Mock Paper 3 Gastroenterology George a 46 year old widowed caretaker, presents to A&E with a 1 hour history of haematemesis, including

one severe episode in the ambulance. On examination he smells of alcohol, his BP is 86/44mmHg, he is peripherally cold and his pulse is 110bpm. 1. What is your immediate management? (2 marks) Maintain patency of the airway and supply 100% oxygen Obtain IV access using 2 large bore cannulas and supply fluids or colloid 2. List 4 causes of haematemesis? Oesophageal varices Peptic Ulcer Disease/ Duodenal Ulcer/ Oesophagitis Gastric carcinoma Mallory-Weiss tear Swallowed blood from severe epistaxis (2 marks)

3. Assuming a diagnosis of oesophageal varices, name 3 physical signs that you would expect to find on further examination of George? (3 marks) Hepatomegaly / hepatosplenomegaly Raised Jugular venous pressure Jaundice Ascites Asterixis Haemorrhoids Spider naevi Caput medusa 4. What 4 blood tests would you request? Full blood count Liver function test Ureas and electrolytes Cross match Clotting 5. How would you score Georges risk of mortality? Rockhall scoring system 6. Give one definitive treatment option for Georges condition Oesopho-gastro-duodenoscopy with sclerotherapy banding (2 marks)

(1 mark) (1 mark) (10 marks)

Neurology Mr S is a 70 year old retired train driver who presents to his GP with his wife, who says she has noticed her husband has been taking longer to get washed and dressed in the morning. She also thinks he has become a little forgetful at times. Mr S also complains of a shaky left hand when sitting at rest and also finding it difficult to cut up his food. On examination Dr H notices Mr Ss blank expression and resting tremor in his left arm. He also finds cogwheel rigidity in the left wrist. 1. What are the 3 cardinal features of Parkinsons Disease? Resting tremor Rigidity Akinesia/ bradykinesia (3 marks)

2. Dr H thinks that Mr S has idiopathic Parkinsonism Disease, if this is true, what would you expect to find on observing his gait and posture? (3 marks) Festinating gait Stupor Shuffling gait Bent posture Loss of arm movement Ambivalence 3. What drug therapy would you commence Mr S on to help control his symptoms? (2 marks) Dopamine antagonist & Decarboxylase inhibitor 4. What advice regarding the efficacy of his treatment should you warn Mr and Mrs S about? (1 marks) Efficacy will reduce over time due to resistance and therefore an increasing dose may be required. Or Efficacy over time may fluctuate with an on off syndrome 5. Give an example of a commonly used drug which can cause parkinsonism? (1 mark) Anti-emetics Anti-psychotics Amiodarone

10 marks

Respiratory A 56 year old woman presents to A&E with acute SOB, chest pain and feeling dizzy. On examination she has a temperature of 38.6oC, a raised JVP, pulse 98, respiratory rate 24 and a BP 98/58. 1. Give 4 differential diagnoses? Pulmonary embolism Myocardial infarction Pneumonia sepsis Congestive cardiac failure Pneumothorax (2 marks)

2. You later discover on history she has recently been on holiday in the Maldives, she is currently taking Microgynon, and she has a positive family history of DVT. What is the most likely diagnosis now? And what is the best investigation to confirm the diagnosis? (2 marks) Pulmonary Embolism Ventilation / perfusion scan or computerised tomography pulmonary angiography 3. What is your immediate three step treatment? Oxygen Low molecular weight heparin Analgesia (morphine) and anti-emetic (3 marks)

4. What further treatment should be given and continued on discharge? For how long should this be continued? What method of monitoring and range of this monitoring should be done regularly? (3 marks) Warfarin for 6 months International ratio, Ideal range: 2-3 (N.B. Except in prosthetic valves, range is 3-4) 5. She makes a full recovery and is discharged 4 days later from your care. She returns 2 days post discharge complaining of chest pain aggravated by inspiration, dyspnoea and productive green sputum cough. Chest radiograph shows lobar consolidation and blood cultures show gram negative bacilli, confirming hospital acquired pneumonia. What is your antibiotic treatment of choice? (2 marks) rd 3 generation Cephalosporin (Cefataxime or cefetrixone) Or Aminoglycoside (Gentamycin) and anti-pseudomonal penicillin

6. If this pneumonia was community acquired what is the likely organism and antibiotic treatment of choice? (4 marks) Streptococcus Pneumonaie Amoxicillin or Erythromycin (if allergic to penicillins)

(Other community infections Mycoplasma and Haemophilus Influenza) 7. List 4 clinical signs that would increase the risk of death from pneumonia? (4 marks) Confusion Respiratory Rate > 30 Blood pressure is below 90/6 Mutlilobar involvement Atrial fibrillation (20 marks)

Obstetrics Jesse is a 29 year old nurse who is 37 weeks pregnant. She presents to A&E with a 1 day history of dark vaginal bleeding and generalised abdominal pain. 1. What are the main differential diagnoses? Abruption Placenta praevia Vasa praevia Labour 2. What initial investigation would you like to carry out? Ultrasound scan Cardiotocography Full blood count Group & save (3 marks)

(3 marks)

On examination, she is found to have hypotension and tachycardia. Her uterus is hard and tender, and auscultation of the foetal heart rate shows it to have an abnormal rhythm. 3. What is your diagnosis? Placental abruption 4. Name 4 risk factors for this condition? Previous abruption Smoking Multiple pregnancy Pre-eclampsia 5. How would you manage this patient? Emergency Caesarean Section (1 mark)

(2 marks)

(1 mark)

(10 marks)

Endocrine A 60 year old lady has a history of weight loss, lethargy, nausea and dizziness on standing. She has also noticed pigmentation on her buccal mucosa and in the creases of her hands. Her biochemical tests shows she has a low Na+ and a high K+ 1. What would be your most likely diagnosis? Addisons Disease 2. What is the most common cause of this condition? Autoimmune (80%) 3. What 2 diagnostic tests would you want to carry out? Long acting and short acting synacthen test 4. If your diagnosis is correct what would be your management? Fludrocortisone Hydrocortisone IV fluids 5. List 4 side effects of long term use of this drug? Peptic ulcers Osteoporosis Immunosuppression Diabetes Hypertension Bruising (1 mark) (1 mark) (2 marks) (2 marks)

(2 marks)

This lady was treated appropriately and discharged home but 1 month later she represented with an adjusted calcium level of 4.2mmol/l. 6. What is this lady suffering from? (1 mark) Hypercalcaemia Hyperparathyroidism 7. What are the other diseases that can cause this? Malignancy (1o bone, bone metastasis, lung cancer, myeloma) Renal osteodystrophy Hypothyroidism Sarcoidosis 8. What is the main class of drug used to treat this condition? Biphosphonates (2 marks)

(1 mark)

9. What is the main side effect of this drug and how is that avoided? (2 marks) Oesophageal irritation / reactions Take the tablet upright and stay upright for the next 30 minutes to an hour (On empty stomach) (14 marks)

Cardiovascular Tim is a 62 year old factory supervisor. After visiting his GP complaining of breathlessness, he is referred to a cardiologist. On examination the cardiologist finds a collapsing pulse, displaced apex beat and an early diastolic murmur which is loudest at the left sternal edge. 1. What is the most likely cause of Tims clinical signs? Aortic Regurgitation (1 mark)

2. Name and describe 2 other signs associated with this diagnosis that the cardiologist may be able to elicit on examination (4 marks) Wide pulse pressure (high systolic and low diastolic) Traubes sign (Pistol shot femoral pulse on palpation) Corrigans sign (Visible pulsation of the carotid artery) Muellers sign (Visible pulsation of the uvula) Quinckes sign (Visible pulsation of the nails) Duroziezs sign (Femoral artery bruits on auscultation) 3. Name 3 investigations that you would perform? Echocardiogram Chest X-ray Electrocardiogram (3 marks)

4. What two classes drug may be used to control Tims symptoms and improve his ventricular function? (2 marks) Calcium channel blockers Diuretics Angiotensin Converting Enzyme Inhibitors (10 marks)

Gynaecology Rachael, a 28 year old physiotherapist is married with no children. She comes to see you in the GP as she has received a letter about the NHS national cervical screening programme. 1. Between what ages are women in the UK routinely screened under this programme? (2 marks) 25-65 2. List some factors Rachael might have for cervical cancer? Multiple sexual partners Early first coitus History of sexually transmitted infections Smoking Has a partner who has had multiple sexual partners 3. How long should you tell her she will have to wait for her results? 6-8 weeks Rachaels results show CIN1 4. What does this result mean histologically? Dysplastic cells that occupy the lower third of the epithelium (1 mark) (4 marks)

(1 mark)

5. What follow up would you recommend for Rachael? (2 marks) Repeat the smear in 6 months (six monthly repeat until they return to normal allowing two years for this to happen) Or refer to colposcopy

(10 marks)

Paediatrics Charlie a 2 year old boy is referred to Alder Hey after his mum noticed that he has had diffciluty standing up, and a funny walk. After taking a history the paediatric consultant decides to examine Charlie and perform a developmental assessment. 1. Name 4 areas of development that should be assessed? Gross motor Fine motor and vision Social and emotional Speech and hearing (2 marks)

On examination, Charlie is found to have proximal muscle weakness and a waddling gait. 2. Give 2 possible causes of Charlies proximal muscle weakmess? (2 marks) Duchennes Muscular Dystrophy Beckets Muscular Dystrophy Cerebral palsy Rickets 3. On examination, Charlie is also found to have a positive Gowers sign, what is this? (1 mark) Patient uses their hands to climb up their legs 4. The consultant paediatrician orders some blood tests which reveal an elevated creatinine phosphokinase. How can Charlies suspected diagnosis be confirmed? (1 mark) Muscle biopsy 5. How is Charlies condition inherited? X linked recessive (2 marks)

6. It is likely that Charlie at some stage of his disease will require steroids. Give 2 metabolic abnormalities that may develop with their use? (2 marks) Hypernatraemia Hypokalaemia Hypercalcaemia Hyperglycaemia

(10 marks)

Rheumatology A 56 year old lady goes to see her GP with a 4 month history of swelling in her hands. Her fingers are stiff and painful, especially in the mornings, but tend to get better as the day goes on. She is now finding it difficult to do up small buttons and get dressed of a morning. On examination the GP notes that she has swollen warm and tender MCP joints and a reduced range of movement in both hands. 1. List 3 possible joint deformities in advanced rheumatoid arthritis? Swan neck deformities Z shaped thumb Boutonnieres Subluxation of the joint Ulnar deviation 2. What investigations should the GP request for this condition? Full blood count Rheumatoid factor X-ray of the hand Erythrocyte Sedimentation Rate Antinuclear Antibodies (3 marks)

(3 marks)

3. Give 2 findings you would expect to find on radiological assessment of rheumatoid arthritis? (2 marks) Loss of joint space Erosion of the joint Soft tissue swelling Subluxation

4. List 4 management options for this ladies arthritis? Multidisciplinary team approach - Physiotherapy / occupational therapy Non steroidal anti inflammatory drugs Steroids (intrarticular or oral) Disease modifying anti-rheumatic drugs Surgery fixing or joint replacement

(2 marks)

(10 marks)

Psychiatry Mr Bojangles presents to A&E at 02:00 having broken his ankle rushing down a flight of stairs. Mr Bojangles is a poor historian. Whilst given his history he speaks very quickly and abruptly changes topics via tedious connections. He appears to be euphoric and does not seem particularly concerned about his broken ankle. He is dressed in bright colourful clothing and is noted to have poor concentration and poor personal hygiene and is clinically dehydrated. He admits to hearing voices telling him you are the most important human being in the world. He does not smell of alcohol and denies taking both alcohol and illicit drugs. 1. List 3 differential diagnoses? Schizophrenia (Acute) Drug-induced psychosis Acute confusion/ delirium Bipolar disorder Head trauma Organic space occupying lesion 2. Name 2 investigations you would like to carry out on Mr Bojangles? Drug screen Glucose Urea and electrolytes Full blood count Folate / B12 deficiency Thyroid function tests X-ray of the ankle Urine dipstix Computerised tomography of the head (3 marks)

(2 marks)

3. Assuming he has a psychosis, what drug could be used to alleviate Mr Bojangles psychiatric symptoms? (1 mark) Haloperidol You decide to admit Mr Bojangles to the orthopaedic ward. Initially he is willing to remain in hospital and undergo further treatment however a couple of hours later he decides he wants to leave. You are concerned about his level of self neglect and the possibility of harm to himself and to others, and you decide to detain him. The duty psychiatrist is unavailable. 4. Which section of the mental health act is best suited to this case and who is required to perform it? (2 marks) Section 5 part 2 (Treating as an in-patient) Section 4 (Performed by most senior doctor available)

Mr Bojangles makes a complete recovery from both his broken ankle and his psychiatric condition and is discharged. Unfortunately 4 months later he again presents to A&E having attempted to commit suicide by cutting his radial artery. 5. Name 2 features of an attempted suicide that would put Mr Bojangles at a high risk of trying again? (2 marks) Concealed / Locked himself in room Violent suicide method Did he leave a suicide note / premeditated Putting affairs in order Expressed wish to die Showed regret that attempt was unsuccessful

(10 marks)