26 year old female presented to her GP complaining of weight loss, diarrhoea

and palpitations and feeling hot all the time.

Q1 What is the most likely diagnosis? (3)

Thyroid problem (1)

Hyperthyroidism (2)
Graves’ disease (3)

Q2 How would you investigate this patient and indicate what abnormalities you
would expect to find? (7)

Any combination to maximum of 7:

If they only mention TFT without specifics they get 1 mark
Thyroid stimulating hormone(1) reduced (1)
T4 (1) increased(1)
T3 (1) increased (1)
Anti-thyroperoxidase antibody (1)
Anti – thyroglobulin antibody (1)
Thyroid uptake scan – increased uptake (1)

Q3 How would you treat this patients condition? (4)

Up to 2 marks for any of the following 3:
 Thionamides(2)
 propylthiouracil (PTU) (2)
 carbimazole (2)
Partial or total thyroidectomy (1)
Beta-blockers(1)
Q4 What condition involving the eyes is specific to this patients diagnosis? and
describe Two of the features.(3)

Graves’ ophthalmopathy (1)

Exopthalomos/proptosis (1)
Lagophthalmos (1)
Peri-orbital oedema (1)
Impairment of extra-ocular muscle movement (1)
Corneal scarring/ulcer secondary to lagophthalmos (1)
Sight loss due to CN2 compression (1)

Note: Ophthalmoplegia is also seen in thyroid myopathy secondary to hypothyroidism

Q5 What other additional clinical signs would you expect to find in this patient? (3)
1 mark each to a maximum of 3 for any of:

 Tremor
 Skin is warm
 Onycholysis
 Hyperpigmentation can occur in severe cases
 Pruritus and scratch marks especially in graves
 Pretibial mxyoedema
 Signs recent weight loss – temporalis wasting, wasting SMoH
 Goitre
 Hyperreflexia
 Proximal myopathy
 Hypertension
 Stridor
 Pemberton’s sign

Any other feature of hyperthyroidism on examination is acceptable

You are asked to review a 70 year old man, complaining of weakness.

He has a background history of hypertension, type 2 diabetes, and his

medications include an ACE inhibitor and spironolactone.

His U&E is as follows:

Level Reference Range Units

Urea 5.6 2.5-8.5 mmol/L

Creatinine 180 135-145 mmol/L
K 7.1 3.5-5.0 mmol/L
Na 138 135-145 mmol/L
Chloride 100 98-108 mmol/L

1: What abnormality on this U&E requires the most urgent attention? (2 marks)

Hyperkalaemia

2: What are the likely causes of this abnormality in this patient? (6 marks)
2 marks each for any of following, to a maximum of 6:

Renal impairment secondary to diabetes

Renal impairment secondary to hypertension
ACE inhibitor
Spironolactone.
Renal tubular acidosis type 4 secondary to Diabetes Mellitus

3: An ECG taken on this patient is below:

What are the abnormal features on this ECG? (6 marks)
2 marks each for any of the following:

Flat p waves
Peaked T waves,
Prolonged PR interval
Widening of QRS complex
Left axis strain

4: Outline your emergency initial management of this patient. (6 marks)

Up to a maximum of 6 for any combination of the following:
Stop ACE/Spironolactone – 1 mark
Calcium gluconate – 1 mark (10ml of 10%, i.v.) – 1 mark
Glucose 0.5 marks (50ml of 50% dextrose i.v. ) 0.5 marks and insulin 0.5 marks (10
units) 0.5 marks
B agonist 1 mark ( Salbutamol 10-20mg inhaled or 0.5-1mg IV) 1 mark
Sodium bicarbonate (mention) 1 mark
Dialysis 1 mark
Calcium resonium 1 mark
A 19 year old male is referred to the out-patient’s department with a recent onset
rash confined to his lower limbs (see image). Of note, he complains of diarrhoea,
abdominal pain and weight loss over the past two months.

1. What is the classic description for this rash? (2 marks). What is the name
for this rash? (2 marks)
 One mark each for any of the following
a. Well circumscribed lesions
b. Erythematous
c. Palpable
d. Tender
e. Paniculitis / nodular vasculitis
f. Confined to the shins predominantly
 Two marks for correct name (erythema nodosum)

2. What is the most likely diagnosis? (4 marks)

 Inflammatory bowel disease; Crohn’s more likely than UC based on history
 2 marks for mentioning IBD alone, 1 mark for mentioning Crohn’s or UC
with 1 mark for giving an explanation for choice.
3. What agents would be used to treat this disease acutely? (4 marks)
 Steroids: intravenous / per oram / per rectum
a. Eg iv hydrocortisone, po prednisolone, PR predfoam
 5 ASA compounds:
a. Eg mesalazine, sulphasalazine, olsalazine)
 1 mark given for drug category and 1 mark for example

4. List two indications for surgical therapy. (4 marks)

 One mark for each of any of the following:
a. Perforation
b. Massive bleeding
c. Toxic dilatation
d. Carcinoma / risk of carcinoma
e. Fistula formation
f. Abscess formation
g. Limited disease unresponsive to maximum medical therapy, e.g. high
dose steroids
h. Bowel obstruction

5. What are the therapeutic options for refractory disease? (4 marks)

 One mark for each of the following
a. Immunosuppressants eg cyclophsphamide – 1 mark
b. Biologics eg TNFa inhibitors (infliximab) – 2 marks
c. Nutritional : elemental feeding – 1 mark
An 82 year old man is brought to the Accident and Emergency Department with
a four hour history of acute confusion. A care attendant from his nursing home
accompanies him. She gives a collateral history of cough productive of green
sputum associated with wheeze and dyspnoea on exertion, for the past 7 days.
The general practitioner commenced him on clarithromycin 500 mg b.d. p.o. 6
days ago, but his symptoms have persisted. Today he had a fever of 38.5 degrees
Celsius.
A chest x-ray is performed, as below.
Q1. What is the diagnosis? (3 marks)
Hospital acquired (1 mark) Pneumonia (1 mark) with para-pneumonic pleural effusion
(1 mark)
OR
Empyaema (3marks)

Q2. List the most appropriate additional investigations in assessment of this

patient. Include the indication AND expected abnormality. (6 marks)
Must say:

 Pleural fluid tap+analysis (1mark)– WCC/pH/Glucose/LDH/culture,

etc. (1mark)– Neutrophilic exudates/low pH/Light’s criteria, etc.
(1mark)

In addition, any one of the following:

 Full blood count- suspected pneumonia - neutrophilia leucocytosis
 Blood cultures – suspected pneumonia – gram negative/mixed
microbes most likely growth (appropriate alternative accepted)
 Urea/electrolytes – CURB score/SIADH causing confusion - Pre-renal
failure, urea disproportionately high/
 Any other appropriate investigation with indication and expected
abnormality
 Students should not be awarded marks for investigations which are
appropriate for an incorrect diagnosis.

Q3, List the features you would expect to find on clinical examination (2marks)

Any 2 of:

 Sinus tachycardia
 Tachypnoea
 Increased tactile fremitus LLZ
 Incrased vocal resonance LLZ
 Unilateral left-sided decreased chest expansion (must give
full description)
 Stony dullness to percussion LLZ
 Decreased breath sounds LLZ
 Bronchial breathing LLZ
 Any other appropriate climical feature
Q4. Write the appropriate prescription for treatment of the underlying condition
(several options applicable – only one regimen is required) (6 marks)
RF for MDR

1 of:
 Cefepime (2 g intravenously every eight hours) , ceftriaxone 1-2 gr o.d. or b.d.
or ceftazidime (2 g intravenously every 8 hours)
 Imipenem (500 mg intravenously every six hours) or meropenem (1 g
intravenously every eight hours
 Piperacillin-tazobactam (4.5 g intravenously tds)

And

1 of:
 Antipseudomonal fluoroquinolone, such as ciprofloxacin (400 mg
intravenously every eight hours) or levofloxacin (750 mg intravenously daily).
 Aminoglycoside such as gentamicin (3-5 mg/kg b.d.)

Q5. List prognostic indicators for determining the severity of his condition. (3
marks)

Any 3 of:
 Confusion
 Urea> 7 mmol/L
 Respiratory rate > 30/min
 BP < 90mmHg systolic or 60mmHg diastolic
 Age > 65
A 76 year old male presents to the accident and emergency department with low back pain.
He undergoes the following blood tests.

Complete Blood Count

Result Reference Range Units

Hb 9.1 11.7-16.0 gm/dl
PCV .295 .355-.520 L/L
RBC 3.28 3.80-5.60 10^12/L
MCV 80.0 79.0-96.0 fl
MCH 28.0 27.0-32.0 pg
WBC 6.8 4.00-11.00 10^9/L
Platelets 160 140-440 10^9/L

Urea and Electrolytes

Urea 16.9 2.5-8.5 mmol/l

Sodium 141 135-145 mmol/l
Potassium 4.5 3.2-5.2 mmol/l
Chloride 105 98-108 mmol/l
Creatinine 266 50-120 umol/l
Calcium (corrected) 2.72 2.2-2.6 mmol/l

1. What abnormalities are present on the above blood results? (Arrows indicating elevated/low
levels not acceptable) (5 marks)
-Normochromic/Normocytic Anaemia - 1 mark for each
-Renal Failure – 1 mark
-Hypercalcaemia – 1 mark

The diagnosis of multiple myeloma is made.

2. Name 2 characteristic features that may be present on xray? (2 Marks)

1 mark each for any of following:
-Osteolytic lesions
-Pepperpot skull
-Pathological Fracture
Vertebral compression
Plasmacytoma

3. List symptoms of hypercalcaemia (5 Marks)

1 mark each for any of following:
Constipation
 Nausea and vomiting
Anorexia
Constipation
Abdominal pain
Renal colic
Weakness
Depression
Confusion

What three processes could contribute to renal failure in a patient with Multiple Myeloma? (3 marks)
 Amyloid deposition
 Light chain deposition
 Plasma cell infiltration
 Recurrent pyelonephritis secondary to immune paresis
 Hypercalcaemia/stone formation
 Hyperuricaemia
 Renal vein thrombosis secondary to hyperviscosity

4. Describe the management of acute hypercalcaemia (5 marks)

-IV fluids – 0.5 (0.9% saline) 0.5

-Bisphosphonates 0.5 IV 0.5
-Steroids (prednisolone)0.5 IV 0.5
-Calcitonin 0.5 IM 0.5
Loop diuretic/furosemide 0.5 mark IV 0.5 mark
-Consider Dialysis 1 mark