1. A 27-year-old female with Adult Respiratory Distress Syndrome (ARDS) is ventilated on Intensive Care. Her inspired oxygen is 100%, Positive End Expiratory Pressure is 15cmH20 and Peak Airway Pressure is 40cmH2O. Her arterial blood gas shows:

PaO2    6 kPa (11.3-12.6)

PaCO2 6.9 kPa (4.7-6.0)

SpO2   88% (>92%)

Which further ventilatory strategy is appropriate in this case? (September 12)

1. Intravenous Oxgenation (IVOX)

2. Inhaled nitric oxide therapy

3. High Frequency Oscillatory Ventilation (HFOV)

4. Prone position

5. Increasing tidal volume and respiratory rate on the ventilator

 

2. A patient needs central venous access for total parenteral nutrition (TPN). Which of the following is the cleanest site for placement? (April 13)

1. Left femoral

2. Left internal jugular

3. Right femoral

4. Right internal jugular

5. Right sublcavian

 

3. A 64-year-old man is admitted with central epigastric pain. Abdominal X-ray shows a central dilated bowel loop. His temperature is 37.0oC, pulse 130 beats per min, blood pressure 80/50 mmHg, respiratory rate 29/min and SpO2 90 on air. His Full blood count reveals:

Haemoglobin 13.0 g/dL (13.0-18.0)

White Cell Count 3.2 x109/L (4-11 x109)

Platelets 108 x109/L (150-400 x109)

MCV 105 fL (80-96)

Which of the following is the most likely diagnosis? (April 13)

1. Gall stone ileus

2. Ischaemic bowel

3. Pancreatitis

4. Perforated duodenal ulcer

5. Small bowel obstruction 

 

4. A 64-year-old man is admitted with central epigastric pain. Abdominal X-ray shows a central dilated bowel loop. Temperature 38.4oC; pulse 130 beats per min; blood pressure 80/50 mmHg; respiratory rate 29/min; SpO2 90 on air. His Full blood count

Haemoglobin 13.0 g/dL (13.0-18.0)

White cell count 3.2 x109/L (4-11 x109)

Platelets 108 x109/L (150-400 x109)

MCV 105 fL (80-96)

Which of the following is the most likely diagnosis? (September 11)

1. Leaking aortic aneurysm

2. MODS

3. Pancreatitis

4. Septic shock

5. SIRS

 

5. An 18-year-old with Cerebral Palsy is admitted after a respiratory arrest having been intubated by paramedics. Nobody can gain intravenous access as the patient is too shut down. A femoral line is not possible due to contractures. You don’t have the experience to perform central venous cannulation.

Which of the following is the best option for administering intravenous fluids/emergency drugs in this situation of inability to gain venous access? (January 13)

1. Down the endotracheal tube

2. Interosseus

3. Intramuscular

4. Nasogastric

5. Subcutaneous 

 

6. A 40-year-old male presents with a 6hour history of profuse vomiting and over the last two hours had developed left sided chest pain and dyspnoea. On examination he had a pulse of 110 beats per minute regular anda blood pressure of 168/90 mmHg. On palpation, he had crepitus over the left supraclavicular region and neck, reduced heart sounds and left basal sided crackles plus some dullness to percussion over the right base of the chest.

What is the most likely diagnosis? (September 12)

1. Aortic dissection

2. Aspiration pneumonia

3. Oesophageal rupture

4. Perforated peptic ulcer

5. Pneumothorax

 

7. A 29-year-old motorcyclist is brought to the Accident and Emergency department after he was involved in a high speed road traffic accident in the motorway. He was thrown off his bike onto the road. On examination, severe bruising is noticed over his left antero-lateral chest wall. There is decreased air entry over the left lower lobe of lung and bowel sounds are heard in the chest. A chest x-ray reveals fracture of the lower four ribs on the left side and a raised left dome of the diaphragm.

From the options below choose the ONE which you think is the most likely diagnosis in this patient: (January 14)

1. Cardiac tamponade

2. Diaphragmatic rupture

3. Left basal pneumonia

4. Tension pneumothorax

5. Traumatic haemothorax

 

8. A 67-year-old man who is 3 days post-operation for a sigmoid colectomy. He has insulin dependent diabetes mellitus. He complains of dizziness and faintness. His blood pressure is 80/50 mmHg, his pulse is 110 bpm, he has a respiratory rate 24/min, and he has SpO2 99% on air. His blood glucose is 18 mmol/L (3.06.0 Fasting).

His electrocardiogram shows ST depression of 2mm in leads II, III and AVF.

Which of the following is the initial drug therapy for this patient?: (April 12)

1. Aspirin 300mg

2. Clexane 1mg/kg subcutaneously

3. Clopidogrel 75mg

4. Diamorphine 2.5mg

5. Glycerol Tri-Nitrate 800mcg sublingually

 

9. A 74-year-old man with ischaemic heart disease is in the surgical High Dependency Unit following a Hartmanns procedure. He is in pain. He has drained 100/200/300 mls of blood into his drains in the last 3 hours. His blood pressure is 110/80 mmHg, his pulse 105 beats/min, he has a respiratory rate 32/min, SpO2 100% on oxygen by face mask.

Haemoglobin 8.1 g/dL (13.0-18.0)

White Cell Count 4.5 x109/L (4-11 x109)

Platelets 132 x109/L (150-400 x109)

Which of the following is the next most appropriate therapeutic intervention? (April 13)

1. 2 units of packed red blood cells

2. 1000mls of crystalloid stat 

3. Morphine 5mg intravenously

4. Reassurance

5. Return to theatre

 

10. An 18-year-old woman sustains severe head injuries in a road traffic accident

The following day her investigations show:

Sodium 160 mmol/L (137-144)

Potassium 3.7 mmol/L (3.5-4.9)

Chloride 120 mmol/L (95-107)

Urea 3.0 mmol/L (2.5-7.5)

Creatinine 90 µmol/L (60- 110)

Which one of the following statements is correct? (January 12)

1. Rapid rehydration with 5% dextrose is indicated

2. She should be treated with sodium restriction

3. She has the syndrome of inappropriate antidiuretic hormone secretion (SIADH)

4. She will have a hypercholraemic acidosis

5. Urine osmolality will be low 

 

11. A 64-year-old man is admitted with central epigastric pain. Abdominal X-ray shows a dilated bowel loop. His temperature is 37.0oC, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min, SpO2 90 on air. His Full blood count reveals:

Haemoglobin 13.0 g/dL (13.0-18.0)

White cell count 3.2 x109/L (4-11 x109)

Platelets 108 x109/L (150-400 x109)

MCV 105 fL (80-96)

Which of the following is the most appropriate treatment of this patient? (September 10)

1. 100% oxygen by rebreather

2. 2x 14 gauge venflons and 2 litres Hartmanns

3. Intensive care

4. Intubation and ventilation

5. Invasive monitoring

 

12. A patient post retrosternal thyroidectomy resection has sudden onset shortness of breath. On examination, she is talking clearly but has decreased breath sounds on her right side with increased resonance. Her blood pressure is 110/80 mmHg, his pulse is 95 bpm, respiratory rate 24/min and his SpO2 92 on air.

Which of the following would be most appropriate for her? (January 11)

1. Chest X-ray

2. Furosemide 40 mg intravenously

3. Intercostal chest drain insertion

4. Needle thoracocentesis

5. Removal of surgical clips

 

13. A 56-year-old man is admitted with epigastric pain after drinking heavily. He has a temperature of 36.9oC, a pulse of 95/min, a blood pressure of 85/60 mmHg, and a respiratory rate of 32/min. Investigations reveal:

Haemoglobin 12.6 g/dL (13.0-18.0)

Platelets 169 x109/L (150-400 x109)

White cell count 3.9 x109/L (4-11 x109)

Which of the following is the diagnosis? (September 12)

1. Leaking aortic aneurysm

2. Multi-organ dysfunction syndrome

3. Pancreatitis

4. Septic shock

5. Systemic Inflammatory Response Syndrome

 

14. A ten-month-old male baby with haemophilia is brought to the Accident and Emergency by his parents with a 36-hour history of intermittent episodes of inconsolable crying and vomiting. The parents say the babys stools are mixed with blood. On examination, a sausage-shaped mass is palpable over the right side of abdomen. Per rectal examination reveals an empty rectum but blood is noticed in the glove of the examining finger.

From the options below choose the ONE which you think is the most likely diagnosis in this patient: (January 14)

1. Infantile hypertrophic pyloric stenosis

2. Intestinal atresia

3. Intussusception

4. Meckel’s diverticulum

5. Meconium ileus

 

15. A 5-year-old boy presents to Accident and Emergency complaining of acute pain over his upper tibia. He is febrile and he refuses to move his leg. A diagnosis of osteomyelitis is suspected.

The likely infecting organism is? (January 11)

1. Clostridium difficile

2. Haemophilus influenzae

3. Pseudomonas

4. Salmonella

5. Staphylococcus aureus

 

16. A 12-year-old girl presents with left ear pain and fever, worsening over the past 3 days. Today mother has noted a whitish creamy discharge from the ear canal. She was born at 38/40 gestation weighing 3.8kg and there were no neonatal problems. She is fully immunised. She trains regularly in a swimming team.

On examination she has a temperature of 38.2°C and has a red left tragus. This is exquisitely tender, and examination of the drum is impossible because of the pain and creamy thin discharge. She has shotty tender posterior cervical glands.

What is the most likely diagnosis? (September 13)

1. Group A streptococcal pharyngitis

2. Mastoiditis

3. Otitis externa

4. Otitis media, acute

5. Otitis media, recurrent

 

17. The following laboratory results were returned in a 6 week old boy admitted with 6 days of severe projectile vomiting:

pH 7.51 (7.36-7.44)

PO2 12 kPa/95 mmHg (11.3-12.6 kPa)

PCO2 4.7 kPa/35 mmHg (4.7-6.0 kPa)

Blood Urea 11 mmol/L (2.5-7.5)

Sodium 131 mmol/L (137-144)

Potassium 3 mmol/L (3.5-4.9)

Chloride 83 mmol/L (95-107)

Which of the following is true concerning this patient? (January 12)

1. He has respiratory alkalosis

2. He is likely to have a bulging anterior fontanelle

3. He should be resuscitated immediately with normal saline

4. He should be commenced immediately on half strength soy protein, low lactose formula

5. X-ray of abdomen is likely to show dilated loops of small bowel

 

18. A four-day old male baby is brought to the paediatric acute surgical ward with mild abdominal distension, bilious vomiting, refusing to feed, and failure to pass meconium after birth. Abdominal examination is unremarkable. Plain abdominal x-ray reveals dilated loops of bowel with fluid levels. A barium enema demonstrates a ‘conical appearance’ in the distal segment of the colon. The parents have been informed that the baby requires a rectal biopsy.

From the options below choose the ONE which you think is the most likely diagnosis in this patient: (January 11)

1. Anal atresia

2. Hirschsprung’s disease

3. Intestinal atresia

4. Meconium ileus

5. Necrotizing enterocolitis

 

19. A motorcyclist is involved in an RTA and sustains a closed fracture of his left tibia. This is stabilised with an external fixator. You are called to see him some hours later because of unbearable pain in his leg. You use a manometer to measure the pressures in his muscle compartments and the reading in the extensor compartment is 40mmHg. He is taken to theatre for emergency fasciotomy.

Which of the following would you encounter in the extensor compartment? (April 12)

1. Deep peroneal nerve

2. Peroneus brevis

3. Peroneus longus 

4. Sural nerve

5. Tibial nerve

 

20. You are an orthopaedics SHO assisting your registrar in a local anaesthetic day surgery list. The first case is a carpal tunnel decompression. After the patient has been positioned, anaesthetised, cleaned and draped your registrar makes the skin incision. This is in the palm from the base of the thenar eminence in a line towards the radial border of the ring finger down to the transverse flexor skin incision of the wrist (proximal limit). What is the first tendon that is seen beneath the fat? (September 11)

1. Flexor carpi radialis

2. Flexor carpi ulnaris

3. Flexor digitorum profundus

4. Flexor digitorum superficialis

5. Palmaris longus

 

21. A 32-year-old male presents to the casualty department after being involved in a fight in a pub where glasses have been broken. He has sustained a deep laceration to the thenar eminence. Which of the following structures is most at risk in this type of injury? (April 12)

1. Adductor pollicis muscle 

2. First dorsal interosseus muscle

3. Flexor digiti minimi brevis

4. Opponens digiti minimi

5. Ulnar artery

 

22. A 35-year-old man presents to A+E complaining of severe pain in his lower back after lifting a heavy box at work. The pain radiates to his right buttock and thigh. He has had no urinary symptoms. On examination he can straight leg raise to 90 degrees on the left side but only to 30 degrees on the right. Sciatic stretch test is positive. He has difficulty plantarflexing his right ankle and has abnormal sensation on the plantar aspect of the foot. His right ankle reflex is absent but all other reflexes are normal. There is no other sensory disturbance. The likely diagnosis is? (September 13)

1. Cauda equina syndrome

2. L3/L4 disc prolapse

3. L4/L5 disc prolapse 

4. L5/S1 disc prolapse

5. Old Shuerman’s disease

 

23. A 27-year-old man attends the fracture clinic. He suffered an anterior dislocation of his shoulder whilst playing rugby three days before. This has been successfully manipulated back into joint in the emergency department. Since then his arm has been in a broad arm sling. When you examine him in the fracture clinic, he is unable to abduct his shoulder and there is a numb patch over the lateral side of his arm. Which nerve has been affected? (January 11)

1. Axillary nerve 

2. Musculocutaneous nerve

3. Nerve to subscapularis

4. Radial nerve

5. Upper cord of brachial plexus

 

24. A 23-year-old male attends casualty with a nose bleed following a blow to his face during a rugby match. On examination the blood appears to be coming from the anterior inferior part of the left nostril. The artery responsible for the bleeding is: (April 10)

1. The posterior ethmoidal artery

2. The anterior ethmoidal artery

3. The superior labial artery

4. The greater palatine artery

5. The sphenopalatine artery

 

25. A 31-year-old woman is seen in the clinic complaining of weight loss and palpitations. On examination she has a tremor and an irregularly irregular pulse. She has a smooth goitre which has a bruit and there is exophthalmos. Thyroid function tests are requested. Which of the following combinations represents the clinical condition? (April 13)

1. T4 ↑; T3 ↑; TSH ↓ 

2. T4 ↑; T3 N; TSH ↓

3. T4 ↑; T3 ↑; TSH ↑ 

4. T4 ↓; T3 ↓; TSH ↑

5. T4 ↓; T3 ↓; TSH ↓

 

26. A 24-year-old man is seen in pre-clerking prior to panproctocolectomy for familial adenomatous polyposis. His past medical history also includes asthma for which he takes regular inhalers. Preoperative respiratory function tests are requested. Which of the following changes is likely to be observed? (January 12)

1. Decreased functional residual volume

2. Increased FEV1/FVC ratio

3. Reduced FEV1/FVC ratio

4. Reduced forced vital capacity

5. Reduced total lung capacity

 

27. A 23-year-old female is seen in the accident and emergency department. She has suffered severe vomiting and diarrhoea over the last four days. She states that she has been unable to keep down any fluids. Clinically she is dehydrated and she is started on an intravenous infusion. Investigations reveal a potassium of 2.6 mmol/L (3.5-4.9). Which of the following abnormalities would you expect to see on her ECG? (April 12)

1. Shortened P-R interval

2. Small P waves

3. S-T segment depression

4. Tall, tented T waves

5. Wide QRS complexes

 

28. A 42-year-old man is seen in the clinic reporting lethargy, nausea and vomiting and weight loss. On examination he is hypotensive and there is pigmentation of his palmar skin creases and of an old appendicectomy scar. Routine biochemistry reveals:

Potassium 5.8 mmol/L (3.5-4.9)

Sodium 131 mmol/L (137-144)

What is the likely diagnosis? (September 11)

1. Addison’s disease 

2. Conn’s syndrome 

3. Cushing’s syndrome

4. Hypopituitarism

5. Waterhouse-Friderichsen syndrome

 

29. A researcher compared the mean scores for nausea on a rating scale between standard therapy and a new drug in the treatment of chemotherapy induced nausea.

Which one of the following is the most appropriate statistical test? (January 12)

1. Chi-square test

2. Paired T-test

3. Life table analysis (log rank test)

4. Pearson correlation

5. Unpaired T-test

 

 

30. You are in the weekly breast clinic and an anxious young lady whose mother is currently being treated for breast cancer in your unit asks you about the risk factors for developing breast cancer.

Which of the following has been linked with a significantly increased risk of breast cancer? (January 11)

1. Breast feeding

2. Late menarche

3. Late menopause

4. Multiparity

5. Oophorectomy

 

31. On an evening ward round you glance at the blood results of a patient from another team. The results show an increased prothrombin time (PT), an increased activated partial thromboplastin time (APPT), an increased thrombin time (TT) and a low platelet count. The most likely underlying explanation for this set of blood results is: (April 12)

1. Disseminated intravascular coagulation (DIC)

2. Haemophilia

3. Heparin

4. Liver failure

5. Warfarin

 

32. A 38-year-old lady is admitted with cellulitis surrounding a traumatic wound. She has never taken penicillin previously. She is placed on intravenous flucloxacillin and benzylpenicillin. Shortly after the second dose she becomes acutely short of breath and collapses. She is resuscitated successfully after administration of intravenous adrenaline.

What type of reaction has this lady experienced? (January 12)

1. Type I hypersensitivity 

2. Type II hypersensitivity

3. Type III hypersensitivity 

4. Type IV hypersensitivity

5. Type V hypersensitivity