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1)72 year old female was admitted with a deteriorating dyspnoea and fever which had deteriorated over the preceding three days. Prior to this admission she had been well having returned one week ago from an Asian holiday with her husband. She is a smoker of 5 cigarettes per day. On examination she was suntanned, slightly confused with saturations of 92% on air. She had a pyrexia of 40oC, a pulse of 118 bpm and a blood pressure of 118/90 mmHg. Auscultation of the chest revealed left basal crackles only. The following detail her investigations:Haemoglobin 14.3 g/dlWhite cell count 8.2 x109/lPlatelets 320 x109/lSerum Sodium 123 mmol/lSerum Potassium 3.6 mmol/lUrea 4.2 mmol/lPlasma Glucose 10.9 mmol/lUrine sodium concentration 35 mmol/lArterial blood gas analysis:pH 7.36pCO2 38 mmHg pO2 80 mmHgStandard bicarbonate 30 mmol/lWhich of the following tests would be most useful in providing diagnostic information?
1 ) Blood culture
2 ) Serum antibody tests
3 ) Short synacthen test
4 ) Sputum culture
5 ) Urine antigen test
ANSWER: 5
2)A 22 year old male is referred by his General practitioner due to problems related to his sex life. He has recently entered into his first sexual relationship but is worried by his poor sexual development. He is aware of a paucity of pubic hair and he has been embarrassed about his gonadal development. He started to shave at the age of 18 but shaves only twice weekly. He is quite fit and active and works as a labourer on a building site. He takes no medication and drinks 20 units of alcohol weekly, mostly on weekends. He has one younger brother. Examination reveals a phenotypically normal male, who is tall but lean with a BMI of 21.2 kg/m2. He has little beard growth, fine skin, a paucity of body hair and scanty pubic hair. His penile length is approximately 6 cm with testicular volumes of approximately 6-7 mls bilaterally (Normal 10-15 mls). Cardiovascular, respiratory and abdominal examination are all normal. Fundal examination is normal and he has normal visual fields.
His investigations are as follows:
Plasma testosterone concentration 6.2 nmol/l (10 - 30)
LH 20.2 mU/l (2-10)
FSH 22.2 mU/l (2-10)
Prolactin 433 mU/l (50-500)
free T4 12.6 nmol/l (9-23)
TSH 2.3 mU/l (0.5-4.5)
What are the chances of his brother developing this disorder?
1 ) <1%
2 ) 25%
3 ) 50%
4 ) 75%
5 ) 100%
ANSWER: 1
3)A 69 year-old lady presents to you complaining of being non-specifically unwell over the last month. She is stiff especially in the mornings and has difficulty lifting her hands to comb her hair. Her arms and shoulders ache constantly and she has jaw pain when chewing. She has lost 4kg in weight and has a persistent headache. She smokes 10 cigarettes a day and consumes 10 units of alcohol a week.On examination, temperature is 38°C, pulse 84 beats/min and BP 125/80. Apart from reduced power in the proximal muscles of her arms and legs, the rest of the examination is unremarkable.Investigations:Hb 9.9 g/dl
WCC 13.9 x 109/l
Platelets 400 x 109/l
Plasma sodium 139 mmol/l
Plasma potassium 4.7 mmol/l
Plasma urea 5.0 mmol/l
Plasma creatinine 109 µmol/l
Plasma glucose 5.9 mmol/l
Bilirubin 15 µmol/l (normal range 3-17 µmol/l)
Plasma alkaline phosphatase 390 iu/l (normal range 30-300 iu/l)
Plasma aspartate transaminase 65 iu/l (normal range 5-35 iu/l)
Plasma creatine kinase 150 iu/l (normal range 25-195 iu/l)
What is the most appropriate investigation to be performed next?
1 ) Anti-double stranded DNA antibodies
2 ) Erythrocyte sedimentation rate
3 ) Muscle biopsy
4 ) Plasma calcium
5 ) Thyroid function tests
ANSWER: 2
4)A 50 year old woman presents with dry eyes, a dry mouth, an erythematous rash and polyarthralgia. Investigations: ANA strongly positive (1:1600), anti-Ro/SSA antibodies strongly positive, rheumatoid factor positive, IgG markedly elevated at 45 g/l (normal - <15 g/l), IgM and IgA levels are normal and the kappa/lambda ratio is normal. What is the most likely diagnosis?
1 ) Hyperviscosity syndrome
2 ) Myeloma associated vasculitis
3 ) Primary Sjogren's Syndrome
4 ) Rheumatoid arthritis with secondary Sjogren's Syndrome
5 ) Systemic Lupus Erythematosus
ANSWER: 3
5)This lady presents with dysphagia, what is the diagnosis?
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1 ) Dermatomyositis
2 ) Raynaud's phenomenon
3 ) Systemic sclerosis
4 ) Plummer-Vinson syndrome
5 ) Hyperthyroidism
ANSWER:3
6)This gentleman has pain over with his ankle and presents with fever
What is the most likely synovial fluid finding?
1 ) Bipyramidal crystals that exhibit strong positive birefringence under polarised light
2 ) Gram positive cocci in clusters
3 ) Needle-shaped crystals that exhibit strong negative birefringence under polarised light
4 ) Rhomboid crystals that exhibit weak positive birefringence under polarised light
5 ) Small, non-birefringent crystals visible only under electron microscopy
ANSWER:3
7)This lady presents to A+E lower limbs pain, what is the likely diagnosis?
1 ) Secondary syphilis
2 ) Cat scratch fever
3 ) Oral contraceptive pill
4 ) Sarcoidosis
5 ) Streptococcal infection
ANSWER: 5
8)A 24 year old male who works in a plastic factory presented with shortness of breath. He went for 2 weeks to Thailand and was completely well. He presented to the Accident & Emergency Unit after having used his Salbutamol inhaler 3 times. .The most likely diagnosis is?
1 ) Broncho pulmonary aspergillosis
2 ) Chemical pneumonitis
3 ) Extrinsic allergic alveolitis
4 ) Late onset asthma
5 ) Occupational asthma
ANSWER: 5
9)A 47-year-old man with HIV disease presents to hospital with a tonic-clonic seizure. He had initially presented six months previously with Pneumocystis carinii pneumonia with a CD4 T-lymphocyte count of 10 cells/mm3 and had subsequently started on highly active antiretroviral therapy. His most recent CD4 count, taken one month prior to his new presentation, was 50 cells/mm3. On examination he has no focal weakness, but both plantar responses are extensor. Fundoscopy is normal.A CT scan of his brain is shown.
1) AIDS related dementia
2 ) Brain abscess
3 ) Cerebral toxoplasmosis
4 ) Primary CNS lymphoma
5 ) Progressive multifocal leukoencephalopathy
ANSWER: 3
10)This 32 year-old gentleman presented with a grand mal seizure. CT scan of his head showed several small areas of periventricular calcification.
1 ) Neurofibromatosis
2 ) Tuberose sclerosis
3 ) von Hippel-Lindau syndrome
4 ) Multiple endocrine neoplasia type IIb
5 ) Gardner's syndrome
ANSWER 2
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