500 Single Best Answers in Medicine PDF

500 Single Best Answers in MEDICINE This page intentionally left blank 500 Single Best Answers in MEDICINE Sukhpreet Singh Dubb BSc (Hons) MBBS AICSM Final Year Medical Student, Department of Investigative Medicine and Academic Surgery, Imperial College London Kumaran Shanmugarajah BSc (Hons) M...

500 Single Best Answers in MEDICINE This page intentionally left blank 500 Single Best Answers in MEDICINE Sukhpreet Singh Dubb BSc (Hons) MBBS AICSM Final Year Medical Student, Department of Investigative Medicine and Academic Surgery, Imperial College London Kumaran Shanmugarajah BSc (Hons) MBBS AICSM FY2 Doctor, Northwest Thames Deanery, Imperial College Healthcare Trust, London Darren K Patten BSc (Hons) MBBS AICSM Academic Clinical Fellow and Core Surgical Trainee, London Deanery, Department of Biosurgery and Surgical Oncology, St Mary’s Hospital, Imperial College Healthcare Trust, London, UK Michael Schachter BSc MB FRCP Department of Clinical Pharmacology, National Heart and Lung Institute, Imperial College London Cristina Koppel BSc MBBS (AICSM) Neurology Registrar, Fellow in Medical Education, Chelsea and Westminster Hospital, Imperial College School of Medicine, London Editorial Advisor Karim Meeran Professor of Endocrinology, Imperial College London First published in Great Britain in 2011 by Hodder Arnold, an imprint of Hodder Education, a division of Hachette UK 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2011 Hodder & Stoughton Ltd All rights reserved. Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright licensing Agency: Saffron House, 6-10 Kirby Street, London EC1N 8TS. Hachette UK’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-13 978-1-444-12152-0 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Joanna Koster Project Editor: Stephen Clausard Production Controller: Jonathan Williams Cover Design: Amina Dudhia Indexer: Laurence Errington Cover image © Steve Allen/Science Photo Library Typeset in 9.5/12 Rotis Serif by MPS Limited, a Macmillan Company Printed in India What do you think about this book? Or any other Hodder Arnold title? Please visit our website: www.hodderarnold.com Dedication To my parents and brother, who during the darkest nights have forever remained the brightest stars. Sukhpreet S Dubb To my parents – thank you for your support and encouragement Kumaran Shanmugarajah To my family and friends, your priceless support and inspiration made this possible. Darren K Patten To the memory of my parents Michael Schachter For Alexander and Andreas Cristina Koppel This page intentionally left blank Contents Foreword ix Preface xi Acknowledgements xiii List of Abbreviations Used xv Common Reference Intervals xix SECTION 1: CARDIOVASCULAR Questions 1–40 3 Answers 17 SECTION 2: RESPIRATORY Questions 1–40 33 Answers 46 SECTION 3: GASTROINTESTINAL Questions 1–40 67 Answers 80 SECTION 4: RENAL Questions 1–30 99 Answers 110 SECTION 5: ENDOCRINOLOGY Questions 1–35 127 Answers 139 SECTION 6: RHEUMATOLOGY Questions 1–35 159 Answers 171 SECTION 7: HAEMATOLOGY Questions 1–35 189 Answers 203 SECTION 8: NEUROLOGY Questions 1–40 219 Answers 232 SECTION 9: ONCOLOGY Questions 1–25 250 Answers 259  viii Contents SECTION 10: DERMATOLOGY Questions 1–40 273 Answers 286 SECTION 11: INFECTIOUS DISEASES Questions 1–40 305 Answers 318 SECTION 12: EMERGENCIES Questions 1–35 335 Answers 348 SECTION 13: PRACTICE EXAM Questions 1–65 367 Answers 388 Index 409 Foreword A continuing pursuance of clinical excellence can be a long and difficult path to follow. Nevertheless, it is something we all aspire to in order to use our best knowledge in serving our patients. But first, one has to pass the qualifying examination! This book helps to test your knowledge and aims to provide a question and answer format that closely follows the curriculum for Finals. It reflects the clinical scenarios that medical students will encounter when they first start as doctors and also face in Finals. It follows the single best answer format; a format of questioning that is more like real life. The authors have given comprehensive and informative answers, as well as reasons for the choice of the correct answer. It is very readable. It is also refreshing to see that the authors have combined together to write this text from a wide range and level of knowledge – from a final year medical student to a professor. They will all remember what Finals entailed, from the sheer anxiety to the excitement of getting the knowledge of medicine into focus. I am sure this book will be useful and enjoyable. Good luck for Finals! Professor Parveen J Kumar CBE, BSc, MD, FRCP, FRCPE Professor of Medicine & Education Barts & the London School of Medicine and Dentistry Queen Mary, University of London This page intentionally left blank Preface Medical schools have undergone a number of changes in deciding upon the ideal format for testing clinical knowledge in examinations. Multiple choice questions (MCQs) in the past were the most common modality by which medical students were examined. Although able to test a broad range of topics and being cost efficient for marking purposes, MCQs have largely been abandoned in favour of extending matching questions (EMQs) and more recently the single best answer (SBA) question format. EMQs and SBAs overcome the ambiguity that occurs in MCQ exams, as well as being able to provide more clinical question stems reflecting real-life situations. The SBA format is highly favoured in examinations at both the undergraduate and postgraduate level since students must not only demonstrate their clinical knowledge and understanding but also make sound judgements which are more congruent with clinical practice. 500 Single Best Answers in Medicine provides a significant number of high quality SBA questions that comprehensively examines the typical undergraduate curriculum. Each question not only provides an opportunity to apply clinical knowledge and correctly identify the single best answer to a question, but also to learn why the other answers are wrong, greatly increasing the clinical acumen and learning opportunity of the reader. This book aims to provide medical students with a useful source for exam revision as well as supplementing the reader’s knowledge such that they feel fully prepared for the undergraduate medical written examinations. Sukhpreet Singh Dubb and Professor Karim Meeran This page intentionally left blank Acknowledgements Professor Karim Meeran Professor of Endocrinology Department of Medicine Imperial College London Dr Michael Schachter Senior Lecturer in Clinical Pharmacology St. Mary’s Hospital London Imperial College NHS Healthcare Trust Dr Maisse Farhan Accident and Emergency Consultant St. Mary’s Hospital London Imperial College NHS Healthcare Trust Dr Frederick Tam Consultant Nephrologist Hammersmith Hospital Imperial College NHS Healthcare Trust Dr Richard Russell Consultant Chest Physician Heatherwood and Wexham Park Hospitals NHS Foundation Trust Dr Jane Currie Fellow in Medical Education Chelsea and Westminster Hospital Imperial College London We would also like to thank Dr Joanna Koster, Stephen Clausard and the rest of the Hodder Arnold team whose support and advice have made this project possible. This page intentionally left blank List of Abbreviations Used 5 ASA 5-aminosalicylic acid CML chronic myeloid AAA abdominal aortic leukaemia aneurysm CMV cytomegalovirus ABG arterial blood gas CN cranial nerve ABPA allergic bronchopulmonary CNS central nervous system aspergillosis COPD chronic obstructive ACEI angiotensin converting pulmonary disease enzyme inhibitor CRP C-reactive protein ACTH adrenocorticotropic CSF cerebrospinal fluid hormone CT computed tomography ADH anti-diuretic hormone CT PA CT pulmonary angiogram AFP alpha fetoprotein DCM dilated cardiomyopathy AIDS autoimmune deficiency DIC disseminated intravascular syndrome coagulation AIH autoimmune hepatitis DIP distal interphalangeal ALL acute lymphoblastic joint leukaemia DMARD disease-modifying AMA anti-mitochondrial antirheumatic drug antibody DVT deep vein thrombosis AML acute myeloid leukaemia EBV Epstein–Barr virus ANA anti-nuclear antibodies ECG electrocardiogram ANCA anti-neutrophil ERCP endoscopic retrograde cytoplasmic antibodies cholangiopancreatography ARDS acute respiratory distress ESR erythrocyte sedimentation syndrome rate ASO anti-streptolysin O FBC full blood count BCC basal cell carcinoma FEV1 forced expiratory volume BEP cisplatin in one second Beta-hCG beta-human chorionic FVC forced vital capacity gonadotrophin GABA gamma-aminobutyric acid BMI body mass index GBM glomerular basement BNF british National Formulary membrane BPPV benign paroxysmal GCS glasgow Coma Scale positional vertigo GH growth hormone CCP citrullinated peptide GMP guanosine monophosphate antibody GORD gastro-oesophageal reflux CEA carcinoembryonic antigen disease CFTR cystic fibrosis GTN glyceryl trinitrate transmembrane HbA1c glycated haemoglobin conductance regulator HCC hepatocellular carcinoma CLO campylobacter-like HIV human immunodeficiency organism virus  xvi List of Abbreviations Used HPV human papilloma virus MRI magnetic resonance HRCT high-resolution CT chest imaging HSV herpes simplex virus MSH melanocyte stimulating HUS haemolytic uraemic hormone syndrome NSAID non-steroidal anti- IBD inflammatory bowel inflammatory drug disease NSCLC non-small cell lung ICP intracranial pressure carcinomas ICS inhaled corticosteroid NSTEM non-ST elevation INO intranuclear myocardial infarction opthalmoplegia OCP oral contraceptive pill INR international normalized PAN polyarteritis nodosa ratio PBC primary biliary cirrhosis ITP immune thrombocytopenic PCI percutaneous coronary purpura intervention IV intravenous PD Parkinson’s disease IVU intravenous urography PE pulmonary embolism JVP jugular venous pressure PEF peak expiratory flow KUB kidneys, ureter and PEFR peak expiratory flow rate bladder PET positron emission LABA long-acting beta agonist tomography LADA latent autoimmune PFO patent foramen ovale diabetes of adults PIP proximal interphalangeal LAMA long-acting muscarinic joint antagonist POMC pro-opiomelanocortin LFT liver function tests PPI proton pump inhibitor LMN lower motor neurone PSA prostate-specific antigen LP lumbar puncture PSC primary sclerosing LRTI lower respiratory tract cholangitis infections PTH parathyroid hormone MC&S microscopy, culture and PV per vaginum sensitivity RA rheumatoid arthritis MCH mean cell haemoglobin RAPD relative afferent pupillary MCP metacarpophalangeal joint defect MCV mean cell volume RBC red blood cell MG myasthenia gravis RF rheumatoid factor MI myocardial infarction SAH subarachnoid MLF medial longitudinal haemorrhage fasciculus SAMA short-acting muscarinic MND motor neurone disease antagonist MR magnetic resonance SBP spontaneous bacterial MRCP magnetic resonance peritonitis cholangiopancreatography SCC squamous cell carcinoma  List of Abbreviations Used xvii SIADH syndrome of inappropriate TOE transoesophageal anti-diuretic hormone echocardiography SLA soluble liver antigen TSH thyroid stimulating SLE systemic lupus hormone erythematosus TTP thrombotic SMA smooth muscle antibody thrombocytopenic SSRI selective serotonin purpura reuptake inhibitor U&E urea and electrolytes STEMI ST elevation myocardial UC ulcerative colitis infarction UMN upper motor neurone T2DM type 2 diabetes mellitus URTI upper respiratory tract T3 tri-iodothyronine level US ultrasound scan T4 tetraiodothyronine UTI urinary tract infection TB tuberculosis V/Q scan ventilation perfusion TFT thyroid function test scan TIBC total iron-binding capacity VZV varicella zoster virus TIPPS transjugular intrahepatic WBC white blood cell portosystemic shunting WCC white cell count TNF tumour necrosis factor WHO World Health Organization This page intentionally left blank Common Reference Intervals Investigation/Test Range Units Alanine transaminase (ALT) 0–31 IU/L Albumin 33–47 g/L Alkaline phosphatase (ALP) 30–130 IU/L Amylase 70–400 U/L APTT 22.0–29.0 secs Aspartate transaminase (AST) 0–31 IU/L Bicarbonate 22–29 mmol/L Bilirubin 0–17 umol/L Calcium 2.15–2.65 mmol/L Chloride 95–108 mmol/L Cholesterol 10.6 Kpa PaO2 75–100 mmHg pH 7.35–7.45 Phosphate 0.80–1.40 mmol/L Platelets 120–400 109/L xx Common Reference Intervals Investigation/Test Range Units Potassium 3.8–5.5 mmol/L Prolactin female 0–750 mU/L Prolactin male 150–500 mU/L Prothrombin time 9.0–12.0 secs RBC 3.74–4.99 ×10 Serum vitamin B12 160–800 ng/L Sodium 135–145 mmol/L Total iron binding capacity 49–78 umol/L Total protein 64–83 g/L Transferrin Sat 20–45 % Triglycerides 0.00–1.80 mmol/L TSH 0.3–4.2 mU/L Urea 2.5–7.0 mmol/L WBC 4.0–11.0 109/L SECTION 1: CARDIOVASCULAR Questions 1. Myocardial infarction 3 2. Heart failure (1) 3 3. Valve lesion signs 3 4. CHAD2 score 4 5. Chest pain (1) 4 6. Shortness of breath (1) 4 7. Murmurs (1) 5 8. Chest pain (2) 5 9. Chest pain management 5 10. Ventricular tachyarrhythmia 6 11. Jugular venous pressure 6 12. Heart failure (2) 6 13. First degree heart block 7 14. Mitral stenosis 7 15. Hypertension (1) 7 16. Palpitations 8 17. Murmurs (2) 8 18. Postmyocardial infarction (1) 8 19. Hypertension (2) 9 20. Mid-systolic murmur 9 21. Ventral septal defect 9 22. Microscopic haematuria 10 23. Retrosternal chest pain 10 24. Pulmonary embolism management 10 25. Mid-diastolic murmur 11 1 CARDIOVASCULAR 26. Severe chest pain 11 27. Decrescendo diastolic murmur 11 28. Supraventricular tachycardia 12 29. Chest pain (3) 12 30. Shortness of breath (2) 12 31. Hypertension (3) 13 32. Chest pain (4) 13 33. Constrictive pericarditis 13 34. Visual disturbance 14 35. Weight loss 14 36. Postmyocardial infarction (2) 14 37. Mitral valve prolapse complication 15 38. Mitral valve prolapse 15 39. Paroxysmal atrial fibrillation 15 40. Hypertension management 16 Answers 17  Questions 3 QUESTIONS 1. Myocardial infarction A 65-year-old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What are the most likely changes to have occurred on ECG during admission? A. ST depression in leads V1–4 B. ST elevation in leads V1–6 C. ST depression in leads II, III and AVF D. ST elevation in leads V5–6 E. ST elevation in leads II, III and AVF 2. Heart failure (1) A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present? A. Pleural effusion on chest x-ray B. Raised jugular venous pressure (JVP) C. Bilateral pedal oedema D. Bibasal crepitations E. Atrial fibrillation 3. Valve lesion signs A patient is admitted with pneumonia. A murmur is heard on examination. What finding points to mitral regurgitation? A. Murmur louder on inspiration B. Murmur louder with patient in left lateral position C. Murmur louder over the right 2nd intercostal space midclavicular line D. Corrigan’s sign E. Narrow pulse pressure  4 Section 1: Cardiovascular 4. CHAD2 score A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment? A. Aspirin and clopidogrel B. Digoxin C. Cardioversion D. Aspirin alone E. Warfarin 5. Chest pain (1) A 55-year-old man has just arrived in accident and emergency complaining of 20 minutes of central crushing chest pain. Which feature is most indicative of myocardial infarction at this moment in time? A. Inverted T waves B. ST depression C. ST elevation D. Q waves E. Raised troponin 6. Shortness of breath (1) A 66-year-old woman presents to accident and emergency with a 2-day history of shortness of breath. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also complains of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is: A. Muscular strain B. Heart failure C. Pneumothorax D. Angina E. Pulmonary embolism  Questions 5 7. Murmurs (1) A 59-year-old man presents for a well person check. A cardiovascular, respiratory, gastrointestinal and neurological examination is performed. No significant findings are found, except during auscultation a mid systolic click followed by a late systolic murmur is heard at the apex. The patient denies any symptoms. The most likely diagnosis is: A. Barlow syndrome B. Austin Flint murmur C. Patent ductus arteriosus D. Graham Steell murmur E. Carey Coombs murmur 8. Chest pain (2) A 60-year-old man presents to accident and emergency with a 3-day history of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the centre of his chest and radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is 155/95 mmHg. The most likely diagnosis is: A. Myocardial infarction B. Myocardial ischaemia C. Aortic dissection D. Pulmonary embolism E. Pneumonia 9. Chest pain management A 49-year-old man is rushed to accident and emergency complaining of a 20-minute history of severe, crushing chest pain. After giving the patient glyceryl trinitrate (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes and is allergic to aspirin. The most appropriate management is: A. Aspirin B. Morphine C. Heparin D. Clopidogrel E. Warfarin  6 Section 1: Cardiovascular 10. Ventricular tachyarrhythmia While on call you are called by a nurse to a patient on the ward complaining of light headedness and palpitations. When you arrive the patient is not conscious but has a patent airway and is breathing with oxygen saturation at 97 per cent. You try to palpate a pulse but are unable to find the radial or carotid. The registrar arrives and after hearing your report of the patient decides to shock the patient who recovers. What is the patient most likely to have been suffering? A. Torsades de Pointes B. Ventricular fibrillation C. Sustained ventricular tachycardia D. Non-sustained ventricular tachycardia E. Normal heart ventricular tachycardia 11. Jugular venous pressure A 67-year-old man presents to accident and emergency with a 3-day history of shortness of breath. On examination you palpate the radial pulse and notice that the patient has an irregular heart beat with an overall rate of 140 bpm. You request an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation. Which of the following would you expect to see when assessing the JVP? A. Raised JVP with normal waveform B. Large ‘v waves’ C. Cannon ‘a waves’ D. Absent ‘a waves’ E. Large ‘a waves’ 12. Heart failure (2) A 78-year-old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen on chest x-ray in patients with congestive cardiac failure? A. Lower lobe diversion B. Cardiomegaly C. Pleural effusions D. Alveolar oedema E. Kerley B lines  Questions 7 13. First degree heart block A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is relieved by rest. You request an ECG which reveals that the patient has first degree heart block. Which of the following ECG abnormalities is typically seen in first degree heart block? A. PR interval >120 ms B. PR interval >300 ms C. PR interval 200 ms E. PR interval 4 per cent annual stroke risk) is classified as high risk and warfarin (E) should be started unless there are clear contraindications. A patient with a full-house of risk factors (scores 6) has an almost 20 per cent chance of stroke/year. Chest pain 5 C Acute coronary syndrome is a spectrum of cardiac ischaemia-infarction determined by the presence of two out of three factors: chest pain, ECG changes and cardiac enzyme rise. Depending on these results, patients will fall into one of the following categories: unstable angina, NSTEMI or STEMI. Inverted T waves (A) and ST depression (B) are signs of ischaemia. ST elevation, Q waves and raised troponin are indicative of infarction. Initially, ‘ST elevation’ or ‘non ST elevation’ ECG changes are used to stratify each patient’s risk as the results of blood tests for troponin levels (E) (which should be carried out 12 hours after the pain started) are not known and Q waves have not had time to develop. ST elevation (C) is a very good predictor of imminent infarction (positive troponin). However, if this patient is treated quickly enough with thrombolysis or primary PCI, infarction can be avoided. A patient with STEMI who goes on to have  20 Section 1: Cardiovascular negative troponin is termed to have had an ‘aborted MI’. Q waves (D) (indicating full-thickness MI) take time to develop, so ‘Q wave’ or ‘non Q wave’ MI is a diagnosis given on discharge. ECG: ST elevation + − Troponin + STEMI NSTEMI − Aborted MI Unstable angina Shortness of breath 6 E This patient is most likely suffering from a pulmonary embolism (E), defined as an occlusion of the pulmonary vasculature by a thrombus causing an area of lung that is ventilated but not perfused. Patients most often complain of shortness of breath, pleuritic chest pain and haemoptysis. Clinical signs can include a pleural rub, coarse crackles and atrial fibrillation. In massive pulmonary embolism there can be a raised JVP, respiratory rate, heart rate and hypotension. The Geneva scoring system (see below) is useful for predicting the risk of a pulmonary embolism: a score of ≤3 (mild), 4–10 (moderate) and ≥11 (high). Muscular strain (A) typically occurs on movement and is not associated with shortness of breath or leg pain and there is usually an indicator of injury or a preceding stressor. Heart failure (B) is unlikely due to the acute presentation of symptoms which tend to occur more insidiously and can be associated with bilateral leg oedema, murmurs, orthopnoea or hepatomegaly, among others. A pneumothorax (C) can present with a similar pleuritic chest pain that occurs in an embolism, however, there is no association with limb pain and a respiratory examination is likely to reveal hyper-resonance. Angina (D) is typically described as a dull or crushing chest pain in the centre of the chest, patients have risk factors such as diabetes, hyperlipidaemia, obesity, smoking and hypertension. Measurement Score ≥65 years 1 Previous DVT or PE 3 Surgery or fracture ≤4 weeks 2 Malignancy 2 Unilateral leg pain 3 Unilateral oedema 4 Haemoptysis 2 Heart rate: 75–94 3 Heart rate: >95 5  Answers 21 Murmurs 7 A This patient is suffering from a mitral valve prolapse (Barlow syndrome, click murmur syndrome) (A). A mid-systolic click followed by a late systolic murmur is heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole. An Austin Flint murmur (B) produces a low pitched, mid-diastolic rumble at the apex. Classically, mitral valve displacement as well as aortic turbulence due to regurgitation qualifies as an Austin Flint murmur. A patent ductus arteriosus (C) produces a constant machinery murmur. A Graham Steell murmur (D) is typically heard best at the left sternal edge, second intercostals space during inspiration. A high pitched early diastolic murmur is heard associated with pulmonary hypertension. A Carey Coombs murmur (E) is a short, mid-diastolic rumble heard best at the apex due to turbulent blood flow over a thickened mitral valve, most often due to rheumatic fever. Chest pain 8 C All of the answer options can present as central chest pain, however the patient describes a very typical description of an aortic dissection (C), usually a severe, tearing pain that radiates toward the back though this can be to the jaw depending on the location of the dissection. An MI (A) is typically described as severe, crushing chest pain with an acute onset, this patient has been suffering from a 3-day history of chest pain which makes an infarction unlikely. Although myocardial ischaemia (B), i.e. angina, can occur for a longer period of time they tend not radiate to the back but more toward the jaw, arms or epigastrum, and again are described as crushing in nature rather than tearing. A pulmonary embolism (D) typically presents with pleuritic chest pain, cough and haemoptysis which are not present in this patient, or preceding risk factors such as long haul travel or surgery. Pneumonia (E) is associated with fever and productive coughing. Chest pain management 9 D NICE guideline protocols state that in a patient with suspected MI, pain relief in the form of GTN spray or morphine should be administered. Since the patient has had an adequate response to GTN spray, further pain relief in the form of morphine (B) is unnecessary. In patients who are not allergic, 300 mg of aspirin is recommended and ideally should be given in the ambulance. However, if the patient is allergic to aspirin (A) it should not be given since an anaphylactic reaction would compromise the patient’s airway and does not overrule the harm from a possible MI. Although heparin (C) and warfarin (E) would provide good anticoagulant cover, they are slower to act and current guidance advises clopidogrel monotherapy (D) in those patients allergic to aspirin.  22 Section 1: Cardiovascular Ventricular tachyarrhythmia 10 B This patient is suffering from a life-threatening ventricular tachyarrhythmia of which there are two types, sustained ventricular tachycardia and ventricular fibrillation. In ventricular fibrillation (B) the patient is pulseless and cardioversion is required. A sustained ventricular tachycardia (C) is usually recognized by cannon ‘a’ waves on JVP and broad QRS complexes if an ECG is available. If stable, patients can be cardioverted with amiodarone, if unstable, electrocardioversion is required. Torsades de pointes (A) presents with irregular QRS complexes and prolonged QT interval, a non-sustained ventricular tachycardia (D) is defined by more than five consecutive heart beats within 30 seconds, while a normal heart ventricular tachycardia (E) is a benign tachyarrhythmia. Answers (A), (D) and (E) are not shockable rhythms. Jugular venous pressure 11 D The JVP provides clinicians with information regarding right atrial pressures and filling. It mainly consists of five wave forms: 1 a wave – representing atrial systole; 2 c wave – representing closure of the tricuspid valve (this wave is not usually visible); 3 x descent – representing a fall in atrial pressure during ventricular systole; 4 v wave – representing atrial filling against a closed tricuspid valve; 5 y descent – representing the opening of the tricuspid valve. In atrial fibrillation, the ‘a waves’ are absent (D) due to dysfunctional atrial systole. A raised JVP with normal waveform pattern (A) is usually seen in fluid overload and right heart failure. Large v waves (B) are usually seen in patients with tricuspid regurgitation. Cannon ‘a waves’ (C) are seen in patients with complete heart block, single chamber ventricular pacing, ventricular arrhythmias and ventricular ectopics. Large ‘a waves’ (E) can be seen in pulmonary hypertension and pulmonary stenosis. Heart failure 12 A Cardiomegaly (B), bilateral pleural effusions (C), alveolar oedema (D) and Kerley B lines (E) (representing interstitial oedema) are all features that can be seen in a chest x-ray in patients with congestive cardiac failure. Upper lobe diversion is usually seen on chest x-ray and not lower lobe diversion (A). First degree heart block 13 D The PR interval is usually measured from the start of the P-wave to the start of the QRS and the normal range lies within 0.12–0.2s (i.e. 120–200 ms). In  Answers 23 first degree heart block, the PR interval is prolonged, greater than 0.2 s (200 ms) (D). Shortened PR interval (i.e 30 g/L. From the list below, select the most likely diagnosis: A. Bronchogenic carcinoma B. Congestive cardiac failure C. Liver cirrhosis D. Nephrotic syndrome E. Meig’s syndrome  Questions 35 7. Diagnostics in respiratory medicine (2) You are discussing a patient with your registrar who has become acutely short of breath on the ward. After performing an arterial blood gas, you have high clinical suspicion that the patient has a pulmonary embolism. Which of the following is the investigation of choice for detecting pulmonary embolism? A. Magnetic resonance imaging (MRI) of the chest B. High-resolution CT chest (HRCT) C. Chest x-ray D. Ventilation/perfusion scan (V/Q scan) E. CT pulmonary angiogram (CT-Pa) 8. Management of asthma A 28-year-old man has been newly diagnosed with asthma. He has never been admitted to hospital with an asthma exacerbation and experiences symptoms once or twice a week. You discuss the treatment options with him. His peak expiratory flow reading is currently 85 per cent of the normal predicted value expected for his age and height. Which of the following is the most appropriate first step in treatment? A. Short-acting beta-2 agonist inhaler B. Long-acting beta-2 agonist inhaler C. Low-dose steroid inhaler D. Leukotriene receptor antagonists E. High-dose steroid inhaler 9. Investigations You see a 46-year-old man who has presented to accident and emergency with an acute onset of shortness of breath. Your registrar has high clinical suspicion that the patient is suffering from a pulmonary embolism and tells you that the patient’s ECG has changes pointing to the suspected diagnosis. From the list below, which of the following ECG changes are classically seen? A. Inverted T-waves in lead I, tall/tented T-waves in lead III and flattened T-waves in lead III B. Deep S-wave in lead I, pathological Q-wave in lead III and inverted T-waves in lead III C. Flattened T-wave in lead I, inverted T-wave in lead III, and deep S-wave in lead III D. No changes in lead I, deep S-wave in lead III E. Deep S-wave in lead I with no changes in lead III  36 Section 2: Respiratory 10. Interpretation of arterial blood gases (2) Which of the following arterial blood gas results, taken on room air, would you expect to see in a 67-year-old patient who has been suffering with COPD for two years and is not on home oxygen? A. pH 7.35, PO2 11, PCO2 5.3, HCO3 24, SO2 98 per cent B. pH 7.47, PO2 12, PCO2 5.1, HCO3 30, SO2 97 per cent C. pH 7.44, PO2 8.3, PCO2 6.7, HCO3 28, SO2 93 per cent D. pH 7.31, PO2 10.2, PCO2 6.8, HCO3 25, SO2 95 per cent E. pH 7.30, PO2 11.5, PCO2 5.2, HCO3 18, SO2 96 per cent 11. Bronchiectasis You see a 46-year-old woman on your ward who has been diagnosed with bronchiectasis following a three-month history of a mucopurulent cough. Which of the following from the list below is not a cause of bronchiectasis? A. Kartagener’s syndrome B. Cystic fibrosis C. Pneumonia D. Left ventricular failure E. Bronchogenic carcinoma 12. Finger clubbing A 30-year-old man presents to your clinic with a cough and finger clubbing. From the list below, which of these answers is not a respiratory cause of finger clubbing? A. Empyema B. Mesothelioma C. Bronchogenic carcinoma D. Cystic fibrosis E. COPD 13. Lung tumours A 55-year-old woman, who has never smoked, presents to you on the ward with a history of weight loss, decreased appetite and finger clubbing. You are told that her chest x-ray revealed opacity in the hilar region of the right lung suggesting a bronchogenic carcinoma. She is currently awaiting a CT-chest with bronchoscopy to follow. From the list below, select the most likely diagnosis: A. Squamous cell carcinoma of the lung B. Adenocarcinoma of the lung C. Small cell carcinoma of the lung D. Large cell carcinoma of lung E. Carcinoid tumour of the lung  Questions 37 14. Shortness of breath (2) You see a 28-year-old man, with no past medical history, in accident and emergency who developed an acute onset of pleuritic chest pain and shortness of breath while playing football. On examination, oxygen saturations are 93 per cent on room air, respiratory rate 20 and temperature is 37.1°C. There is decreased expansion of the chest on the left side, hyper-resonant to percussion and reduced air entry on the left. The most likely diagnosis is: A. Left-sided pneumothorax B. Left-sided pneumonia C. Left-sided pleural effusion D. Lung fibrosis E. Traumatic chest injury 15. Investigating shortness of breath You are asked to request imaging for a patient with a suspected pneumothorax who you have just examined in accident and emergency. Which of the following would be the most appropriate first step imaging modality? A. CT-chest B. Ultrasound chest C. Chest x-ray D. V/Q scan E. CT-PA 16. Management of pulmonary emboli A 68-year-old woman has presented with acute onset shortness of breath 24 hours after a long haul flight. Her blood results show a raised D-dimer level and the arterial blood gas shows a PO2 of 8.3 kPa and PCO2 of 5.4 kPa. Your consultant suspects a pulmonary embolism and the patient needs to be started on treatment while a CT-PA is awaited. From the list below, please select the most appropriate treatment regime. A. Commence loading with warfarin and aim for an international normalized ratio (INR) between 2 and 3 B. Thromboembolic deterrent stockings C. Aspirin 75 mg daily D. Prophylactic dose subcutaneous low molecular weight heparin + loading with warfarin and aim for INR between 2 and 3 E. Treatment dose subcutaneous low molecular weight heparin + loading with warfarin and aim for INR between 2 and 3  38 Section 2: Respiratory 17. Pancoast’s tumour You see a 67-year-old man who has been referred to the chest clinic following a three-month history of weight loss and signs which may suggest a Pancoast’s tumour. Which of the following symptoms from the list below is not associated with a Pancoast’s tumour? A. Hoarse voice B. Miosis C. Anhydrosis D. Exopthalmos E. Ptosis 18. Cough A 50-year-old Afro-Caribbean man, with no past medical history, presents with a four-month history of dry cough and shortness of breath on exertion. The patient’s GP referred him to the chest clinic after performing blood tests which revealed a raised erythrocyte sedimentation rate (ESR) and serum angiotensin-converting enzyme (ACE) level. You review the patient’s chest x-ray which reveals bilateral hilar lyphadenopathy. From the list below, select the most likely diagnosis: A. Rheumatoid arthritis B. Systemic lupus erythematosus (SLE) C. Sarcoidosis D. Idiopathic pulmonary fibrosis E. Bronchogenic carcinoma 19. Cor pulmonale A 67-year-old man presents with dyspnoea and fatigue with signs of a raised jugular venous pressure (JVP), hepatomegaly and peripheral oedema. The patient has a longstanding history of COPD. You suspect cor pulmonale. Which of the following is not a cause of cor pulmonale? A. Pulmonary fibrosis B. Primary pulmonary hypertension C. Myasthenia gravis D. COPD E. Multiple sclerosis  Questions 39 20. Chest x-ray interpretation You are told by your registrar that a 69-year-old man has been admitted to the chest ward with dyspnoea, cyanosis and finger clubbing. His chest x-ray shows bilateral lower zone reticulo-nodular shadowing. From the list below, which is the most likely diagnosis? A. Bronchiectasis B. Pulmonary fibrosis C. Bronchogenic carcinoma D. Bronchitis E. COPD 21. Asthma A 25-year-old woman is admitted to accident and emergency with a severe exacerbation of asthma. On examination, her respiratory rate is 30, oxygen saturations are 95 per cent on 15 L O2 and temperature is 37.2°C. As you feel the peripheral pulse, the volume falls as the patient inspires. Which of the following explains this clinical sign? A. Increased left atrial filling pressures on inspiration B. Decreased right ventricular filling pressures on inspiration C. Peripheral vasodilation D. Decreased right atrial filling pressures on inspiration E. Decreased left atrial filling pressures on inspiration 22. Management of community-acquired pneumonia A 55-year-old man, who has never smoked and with no past medical history, has been diagnosed with right basal community-acquired pneumonia. There are minimal changes on his chest x-ray and bloods reveal a neutrophil count of 8.2 and a C-reactive protein (CRP) of 15. He has no drug allergies. Although he has a productive cough of green sputum, his respiratory rate is 16, oxygen saturations are 97 per cent on room air and his temperature is 37.4°C. You are asked to place him on treatment. Which of the following treatment options would be appropriate for this patient? A. Oral amoxicillin B. Oral erythromycin C. Intravenous ertapenem D. Intravenous ertapenem with a macrolide (e.g. clarithromycin) E. Intravenous tazocin  40 Section 2: Respiratory 23. Complications of pneumonia A 56-year-old woman who has recently been discharged from your ward, with oral antibiotics for right basal community-acquired pneumonia, is re-admitted with transient pyrexia and shortness of breath. She is found to have a right-sided pleural effusion which is drained and some pleural aspirate sent for analysis. The results reveal an empyema. Which of the following, from the pleural aspirate analysis, would typically be found in a patient with an empyema? A. pH >7.2, ↑ LDH, ↑ glucose B. pH 7.2, ↓ LDH, ↓ glucose D. pH