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Free Test 1
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1 / 5
A 55-year-old man is receiving a transfusion of packed red cells during his recovery from colorectal surgery. He has suddenly developed a fever 30min into the transfusion. T 38.3 ° C, HR 90bpm, BP 125/70mmHg, SaO 2 98% on air. The transfusion has been stopped. Which single development should make the junior doctor most wary about restarting the transfusion?
Increasing hypotension (with fever) is the most worrying sign as it heralds sepsis (i.e. bacterial contamination) or an acute haemolytic reaction and warrants stopping the transfusion and urgent discussion with a haematologist and a microbiologist. As this man’s temperature is already raised, it would be the fall in blood pressure rather than a specific temperature ( ° ) that would be the most worrying development.
2 / 5
A 32-year-old woman has had profuse green diarrhoea and a headache for 3 days. For the last week, she has had a nonproductive cough and has felt increasingly lethargic. She has recently returned from a 3-week tour of rural Thailand. T 39.8 ° C, HR 58bpm, BP 110/62mmHg, SaO 2 97% on air. She is tender in the right and left upper quadrants. Which is the single most likely cause of her symptoms?
This is caused by faecal-oral transmission of Salmonella typhi. In the early stages, it typically features a headache and a slow rising fever, but with a relative bradycardia. As the illness progresses, hepatosplenomegaly and green ‘pea-soup diarrhoea commonly occur. Intestinal haemorrhage/ perforation and neurological complications can occur.
3 / 5
A 32-year-old woman has lost 3kg over the past 3 months. She has no loss of appetite, but has felt rather irritable and ‘stressed’. T 37.1 ° C, HR 110bpm, BP 100/65mmHg. Her thyroid function tests are returned as follows: Thyroid-stimulating hormone (TSH) 0.21mU/L, thyroxine (T4) 218nmol/L. There is a fi ne tremor of both hands. She is started on propranolol 40mg PO once daily. Which is the single most appropriate next step in management?
Having addressed symptom control with a beta-blocker, the next stage is to reduce circulating levels of thyroid hormones. This can be achieved either by blocking the overactive thyroid gland with carbimazole (and replacing reduced thyroxine to avoid iatrogenic hypothyroidism) or with propylthiouracil, which inhibits thyroid hormone synthesis.
4 / 5
An 18-year-old man has recently been diagnosed with idiopathic generalized epilepsy. He lives with his parents who have not witnessed any of his three previous fits and are concerned about what to do if he has another one and ask their doctor for advice. Which single course of action should be stressed to the parents?
A prolonged seizure is one that which lasts 5min or more. Rectal diazepam remains the first-line therapy for seizures occurring outside the hospital setting. They are usually kept at home by the family in case they are needed. It has very short-acting anticonvulsant properties (20min as opposed to 12h for lorazepam) and can therefore be given again after 15min if status is threatening. An alternative treatment is buccal midazolam, which may be easier and more socially acceptable to administer. A 10mg dose is given between the cheek and lower gum.
5 / 5
A 72-year-old woman is recovering from an episode of temporal arteritis. She is due to start gradually reducing her dose of prednisolone tablets and is being counselled on the risks of stopping the tablets suddenly. Which single symptom should this patient be warned to expect if she stops her tablets suddenly?
Feeling faint or dizzy on standing up is suggestive of postural hypotension. It is a feature of hypovolaemia, autonomic dysfunction, and—as here—adrenal gland dysfunction. After long-term steroid use, normal hormone production by the adrenals is suppressed. As it will take some time for endogenous production to restart, patients need to be gradually weaned off steroids to avoid a period of ‘hypoadrenalism and the dangerous symptoms that go with it. The other options are all features of prolonged steroid use.
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Free Test 2
A 68-year-old man undergoes annual retinal screening. He has type 2 diabetes and uses insulin twice daily. Following the scan, he asks his doctor what causes the presence of ‘cotton-wool’ spots in his report. Which is the single most appropriate response?
Cotton-wool spots are also known as ‘soft exudates’ and are yellowish-white discolourations of the retina. They are local infarcts of the surface of the retina that occur due to impairment of blood supply. Along with haemorrhages and venous beading, they are signs of retinal ischaemia. The patient should be told, therefore, that the spots themselves will not cause visual difficulties, but the condition of which they are symptomatic will continue to cause blood-flow problems and further retinal damage if it is not adequately controlled.
A 72-year-old woman has been breathless and unwell for the past week. She is admitted to hospital and started on IV antibiotics for a chest infection. She has ischaemic heart disease and atrial fibrillation and is on warfarin 2mg once daily. The on-call junior doctor is asked to check her blood results after she is moved to the medical ward. Her INR is 6.6. Which is the single most appropriate management?
This is a common dilemma for the junior doctor. With such a high INR, it may be tempting to reverse it, but in the absence of bleeding, the British Society of Haematology guidelines state that readings <8 just need to be watched while warfarin is withheld. If the INR is >8 and/or there is minor bleeding, then the agent of choice for reversal is vitamin K (0.5mg IV or 5mg PO). If there is major bleeding, then vitamin K 5–10mg may be needed.
A 23-year-old woman has been feeling tired and lethargic for the past 18 months. She occasionally feels dizzy on standing and is generally weak. She is otherwise well. Hb 95g/L, MCV 69fL. Which is the single most appropriate further investigation to confirm the diagnosis?
It is not enough to know that a patient is anaemic. Before presenting such a
finding on a ward round, it is vital to know what ‘type’ of anaemia it is. The
first step to doing this is to look at the MCV. Different MCVs suggest different reasons behind the anaemia and so prompt the next stage in investigations:
● A raised MCV (>100fL) should be followed up with thyroid function
tests, liver function tests, reticulocytes, and vitamin B 12 and folate
● A normal MCV should prompt examination of the rest of the blood
count including platelets along with renal function.
● A low MCV (<75fL) is most commonly indicative of iron deficiency,
especially—as in this case—where it may be associated with menorrhagia. Low serum iron and ferritin with a raised total iron-binding
capacity (TIBC) and transferrin would seal the diagnosis. If there is no
convincing source of iron loss, then it is important to investigate the
gastrointestinal tract: an incidental microcytic anaemia can be the way
in which a tumour of the caecum or ascending colon presents.
A 60-year-old woman has lost the ability to pick up small objects with her right hand. She also finds it difficult to fasten buttons. There is no other weakness. She is unable to copy one particular movement made by the doctor examining her
Which single nerve is most likely to have been compromised?
The anterior interosseous nerve arises from the median nerve about 5cm above the medial epicondyle supplying the flexor digitorum profundus and the flexor pollicis longus muscles. It can be compromised by direct trauma or by compression by surrounding muscles (pronator teres), ligaments, or scar tissue. The result is the inability to pinch the thumb and forefinger together (in the way shown) and thus difficulty with fine motor pincer movements.
Which of the following is the most important first step in the diagnostic and treatment process?
A thorough history and physical examination is the core of the diagnostic and treatment process. Any further assessment with blood work and the other tests listed must be integrated with the initial information compiled in the history and physical examination. The H&P is always the most important first step in any diagnostic and treatment process
Free Test 3
A 27-year-old woman presents with sharp chest pain that is worsened with inspiration and improved when bending forward. Pain is precipitated by breathing deeply or coughing and is relieved when the patient holds her breath. Heart examination reveals coarse, scratchy sounds heard in both systole and diastole that overlie the cardiac sounds. Electrocardiogram (ECG) reveals ST elevations diffusely and PR segment depressions. Which of the following is the most likely diagnosis?
The pericardium is a double-walled sac that protects the heart; inflammation and roughening of the sac may result in the formation of a pericardial rub. The sounds represent heart movement against the inflamed pericardium and are best heard with the diaphragm of the stethoscope placed at the left lower sternal border with the patient leaning forward. The scratchy nature of the triphasic sound represents systole and diastole of the ventricle and atrial systole. The ECG in pericarditis often reveals ST elevation and PR depression. The treatment for benign pericarditis is anti-inflammatory agents. The most common finding in MVP is a midsystolic click followed by a high-pitched late systolic crescendo-decrescendo murmur. The pain of costochondritis (Tietze syndrome) is often associated with swelling, erythema of the overlying skin, and tenderness on palpation of the involved costicartilages
A 59-year-old woman presents complaining of a cough productive of sputum for nearly 10 years. Her cough occurs during the day and she produces sputum daily. The woman states that as a child, she had several episodes of pneumonia requiring hospital admissions and antibiotics. Several times a year, her sputum becomes purulent and she requires antibiotic therapy. She denies smoking cigarettes and has worked as a seamstress all of her life. On physical examination, the lungs are clear without wheezes, rhonchi, or crackles. A chest radiograph reveals “tram-track” markings at the bases. Which of the following is the most likely diagnosis?
Bronchiectasis is an acquired disease that causes abnormal dilatation of the bronchi leading to pooling of secretions in the airways and recurrent infections. Patients typically present with cough and with the production of purulent sputum. Lung auscultation may be normal or remarkable for wheezes, rhonchi, or crackles. Chest radiograph may be normal, but occasionally the damaged, dilated airways will appear as “tram tracks” or “ring shadows.” Bronchiectasis may be a sequela of foreign body aspiration, cystic fibrosis, rheumatic diseases (rheumatoid arthritis and Sjögren’s disease), pulmonary infections (tuberculosis, pertussis, Mycoplasma), AIDS, and allergic bronchopulmonary aspergillosis (ABPA)
A Weber test that lateralizes to the deaf ear with a Rinne test that is negative detects which kind of hearing loss?
The Weber test is performed by placing the tuning fork on the midline vertex of the head. In conductive hearing loss, the Weber lateralizes to the deaf ear, while in sensorineural hearing loss the Weber lateralizes to the better ear. The Rinne test is performed by placing a 512-Hz tuning fork over the mastoid process. When the vibration is no longer heard via bone conduction, the tuning fork is placed near the ear to determine if the vibration is heard. If the vibration is heard, then air conduction is greater than bone conduction and the test is considered positive or normal. If the vibration is not heard, then bone conduction is greater than air conduction and this negative Rinne test denotes conductive hearing loss. Sensorineural hearing loss occurs when a positive or normal Rinne test is complemented by a Weber test that lateralizes to the better ear.
A 10-year-old girl presents with multiple pigmented macules on the vermilion border of her lower lip. The dark brown lesions are 2–5 mm in size and are arranged in a cluster. The patient’s older brother has similar lesions. The patient complains of recurrent bouts of abdominal pain. Which of the following is the most likely diagnosis?
The most likely diagnosis in this patient is Peutz-Jeghers syndrome (PJS). This is an autosomal dominant polyposis characterized by multiple small macules (lentigines) on the lips and oral membranes. Abdominal symptoms occur because of multiple benign hamartomatous polyps in the small and large bowel and in the stomach. Freckles (ephelides) are lighter lesions due to increased epidermal pigment in the distribution of sun-exposed areas. Gardner’s syndrome is an autosomal dominant disease characterized by facial cysts and adenomatous polyps in the small and large intestines. Herpes simplex virus is characterized by painful vesicles, which are grouped and confluent. Hand-foot-and-mouth disease is a highly contagious systemic infection caused by coxsackievirus A16 and characterized by ulcerative oral lesions and a vesicular exanthem on the distal extremities
Free Test 4
A 29-year-old woman was an unbelted passenger in a motor vehicle accident. On arrival to the hospital, the paramedics inform you that she opens her eyes in response to verbal stimuli. She is incoherent and withdraws from painful stimuli. Which of the following is the patient’s calculated Glasgow Coma Scale (GCS)?
The Glasgow Coma Scale (GCS) is often used to quantify consciousness and assess cerebral cortex and brainstem function by assessing the patient’s verbal response, motor response, and eye opening response to stimuli. It may be repeated at inter-vals to detect improvement or deterioration and is now widely used in coma assessment. The minimum score is 3 and the maximum score is 15. Three behaviors are assessed in the GCS:
A 21-year-old man presents to your office for a pre-employment physical examination. He is 6 ft 3in. tall and weighs 70 kg. Heart examination is remarkable for a midsystolic click and a grade 2 systolic murmur that increases with Valsalva maneuver. The patient has an arm span that exceeds his height and has long, slender fingers. The thumb sign (Steinberg sign) is positive. Which of the following is the most likely diagnosis?
Persons with Marfan syndrome have arm spans that are greater than their height and above-average crown-to-heel height. Joints are hyperextensible and patients have long, spiderlike, slender fingers (arachnodactyly). The Steinberg sign or thumb sign is positive when the fingers are clenched over the thumb and the thumb protrudes beyond the ulnar margin of the hand. Patients often have a high-arched palate, kyphoscoliosis, subluxation of the lens, and a murmur of mitral valve prolapse. Aortic regurgitation and dissection of the aorta may complicate Marfan syndrome. Patients with Lesch-Nyhan syndrome (X-linked disorder) present with self-mutilation, choreoathetosis, spasticity, gout, and mental retardation. Patients with gonadal dysgenesis or Turner syndrome are 45,X; the syndrome is characterized by primary amenorrhea, short stature, webbed neck with a low posterior hairline, and multiple congenital abnormalities. Patients with Ehlers-Danlos syndrome (EDS) present with hyperelasticity of the skin (“rubber man” syndrome) and hypermobile
joints. Noonan syndrome is an autosomal dominant disorder characterized by webbed neck, short stature, and congenital heart disease. Patients have normal karyotypes and normal gonads
A nursing home patient is transferred to the hospital for possible dehydration after several days of vomiting and diarrhea due to a recent viral syndrome. Which of the following best defines orthostatic changes from volume depletion?
Postural or orthostatic hypotension refers to hypotension in the erect position relative to the recumbent position; causes include volume depletion, autonomic dysfunction, and certain antihypertensive medications. Criteria for diagnosis include a postural decrease from the recumbent position to the standing position of at least 20 mm Hg in systolic or 10 mm Hg in diastolic blood pressure or a pulse increase of 20 beats/min.
Which of the following is most likely to cause muscle atrophy?
Disuse, loss of innervation, and muscle destruction are common causes of muscle atrophy. Tetany is the result of peripheral nerve hyperexcitability characterized by contractions of the distal muscles of the hand (carpal spasm). It is often caused by hypocalcemia, hypomagnesemia, or alkalosis. Hypotonia is a floppy extremity seen with cerebellar disease or severe peripheral nerve disorders. Duchenne muscular dystrophy is an X-linked muscle disorder due to the absence of dystrophin, and persons will have pseudohypertrophy.
A 59-year-old patient presents with fever and agitation. On physical examination, his temperature is 103.2°F. His respirations are 26/min, pulse 126/min, and blood pressure is 100/70 mm Hg. He appears to be warm and flushed. A Swan-Ganz catheter is inserted that demonstrates an increased cardiac output, a decreased peripheral vascular resistance (vasodilation), and a normal pulmonary capillary wedge pressure (PCWP). The patient’s urine gram stain reveals pyuria and gram-negative rods. Which of the following is the most likely diagnosis?
The early phase of septic shock is characterized by vasodilation resulting in a warm, flushed patient with a normal or elevated cardiac output. Fever, agitation, or confusion is often present. In late septic shock, patients become obtunded with decreased cardiac output and hypotension that is not reversible by volume replacement. Patients with cardiogenic shock have signs of pulmonary vascular congestion (jugular venous distention, S3 gallop, bilateral lung crackles), increased PCWP, and decreased cardiac output. Neurogenic shock follows a spinal cord injury (warm skin, bradycardia, neurologic deficits), and hypovolemic shock is characterized by a physical examination consistent with volume depletion (tachycardia; hypotension; cool, clammy skin; and poor capillary refill) and a PCWP that is decreased. A mnemonic to remember the causes of shock is SHOCK: Sepsis, Hypovolemia, Other (i.e., Addison’s disease), CNS (neurogenic), and Kardiac causes