Updated 17-Aug-2012

Specialty Certificate in Acute Medicine Sample Questions Question 141 A 50-year-old woman was admitted with sepsis secondary to pneumonia. She was treated with oxygen, intravenous antibiotics and repeated fluid challenges to a total volume of 4.5 L (equivalent to 60 mL/kg) of sodium chloride 0.9%. On re-assessment, her pulse was 122 beats per minute, her blood pressure was 82/40 mmHg (mean arterial pressure 54) and her respiratory rate was 24 breaths per minute. Oxygen saturation was 92% (94–99), breathing 40% oxygen. Her central venous pressure was 12 mmHg. In attempting to restore the blood pressure, what is the most appropriate intravenous therapy? A colloid B dopamine C furosemide D further crystalloid E noradrenaline (norepinephrine)

Updated 17-Aug-2012

Question 2 A 73-year-old woman was referred to the acute medical unit for assessment of her palpitations. One hour after arriving, she complained of a return of her palpitations with a central crushing chest pain. She became distressed and agitated. She was given aspirin and sublingual glyceryl trinitrate. Oxygen was given at 15 L per minute via a reservoir mask. On examination, her pulse was thready and hard to count. Her blood pressure was 88/55 mmHg, her respiratory rate was 20 breaths per minute and her oxygen saturation was 98% (94–99). A cardiac monitor was attached and showed a narrow-complex irregular tachycardia with a ventricular rate between 150 and 160 beats per minute. A large-bore intravenous cannula was inserted. What is the most appropriate next step in management? A intravenous adenosine B intravenous digoxin C intravenous flecainide D intravenous verapamil E synchronised cardioversion

Updated 17-Aug-2012

Question 3 A 77-year-old man presented after a single episode of unilateral weakness of the left arm that lasted for 2 hours. On examination, his pulse was 80 beats per minute and regular, and his blood pressure was 170/100 mmHg. There was no neurological deficit. His ABCD2 score was 6. He was given 300 mg of aspirin while awaiting investigations. What is his chance of having a stroke in the first week? A 5% B 10% C 20% D 30% E 40%

Updated 17-Aug-2012

Question 4 A 43-year-old woman was referred to hospital with a persistent headache of 4 days’ duration. It had come on gradually and had not been associated with vomiting. Her general practitioner had found her blood pressure to be elevated at 214/118 mmHg and had arranged emergency admission. She had no other significant medical history and was taking no regular medication. On examination, she appeared well. She had a round face and her body mass index was 32 kg/m2 (18–25). Her pulse was 90 beats per minute and her blood pressure was 218/116 mmHg. Peripheral pulses were normal with no radiofemoral delay. Heart sounds were normal. Fundoscopy showed grade 2 hypertensive changes but no papilloedema. Urinalysis showed protein 2+, blood negative, nitrite negative, leucocytes negative. Investigations: 12-lead ECG sinus rhythm with changes

consistent with left ventricular hypertrophy

What is the most likely diagnosis? A acute glomerulonephritis B cerebral tumour C Cushing’s syndrome D essential hypertension E phaeochromocytoma

Updated 17-Aug-2012

Topic: SG Question 5 A 42-year-old woman presented with a 1-week history of vomiting and diarrhoea. This had begun after she was involved in a road traffic collision. She also complained of feeling dizzy on standing. Her family said that she had been slightly confused and slurred her words. On examination, her pulse was 114 beats per minute and her blood pressure was 85/40mmHg. Investigations: haemoglobin 116 g/L (115–165)

platelet count 364 109/L (150–400) serum sodium 123 mmol/L (137–144) serum potassium 6.4 mmol/L (3.5–4.9) serum creatinine 123 µmol/L (60–110) random plasma glucose 2.8 mmol/L What is the most likely diagnosis? A autoimmune adrenal failure (Addison's disease) B gastroenteritis C hypothyroidism D insulinoma E syndrome of inappropriate antidiuretic hormone

Updated 17-Aug-2012

Question 6 A 23-year-old man presented after having collapsed in a Chinese restaurant. He gave a history of a previous similar episode after having eaten nuts. On examination, his pulse was 120 beats per minute and his blood pressure was 95/60 mmHg. His chest was wheezy with an oxygen saturation of 89% (94–99). High-flow oxygen was administered and a dose of adrenaline (epinephrine) was requested. In what dose and by what route should adrenaline (epinephrine) be given? A 500 µg intramuscularly B 500 µg intravenously C 1 mg intramuscularly D 1 mg intravenously E 10 mg intravenously

Updated 17-Aug-2012

Question 7 A 32-year-old man presented with a 3-week history of headaches, fever, sore throat, myalgia, anorexia and generalised non-pruritic rash. He had no other significant medical history and had not been given a blood transfusion in the past. On examination, vital signs were normal except for a temperature of 37.4°C. Enlarged non-tender lymph nodes were noted in the axillae, submandibular areas and both groins. Throat examination was normal. He had no meningeal signs and detailed cardiorespiratory, abdominal and neurological examinations were normal. Generalised maculopapular rash was noted. Investigations: heterophil antibody test negative blood film atypical lymphocytosis What is the most likely diagnosis? A cytomegalovirus infection B group A streptococcus infection C HIV seroconversion D secondary syphilis E toxoplasmosis

Updated 17-Aug-2012

Question 8 A 70-year-old man was admitted to hospital with severe shortness of breath. He had a history of emphysema. On examination, he had diminished breath sounds over the left side of the chest. Investigations: chest X-ray large left pneumothorax What is the most appropriate next step in management? A insert 14F drain immediately above a rib margin B insert 14F drain immediately below a lower rib margin C insert 14F drain in the scalene triangle D insert 28F drain immediately below a lower rib margin E insert 28F drain in the scalene triangle

Updated 17-Aug-2012

Question 9 A 72-year-old man was admitted with community-acquired pneumonia. He had permanent atrial fibrillation and was taking digoxin. He had been treated with high-flow oxygen and intravenous benzylpenicillin and clarithromycin. On examination, his pulse was 120 beats per minute and irregular, and his blood pressure was 90/60 mmHg. His capillary refill time was 3 seconds. His respiratory rate was 24 breaths per minute and oxygen saturation was 98% (94–99), breathing 4 L/min oxygen via a simple face mask. What is the most appropriate management of his haemodynamic state? A intravenous amiodarone B intravenous digoxin C intravenous magnesium D intravenous sodium chloride 0.9% E synchronised cardioversion

Updated 17-Aug-2012

Question 10 A 48-year-old man with a history of alcohol dependency was admitted with confusion. On examination, he was unkempt and showed signs of poor nutrition. He had cool peripheries. His temperature was 35.6°C and his blood pressure was 86/58 mmHg. He had mild dysdiadochokinesis but no evidence of ophthalmoplegia or nystagmus. His capillary blood glucose concentration was 2.6 mmol/L. Intravenous access was established and he was immediately treated with glucose 10% 250 mL and vitamins B and C (Pabrinex®) by intravenous infusion. His blood pressure improved to 106/80 mmHg and his capillary glucose to 4.9 mmol/L. He became more drowsy. His neurological condition was noted to have deteriorated by the nursing staff. They re-checked his capillary glucose, which was 3.5 mmol/L. His blood pressure was 98/68 mmHg. What is the most appropriate next management step? A CT scan of head B intravenous co-amoxiclav C intravenous sodium chloride 0.9% D repeat intravenous glucose 10% 250 mL E repeat vitamins B and C (Pabrinex®) by intravenous infusion

Updated 17-Aug-2012

Question 11 A 29-year-old woman was brought to hospital by ambulance. She had been found unconscious by her husband with imipramine tablets by her bed. On arrival in the department she had a tonic–clonic seizure, which lasted for 2 minutes. She was otherwise fit and well. Investigations: ECG broad-complex tachycardia What is the most appropriate immediate treatment? A amiodarone B DC cardioversion C lorazepam D phenytoin E sodium bicarbonate

Updated 17-Aug-2012

Question 12 A 72-year-old woman presented with a 4-day history of palpitations. She had not experienced any dyspnoea or chest discomfort and was not distressed by the palpitations. Her general practitioner had noted rapid atrial fibrillation and referred her for assessment. She had type 2 diabetes mellitus and hypertension but no other significant medical history. Her medication comprised irbesartan, gliclazide, amlodipine and simvastatin. On examination, she was comfortable. Her pulse was 130 beats per minute, her blood pressure was 138/82 mmHg and her respiratory rate and oxygen saturation were normal. Her heart sounds were normal and her chest was clear. She had no oedema. Investigations: haemoglobin 146 g/L (115–165)

platelet count 164 109/L (150–400) serum sodium 143 mmol/L (137–144) serum potassium 4.4 mmol/L (3.5–4.9) serum creatinine 123 µmol/L (60–110) plasma thyroid-stimulating hormone 3.2 mU/L (0.4–5.0) 12-lead ECG atrial fibrillation with rapid ventricular

response What is the most appropriate next step in management? A DC cardioversion B intravenous digoxin C intravenous flecainide D oral bisoprolol E oral digoxin

Updated 17-Aug-2012

Question 13 A 54-year-old man was referred to the rapid access chest pain clinic for assessment. Based on a thorough history, his likelihood of coronary artery disease was calculated to be 25%. What is the most appropriate investigation? A cardiac stress echocardiography B CT coronary angiography C CT coronary artery calcium scoring D invasive coronary angiography E myocardial perfusion imaging

Updated 17-Aug-2012

Question 14 A 53-year-old woman was admitted to the emergency department following a tonic–clinic seizure at home. Her husband, who was with her, said that she had developed a sudden severe headache while doing the washing up about 2 hours previously. She had gone to bed because of the severity of the pain and he had found her convulsing. On arrival, she was not convulsing but her Glasgow coma score was 10. Her temperature was 36.9°C, her pulse was 85 beats per minute and her blood pressure was 168/93 mmHg. Fundal examination was normal. Tone and reflexes in her limbs were normal. Neck stiffness was present. Investigations: CT scan of head see image

What is the most appropriate next investigation? A blood culture

B CT cerebral angiography

C lumbar puncture 12 h after headache onset

D lumbar puncture immediately

E MR cerebral angiography

Updated 17-Aug-2012

Question 15 A 67-year-old man was admitted with chest pain. He had recently returned from a transatlantic holiday. He smoked heavily and his alcohol consumption was 40 units weekly. He had no past medical history of note and was taking no medication. On examination, his temperature was 37.5°C, his pulse was 90 beats per minute and his blood pressure was 160/96 mmHg. His respiratory rate was 30 breaths per minute and his oxygen saturation was 90% (94–99) breathing air. There were crackles over the right lung base. Investigations: chest X-ray see image ECG flat T waves in V1, V2, V3

He was treated with oral amoxicillin. What is the most appropriate next step? A assess clinical probability score for pulmonary thromboembolism B CT pulmonary angiography C D-dimer concentration D serum troponin I test E ventilation/perfusion isotope scan of lung

Updated 17-Aug-2012

Question 16 A 32-year-old woman was admitted with a 7-day history of nausea, sparse bloodstained diarrhoea and cramping lower abdominal pains. She was feeling increasingly exhausted and short of breath. On examination, she appeared pale and mildly icteric, with ankle oedema. There was a petechial rash over her face. Her temperature was 37.2°C, her pulse was 104 beats per minute and regular, and her blood pressure was 160/92 mmHg. No neurological abnormality was identified. Urinalysis was positive for blood and protein. Investigations: haemoglobin 70 g/L (115–165)

platelet count 56 109/L (150–400) prothrombin time 18.0 s (11.5–15.5) activated partial thromboplastin time 46 s (30–40) serum sodium 139 mmol/L (137–144) serum urea 37.0 mmol/L (2.5–7.0) serum creatinine 440 µmol/L (60–110) serum total bilirubin 63 µmol/L (1–22) serum lactate dehydrogenase 2600 U/L (10–250) What is the most likely underlying diagnosis? A acute lymphatic leukaemia B disseminated intravascular coagulation C haemolytic uraemic syndrome D idiopathic thrombocytopenic purpura E thrombotic thrombocytopenic purpura

Updated 17-Aug-2012

Question 17 A 70-year-old woman was admitted with chest and upper abdominal pain associated with sweating. She described the pain as having intensity 8/10. She had been previously fit and well. On examination, her pulse was 82 beats per minute and her blood pressure was 168/94 mmHg in the right arm and 156/88 in the left. Her respiratory rate was 15 breaths per minute and oxygen saturation was 95% (94–98), breathing air. There were no heart murmurs and the chest was clinically normal. There was epigastric tenderness. Initial investigations showed a normal full blood count, normal electrolytes and creatinine, and normal serum C-reactive protein. Her ECG was normal. A chest X-ray was performed (see image). A working diagnosis of dyspepsia was made. Early the following morning, she had a cardiac arrest and died.

What is most likely to have caused her death? A aortic dissection B massive gastrointestinal bleeding C perforated duodenal ulcer D pulmonary embolism E tension pneumothorax

Updated 17-Aug-2012

Question 18 A 47-year-old man presented with an acutely painful right ankle, shivering and mild fever. He was unable to bear weight. He had no history of joint problems but was taking treatment for hypertension. On examination, his temperature was 37.4°C. He was overweight and had a swollen right ankle with erythema over the joint. What is the most important investigation? A blood culture B joint fluid examination C serum C-reactive protein D serum urate E X-ray of ankle

Updated 17-Aug-2012

Question 19 A 24-year-old woman was admitted complaining of feeling unwell. She had returned from a 2-month tour of Malaysia the previous week. She complained of a severe headache, which was worse behind the eyes, and sore muscles, especially in her back, arms and legs. She had also had an intermittent fever for 3 days. She had no past medical history of note, and her only medication was the combined oral contraceptive. On examination, she was suntanned, with a temperature of 38.5°C, a pulse of 76 beats per minute and a blood pressure of 95/60 mmHg. She had some palpable lymph nodes in the axillae and inguinal regions, but no other abnormality was detected. Investigations: haemoglobin 144 g/L (115–165)

white cell count 1.8 109/L (4.0–11.0)

neutrophil count 0.6 109/L (1.5–7.0)

lymphocyte count 0.9 109/L (1.5–4.0)

monocyte count 0.4 109/L (<0.8)

eosinophil count 0.03 109/L (0.04–0.40)

basophil count 0.02 109/L (<0.1)

platelet count 135 109/L (150–400) serum sodium 137 mmol/L (137–144) serum potassium 4.1 mmol/L (3.5–4.9) serum bicarbonate 27 mmol/L (20–28) serum creatinine 95 µmol/L (60–110) serum total bilirubin 8 µmol/L (1–22) serum alanine aminotransferase 56 U/L (5–35) serum alkaline phosphatase 46 U/L (45–105) serum C-reactive protein 25 mg/L (<10) What is the most appropriate next step in management? A intravenous aciclovir B intravenous cefotaxime C intravenous quinine D oral oseltamivir E oral paracetamol

Updated 17-Aug-2012

Question 20 A 48-year-old man presented with a short history of fever, headache and confusion. He had a history of type 2 diabetes mellitus. On examination, his temperature was 40.1°C, his pulse was 103 beats per minute and his blood pressure was 87/52 mmHg. His Glasgow coma score was 9. His neck was stiff and he had photophobia. A CT scan of head was normal. He was given intravenous fluids. Investigations:

cerebrospinal fluid: total protein 1.80 g/L (0.15–0.45) glucose 1.9 mmol/L (3.3–4.4) cell count 2100/µL (≤5) lymphocyte count 100/µL (≤3) neutrophil count 2000/µL (0) Gram stain negative

In addition to cefotaxime, what is the most appropriate treatment? A aciclovir B amphotericin C chloramphenicol D dexamethasone E vancomycin

Updated 17-Aug-2012

Question 21 A 40-year-old man was brought to the emergency department by his friends. He was thought to have ingested an unknown medication in a suicide attempt. On examination, he was disorientated in time. His temperature was 39.3°C, his pulse was 100 beats per minute and irregular, his blood pressure was 120/85 mmHg and his respiratory rate was 22 breaths per minute. His skin was flushed and dry. On physical examination, he was noted to have dilated pupils and muscle twitching. There was no apparent neurological abnormality. Investigations: arterial blood gases, breathing air: PO2 12.0 kPa (11.3–12.6) PCO2 4.1 kPa (4.7–6.0) pH 7.36 (7.35–7.45) H+ 44 nmol/L (35–45) bicarbonate 27 mmol/L (21–29) oxygen saturation 96% (94–98) ECG sinus tachycardia PR interval 145 ms (120–200) QRS complex 128 ms (40–120) Ingestion of what substance is most likely to have resulted in these findings? A citalopram B dosulepin C ethyl alcohol D lithium citrate E venlafaxine

Updated 17-Aug-2012

Question 22 A 74-year-old woman was admitted to hospital at 04.00 h, having suddenly woken from sleep with a feeling of severe anxiety, breathlessness and suffocation. She felt she had needed to sit upright in bed and had become extremely breathless very rapidly. She had not suffered chest pain. She had a history of an uncomplicated anterior myocardial infarction 6 years previously. Hypertension had been diagnosed 10 years previously, and she had occasional angina when walking up a hill on a cold day. She had mild asthma, but was taking no regular treatment. Her treatment included aspirin, simvastatin, furosemide, ramipril and amlodipine. She needed to use a nitrate spray only once or twice a month. On examination, she was apyrexial. She had oedema of both lower limbs to her knees. Her pulse was 35 beats per minute and irregular, and her blood pressure was 86/48 mmHg. Her jugular venous pressure was elevated to the level of her earlobes while sitting at 45 degrees. There was a gallop rhythm on auscultation of the heart, and crackles were heard at both lung bases. Investigations: haemoglobin 109 g/L (115–165) serum sodium 129 mmol/L (137–144) serum potassium 7.2 mmol/L (3.5–4.9) serum urea 14.9 mmol/L (2.5–7.0) serum creatinine 168 µmol/L (60–110)

ECG see images a and b Image a

Updated 17-Aug-2012

Image b

What is the most appropriate initial treatment? A intravenous atropine B intravenous calcium C intravenous dobutamine D intravenous insulin and glucose E nebulised salbutamol

Updated 17-Aug-2012

Question 23 A 62-year-old man presented with chest pain. A few minutes after arrival he suffered a cardiopulmonary arrest. Basic life support was started without delay. After 2 minutes of chest compressions the cardiac rhythm was as shown (see image). Defibrillation was attempted but there was no change in the rhythm. After a further 2 minutes of basic life support there was still no palpable carotid pulse and no change in rhythm. One further shock was delivered without beneficial effect. A further 2 minutes of basic life support was performed. The cardiac monitor showed that the rhythm was unchanged and there was still no carotid pulse.

What is the most appropriate intervention? A further shock B intravenous adrenaline (epinephrine) C intravenous amiodarone D intravenous magnesium sulphate E intravenous sodium bicarbonate 8.4%

Updated 17-Aug-2012

Question 24 A 19-year-old man was brought to hospital after collapsing during a national marathon race. He had enjoyed good health in the past. There was no family history of sudden cardiac death. Attempts to resuscitate him failed. Post-mortem examination revealed the cause of death. What is the most likely cause of death? A anomalous coronary artery B aortic stenosis C arrhythmogenic right ventricular dysplasia D hypertrophic obstructive cardiomyopathy E ischaemic heart disease

Updated 17-Aug-2012

Question 25 A 23-year-old man presented to the acute medicine unit at 20.00 h with a 2-week history of excessive thirst, urinary frequency and some weight loss. His general practitioner had found his random blood glucose to be 25.0 mmol/L. On examination, his pulse was 80 beats per minute and his blood pressure was 120/70 mmHg. He had normal skin turgor and capillary refill. His abdomen was soft, and not tender. His body mass index was 22 kg/m2 (18–25). Urinalysis showed ketones 1+. Investigations: serum sodium 143 mmol/L (137–144) serum potassium 4.2 mmol/L (3.5–4.9) serum bicarbonate 22 mmol/L (20–28) serum urea 5.2 mmol/L (2.5–7.0) serum creatinine 75 µmol/L (60–110) random plasma glucose 26.0 mmol/L What is the most appropriate next management step? A intravenous insulin and admit for observation B long-acting insulin and admit for observation C long-acting insulin and discharge for review next day D short-acting insulin and admit for observation E short-acting insulin and discharge for review next day

Updated 17-Aug-2012

Question 26 A 72-year-old man presented after having vomited bright-red blood the previous day. He had no significant medical history and was taking no regular medication. He was a smoker and admitted to consuming roughly 20 units of alcohol per week. On examination, his pulse was 105 beats per minute, his blood pressure was 110/65 mmHg, his heart sounds were normal and his chest was clear. His abdomen was soft but mildly tender. Investigations: haemoglobin 101 g/L (130–180) MCV 102 fL (80–96) serum sodium 134 mmol/L (137–144) serum potassium 4.1 mmol/L (3.5–4.9) serum urea 8.1 mmol/L (2.5–7.0) serum creatinine 85 µmol/L (60–110) Upper gastrointestinal endoscopy the next morning showed a gastric ulcer with adherent blood clot. What is the likelihood of a further significant bleed? A 7% B 14% C 25% D 35% E 55%

Updated 17-Aug-2012

Question 27 A 48-year-old man presented with vomiting followed by streaks of haematemesis. He had been self-medicating with diclofenac for abdominal pain. On examination, his pulse was 120 beats per minute and irregularly irregular, and his blood pressure was 140/60 mmHg. The abdomen was mildly distended. Dullness over the liver was reduced. Bowel sounds were present. Investigations: haemoglobin 160 g/L (130–180)

white cell count 14.4 109/L (4.0–11.0) serum sodium 145 mmol/L (137–144) serum potassium 3.5 mmol/L (3.5–4.9) serum chloride 104 mmol/L (95–107) serum bicarbonate 20 mmol/L (20–28) serum urea 12.0 mmol/L (2.5–7.0) serum creatinine 110 µmol/L (60–110) X-ray of abdomen see image

What is the most likely diagnosis? A drug-induced gastritis B ischaemic bowel C Mallory–Weiss tear D perforated viscus E volvulus

Updated 17-Aug-2012

Question 28 A 48-year-old man developed breathlessness, non-productive cough and fever with chills within 6 hours of starting a blood transfusion (on the second unit). He had been admitted with gastrointestinal bleeding as a result of peptic ulcer disease. He had no significant medical history. On examination, his temperature was 37.8°C, his pulse was 100 beats per minute and regular, his blood pressure was 90/70 mmHg and his respiratory rate was 30 breaths per minute. His oxygen saturation breathing maximal high-flow oxygen was 85%. Investigations:

ECG sinus tachycardia; 100 beats per minute

chest X-ray bilateral nodular infiltrates with bat’s

wing pattern The transfusion was discontinued. What is the most appropriate next step in management? A intravenous chlorphenamine B intravenous furosemide C intravenous hydrocortisone D mechanical ventilation E non-invasive ventilation

Updated 17-Aug-2012

Question 29 A 20-year-old woman was admitted with a 2-day history of headache, photophobia and fever. There were no other symptoms and she had no other medical history. On examination, she had signs of meningism. She was alert, her vital signs were normal and there was no papilloedema. A lumbar puncture was planned. What is the most appropriate type of needle to use?

A 16G Quincke’s (bevelled) needle B 18G Quincke’s (bevelled) needle C 18G Sprotte® (atraumatic) needle D 22G Quincke’s (bevelled) needle E 22G Sprotte® (atraumatic) needle

Updated 17-Aug-2012

Question 30 A 58-year-old man was admitted with a history of occipital headache of sudden onset associated with nausea, vomiting, vertigo, double vision and slurred speech. On examination, he was confused and had mild dysarthria. There was no neck stiffness. He had normal tone and power in his limbs with normal reflexes. Sensation seemed normal but was hard to assess because of his confusion. Investigations: unenhanced CT scan of head see image

What is the most appropriate interpretation of the scan appearance? A basilar artery thrombosis B cerebral infarction C lacunar infarct D no abnormality E subarachnoid haemorrhage

Updated 17-Aug-2012

Question 31 A 43-year-old man was admitted with a 4-day history of progressive leg weakness and poorly localised lower back pain. On examination, he had reduced tone in both lower limbs, with grade 4 power of flexion and extension of hips and knees bilaterally, and grade 3 power of foot dorsiflexion and plantar flexion bilaterally. His deep tendon reflexes in the lower limbs were absent, and the plantar responses were flexor. There was loss of all modalities of sensation in both feet in a stocking distribution. Examination of the upper limbs was normal. What respiratory function variable is it most important to measure regularly? A forced expiratory volume in 1 s

B oxygen saturation

C peak expiratory flow

D respiratory rate

E vital capacity

Updated 17-Aug-2012

Question 32 A 32-year-old woman was referred with a 3-week history of a left-sided headache. This had not interfered with her life until the previous 2 days when she had also developed slight nausea and some weakness of her right hand. On examination, she looked well and her temperature was 36.8°C. Her pulse was 68 beats per minute and her blood pressure was 135/75 mmHg. Cranial nerve examination was normal and there was no papilloedema. Power in her right arm was grade 4/5. Her right biceps reflex was brisker than the left, and there was reflex spread. Sensation was normal. Investigations: MR scan of brain (T2 weighted) see image

What is the most appropriate diagnostic investigation? A blood culture B HIV test C open biopsy D PET–CT scan E toxoplasma serology

Updated 17-Aug-2012

Question 33 A 60-year-old woman was admitted with deterioration in her renal function. She had a history of type 2 diabetes mellitus, hypertension and chronic kidney disease stage 3a, with an estimated glomerular filtration rate (MDRD) of 45–60 mL/min (>60). She was taking perindopril for hypertension, and had recently started taking celecoxib for osteoarthritis. What best describes the mechanism of her celecoxib-induced deterioration in renal function? A hypersensitivity reaction B inhibition of afferent arteriole vasodilatation C interstitial nephritis D renal parenchymal infarction E renal tubular acidosis

Updated 17-Aug-2012

Question 34 A 68-year-old man with chronic obstructive pulmonary disease presented with a 24-hour history of increased wheeze and breathlessness. He was treated with nebulised salbutamol 2.5 mg and ipratropium 500 micrograms, oral prednisolone 30 mg and 28% oxygen via a Venturi mask. On examination, his pulse was 84 beats per minute and his blood pressure was 146/88 mmHg. His respiratory rate was 24 breaths per minute. He had polyphonic wheeze throughout both lung fields. Investigations: chest X-ray hyperexpanded lungs consistent with emphysema; no consolidation or pulmonary oedema arterial blood gases, 1 h after admission, breathing FiO2 0.28: PO2 7.4 kPa PCO2 7.1 kPa (4.7–6.0) pH 7.28 (7.35–7.45) H+ 53 nmol/L (35–45) bicarbonate 24 mmol/L (21–29) oxygen saturation 84% What is the most appropriate next step in management? A bilevel positive airway pressure ventilation B increase oxygen to FiO2 0.35 C intravenous aminophylline D intravenous hydrocortisone E reduce oxygen to FiO2 0.24

Updated 17-Aug-2012

Question 35 A 74-year-old woman was admitted with an exacerbation of chronic obstructive pulmonary disease. She had been admitted three times in the previous 9 months. She was using a salbutamol inhaler. On examination, her oxygen saturation was 94% (94–98) breathing air. What change in her management is most likely to reduce the number of further exacerbations? A addition of tiotropium bromide B long-term domiciliary oxygen C long-term low-dose prednisolone D pneumococcal vaccine E regular nebulised salbutamol

Updated 17-Aug-2012

Question 36 A discussion took place on how to improve the management of patients presenting with diabetic ketoacidosis and development of a diabetic ketoacidosis care bundle was suggested. What best describes a care bundle? A a checklist of medical and nursing interventions designed to ensure all steps are

completed B a series of processes that must be completed to ensure patient safety C a small group of evidence-based processes that, when performed collectively, improve

outcomes D a small group of interventions that define minimum care standards E steps in patient management that must be completed sequentially within a defined time period

Updated 17-Aug-2012

Question 37 A 65-year-old woman presented with an acute stroke with aphasia and flaccid paralysis of the left side. She had a history of heart failure. On examination, her oxygen saturation was 94% (94–98) breathing air. What is the most appropriate treatment? A 2 L oxygen via nasal cannulae B 5 L oxygen via simple face mask C 15 L oxygen via reservoir bag mask D 28% oxygen via Venturi mask E no additional oxygen F

Updated 17-Aug-2012

Answers: 1 E 2 E 3 B 4 D 5 A 6 A 7 C 8 A 9 D 10 D 11 E 12. D 13 C 14 B 15 A 16 C 17 A 18 B 19 E 20 D 21 B 22 B 23 A 24 D 25 C 26 B 27 D 28 D 29 E 30 A 31 E 32 C 33 B 34 A 35 A 36 C 37 E