml contains 6,000 microgram of Morphine Now, take 0.6 ml Morphine in a syringe and add 99.4 ml Normal Saline to make it 100 ml. In it 1 ml contains=6,000/100=60 microgram of Morphine Now, take this 100 ml Morphine solution in a Syringe driver and set it at a rate of 1 ml/hr.
Tell the examiner: “Finally, I shall write the concentration, rate of flow on the syringe and should sign it. I have also to check it with a colleague.”