SAQ – Practice Paper 1

Question 1:
A 64-year-old female is brought in to the Emergency Department by ambulance feeling
generally unwell. She collapsed at home. Her family says that she has been complaining
of feeling generally weak and has severe abdominal pains. She has a background of
autoimmune hepatitis and her medications included Prednisolone, Azathioprine and
Ramipril. The ambulance crew found her to be confused, lethargic and jaundiced.

Observations are:
• BP 85/43

• HR 160/min, regular
• Capillary blood glucose 0.8
• Temperature 36.5⁰C
Blood results are:
• Na+ 121 [134-143] mmol/L

• K+ 6.7 [3.6-5.3] mmol/L

• Urea 6.0 [2.0-6.8] mmol/L
• Creat 92 [51-96] mmol/L
• Hb 12
• WCC 4
• Plt 160
Arterial blood gas results are:
• pH 7.10 [7.35-7.45]

• pCO2 4.5 [4.6-6.1] kPa

• pO2 12.1 [12-15] kPa
• HCO3 10 [23-27] mmol/L
• BE -12 [0-2] mmol/L
1. What is the likely diagnosis? [1 mark]

2. What is the immediate treatment? [4 marks]

3. You decide to perform a short synacthen test. How is this done? [1 mark]

4. She starts to vomit blood and passes a large amount of melaena. She is still shocked
and you suspect moderate to severe haemorrhage. Outline your immediate
management. [4 marks]
 Answer:
1. What is the likely diagnosis? [1 mark]

• Addisonian Crisis
2. What is the immediate treatment? [4 marks]

• Fluid Resuscitation
• Head Down
• Treat Hypoglycaemia
• Hydrocortisone
• Consider Antibiotics
3. You decide to perform a short synacthen test. How is this done? [1 mark]

• Initial sample before Synacthen test.

• Take another sample after 30 mins
• Then another at 60 mins
4. She starts to vomit blood and passes a large amount of melaena. She is still shocked
and you suspect moderate to severe haemorrhage. Outline your immediate
management. [4 marks]

• Protect airway
• IV access
• IV Fluids
• PPI intravenous
• Organise endoscopy
• Cross match 6 units of packed cells
• Correct clotting

Question 2:
At your local university research laboratory, a porter accidentally dropped a box with this
sign printed on it.
1. What are the symptoms of mild cyanide poisoning? [2 marks]

2. Following an ingestion of potassium cyanide, what are the antidotes for severe
poisoning? [4 marks]

3. What is the Emergency Department management of patients with mild cyanide

poisoning? [2 marks]

4. A treatment for cyanide poisoning binds cyanide by forming methaemoglobin . How is

methaemoglobinaemia treated? [2 marks]

Answer:
1. What are the symptoms of mild cyanide poisoning? [2 marks]

Dizziness, Anxiety, Headache, Palpitations, Breathlessness

2. Following an ingestion of potassium cyanide, what are the antidotes for severe
poisoning? [4 marks]

• Dicobalt Edetate
• Sodium thiosulphate
• Sodium nitrite
• Hydroxocobalamine

3. What is the Emergency Department management of patients with mild cyanide

poisoning? (2)

• Avoid contaminating yourself

• Remove contaminated clothing and wash exposed skin
 • Provide supportive measures, oxygen and cardiac monitoring
• Observation

4. A treatment for cyanide poisoning binds cyanide by forming methaemoglobin . How is

methaemoglobinaemia treated? [2 marks]

• Oxygen
• Methylene blue

Question 3:
A one and a half year-old girl is brought to the Emergency Department with pyrexia and
irritability.

The urine microscopy shows:

• Red blood cells scanty

• White blood cells ++
• Epithelial cells ++
1. How many colony forming units is considered as a positive culture result for E. Coli?
[1 mark]
2. Give 4 long term complications of untreated urinary tract infection in infants. [4 marks]

3. Give 4 factors that would increase this child’s risk of long term damage from a UTI. [4
marks]

4. Give 3 gram-negative organisms that cause UTIs. [3 marks]

Answer:
1. How many colony forming units is considered as a positive culture result for E. Coli?
[1 mark]
• 100,000

2. Give 4 long term complications of untreated urinary tract infection in infants. [4 marks]

• Renal impairment/scarring/failure
• Early Hypertension
• Poor renal Growth
• Recurrent adult pyelonephritis
• Failure to thrive
• Bed wetting
3. Give 4 factors that would increase this child’s risk of long term damage from a UTI. [4
marks]

• Structural / anatomical abnormalities Duplex/horseshoe kidney

• Untreated UTI
• Recurrent UTI
• Prolonged illness
• Reflux
• Lower Age, infants more prone to renal scarring.
• Non E.coli infection

4. Give 3 gram-negative organisms that cause UTIs. [3 marks]

• Proteus
• Klebsiella
• Enterobacter
• Yersinia
• (E. Coli)

Question 4:
A. An 80-year-old male attends with generalised aches and pains. He says he feels tired
and weak with occasional spasms in his calves. He is hypertensive and has ischaemic
heart disease. He takes Aspirin, Furosemide, Isosorbide Mononitrate and Lisinopril. He
has no allergies.

Blood results are: Na+ 136, K+ 2.4, Urea 7.4, Creatinine 206.
 B. On the same night, a patient is sent to the Emergency Department by his GP with a
potassium of 7.5 mmol/L.

A.

1. Describe the abnormalities on the ECG. [3 marks]

2. How would you correct the electrolyte abnormality? Give dose and route. [2 marks]

3. What other electrolyte abnormality is often associated with the above electrolyte
abnormality? [1 mark]

B.

1. How would you manage this patient? [4 marks]

Answer:
1. Describe the abnormalities on the ECG. [3 marks]

• ST Depression
• T inversion
• Prominent U Waves

2. How would you correct the electrolyte abnormality? Give dose and route. [2 marks]

• Potassium Chloride infusion at 20mmol/hr intravenously

3. What other electrolyte abnormality is often associated with the above electrolyte
abnormality? [1 mark]
• Hypomagnesamia
B.
1. How would you manage this patient? [4 marks]

• Repeat ECG and check cardiac monitor

• Re Check K+ Level
• Salbutamol Nebs
• Calcium Chloride/Gluconate 10mls of 10%
• Actrapid 10u in 50mls 50% Glucose iv over 20mins

Question 5:
A 45-year-old male is brought to the Emergency Department unconscious. One of the
staff recognises him as a local tramp.

Blood results are:

• Sodium 140 [134-143] mmol/L

• Potassium 4.6 [3.6-5.3] mmol/L
• Chloride 96 [95-110] mmol/L
• Creatinine 149 [51-96] mmol/L
• Urea 13 [2.0-6.8] mmol/L
Arterial blood gas results are:

• pH 7.13 [7.35-7.45]
• pCO2 1.2 [4.6-6.1] kPa
• pO2 16.0 [12-15] kPa
• Base excess -22 [0-2] mmol/L
• Standard Bicarbonate 3.0 [23-27] mmol/L
• Oxygen Saturation 100%
1. How do you calculate the osmolar gap? [1 mark]

2. Give 2 clinical manifestations of Stage 1 ethylene glycol poisoning. [2 marks]

3. Give 2 drugs that can be used to treat ethylene glycol poisoning and what is their
mechanism of action? [3 marks]

4. Calculate this patient’s anion gap. [1 mark]

 5. Give 6 other causes of metabolic acidosis with an elevated anion gap. [3 marks]

Answer:
1. How do you calculate the osmolar gap? [1 mark]

[Measured osmololity] – [calculated osmolarity]Calculated osmolarity = 2 Na +

Glucose + Urea ( all in mmol/L) [several formalae available]
2. Give 2 clinical manifestations of Stage 1 ethylene glycol poisoning. [2 marks]

• Apparent intoxication but no ethanol in breath

• Nystagmus
• Slurred speech
• Coma
• Convulsions

3. Give 2 drugs that can be used to treat ethylene glycol poisoning and what is their
mechanism of action? [3 marks]

• Absolute alcohol iv or 40% alcoholic spirits orally

• Fomepizole
• Both act by inhibiting alcohol dehydrogenase

4. Calculate this patient’s anion gap. [1 mark]

• Na+K] - [HCO3+Cl]
• [140+4.6] – [3+96]
• 144.6- 99
• 45.6 (raised)

Question 6:
A 38-year-old woman who is first time pregnant at 36 weeks with twins presents with
acute shortness of breath and pleuritic chest pain. She was on weekend leave from the
ward as she has had bilateral swollen ankles and moderate persistent proteinuria and
normal BP during monitoring.

Observations are:

• SpO2 96% on air

• RR 28 shallow
• HR 110/min, regular
• BP 120/60
You suspect a pulmonary embolus. You investigate with a leg duplex Doppler scan,
which excludes deep vein thrombosis. She has a normal CXR.

1. What is your next line of investigation? What is the associated childhood cancer risk?
What is the risk to the maternal breasts? [3 marks]

2. A small pulmonary embolus is detected. What is the treatment and dose? [3 marks]

3. She unfortunately loses consciousness and starts to fit. What is the immediate
treatment? Give drug doses/routes where appropriate. [4 marks]

Answer:
1. What is your next line of investigation? What is the associated childhood cancer risk?
What is the risk to the maternal breasts? [3 marks]

Investigation Childhood cancer risk Maternal breast cancer risk

CTPA 1/1,000,000 High

V/Q Scan 1/280,000 Low

2. A small pulmonary embolus is detected. What is the treatment and dose? [3 marks]

Low molecular weight Heparin, 1.5mg/kg in 2 divided dose calculated on early

pregnancy weight
3. She unfortunately loses consciousness and starts to fit. What is the immediate
treatment? Give drug doses/routes where appropriate. [4 marks]

• Crystalloid iv 1-2 mls/kg/hr

• Magnesium 4g iv in 10 minutes
• Labetolol 10 slow iv mg
• Hydralazine 5mg iv over 20 mins
• Consider urgent delivery
Question 7:
A 5-year-old child is brought to the Emergency Department with his parents. He was
recently diagnosed as having suffered with Kawasaki’s disease and was fully
investigated and placed on long term treatment.

On this attendance, his parents found some flat red spots that rose up and then
blistered. They were itchy. He has a cough, a runny nose, and a pyrexia of 38.5⁰ C. The
parents brought him for a check-up as they could not get an appointment from the GP.

1. What are the features of Kawasaki disease? [4 marks]

2. What potential condition results from the long term treatment of Kawasaki disease and
the viral illness described? [1 mark]

3. There are 5 stages of this syndrome. What are the features of stage one? [2 marks]

4. The last stages include seizures, multi organ failure, flaccidity, high blood ammonia
and death. What is the pathophysiology of this condition? [2 marks]

5. What is the risk of death in children with brain damage? [1 mark]

Answer:
1. What are the features of Kawasaki disease? [4 marks]

• Fever, >5 days

• Erythema polymorphic
• Desquamation of hand and feet
• Uveitis, Acute Cervical lymphadenopathy, Strawberry Tongue, Fissured Lips,
Arthritis
• Diarrhoea

2. What potential condition results from the long term treatment of Kawasaki disease and
the viral illness described? [1 mark]

• Reye’s Syndrome
(Associated with children taking aspirin when suffering from viral illnesses like
Chicken Pox)

3. There are 5 stages of this syndrome. What are the features of stage one? [2 marks]

• Vomiting, Lethargy, Confusion, Nightmares

4. The last stages include seizures, multi organ failure, flaccidity, high blood ammonia
and death. What is the pathophysiology of this condition? [2 marks]

• Fatty liver leads to Encephalopathy

Aspirin causes mitochondrial damage in liver -> Liver failure leads to increase in
Ammonium -> crosses Blood Brain Barrier -> Glutamine formation -> Cerebral
Oedema -> encephalopathy -> seizures

5. What is the risk of death in children with brain damage? [1 mark]

• 30%

Question 8:
You are called to see a young man. He is unkempt and has lots of layers of clothing on
him. He says that he has been unwell for a while and worsened tonight. A friend of his
called the ambulance. The ambulance crew recognise him as an intravenous drug user.
They also say that he looks a lot thinner since the last time they were called to him.

He is short of breath, sweaty, shivering and pale. He has a high fever.

On examination, his clothes are too big for him. His chest has coarse basal crackles and
you notice that he has a systolic murmur.

You suspect that he is septic and has acute heart failure.

Questions:
1. What is the likely diagnosis? [1 mark]

2. Give 2 common causes of the above diagnosis. [2 marks]

3. What group of infection is associated with the above diagnosis? [1 mark]

4. What is the name and the diagnostic criteria attached to the above diagnosis? [4
marks]

5. Give 4 presentations when surgery is considered. [2 marks]

Answer:
1. What is the likely diagnosis? [1 mark]

• Infective Endocarditis
 2. Give 2 common causes of the above diagnosis. [2 marks]

• Strep Viridans 35-50%

• Staph
• Strep Epidermidis
• Diphteroids and icroaerophilic streptococci

3. What group of infection is associated with the above diagnosis? [1 mark]

• HACEK organisms (Haemophilus , Aggregatibacter, Cardiobacterium hominis, Eikenella

corrodens, Kingella)

4. What is the name and the diagnostic criteria attached to the above diagnosis? [4
marks]

• Dukes Criteria
• 2 Major
• 1 Major and 3 minor
• All 5 minor criteria

5. Give 4 presentations when surgery is considered. [2 marks]

• Heart failure
• Valvular obstruction
• Repeated emboli
• Fungal endocarditis
• Persistent bacteraemia
• Myocardial abscess
• Unstable infected prosthetic valve

Question 9:
The parents of a two and a half year-old child tell you that he appears to be complaining
of right leg pain for the last day. He has an intermittent limp that has been going on for a
while. Today he will not weight-bear at all. There is no history of trauma. He has suffered
with a cold and flu-like illness in the last 3 weeks.

A. Blood results are:

• Platelets 46
• Hb 11.9
• Nucleated RBC 2
• MCV Normal
• MCH Normal
• WCC 72.3
• Neut 11.56
• Lymph 21.68
• Mono 3.61
• Blast Cells 35.40
• U&E Normal
B.

A.

1. What is the differential diagnosis in a child of this age presenting with a limp? [4
marks]

2. On examination he is found to have small petechial rashes <1mm in diameter on both

forearms. Other than FBC U&E’s, what investigations will you organise next? [2 marks]

3. What is the more likely diagnosis? [1 mark]

B.

1. Describe the Radiograph. [2 marks]

2. What age group suffer with this condition? [1 mark]

Answer:
A.
1. What is the differential diagnosis in a child of this age presenting with a limp? [4
marks]

2. On examination he is found to have small petechial rashes <1mm in diameter on both

forearms. Other than FBC U&E’s, what investigations will you organise next? [2 marks]

• CRP, ESR, Blood Culture, Coagulation screen, USS, Pelvic Xray, Frog Lateral
views

3. What is the more likely diagnosis? [1 mark]

• Acute Lymphoblastic leukemia

B.
1. Describe the Radiograph. [2 marks]

• Left Slipped Upper Femoral Epiphysis

2. What age group suffer with this condition? [1 mark]

• 10-16 years

Question 10:
A 15-year-old boy attends the Emergency Department with severe halitosis and painful,
deep ulcerations on the gums. He was previously well.

He is due to be in court this week for a hearing as a suspect for causing death by
dangerous driving whilst under the influence of alcohol.

1. What is the most likely diagnosis? [1 mark]

2. What is the likely organism? [1 mark]

3. What is the complication if treatment is not initiated? What is the treatment in

question? [2 marks]

B.

1. You suspect acute bacterial sialadenitis in a 76 year-old woman. What clinical findings
would you expect? [4 marks]

2. What are the organisms commonly involved? [2 marks]

Answer:
1. What is the most likely diagnosis? [1 mark]

• Acute Necrotising Gingivitis

• Or Vincent’s Angina

2. What is the likely organism? [1 mark]

• Borrelia Vincentii (Spirochete)

3. What is the complication if treatment is not initiated? What is the treatment in
question? [2 marks]

• Bone loss and loosening of teeth

• Pen V for 10 days
• Refer to dentist and may require debridement and surgery

B.
1. You suspect acute bacterial sialadenitis in a 76-year old woman. What clinical findings
would you expect? [4 marks]

• Fever
• Trismus
• Dysphagia
• Painful enlargement of parotid and submandibular glands

2. What are the organisms commonly involved? [2 marks]

• S.Aureus
• S Viridans
• E Coli

Question 11:
1. Draw and name the sensory nerve supply to the ear. [3 marks]

2. Indicate where you would infiltrate local anaesthetic to block sensation to the ear. [2
marks]

3. What does 0.05% mean when describing local anaesthetic drug concentration? [1
mark]

4. Give four early signs and symptoms of local anaesthetic toxicity. [2 marks]

5. What is the antidote to local anaesthetic poisoning? Give drug and dose. [2 marks]

Answer:
1. Draw and name the sensory nerve supply to the ear. [3 marks]

2. Indicate where you would infiltrate local anaesthetic to block sensation to the ear. [2
marks]
3. What does 0.05% mean when describing local anaesthetic drug concentration? [1
mark]

• 0.05 gm in 100mls volume of solution

4. Give four early signs and symptoms of local anaesthetic toxicity. [2 marks]

• Neurological – Numbness of mouth and tongue

• Slurring of speech
• Light headedness
• Tinnitus
• Confusion and drowsiness (Muscle twitching, Convulsion and coma can occur)
• Cardiovascular – tachycardia with hypertension (Later – bradycardia and
hypotension and heart block, ventricular arrhythmia cardiac arrest can occur)

5. What is the antidote to local anaesthetic poisoning? Give drug and dose. [2 marks]

• Intralipid 20% 1.5mls/kg over 1 minute. Give a bolus of 100mls.

Question 12:
A. This patient has been generally unwell and has Type 2 Diabetes. He says that his
vision has been deteriorating over the last few weeks. And has sudden loss of vision in
his one eye. He tells you that he has severe retinopathy.

B. This patient has acute closed angle glaucoma.

A
1. Describe the changes that can be seen on his retina. [3 marks]
2. What is the cause of his sudden blindness? [1 mark]

B
1. Give two systemic symptoms of this condition. [2 marks]
 2. What is the drug type and mechanism of action of the following drugs used to treat
this condition? [4 marks]

Answer:
1. Describe the changes that can be seen on his retina. [3 marks]

• Flame shaped and dot blot haemorrhage

• Large cotton wool spots
• Macular oedema and exudates
• New Vessel Formation

2. What is the cause of his sudden blindness? [1 mark]

• Vitreous Haemorrhage

B.
1. Give two systemic symptoms of this condition. [2 marks]

• Headache
• Vomiting

2. What is the drug type and mechanism of action of the following drugs used to treat
this condition? [4 marks]

• Mannitol
Osmotic Diuretic reduce intraocular pressure

• Acetazolamide
Carbonic Anhydrase inhibitor Decrease aqueous humour production

Question 13:
A 76-year-old man presents to the Emergency Department with dyspnoea, productive
cough, chest pain and acute confusion. A week ago he was admitted for 6 days, with a
urinary tract infection that was treated and cleared.

Observations are:

• RR 26/min
• BP 130/45
• HR 110/min
• SpO2 98%
• Temperature 38.6⁰C.
The blood results are:

• Hb 9.8
• WCC 14.2
• Platelets 170
• Na+ 138
• K+ 4.2
• Urea 6.6
• Creat 98
1. Define sepsis. [1 mark]

2. Define septic shock. [1 mark]

3. Define neutropenic sepsis. [1 mark]

4. What is this patient’s CURB-65 score and what does it predict? [3 marks]

5. What antibiotics are considered as first line for Community Acquired Pneumonia
treated at home? Give route and dose. [2 marks]

Answer:
1. Define sepsis. [1 mark]

• Systemic Inflammatory Response Syndrome due to Infection

2. Define septic shock. [1 mark]

• Hypotension/hypoperfusion unresponsive to adequate intravenous fluid

resuscitation, in a patient with severe sepsis.

3. Define neutropenic sepsis. [1 mark]

• Sepsis with neutrophils count <1.0x10 to the power 9 /L

4. What is this patient’s CURB-65 score and what does it predict? [3 marks]

• Confusion 1
• Urea 0
• RR 0
• BP 90/60 0
• >65 1
Risk of death at 30 days / need for ITU care due to pneumonia

5. What are the criteria to suggest hospital acquired pneumonia? [2 marks]

• Pulmonary infiltrates
• 2-3 days after discharge from Hospital
• Increased tracheal secretions
• WCC > 10
• Fever >37.8 C

6. What antibiotics are considered as first line for Community Acquired Pneumonia
treated at home? Give route and dose. [2 marks]

• Amoxycillin 500-1000mg oral tds, Erythromycin 500mg oral qds

Question 14:
A.
A police officer attends the Emergency Department stating that she injured herself on a
dirty hypodermic needle while investigating a suspect’s house.
She has made the wound bleed and washed it under running water. Her Occupational
Health adviser told her to attend the Emergency Department out of hours as the police
have a contract with your local Emergency Department.

B.
There are no materials for this section.
A.
1. What is the risk of HIV following a needlestick injury? [1 mark]
2. What is the current antiviral recommendation? Give name and doses. [2 marks]

3. What other drugs/treatment will you consider for her? [2 marks]

B.
1. What is Clinical Governance? [2 marks]
2. What are the components of Clinical Governance? [3 marks]

Answer:
1. What is the risk of HIV following a needlestick injury? [1 mark]
• 1 in 300 HIV percutaneous

2. What is the current antiviral recommendation? Give name and doses. [2 marks]

• Lopinavir + ritonavir (trade names Kaletra and Aluvia), 2 tablets BD

• Tenofovir + emtricitabine (trade name Truvada) 1 tablet OD

3. What other drugs/treatment will you consider for her? [2 marks]

• Anti emetic
• Anti diarrhoeal
• Tetanus status
• HBV vaccination

B.

What is Clinical Governance? [2 marks]

'A framework through which NHS organisations are accountable for continuously
improving the quality of their services and safeguarding high standards of care by
creating an environment in which excellence in clinical care will flourish’
What are the components of Clinical Governance? [3 marks]

Any 6 or 7 from PIRATES or CECROR Clinical AuditEducation and

Patient and Public involvementIT and
information (Openness)Risk
ManagementAuditTraining and
EducationEffectiveness (Clinical) and
researchStaff Management
trainingClinical EffectivenessRisk
ManagementOpennessResearch and
Development

PEP: UK Guidelines from BASHH

Question 15:
A 14-year old boy is brought to the Emergency Department after being involved in a car
crash at 50mph. He was an unrestrained rear seat passenger.
1. What investigation is shown? [4 marks]

2. Identify the structured labelled A-F. [3 marks]

3. Identify 6 abnormalities on this investigation. [3 marks]

Answer:
1. What investigation is shown? [4 marks]

• CT Scan with intravenous contrast.

• Images in arterial and venous phases.
• Slice shown at T3/4 level

2. Identify the structured labelled A-F. [3 marks]

• A - SVC
• B - Trachea
• C - Oesophagus
• D – Arch of aorta
• E – Body of T3 (accept T4)
• F - Subscapularis

3. Identify 6 abnormalities on this investigation. [3 marks]

• Mediastinal haematoma
• Fractured rib on left side
• Fractured rib on right side
• Right sided haemothorax,
• Left sided Haemothorax
• Fractured pedicle/transverse process of T3

How to interpret head CT

Question 16:
A 20-year-old woman attends with a history of lower abdominal pain. She has a pyrexia
of 37.5⁰C

1. What are the four common features of pelvic inflammatory disease? [4 marks]

2. Give 2 of the common pathogens? [2 marks]

3. What combination of drugs would you use to treat this condition? [2 marks]

4. In what circumstances do you consider admission? [2 marks]

Answer:
1. What are the four common features of pelvic inflammatory disease? [4 marks]

• Vaginal discharge
• Dyspareunia
• Spiking temperatures
• Right upper quadrant pain (Fitz Hugh Curtis syndrome)
• Dysmenorrhoea
• Adnexal tenderness
• Irregular Bleeding
• Cervical Excitation

2. Give 2 of the common pathogens? [2 marks]

• N Gonorrhoea
• C trachomatis
 • Garnerella vaginalis
• Mycoplasma genitalium

3. What combination of drugs would you use to treat this condition? [2 marks]

• Ofloxacin 400 mg bd 14 days

• Metronidazole 400mg bd 14 days

4. In what circumstances do you consider admission? [2 marks]

• Symptomatically unwell
• Haemodynamic Shock
• Vomiting
• Equivocal Diagnosis
• Pelvic (tubulo-ovarian) abscess
•

UK Guidelines for PID from BASHH

Question 17
A 72-year-old man attends with a history of general malaise over the past 3 weeks. On
further questioning he has had intermittent pains in his back and in his ribs for several
weeks that he attributed to "old age". His vision has been a bit "blurry" over the last few
days.

The CXR is normal.

The blood results are:

• Hb 8.9
• MCV 84 fl
• MCH 29 pg
• MCHC 34 g/dl
• WCC 8.6
• Plt 334
• Urea 35.7
• Creat 595
• Na+ 139
• K+ 7.9
• Ca2+ 3.06
• Alk Phos 221 u/L
1. Give the most likely diagnosis. [1 mark]

2. Give 5 treatment options available (multiple treatments for the same abnormality not
accepted.) [5 marks]

3. How would you confirm the diagnosis? [1 mark]

4. What are the symptoms of hypercalcaemia other than the ones stated already? [3
marks]

Answer:
1. Give the most likely diagnosis. [1 mark]

• Multiple myeloma

2. Give 5 treatment options available (multiple treatments for the same abnormality not
accepted.) [5 marks]

• Fluid rehydration
• Analgesia
• Dialysis & haemofiltration
• Pamidronate
• Insulin Dextrose / salbutamol
• Consider Transfusion

3. How would you confirm the diagnosis? [1 mark]

• CT
• Bone scan

4. What are the symptoms of hypercalcaemia other than the ones stated already? [3
marks]

“Bone stones groans and psychic moans”Symptoms - Abdominal pain, Vomiting,

Constipation, Polyuria, Depression, Anorexia, Weight loss, Tiredness,
Weakness,Signs - Hypertension, Confusion, Pyrexia, Renal stones, Renal failure,
Corneal calcification, Cardiac arrest, ECG reduced Q-T interval
Multiple Myeloma BMJ Article

Question 18:
A 25-year-old woman presents to the Emergency Department having recently returned
from Central Africa 3 days ago while volunteering for a charity for a month.

She complains of rigors, fevers and diarrhoea. She looks unwell and dehydrated.

1. What is the commonest cause of diarrhoea? [1 mark]

2. What other causes of diarrhoea in a traveller do you know? [3 marks]

3. She also complains of night sweats and admits that she did not manage to take her
malaria prophylaxis regularly. What is the name of the parasite that causes this
condition? [1 mark]

4. What is the incubation period? [1 mark]

5. How often does the symptoms cycle occur? [1 mark]

6. Give 6 poor prognostic features of this condition. [3 marks]

Answer:
1. What is the commonest cause of diarrhoea? [1 mark]

• E Coli

2. What other causes of diarrhoea in a traveller do you know? [3 marks]

• Salmonella
• Shigella
• Campylobacter
• Giardia Lamblia
• Vibrio Cholerae
• Yersinia enterolytica
• Rotavirus

3. She also complains of night sweats and admits that she did not manage to take her
malaria prophylaxis regularly. What is the name of the parasite that causes this
condition? [1 mark]

• Malaria – Plasmodium Falciparum

4. What is the incubation period? [1 mark]

• 7-10 days
5. How often does the symptoms cycle occur? [1 mark]

• 36-48 hourly

6. Give 6 poor prognostic features of this condition. [3 marks]

• Age <3 yrs

• Pregnancy
• Respiratory distress
• Fits
• Coma
• Absent corneal reflexes
• Papilloedema
• Pulmonary oedema
• HCO3 <15 mmol/L
• Plasma or CSF lactate >5 mmol/L
• Glucose < 2.2 mmol/L
• Hyperparasitaemia
• HB <5 g/dL
• DIC
• Creatinine >265
• If 20% of parasite are mature trophozoites or schzonts
• Malaria pigment in >5% of neutrophils

UK Malaria Treatment Guidelines from HPA

Question 19:
A.
A police constable requests to see the names of all the patients who attended your
Emergency Department yesterday with a limp, as there has been a serious assault in
town and a witness saw a man running away from the crime scene limping after falling
from a 9 foot wall.
B.

A.
1. What do you ask from him and what information can you give him? [2 marks]
2. Give 6 serious arrestable (indictable) offences. [3 marks]

B.
1. While looking through your patient list one of them fits the bill but he also complained
of wrist pain. What does this radiograph show? [1 mark]
2. What was the likely mechanism of injury? [1 mark]

3. Which bone is commonly fractured in association with this injury? [1 mark]

4. What are common complications of this condition? [2 marks]

Answer:

A.
1. What do you ask from him and what information can you give him? [2 marks]

• The nature of the Crime – must be a serious arrestable offence

• A personal request from his Inspector. Or a court order.
• Can give - basic patient demographics narrowed down to his specific request

2. Give 6 serious arrestable (indictable) offences. [3 marks]

• TreasonMurderManslaughterRapeKidnapping
• Incest or intercourse with a girl under 13
• Buggery with a boy under 16
• Indecent assault constituting gross indecency
• Causing an explosion likely to endanger life or property
• Certain offences under the Firearms Act 1968
• Causing death by dangerous driving
• Hostage taking
• Torture and many drug-related offences
• Ship hijacking and Channel Tunnel train hijacking
• Taking indecent photographs of children
• Publication of obscene matter

B.
1. While looking through your patient list one of them fits the bill but he also complained
of wrist pain. What does this radiograph show? [1 mark]

• Perilunate dislocation

2. What was the likely mechanism of injury? [1 mark]

• Fall on out stretched Hands

3. Which bone is commonly fractured in association with this injury? [1 mark]

• Scaphoid and Ulnar Styloid

4. What are common complications of this condition? [2 marks]

• Median Nerve injury

• Instability
• Pain
• Loss of function

Question 20:
A 25-year-old male from North Africa is brought to the Emergency Department following
several weeks of progressive weight loss. He reports gradual worsening of tolerance of
solid foods and now fluids. Where he once was able to swallow anything, is now
reduced to spoonfuls of sugar and sips of water to keep him going. He has been
vomiting partly digested food with no bile after eating anything. He admits to years of
indigestion discomfort and now had epigastric pains for the last 3-4 days. He denies
haematemesis or diarrhoea and looks dehydrated and emaciated.
 The arterial blood gases are:

• pH 7.59
• pCO2 8.21
• pO2 11.02
• HCO3- 48.6
• Na+ 133
• K+ 2.4
• Cl- 67 (range 95-105)
1. Comment on these results. [1 mark]

2. Explain the blood gas result. [1 mark]

3. On endoscopy he had a gastric outlet obstruction. What are the possible causes? [2
marks]

4. If this were to occur in a 5-week-old boy with a history of vomiting shortly after feeds,
what is the likely diagnosis? [1 mark]

5. What is typical of the initial presentation, with regards to vomiting and feeding? [1
mark]

6. What 2 ways may this be diagnosed? [2 marks]

7. What are the 2 main goals of preoperative management? [2 marks]

Answer:
1. Comment on these results. [1 mark]

• Hypochloraemic, hypokalaemic metabolic alkalosis

2. Explain the blood gas result. [1 mark]

• Vomiting loss of H+ & Cl- ,leads to Hypochloraemic,

• Metabolic alkalosis
• Renal loss of K, to replace H+ leads to Hypokalaemia

3. On endoscopy he had a gastric outlet obstruction. What are the possible causes? [2
marks]

• Carcinoma of stomach/pylorus/duodenum
• External Compression Pancreatitis Bowel Cancer and Liver Enlargement
• Luminal obstruction Pedunculated lesion of FB obstruction
• Infective /inflammatory causes Gastritis Duodenitis

4. If this were to occur in a 5-week-old boy with a history of vomiting shortly after feeds,
what is the likely diagnosis? [1 mark]

• Hypertrophic Pyloric stenosis

5. What is typical of the initial presentation, with regards to vomiting and feeding? [1
mark]

• The baby in the early stage of the disease remains hungry and sucks vigorously
after episodes of vomiting.

6. What 2 ways may this be diagnosed? [2 marks]

• Test feed may reveal a palpable tumour.

• USS may also be used in diagnosis.
• Rarely, upper GI barium studies
• Very rarely, upper GI endoscopy

7. What are the 2 main goals of preoperative management? [2 marks]

• Correct fluid deficiency

• Correct electrolyte