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• A 25-year-old female presented with six months

history of depression, irritability and painful sensory
symptoms in her legs. Over the last four weeks she
presents a broad base ataxic gait.
• An MRI brain showed bilateral posterior thalamic
nuclei (pulvinar region) high signals.
• Which of the following is the most likely diagnosis?
• Herpes simplex encephalitis.
• Multiple system atrophy.
• New variant CJD.
• Sporadic CJD .
• Wilson disease

• New variant Creutzfeldt-Jakob disease (CJD) usually
presents in a young person, in their twenties or thirties.
• In the majority of the cases the first symptoms are
psychiatric and painful sensory symptoms in the lower
• Ataxia and involuntary movements (for example,
myoclonus) usually appear at an interval of about six
months after the initial symptoms.
• MRI brain shows bilateral pulvinar (posterior thalamic
nuclei) high signals.
• EEG is usually normal in new variant CJD.

• A 35 year old woman has been admitted to hospital for
investigation of progressive weakness in her legs. For the
past 5 years. The patient's mother has similar difficulties with
weakness and sensory problems. Examination revealed
power of 3/5 distally in the upper and lower limbs with a glove
and stocking pattern sensory loss to pain and touch.
• What is the most likely diagnosis?
• A. subacute combined degeneration of spinal cord.
• B. Friedrich's ataxia
• C. Chronic inflammatory demyelinating polyneuropathy .
• D. Multiple sclerosis .
• E. Hereditary sensory & motor neuropathy.

Answer: e) hereditary sensori motor neuropathy. In view of the family history, this
patient is most likely to have hereditary sensori motor neuropathy type I (Charcot
Marie Tooth disease). HMSN 1 is the most common form of hereditary neuropathy.
Severely and uniformly slowed nerve conduction velocities (NCVs) and primary
hypertrophic myelin pathology with prominent onion bulbs and secondary axonal
changes are the hallmarks of the disease. Motor symptoms predominate over
sensory symptoms. Often, patients report loss of balance, muscle weakness, and foot
deformities. Onset in the first decade of life is typical, but disease develops in some
patients in young or mid adulthood.
HMSN 2, on the other hand, represents the nondemyelinating neuronal type with
relatively normal NCVs and primary axonal pathology. Although nerves are not
enlarged in the neuronal form, weakness often is less marked and onset of this
neuropathy is delayed. Peripheral nerves are not enlarged clinically, and weakness of
feet and leg muscles predominates; hands are less severely affected than the legs.
Patients experience sensory loss in the distal extremities, and foot deformities (ie,
pes cavus) tend to be less marked than those of HMSN 1.

• A 40 year old man presents with an
uncomfortable sensation in his face, comes
to the casualty department. He is unable to
lift his eyebrows and also has bilateral facial
weakness. Which one of the following is
most likely to cause bilateral lower motor
neuron weakness?
A. Cerebrovascular disease.
B. Pontine haemorrhage.
C. Lyme disease.
D. Multiple sclerosis.
E. Motor neuron disease

.Answer: c) lyme disease. Causes of Upper Motor Neuron facial weakness are: CVA pontine haemorrhage Multiple Sclerosis motor neuron disease Lyme disease usually causes lower motor neuron facial weakness.

Depression 3. Thyroid function normal Autoimmune screen normal What is the most likely diagnosis? 1. ESR normal. She is also complaining of difficulty sleeping at night and urinary frequency. fibromyalgia 2. rheumatoid arthritis 4.A 47-year-old personal assistant attends the outpatient clinic with a six-month history of malaise and joint pains. LFTs normal. She has had to quit her job. The investigations show: full blood count normal. systemic lupus erythematosus . U&E normal. Vasculitis 5. CRP normal.

Self-management strategies.True 1. reassurance and tricyclic anti– depressants for sleep disturbance are the mainstays of therapy. Aerobic exercises such as swimming are recommended. It presents with musculoskeletal pain that often has multiple trigger points and may be poorly defined. . presenting most often in the 30–50 year age group. Fibromyalgia is said to occur in between 1 and 2% of the general population and has a female to male ratio of 9:1. Symptoms wax and wane for many years.

Which of the following should be used to monitor her? 1) arterial blood gases 2) chest expansion size 3) FEV1/FVC ratio 4) PEFR 5) vital capacity . Her weakness continues to worsen after admission to hospital.A teenage girl presents with Guillain-Barre syndrome.33.

4 )Furosemide . S. .• A 46-year-old male presents passing 4-5 litres of urine per day. 5 )Lithium. after commencing a new drug. 3 )Fluoxetine .What drug was prescribed? 1 )Carbamazepine 2 )Chlorpropamide.sodium 142 mmol/l. Plasma osmolality 295 mosmol/l (275-290). Urine osmolality 280 mosmol/l (350-1000).

What diagnosis would best fit the clinical picture and investigation result? 1. Fasting blood glucose is 4. Cranial diabetes insipidus 3. Nephrogenic diabetes insipidus 5.urine osmolality325 mosm/kg. Water deprivation phase plasma osmolality298 mosm/kg (278–300 mosm/kg) urine osmolality300 mosm/kg DDAVP Phase plasma osmolality295 mosm/kg.5 mmol/l. Sickle cell nephropathy 2. Lithium-induced nephrotoxicity . A water deprivation test was performed. She is not on any medication. Psychogenic polydipsia 4. She has a history of sickle cell disease and had been admitted on two previous occasions to hospital with chest pain precipitated by crisis.A 21-year-old Nigerian woman was referred by her general practitioner with a progressive history of polydipsia and polyuria of 6 months duration.

Nephrogenic diabetes insipidus (NDI) is X-linked recessive. Homozygous affected people (all males) are completely unresponsive to ADH while heterozygous females show normal or slight impairment. polycystic kidney disease. Acquired NDI occurs in disorders that disrupt the medulla or distal nephron and impair concentrating ability. pyelonephritis. vasopressin). The water deprivation test after an overnight fast assesses the kidneys’ urine-concentrating ability and response to ADH.True 4. amyloidosis. a large amount of dilute urine is excreted. this mechanism helps to maintain plasma osmolality and extracellular volume. The result shows abnormally low (< 750 mosm/kg) urine osmolality. Normally the kidneys concentrate urine by increasing water resorption by the collecting duct in the presence of ADH. Causes are: sickle cell nephropathy. . which increases only slightly after exogenous ADH (1-deamino-8-D-argininevasopressin (DDAVP). Without ADH. certain nephrotoxins such as lithium and demeclocycline. The disease is characterised by the inability to concentrate urine due to the lack of response of renal tubules to antidiuretic hormone (ADH).

In Psoriatic arthropathy all true except A is usually associated with psoriatic nail change. D is associated with uveitis.27. E responds to chloroquine. which is the treatment of choice. . B may cause sacro-iliitis . C can occurs in the absence of psoriasis of the skin.

A 25 year-old lady recently diagnosed with rheumatoid arthritis. bilateral ptosis. normal reflexes and sensation. 2) Guillain-Barre syndrome. double vision and tiredness. 5) Polymyositis . 3) Multiple sclerosis. 4) Myasthenia gravis. slightly reduced proximal motor power in the limbs. What is the diagnosis? 1) Chronic progressive external opthalmoplegia. Examination reveals bilateral weakness of eye abduction. She has developed weakness.

In Guillain-Barre syndrome you will expect absent reflexes.The answer is 4 Myasthenia gravis is well known to be associated with other autoimmune diseases such as pernicious anaemia. Polymyositis does not usually cause ptosis or ophthalmoplegia. thyroid disease and rheumatoid arthritis. .

Deep vein thrombosis • B. Coronary artery thrombus due to mural thrombus . Venous thrombosis due to mural thrombus • E. An electrocardiogram shows T wave inversion and q waves in the anterolateral leads at rest. a soft systolic murmur in the mitral area and also bilateral inspiratory crepitations in his lungs.A 70 year man has been short of breath for 1 year. Pulmonary embolus • C. • Which of the following is he at risk of? • A. He has cardiomegaly on the chest X ray. Clinical examination shows a third heart sound. Systemic arterial embolus from mural thrombus • D.

.• Answer: c) systemic arterial embolus from mural thrombus. Poor LV function also causes his symptoms of heart failure. He is at risk of developing mural thrombus with embolus to the arterial circulation. This man has features indicating that he has an enlarged left ventricle from previous anterior myocardial infarction in the LAD artery territory.

.A 12 year old girl has a diagnosis of the 21 hydroxylase deficiency form of congenital adrenal hyperplasia. Alopecia . • D. • B. • C. Which one of these features is likely to be present? • A. High cortisol . Precocious puberty. Ambiguous genitalia . Hypertension. • E.

Hypertension typically occurs in the rarer forms but not 21 hydroxylase deficiency which is the commonest form of CAH.• Answer: b) ambiguous genitalia. • • 21 Hydroxylase deficiency . In congenital adrenal hyperplasia. There is also cortisol deficiency and replacement with dexamethasone is appropriate. ambiguous genitalia and normal puberty (precocious puberty in boys) are seen in girls. hirsutism.

nystagmus.A 63 year old male is admitted with acute onset unsteadiness of gait. dizziness and dysphagia. What is the most likely diagnosis? 1) leaking posterior communicating artery aneurysm 2) left sided acoustic neuroma 3) posterior inferior cerebellar artery occlusion 4) right sided pontine infarct 5) spontaneous left sided cerebellar haemorrhage . and gait ataxia. loss of pain and temperature sensation on the left side of the trunk and in the left arm and leg. Examination revealed a right-sided Horner's syndrome.

.The answer is 3 This is Wallenberg's syndrome/ lateral medullary syndrome and is due to occlusion of the posterior inferior cerebellar artery.

• A 50 year old lady has polyuria.85 mmol/l and phosphate is 0. Bisphosphonates . Diltiazem • E. Lithium • D.9 mmol/l. Her serum calcium is 2. Which of the following could cause this? • A. Vitamin D deficiency • B. Loop diuretics • C.

thiazides (not loop) diuretics and vitamin A or D intoxication can cause hypercalcaemia. Lithium.• Answer: c) lithium. .

Ro C.La B. She has a heliotropic rash around the eyes and also Gottron’s papules. Jo-1 A.. particularly in the lower limbs. SCL-70 E.D.A 45 year old patient presents with proximal muscle weakness. Which one of the following antibodies is most strongly associated? A. Anti DsDNA .

• Answer: C) Jo-1. The limb girdle or proximal muscles are most severely affected in both polymyositis and dermatomyositis. The diagnosis is dermatomyositis. Anti Jo-1 antibody is associated with acute onset myositis. • • Gottron's papules . particularly dermatomyositis.

Prednisolone 20 mg mane D. Hydrocortisone 10mg mane. Hydrocortisone 20mg mane.A 35 year old lady has grey pigmentation of her skin and hypotension. Hydrocortisone 10mg mane. 10 mg mid day . Her early morning cortisol is 45 μmol/l and her sodium is 127 mmol/l. 5mg mid day and 5 mg evening and also fludrocortisone 100 μg mane B. Which of the following is the best replacement regimen? A. Hydrocortisone 40mg mane and fludrocortisone 300 μg mane E. fludrocortisone 100 μg mane C.

although this is adjusted with cortisol day curves. She has Addison's disease and needs both glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement. .• Answer: a) hydrocortisone 10mg mane. Steroid replacement is usually given 10/5/5 mg or 10/5 mg. Fludrocortisone 100 μg mane should be adequate. 5mg mid day and 5 mg evening and also fludrocortisone 100 μg mane.

which changes should be made? A. He is brought in for DC cardioversion because of troublesome palpitations and breathlessness. Continue warfarin for life . Continue digoxin but not warfarin D. His current medications are digoxin and warfarin. Following successful cardioversion. Continue warfarin but not digoxin till outpatient review C.A patient has been in atrial fibrillation for at least several months. Continue both digoxin and warfarin E. Discontinue warfarin and digoxin B.

Digoxin should be stopped once sinus rhythm is achieved since its role is only for rate control. For at least 4 weeks following DC cardioversion. the patient is still at risk of thromboembolism. . If the patient remains in sinus rhythm after 6-8 weeks then warfarin can be discontinued unless there is evidence of paroxysmal AF.• Answer: b) continue warfarin but not digoxin till outpatient review. It does not help in maintenance of sinus rhythm.

Adult-onset Still’s disease . RA 5. ANCA all negative. mild hepatomegaly and synovitis of the proximal interphalangeal (PIP) and wrist joints. Ferritin 4567 μg/l (normal range 14 – 200 μ/l). which is worse on lying down. with a temperature of 39oC. ANA. He is febrile. Investigations show the following:Hb 10. accompanied by chest pain. CT abdomen hepatosplenomegaly. RF. pericardial rub. P82%. ALT69 IU/l. 2D echocardiogram pericardial effusion MSU and blood culture negative. SLE 2. ALK-P 246 IU/l.A 20-year-old man presents with a history of intermittent fever for 1 month. PLT540 x 109/l. WBC 20 x 10 9/l. His pulse is 98/min and his blood pressure is 110/70 mmHg. Mixed connective tissue disease (MCTD) 3. The positive findings on examination are enlarged anterior cervical lymph nodes. Which of the following is most likely diagnosis? 1. ESR110 mm/1st hr. CRP 246 mg/l. CXR cardiomegaly.5 g/dl. Undifferentiated connective tissue disease (UCTD) 4. He has recently also noticed pain in the joints of his hands and feet.

fleeting salmon-pink maculopapular rash which is most prominent with fever. anaemia. and evidence of reticuloendothelial activation. . Clinical features of adult-onset Still’s disease include arthralgia or arthritis. elevated acute phase reactants. The laboratory investigations commonly reveal leucocytosis. Autoantibodies are negative. raised serum ferritin and an elevated erythrocyte sedimentation rate and C-reactive protein.True 5. thrombocytosis. especially in the afternoon and evening. In between the febrile episodes the patient feels rather well. serositis. a high fever (> 39oC).

• A 70-year-old woman referred by a a breast lump.
She was asymptomatic but her investigations
reveal:Corrected calcium2.72 (2.2 2.6)Phosphate0.80 (0.8-1.4)Alkaline
phosphatase110 U/L (20 - 95)PTH
concentration5.1 pmol/L (0.9-5.4)
• What is likely diagnosis?
1 )bony metastases
2 )chronic vitamin D excess
3 )ectopic PTH related peptide (PTHrp) secretion
4 )multiple myeloma
5 )primary hyperparathyroidism

• A 19-year-old male presents with concerns regarding his
pubertal development. On examination he 1.8 m tall, thin
little pubic & axillary hair. Both testes are approximately 5
mls in volume (Normal 15mls). No other abnormalities are
encountered. Investigations reveal: LH 3.3 mu/l (3-10) FSH
5.5 mu/l (3-10) Testosterone 5.5 nmol/l (9-30) Which of
following is the most likely diagnosis?
1 )Anorexia nervosa .
2 )Craniopharyngioma .
3 )Kallmann syndrome .
4 )Klinefelter’s syndrome .
5 )Primary testicular failure.

A 74-year-old man has had increasingly severe, throbbing headaches
for several months, centered on the right. There is a palpable tender
cord-like area over his right temple. His heart rate is regular with no
murmurs, gallops, or rubs. Pulses are equal and full in all
extremities, BP is 110/85 mmHg. A biopsy of this lesion is obtained,
and histologic examination reveals a muscular artery with lumenal
narrowing and medial inflammation with lymphocytes,
macrophages, and occasional giant cells. He improves with a
course of high-dose corticosteroid therapy. Which of the following
laboratory test findings is most likely to be present with this
1) Anti-double stranded DNA titer of 1:1024
2) Erythrocyte sedimentation rate of 110 mm/hr
3) HDL cholesterol of 0.6 mmol/L
4) pANCA titer of 1:160
5) Rheumatoid factor titer of 80 IU/mL

A 21-year-old man has recently returned from a
holiday in the Far East. He gives a history of
symmetrical joint pain in his knees and ankles
and feet and also complains of sore eyes. His
ESR is raised. A synovial fluid aspirate is sterile
but with a high neutrophil count.What is the
most likely diagnosis?
1. Ankylosing spondylitis
2. Septic arthritis
3. Reactive arthropathy
4. Rheumatoid arthritis
5. Still’s disease

True 3. The history of recent travel to the
Far East raises the possibility of
venereal disease. The lower limb
symmetrical arthropathy is
characteristic of reactive arthropathy. A
history should be taken of
urethritis/dysuria and conjunctivitis to
complete the Reiter’s syndrome triad.

2 mU/L(NR 3. . FSH 2.6. She takes no specific therapy.3 – 10) S. • Investigations reveal:Serum oestradiol 100 pmol/L(NR 130 .300)Serum testosterone2.• A 32-year-old woman presents a four month history of amenorrhoea. She has two children her husband has a vasectomy.0) Which investigation 1 )Insulin tolerance test 2 )Pregnancy test 3 )17 hydroxy-progesterone 4 )Urine free cortisol concentration 5 )Magnetic resonance imaging (MRI) of pituitary .1 pmol/L(NR < 3. prolactin 800 mU/L(NR 50 .1 mU/L(NR 3.500) S.0 . Examination reveals an obese individual but no other abnormality.6) S. LH 2.

5 tds of sinemet. intermittent confusion and generalised myoclonus. In the following 2 months he was started experiencing visual hallucinations.A 75-year-old man presents with 12 months history of cognitive impairment. The most likely diagnosis is: 1) Idiopathic Parkinson's disease 2) Alzheimer's disease 3) Diffuse Lewy body disease 4) Multiple system atrophy 5) Progressive supranuclear palsy . He was started on 62. parkinsonism.

The most likely pathologic process that explains these findings is? 1 )Decreased bone mass 2 )Metastatic adenocarcinoma 3 )Paget's disease of bone 4 )Renal failure & renal osteodystrophy 5 )Vitamin D deficiency .A 70-year-old man from Lancashire has noted increasing back & leg pain over several years. lower vertebral. Blood tests reveal an elevated serum alkaline phosphatase. He has orthopnea & pedal edema. He also says his hat does not fit him anymore. & upper tibial regions with cortical thickening. X-rays reveal bony sclerosis of the sacroiliac. but without mass effect or significant bony destruction. He has greater difficulty hearing on the left.

Metastatic disease in bone produces focal lesions. This man has Paget's disease with high output cardiac failure & sensorineural deafness. Renal osteodystrophy leads to lesions of osteitis fibrosa cystica admixed with osteomalacia. . which are focal in nature.Comments: true 3.

• A 17 year presents tingling & muscle cramps. There
is no other past history of note. Investigations reveal
Creatinine68 micromol/L (50-100)calcium1.76 (2.22.6)albumin38 g/L (37-49)
• Which one of following investigations is likely to
confirm diagnosis?
1 )Alkaline phosphatase concentration
2 )CT brain scanning
3 )PTH concentration
4 )Urine calcium concentration
5 )Vitamin D concentration

An otherwise healthy middle-aged man without
prior medical history has had increasing back
pain & right hip pain over the past 10 years.
The pain is worse at the end of the day. He
has bony enlargement of the distal
interphalangeal joints. A radiograph of the spine
reveals the presence of prominent osteophytes
involving vertebral bodies. There is sclerosis
& narrowing of the joint space at the right
acetabulum seen on a radiograph of the pelvis.
Which of the following pathologic processes is
likely to be taking place in this patient?
1 )Gout
2 )Lyme disease
3 )Osteoarthritis
4 )Osteomyelitis
5 )Rheumatoid arthritis

Comments: true 3.
Degenerative osteoarthritis is a common & progressive
condition that becomes more frequent symptomatic
with aging. There is erosion & loss of articular
cartilage. Rheumatoid arthritis typically involves small
joints of the hands & feet, there is a destructive
pannus that leads to marked joint deformity. A gouty
arthritis is more likely to be accompanied by swelling,
deformity & joint destruction. The pain is related to
usage. Osteomyelitis represents an ongoing infection
that produces marked bone deformity, not just joint
narrowing. Lyme disease produces a chronic arthritis,
but it is typically preceded by a deer tick bite & a skin
lesion. It is much less common than osteoarthritis.

A 62-year-old man attends for review. He has
evidence of arthritis affecting the shoulder, elbow,
radiocarpal, and knee joints bilaterally, with pain
also in the left first metatarso-phalangeal joint. Xray of the left knee reveals calcification within the
hyaline cartilage. Aspiration of the left knee
reveals calcium pyrophosphate crystals. Serum
uric acid is slightly above the upper limit of normal.
Other medical history of note is ulcerative colitis.
What is the most likely diagnosis in this case?
1. Gout
2. Pseudogout
3. Primary osteoarthritis
4. Rheumatoid arthritis
5. Sero-negative arthritis

True 2. The clinical picture of joint involvement, coupled with
evidence of chondrocalcinosis and pyrophosphate crystals is
strongly suggestive of a diagnosis of pseudogout. The slightly
elevated uric acid and history of ulcerative colitis are ‘redherrings’ in this case. Management involves use of simple
painkillers and non-steroidal anti-inflammatory agents coupled
with physiotherapy where appropriate. Associated conditions
include haemochromatosis and Wilson’s disease, where there
are other symptoms and signs it may be worth screening for
these concomitant illnesses. Pseudogout has an equal
male:female ratio, with frequency increasing with increasing
age; it is said to affect around 5% of subjects above the age of
30 years.

A 35-year-old man returned from a two-week holiday complaining of pain in the loins and painful swollen knees. Laboratory investigations showed. .6 g/dL • WBC 16.1 x 109/l • ESR 65 mm/h • Rheumatoid factor 10 IU/L • Urinalysis No cells. 4) Reitter's syndrome. 5) Rheumatoid arthritis. • Hb 15.35.2 x 109/l • Neutrophils 14. 3) Reactive arthritis. 2) Lymphogranuloma venereum. On examination he was afebrile and had significant bilateral knee effusions. casts or bacteria seen • What is the most likely diagnosis? 1) Arthritis due to Neisseria gonorrhoeae infection. Mild penile erythema was also noted.

lower limb weakness and dry mouth. he looks cachectic. Which of the following blood test is the most likely to confirm the diagnosis? 1) Acetylcholine receptors 2) Voltage gated calcium channels antibodies 3) Anti GM1 antibody 4) Antinuclear antibody 5) Anti Ro/La antibodies . Sensory examination is normal. There is no wasting or fasciculations. he has proximal lower limb weakness. He has been a heavy smoker. areflexia (reflexes normalise with repetitive muscle contraction). On examination.A 70-year-old man presents with weight loss.

50% of the cases are associated with small cell lung carcinoma.g. The reflexes are depressed or absent but normalise with repetitive muscle contraction. Ptosis and ophthalmoplegia are rare. It results when IgG autoantibodies blockade the voltagegated calcium channels of peripheral cholinergic nerve territory. . Proximal lower limb weakness is the most consistent neurological feature. dry mouth). Autonomic dysfunction is common (e.The answer is 2 The most likely diagnosis is Lambert-Eaton syndrome.

Which of the following is NOT a risk factor for sudden death in patients with hypertrophic cardiomyopathy? • A : Unexplained syncope • B : Sudden death from HOCM in 2 or more first degree relatives <40years of age • C : Family history of sudden death • D : left ventricular wall thickness of >30mm • E : Hypertension. . His general practitioner organised an open access echocardiogram which showed a septal thickness of 26mm and a left ventricular outflow gradient of 85mmHg.A 42-year-old man reviewed in outpatients has a 6month history of increasing shortness of breath on exertion and feelings of lightheadedness when digging in his garden.

• · Unexplained syncope • · Left ventricualr wall thickness>30mm • · Abnormal blood pressure on exercise(failure to rise from baseline by 25mmHg) • · Non sustained Ventricular tachycardia .• Major risk factors for hypertrophic cardiomyopathy are: • · Cardiac arrest (ventricular fibrillation) • · Spontaneous sustained ventricular tachycardia • · Family history of sudden death.

3) Areflexia. Which of the following would exclude Guillain-Barre Syndrome as the diagnosis? 1) Autonomic dysfunction. . 2) Elevated protein on CSF examination. 4) Ophthalmoplegia. 5) Sensory level below D1.54 year old female is admitted with progressive weakness following a trivial flulike illness.61.

Ophthalmoplegia is associated in particular with the Miller-Fisher variant. There is a profound weakness associated with areflexia and peripheral sensory neuropathy. Muscle wasting is typical with prolonged illness. Autonomic disease may also feature.The answer is 5 GBS is a post-infectious acute polyneuritis typified by elevated CSF protein with few cells and often normal glucose. a sensory level is NOT a feature and would suggest cervical myelopathy. However. .

• A 68 year-old presents with a 4 month history of weight loss. • Examination shows tenderness over the temporal region & a left sixth nerve palsy. • Her chest X-ray was reported as normal. her Hb was 10. but she had an ESR of 100 mm/hr . 6 years previously she underwent a right mastectomy for breast carcinoma & remains on treatment with Tamoxifen. headaches & had recently developed double vision.8 g/dl. Which of following statements correct? 1 )An isotope bone scan should be performed 2 )An urgent CT brain scan required 3 )She should be treated prednisolone immediately 4 )She should have a lumbar puncture 5 )She should be given Diamorphine .

An 18 year old man presented with a history of a sudden onset of a frontal headache and photophobia. He had neck stiffness and a temperature of 38°C. Which one of the following findings would suggest a diagnosis of subarachnoid haemorrhage rather than bacterial meningitis? 1) a blood neutrophil leucocytosis 2) a family history of polycystic renal disease 3) a fluctuating conscious level 4) a history of diabetes mellitus 5) a history of opiate abuse .

The answer is 2 Fluctuating level of consiousness can occur in both meningitis and subarachnoid haemorrhage (SAH). Opiate abuse does not increase the risk for SAH. but not diabetes. Hypertension is a risk factor for SAH. . Cerebral aneurysm are associated with polystic kidney disease.

sensory loss in the legs with a sensory level at T10.0 g/dl MCV 99 fl What is the most likely diagnosis? 1) anterior spinal artery occlusion 2) dorsal meningioma 3) multiple sclerosis 4) subacute combined degeneration of the cord 5) tabes dorsalis . On examination. Investigations were as follows:haemoglobin 12. there is a mild spastic paraparesis. with brisk knee reflexes. and loss of vibration sense below the iliac crests. ankle reflexes are present with reinforcement.An 80-year-old woman has a three month history of progressive numbness and unsteadiness of her gait. impaired joint position sense in the toes. extensor plantars.

• A 46-year-old male presents passing 4-5 litres of urine per day. S. 4 )Furosemide . Urine osmolality 280 mosmol/l (350-1000).What drug was prescribed? 1 )Carbamazepine 2 )Chlorpropamide. 5 )Lithium. 3 )Fluoxetine . after commencing a new drug.sodium 142 mmol/l. Plasma osmolality 295 mosmol/l (275-290). .

5). no protein. a left ulnar nerve palsy and a widespread purpuric rash. He complained of arthralgia but had no clinical evidence of inflammatory joint disease. Investigations revealed: ESR100 mm/hr.• A 50-year-old man presented with a six-week history of general malaise and a 2 day history of a right foot drop.14 . ANCA negative.02 g/L (NR 0.0. ANA negative.1.What is the most likely diagnosis? 1 )ANA negative SLE 2 )Cryoglobulinaemia 3 )Infective endocarditis 4 )Polyarteritis nodosa 5 )Rheumatoid arthritis .75 . Urine dipstick Blood ++. An echocardiogram was normal and two sets of blood cultures were negative.8 g/L (NR 0. C3 0. Rheumatoid factor strongly positive. C4 0.6).

Subacute combined degeneration of the cord is unlikely as Hb and MCV are normal. . Anterior spinal artery occlusion is unlikely as the history is progessive.The answer is 2 The presence of a sensory loss at T10 indicates a thoracic mylopathy.

without wasting or fasciculation. The vital capacity was 1. On examination there was severe truncal and proximal limb weakness. Tendon reflexes. What is the most likely diagnosis? 1) cervical myelitis 2) Guillain-Barre syndrome 3) polio 4) polymyositis 5) syringiobulbia .8L.63.A 45-year-old man has a history of progressive weakness for 5 weeks. He had particular difficulty getting out of the bath. plantar and sensation were all normal.

The answer is 4 The presentation of myopathy is characterised by priximal weakness with normal reflexes and sensation and the absence of fasciculations. . Polymyositis is the commonest cause of inflammatory muscle disease in < 50 years old (inclusion body myositis is the commonest in >50 years old).

He has a previous diagnosis of slipped femoral epiphysis diagnosed at the age of 11. .9-5. • • On examination he is on the 12th centile for height. This was treated by the orthopaedic surgeons with nonsurgical containment of the femoral head in the acetabulum using casts. Which of the following is the most likely explanation of this boy's presentation? • Coeliac disease.2-2.0-18.8 g/dL (13.6) Serum Phosphate 1. No abnormalities are noted on examination of the chest. • Vitamin D resistant osteomalacia.0) White cell count 5. • Primary hypoadrenalism . a BMI of 30 and has normal pubertal development.81. • Renal osteodystrophy. He presented with this disorder at this age with pain in the hip and limp.5-4.2 mmol/L (3.9) Serum Creatinine 96 µmol/L (60-110) Serum Calcium 2.4) PTH 15.4).8 mmol/L (0.02 mmol/L (2. • Pseudohypoparathyroidism.8 pmol/L (0.4 x109/L (4-11 x109) Platelets 143 x109/L (150-400 x109) Serum Na 133 mmol/L (137144)Serum K 4. His blood pressure is 108/70 mmHg and he has a pulse of 90 beats per minute. heart and abdomen. Investigations reveal: Haemoglobin 12.A 17-year-old male is investigated for short stature.

• This young boy has short stature and previous history of slipped femoral epiphysis. . • The investigations reveal a hypocalcaemia and a hyperphosphataemia suggesting a hypoparathyroidism (both calcium and phosphate would be expected to be low in vitamin D deficiency and hypophosphataemia in vitamin D resistant rickets) yet the raised parathyroid hormone (PTH) concentration is elevated indicating pseudohypoparathyroidism.

Past medical history included bilateral carpal tunnel decompression.A 55-year-old man who had received haemodialysis for many years presents with deteriorating discomfort in both shoulders. His Investigations reveal: haemoglobin10 g/dl.45)What is the most likely diagnosis? 1 )B2 microglobulin amyloidosis 2 )Gout 3 )Pseudogout 4 )Polymyalgia rheumatica 5 )Osteoarthritis . Urate 0. C-reactive protein 12mg/L (1-10). ESR 30 mm/1st hr (1-10).58 (less than 0.

Comments: true 1. Amyloid deposits composed of b2-microglobulin as a major constituent protein are mainly localized in joints with periarticular bone that lead to destructive arthropathy which tends to develop 5. The features of shoulder pain associated with a past history of carpal tunnel syndrome in a patient receiving haemodialysis suggests a diagnosis of b2 microglobulin amyloidosis.10 years after the initiation of dialysis. . Death from amyloidosis of gut & heart may occur after 20 years of dialysis.

5 mg per day and methotrexate 10 mg per week show T scores of -1.Parathyroid hormone 3. Which of the following would you add? 1.6 at spine and .8 at hips.Strontium 5.No change in therapy .Calcium and vitamin D 2.1.Alendronate 4.The dual X-ray bone absorptiometry (DXA) scan results of a 60-year-old man with RA being treated with prednisolone 7.

Bisphosphonates are most commonly used first-line agents for the treatment of osteoporosis. . a score of -1. although they do offer some benefit. Strontium and parathyroid hormone are used in case of intolerance or lack of response to bisphosphonates.5 is taken as a cut-off value to start osteoporosis therapy.True 3. Use of bisphosphonates (alendronate and risedronate) has been shown to be associated with a reduced risk of fractures. They may be given concomitantly with bisphosphonates. in patients on steroid therapy.5 at hip or spine is indicative of osteoporosis. Calcium and vitamin D alone are not sufficient in reducing the risk of fractures. A T score of less than -2. However.

What is the most likely diagnosis? 1) Benign intracranial hypertension. On examination. 5) Thyroid eye disease. and height 162cms. 3) Pituitary tumour 4) Superior sagittal vein thrombosis. . Neurological examination revealed bilateral papilloedema and a partial right sixth cranial nerve palsy.A 16 year old girl presented with a three week history of headache and horizontal diplopia on far right lateral gaze. On two separate occasions she noted dimmed vision whilst bending forwards. Over the last year she had gained 12 kilograms in weight. her weight was 95 kg. 2) Multiple sclerosis.

The answer is 1
This patient is markedly obese with a BMI of 36 and the
history suggestive of BIH. Vision may be affected with
enlargement of the blind spot and the visual obscuration
with movements that provoke a rise in ICP (eg bending)
is typical of BIH. Dysthyroid eye disease would not
present like this and is more commonly associated with
Hyperthyroidism. The papilloedema would argue against
MS. A bitemporal hemianopia or a visual field defect
would be expected with a pituitary tumour. Venous sinus
thrombosis is a possibility but would be expected to
produce deteriorating symptoms.

5.A 30-year-old lady with a history of intravenous drug use is
admitted feeling generally unwell. She has a fever and is
complaining of arthralgia and a photosensitive rash. On
examination she has a soft systolic murmur at the lower left
sternal edge.
Investigations reveal: Electrocardiogram Sinus tachycardia,
Haemoglobin10.2 g/dl,White cell count 12.2 × 109/l,
Platelets,474 × 109/ l , Sodium 132 mmol/l, Potassium 4.6
mmol/l , Urea15.2 mmol/l,Creatinine 145 µmol/l,Urine
microscopy=Red cell casts,Erythrocyte sedimentation rate 32
mm/h (0–20),C-reactive protein 64 mg/l (<10), Complement
C3--- 20 mg/dl (65–190), Complement C4 --- 3 mg/dl (15–50),
Renal biopsy=Focal segmental proliferative glomerulonephritis
What are the next appropriate investigations?
1. Antinuclear antibodies.
2. Rheumatoid factor.
3. Echocardiography.
4. Anticardiolipin antibodies.
5. Chest x-ray.

6. One of the following features is
consistent with a diagnosis of
polymyalgia rheumatica:

proximal muscle pain & stiffness.
an increased creatine kinase activity .
proximal muscle weakness.
an abnormal EMG.
a macrocytic anaemia .

Which is true of herpes simplex
1) brain MRI is characteristically normal
2) fits are uncommon
3) genital herpes is usually present
4) temporal lobe involvement is common
5) viral identification using polymerase chain
reaction on CSF is non-specific

The answer is 4
Herpes simplex encephalitis (HSE) is associated
with high signal in one or both temporal lobes
(limbic encephalitis). Seizures are commonly
present in HSE. Herpes Simplex Virus type 1 is
the causative virus (Not type 2 which is
associated with genital herpes). PCR for herpes
simplex virus on CSF is highly specific test.

Dilated left atrium • B. Which of the following would contraindicate this procedure? • A. Heavy calcification of the mitral valve • E. Long history of mitral stenosis . Aortic regurgitation • D. Atrial fibrillation • C.• A patient who has rheumatic mitral stenosis is considered for percutaneous mitral valvuloplasty.

thrombus in the left atrial appendage on transoesophageal echocardiography and severe mitral regurgitation.• Answer: d) heavy calcification of the mitral valve. . These patients are indicated for mitral valve surgery instead. The contraindications towards valvuloplasty are heavy MV calcification.

• A 35 year old woman is admitted with a blood pressure of 230/120. Intravenous phentolamine. 24 hour urine shows increased Adrenaline of 720 (<80 nmol/24 hours) and Noradrenaline 2300 (<780 nmol/24 hours). • Which one of the following medications would be most useful? • A. • B. • C. • D. She has a sinus tachycardia of HR 160 with intermittent runs of non sustained ventricular tachycardia. • E. Oral flecainide. Intravenous labetalol. Intravenous diltiazem . Intravenous amiodarone. .

IV administration of sodium nitroprusside. or a1 receptors with prazosin (starting with 1 to 2 mg three times daily. . Preoperatively. nitroglycerine. or phentolamine can be used.• Answer: c) intravenous phentolamine. but should not be commenced before alpha blockers because b-blockade alone can cause marked hypertension. phenoxybenzamine preoperative adrenergic-blockade of a1 and a2 receptors with phenoxybenzamine (10-30 mg twice daily). Beta blockers can be useful for arrhythmias. In the management of acute hypertensive crisis of phaeochromocytoma as in this case.

Family history of hyperlipidaemia • E. Which of the following in the history might elucidate a cause of cardiomyopathy? • A. Inferior T wave inversion • B. Systolic murmur in the mitral area • C. His chest XR shows cardiomegaly.• A 50 year old man presents with breathlessness. History of diabetes and a tanned complexion • D. Family history of myocardial infarction .

. A history of diabetes and bronze / tanned pigmentation suggest haemochromatosis. Liver function tests and iron studies would help to confirm the diagnosis.• Answer: c) history of diabetes and a tanned complexion.

7) mmol/l phosphate 1. Paget’s disease C.27 (2. Osteoporosis D. Osteomalacia E. Multiple myeloma B. Primary hyperparathyroidism .25-2.45) mmol/L ALP 335 (20-120) U/l • What is the likely diagnosis? A.8-1.3 (0.• A 68 year old man with bone pain has the following blood results: • calcium 2.

Parathyroid hormone secretion usually maintains a normal level of calcium ions in the serum. .• Answer: B) Paget’s disease In paget’s disease. . increased plasma alkaline phosphatase reflects osteoblastic activity. Concentration of phosphate in the serum may be normal or slightly elevated.

A 21 year old female with epilepsy is well controlled on sodium valproate 600mg bd and had been taking oral contraceptives for three years. She presented to her general practitioner 12 weeks pregnant. Which of the following is correct? 1) An alternative anticonvulsant should be used in place of sodium valproate 2) Interaction of sodium valproate with the oral contraceptive increased the risk of pregnancy 3) The dose of sodium valproate should be increased 4) There is an increased risk of a neural tube defect in her fetus 5) She is at increased risk of anaemia in pregnancy .

the risks associated with treatment are outweighed by the benefits in preventing seizures. The risks may be minimised through use of folate supplements. . so the drug should be continued.The answer is 4 There is an increased risk of neural tube defects associated with anti-convulsants during pregnancy. Sodium valproate is not an enzyme inducer and would not speed up metabolism of the pill. However.

Liver nodules. Mesothelioma . • E. Perioral puckering. • C. • D. . Non blanching purpura . Which one of the following is an associated feature? • A. • B. Lax skin on the hands.• A 35 year old woman is suspected of having systemic sclerosis following presentation with Raynaud's phenomenon.

telangiectasia and perioral tethering. raynaud's phenomenon. • • Perioral tethering in systemic sclerosis . Systemic sclerosis is usually associated with dry mouth and dry eyes.• Answer: c) perioral tethering.

Her gait is ataxic. CT of the head . Anti Hu antibodies • C. she has horizontal nystagmus. She has lost 5 kg in weight over the past 6 months. General examination reveals a palpable breast lump. Anti Yo antibodies • B. On examination. Anti GAD antibodies • D.• A 60 year old woman has had difficulty walking due to unsteadiness. MRI of the brain • E. There is incoordination of the upper limbs evident on past pointing. Which of the following is most likely to yield the diagnosis? • A. Her speech is slurred.

• Answer: a) Anti Yo antibodies. This lady has a cerebellar syndrome which may be related to a breast malignancy. . Anti Yo antibodies are associated with a cerebellar syndrome due to either lung. breast or ovarian carcinoma.

5) Is distinguished from hydrocephalus by the absence of suture separation. 4) Frequently presents with ataxia. .Regarding pseudotumours cerebri (benign hypercranial hypertension) which is true? 1) A mildly increased CSF cell count is typical. 2) May be caused by prolonged steriod therapy. 3) Is occasionally associated with focal neurological signs.

Papilloedema with an enlarged blind spot is the most consistent sign beyond infancy. obesity. or separation of the cranial sutures may be present. hypoparathyroidism. Addison's Disease. normal ventricular size. steroid therapy. mastoiditis. pregnancy. Destruction of intracranial drainage by venous thrombosis: Lateral sinus or posterior saggital sinus thrombosis. head injury. anatomy and position. hypophosphatasia. Infections: Roseola infantum. Children are alert with no systemic upset. Very rarely are shunts required. menarche. though this is rarely as bad as that associated with posterior fossa tumour. pseudohyperparathyroidism. Causes: Metabolic disorders: galactosaemia. . Focal and neurological signs indicate a process other than pseudotumour cerebri. Diplopia is common due to 6th nerve palsy. cracked pot sounds. It may be complicated by optic atrophy and blindness. and is characterised by raised intracranial pressure with normal CSF cell count and protein content. A bulging fontanelle. multiple lumbar punctures may be necessary to reduce intracranial pressure. obstruction of the superior vena cava. haemolytic and iron deficiency anaemia. Guillain Barré Syndrome.The answer is 2 Pseudotumour cerebri is a clinical syndrome that mimics brain tumours. vitamin A deficiency. It usually presents with headache and vomiting. hypervitaminosis A. chronic otitis media. tetracycline. Most can be treated conservatively with monitoring of visual acuity. Haematological disorders: Polycythemia. oral contraceptives. For others. Wiskott Aldrich Syndrome. · Drugs: Nalidixic acid.

Which of the following features is characteristic of myasthenia gravis? 1) Diplopia 2) Equal sex incidence 3) Fasciculation 4) Lid lag 5) Loss of pupillary reflexes .

It is a neuromuscular disorder and therefore does not cause any lower motor neuron signs such as fasciculations. wasting. The commonest features include ptosis. Lid lag is a feature of thyroid eye disease. and loss of reflexes. . diplopia and ophthalmoplegia. Pupils are always normal.The answer is 1 Myasthenia gravis is commoner in females (it is an autoimmune disease).

The most likely anatomical site of the neurological lesion is at: 1) optic nerve 2) optic tract 3) chiasma 4) optic radiation 5) occipital lobe .A 68-year-old man presents with progressive visual impairment. On examination there is an incongruous homonymous hemianopia.

. an optic tract lesion an incongruous homonymous hemianopia. an optic radiation and occipital lobe lesion a congruous homonymous hemianopia.The answer is 2 Optic neuropathy causes a central scotoma. a chiasmal lesion a bitemporal hemianopia.

On examination there is complete opthalmoplegia. areflexia and gait ataxia. 2 weeks ago she suffered an upper respiratory tract infection.A 25-year-old female presents with 2 days history of diplopia and unsteadiness. Which of the following blood tests is the most likely to confirm the underlying diagnosis? 1) Acetylcholine receptors antibodies 2) Anti GM1 antibodies 3) Anti GQib antibodies 4) Anti Hu antibodies 5) Anti purkinje cell antibodies .

other multifocal neuropathies. areflexia and ataxia. amyotrophic lateral sclerosis. in some instances. to be associated with certain neurological disorders: lower motor neuron syndromes. It is highly specific for the syndrome. It usually follows antecedent infections. .The answer is 3 The most likely diagnosis is Miller Fisher syndrome (variant of Guillain Barre syndrome). and systemic lupus erythematosus (SLE) with central nervous system involvement. It consists of complete or partial ophthalmoplegia. Neuronal Nuclear (Hu) Antibodies (NNA) are found in a number of paraneoplastic syndromes. Elevated levels of antibodies to the glycolipid ganglioside-monosialic acid (GM1 antibodies) have been shown. paraneoplastic encephalomyelitis and paraneoplastic cerebellar degeneration and are associated with small cell lung carcinoma. multiple sclerosis. Serum IgG antibody to the ganglioside GQib is present in more than 95% of patients. Purkinje cell cytoplasmic antibodies are useful for identifying individuals with subacute cerebellar degeneration or peripheral neuropathy due to a remote (autoimmune) effect of gynecologic or breast carcinoma. including subacute sensory neuronopathy.

Two weeks later he was found confused and drowsy.A 17-year-old man has been diagnosed with schizophrenia 4 weeks ago. Which of the following treatment will you initiate? 1) phenytoin 2) diazepam 3) cefuroxime 4) acyclovir 5) dantrolene . He was started on haloperidol. rigid with blood pressure of 200/100.7 C). On examination he was pyrexial (40.

autonomic dysfunction. altered mental state. Withdrawal of neuroleptic treatment is mandatory. Its major features are: rigidity. The treatment of choice is dantrolene and bromocriptine.The answer is 5 Neuroleptic malignant syndrome is the most likely diagnosis. . It is usually caused by potent neuroleptics. and high creatinine kinase. fever. Rhabdomyolysis and acute renal failure are potential complications.

Heart sounds are normal with no murmurs. She has bibasilar fine crackles on auscultation of the lungs but her JVP is not elevated and she has no pedal oedema. A chest X-ray (CXR) shows bilateral air space shadowing throughout both lung fields. Antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis 4. Goodpasture's syndrome 3. with a creatinine of 800 μmol/. What is the most likely diagnosis? 1. Cryoglobulinemia 5.A 60-year-old woman presents with a short history of sinus congestion. On examination. Her haemoglobin (Hb) is 6 g/dl and her urea is 45 mmol/l. epistaxis and joint pains in her hands. She becomes increasingly short of breath and develops haemoptysis precipitating admission to hospital. On direct questioning she admits to passing less urine in the preceding few days. IgA nephropathy 2. Urinalysis demonstrates red blood cells and red blood cell casts. Uric acid nephropathy .

Note (LVF) can lead to pink sputum and may be confused for pulmonary haemorrhage. The low haemoglobin (Hb) in the setting of acute renal failure and the disproportionate degree of abnormality seen on chest X-ray (CXR) compared to clinical findings suggest pulmonary haemorrhage rather than infection or fluid to explain the CXR findings. and pulmonary haemorrhage is typically seen only in Goodpasture's syndrome and ANCA-positive vasculitis. None of the other diagnoses would classically cause sinus or joint involvement. She would need treatment with dialysis. .True 3. To confirm the diagnosis of pulmonary haemorrhage. immunosuppression and most centres would advocate plasma exchange with a creatinine above 400 μmol/l. This is a classic history for Wegener's granulomatosis. a raised potassium channel opening (K+-CO) would be seen on lung function tests.

Neurosarcoidosis E.9 g/l Glucose3. Guillain Barre syndrome (GBS) D. Multiple sclerosis (MS) C. Lyme disease B. CSF Protein 0. There is a right LMN facial nerve palsy but no other abnormalities on examination.5 mmol/l. Ramsey Hunt syndrome . Lumbar puncture findings are: Opening pressure18 cm. Microscopy 85 lymphocytes.26-A 25-year-old man presents with right-sided facial weakness and swelling. What is the most likely diagnosis? A.

On examination she had crepitus but had a full range of movement of both knees. Which one of the following is an appropriate initial treatment for her painful knees? 1 )Dihydrocodeine 2 )Naproxen 3 )Paracetamol 4 )Celecoxib 5 )Topical Diclofenac .An 81-year-old female presents with bilaterally painful knees. There was no history of gastrointestinal diseases.

Studies have shown that short-term & long-term efficacy of paracetamol is comparable to that of ibuprofen & naproxen in people with knee osteoarthritis. The principle goal of systemic therapy is to provide an effective pain relief with the least associated toxicity. . They may be used in patients with GI intolerance of traditional NSAIDs. but less GI toxicity although issues remain regarding their cardiovascualr risk. Specific COX-2 inhibitors such as celecoxib have clinical benefit similar to that of traditional NSAIDS. This woman has osteoarthritis (OA) of both knees.Comments: true 3. Paracetamol is the initial therapy recommended for the treatment of OA of the hip & knee.

On examination he has a peripheral sensory neuropathy and palpable lymph nodes in his neck and axillae.A 50 year-old male epileptic presents with paraesthesia of hands and feet. 2) Clonazepam 3) Lamotrigine. . 4) Phenytoin. 5) Sodium valproate. Which of the following drugs is the most likely cause of these features? 1) Carbamazepine. He also has unsteadiness when walking.

lymphadenopathy hypocalcaemia. hirsutism. Other side effects include gingival hypertrophy.The answer is 4 Phenytoin is well known to cause neurological side effects such as peripheral sensory neuropathy and cerebellar ataxia. .

2 )Start Allopurinol .55 mmol/l (NR 0. 5 )Start Prednisolone. Which of the following is the most appropriate management of this patient? 1 )Lifestyle advice.25-0. Examination was normal but investigations reveal that he has a serum urate concentration of 0.45).18. A 45-year-old male attends for an insurance & is in good health. . 3 )Start Colchicine. 4 )Start Diclofenac. .

White cell count 3.5-16. 2 )Homocystine concentration 3 )Platelet function test 4 )Protein C concentration.5).8 g/dl (12.6 x 109/L (4-11). 5 )Indium-labelled white cell scan. Select one of following investigations which are most likely to be abnormal? 1 )Antiphospholipid antibodies. Investigations revealed: Haemoglobin 12. . Her previous history included investigation for infertility.A 30-year-old woman presented with a deep vein thrombosis. Platelet count 35 x 109/L (150-400).

Start metformin • B. A fasting blood glucose should be sent before treatment • C.• A 30 year old of average height and weight presents with polyuria and thirst. There is no ketonuria and his older sister is diabetic How should he be treated? • A. Dietary advice. review in a month with repeat glucose without any treatment . Subcutaneous insulin should be started • D. Commence on gliclazide and reassessment with BM monitoring at home • E. He has a blood glucose of 15 mmol/l.

. He may have some residual β islet cell function and hence sulphonylureas may help to stimulate insulin production. He is a type 1 diabetic but there are no features of ketonuria or acidosis.• Answer: d) commence on gliclazide and reassessment with BM monitoring at home.

There was no sensory impairment.A 62-year-old man presented with difficult walking. and extensor plantar responses. wasting and weakness in the left deltoid and biceps. weakness of hip flexion and foot dorsiflexion. On examination there was fasciculation. What is the diagnosis? 1) alcoholic myopathy 2) diabetic amyotrophy 3) motor neurone disease 4) recurrent cervical cord compression 5) syringomyelia . with weakness in the shoulder girdle muscles bilaterally. He drank 40 units of alcohol weekly. There was fasciculation in the glutei and quadriceps bilaterally. He had a past history of diabetes mellitus and cervical spondylosis. which had required surgical decompression eight years previously. brisk reflexes in upper and lower limbs.

Motor neuron disease is the commonest cause of such presentation. You expect sensory involvement with cervical cord compression.The answer is 3 There are signs of lower (wasting. fasciculations) and upper (brisk reflexes. Syringomyelia presents with sensory symptoms and signs (spinothalamic). extensor plantar response) motor neuron involvement in the presence of normal sensation. Alcoholic myopathy and diabetic amyotrophy do not share upper motor neuron signs. .

• 5 )X ray of joint. count .left wrist was red. he had a temperature of 38 °C. .• 78 years old man presents with an acute onset of severe pain & swelling of the left wrist which had developed since she had a chest infection two weeks previously. • 3 )Joint aspiration. • 4 )Serum urate concentration. swollen & painful. • What is the appropriate investigation for this pt? • 1)Erythrocyte sedimentation rate. • 2 )Full bl. On examination.

Her basal urine osmolality is 210 mOsm/kg. Primary polydipsia C. Nephrogenic diabetes insipidus . Which of the following is the likely diagnosis? A. She undergoes a fluid deprivation test and her urine osmolality after fluid deprivation (loss of weight 3 kg) is 350 mOsm/kg. Normal B. A subsequent injection of subcutaneous DDAVP (desmopressin acetate) did not result in a further significant rise of urine osmolality after 2 hours (355 mOsm/kg). Osmotic diuresis D. Pituitary diabetes insipidus E. She weighs 60 kg and has a 24-hour urine output of 3500 ml.• A 30-year-old woman is evaluated in the endocrinology clinic for increased urine output.

induced osteoporosis? 1 )Bisphosphonate therapy 2 )Calcium vitamin D 3 )Hormone replacement therapy 4 )Raloxifene.• A 60 years old woman diagnosed with giant cell arteritis was commenced on high dose prednisolone therapy. 5 )Salmon Calcitonin. What is the best appropriate treatment for prevention of steroid. .

She wants to continue with her pregnancy if it is safe to do so. She is worried about her anticonvulsant therapy and the effects on the baby and enquires how she should be managed? 1) Advise termination due to drug teratogenicity 2) Continue with carbamazepine 3) Stop carbamazepine until the second trimester 4) Switch therapy to phenytoin 5) Switch therapy to sodium valproate .A 19 year old girl presents at the antenatal clinic. She is approximately six weeks pregnant and the pregnancy was unplanned. She has a two year history of grand mal epilepsy for which she takes carbamazepine. She has had no fits for approximately six months.

The answer is 2 The patient and fetus are at far more risk from uncontrolled seizures than from any potential teratogenic effect of the therapy. Similarly. Vitamin K should be given to the mother prior to delivery. There is no point in switching therapies as this could precipitate seizures in an otherwise stable patient. both phenytoin and valproate are again associated with teratogenic effects. Screening with AFP and second trimester ultrasound are required. In pregnancy total plasma concentrations of anticonvulsants fall and so the dose may need to be increased. . The potential teratogenic effects (particularly neural tube defects) of carbamazepine do need to be explained and in an effort to reduce this risk she should receive folate supplements.

Which of the following investigations best supports a diagnosis of new variant CJD: 1) CSF analysis 2) CT brain 3) EEG 4) EMG 5) MRI brain .

The answer is 5 MRI brain typically shows bilateral posterior thalamic high signal abnormalities in patient with new variant CJD. CSF analysis only shows non-specific changes. . EMG and CT brain are normal. Sporadic CJD (and not new variant CJD) is associated with specific EEG changes. EEG .

Digoxin D. What medication should be added? A. Her breath sounds are clear. Carvedilol C. She is currently on frusemide 40mg bd and perindopril 4 mg at night.A 65 year old lady has ischaemic cardiomyopathy and symptoms of breathlessness walking up one flight of steps. Spironolactone B. Chest X ray shows cardiomegaly and clear lung fields. Amiodarone E. Diltiazem .

Copernicus) and spironolactone trials (RALES) have shown symptomatic improvement and decreased mortality. The two best options are carvedilol and spironolactone. . In this patient with little signs of fluid overload.Answer: b) carvedilol. and then spironolactone added as well. a beta blocker can be started first. Both B blocker trials (CIBIS II. Merit HF.

A 33 year old epileptic female presents with visual problems. Which of the following may be responsible for her visual deterioration? 1) Vigabatrin 2) Lamotrigine 3) Gabapentin 4) Phenytoin 5) Sodium Valproate . Examination reveals a constriction of visual fields to confrontation.

The answer is 1 Vigabatrin is associated with constricted visual fields and when detected therapy should be stopped. .

• A 45-year-old attends clinic complaining of tiredness. She is hypothyroid & takes thyroxine 150 micrograms daily. Which of following useful test assessing appropriateness of thyroid hormone replacement in primary hypothyroidism? 1)Free T3 & T4 concentrations 2 )Skin biopsy 3 )Thyroid binding globulin 4 )Total T3 T4 5 )TSH .

Her ECG shows a broad complex tachycardia. Heart rate of 150 .• A 52 year old lady has palpitations. QRS of 150 ms • B. Which of these features suggests that the tachycardia is more likely to be of ventricular origin? • A. Left bundle branch block and left axis deviation • C. History of atrial fibrillation • E. P wave for every QRS complex • D.

• Answer: a) QRS of 150ms. Features that favour VT are : QRS of > 140ms. right bundle branch block with left axis deviation. dissociated p waves. history of ischaemic heart disease. . HR >170 beats per minute.

shoulders. D. Which of the following drugs could cause this? A. E. deltiazem C. B. Bendrofluazide B. Amlodipine E. She now has fevers and joint pains in the arms. C. knees and ankles. Methyldopa D.A 59 year lady has a history of hypertension and has recently been prescribed a new antihypertensive agent. Lisinopril .

In druginduced lupus erythematosus. penicillamine.Answer: c) methyldopa. sulfasalazine. hydralazine. such as lupus nephritis and neurological disease. Other symptoms associated with SLE. and quinidine. the features of arthritis. The drugs which may cause this are procainamide. methyldopa. . isoniazid. The history would be consistent with drug induced SLE. chlorpromazine. systemic symptoms. and cardiac and pulmonary (lung) symptoms may be present. are rare.

Which one of the following is an associated feature? • A.• A 55 year old man has bitemporal hemianopia. Hypertension . Rheumatoid arthritis • D. He also has elevated IGF-1 levels in the serum and an enlarged pituitary seen on MRI. Hypolipidemia • B. Myocarditis • E. Hypoglycaemia • C.

• • MRI showing a pituitary tumour in acromegaly . The diagnosis is acromegaly.• Answer: e) hypertension. Carpal tunnel syndrome. carpal tunnel syndrome and high cardiac output cardiac failure are associated. impaired glucose tolerance.

An 18 year-old girl receives radioactive iodine as treatment of thyrotoxicosis. . Which of following is likely long-term complication of this treatment? 1)hypoparathyroidism. 2 )hypothyroidism. 3 )increased risk of developing cancer. 4 )recurrent laryngeal nerve damage. 5 )osteoporosis.

• Which of following percentages accurately reflects mortality associated with modern management of diabetic ketoacidosis? • 1 )0.5% • 2 )1% • 3 )2-3% • 4 )5-6% • 5 )8-10% .

A 72 hour fast reveals periods where her plasma glucose is 2. Insulin antibodies . MRI of abdomen E. Glucose tolerance test D. C.5 mmol/l with elevated insulin and C peptide levels. Repeat 72 hour fast B. D. E. Glucagon stimulation test C. B.A 30 year old lady has recurrent attacks of dizziness and blackouts. What is the next best investigation? A.

• Answer: d) MRI of abdomen. The tests so far suggest an insulinoma. superior mesenteric angiography or pancreatic venous catheterisation. CT. Localisation of the insulinoma can be done with MRI. • • Insulinoma .

Acromegaly • C. Her parents had similar symptoms and passed away in their fourties after doing radical surgery . profuse sweating and irritability. • Which one of the following is the most likely diagnosis? • A.• A 35 year old lady has a history of diarrhoea. Phaeochromocytoma • B. Ovarian carcinoma • E. Medullary thyroid carcinoma . Diabetes • D.

It can be inherited in association with MEN type II. Medullary thyroid carcinoma produces peptides and neurohormones which lead to symptoms of irritability. .• Answer: e) medullary thyroid carcinoma. diarrhoea and sweating.

Which of the following drugs is she most likely to have been prescribed? 1) erythromycin 2) isotretinoin 3) minocycline 4) oxytetracycline 5) trimethoprim . She develops polyarthritis and raised liver enzyme tests. Investigations show AST 95 ALT 170 bilirubin 16 antinuclear antibodies strongly positive at 1/640.A young woman has acne and is taking oral medication.

And all of these can cause hepatotoxicity. .The answer is 3 Except trimethoprim all other drugs are used in the treatment of acne. Erythromycin usually causes cholestasis. Minocycline can cause drug induced SLE.

Which of the following features is characteristic of early Alzheimer's disease? 1) ataxic gait 2) impaired short term memory 3) myoclonic jerks 4) urinary incontinence 5) visual hallucinations .

. The other features listed here would suggest an alternative diagnosis such as normal pressure hydrocephalus (gait ataxia and urinary incontinence). Creutzfeld-Jacob disease (myoclonic jerks) and delirium or vascular dementia (visual hallucinations).The answer is 2 Alzheimer's disease is characterised early in the disease by short term memory loss.

A 45-year-old man presents with an insidious onset of binocular horizontal diplopia and left sided facial pain. The most likely anatomical site of his neurological lesion is: 1) Cavernous sinus 2) Petrous apex 3) Superior orbital fissure 4) Cerebellopontine angle 5) Midbrain . On examination ha has a left abducens nerve palsy and numbness over the maxillary division of the left trigeminal nerve.

abducens. trochlear. . The superior orbital fissure syndrome is similar to the cavernous sinus syndrome except for the presence of proptosis. trigeminal (ophthalmic and maxillary division) and oculo-sympathetic nerves.The answer is 2 In the pre-antibiotic era an abducens nerve palsy with ipsilateral pain and numbness was due to petrous osteitis (Gradenigo syndrome) but is now more likely the result of a meningioma or nasopharyngeal carcinoma of the petrous apex. The cavernous sinus syndrome consists of variable involvement of: oculomotor.

he is generally well. What is the next appropriate investigation for this patient? 1 )24hr tape 2 )Coronary angiography 3 )Echocardiography 4 )Electrophysiological studies 5 )Outpatient Cardiology referral .2. A 75-year-old male was admitted with chest pain & dyspnoea. associated lightheadedness. but can mobilise solely around the ward. Whilst being monitored his telemetry demonstrates short runs of non sustained ventricular tacchycardia. although dyspnoea restricts his mobilisation. He is unable manage the stairs. His pain subsides.

so we feel that an ECHO would be the next appropriate study in this patient. followed by coronary angiography & inpatient cardiology referral.• Comments: 3 )Echocardiography patients with reduced LV function or asymptomatic VT may benefit from implantation of an implantable cardiac defibrillator . You need to know the patients cardiac function. .

what appropriate strategy regarding her Methotrexate therapy? 1 )Continue Methotrexate unchanged & increase folate supplements to 10mg daily. She has being receiving the Methotrexate over just one year with no problems in all routine bl monitoring which are normal. You give her a prescription of erythromycin as she is allergic to penicillins.A 55-year-old female receiving 10 mg of Methotrexate & 5mg of folate* weekly presents with a sore right finger after cutting herself in the garden. . Whilst monitoring the response of the infection to treatment. 2 )Continue Methotrexate & folate unchanged. erythematosus right ring finger up to the proximal interphalangeal joint & you diagnose a cellulitis. On examination. count reveals a neutropaenia. she has a swollen. 3 )Reduce dose of Methotrexate to 5mg weekly 4 )Stop Methorexate until the infection is resolved. 5 )Stop Methotrexate only if full bl.

In the circumstances of infection. However. *some local variations may exist regarding dose & frequency of folate therapy. Any infection should be treated as usual to response to treatment monitored. one should consider temporarily stopping methotrexate as it is an immunosuppressant. its continued long term use should be discussed with the patient's rheumatologist. Once the infection is successfully treated methotrexate can be reinstated.Comments: true 4. . if the patient has recurrent serious infections while taking methotrexate.

He was emaciated. His temperature was 39. Which of the following is the likely diagnosis? 1 )alcoholic cardiomyopathy 2 )pneumococcal pneumonia 3 )pneumocystis pneumonia 4 )pulmonary tuberculosis 5 )tricuspid endocarditis .A 26-year-old man with a history of alcohol & drug abuse was admitted with a 14 day history of fever. cough & fatigue. Chest X-ray showed bilateral areas of pulmonary shadowing.14.4°C. Cervical & axillary lymphadenopathy were present.

Pulmonary embolus . C. E. B. Bronchiolitis obliterans D. She has a known history of rheumatoid arthritis and is on methotrexate and folate. She has a CXR and lung function tests.A 45 year old woman with breathlessness presents for further investigation. Which one of the following is a recognized respiratory manifestation of rheumatoid arthritis? A. Mesothelioma B. D. Pulmonary eosinophilia E. Asthma C.

exudative pleural effusions.• Answer: c) bronchiolitis obliterans. fibrotic lung disease. pulmonary nodules). . Pulmonary eosinophilia may be found in Churg Strauss or Wegener’s vasculitis. In rheumatoid arthritis. and obstructive lung disease in the form of bronchiolitis obliterans (obstruction of bronchiolar lumen with inflammatory exudate) may occur. Caplan’s syndrome (pneumoconiosis.

Hairline fracture . She complains of pain in her right groin radiating down the anteromedial thigh. What is the likely diagnosis? • A. On examination of the hip. Metastatic hip lesion • D. Avascular necrosis of the femoral head • E. Osteoarthritis • B. Rheumatoid arthritis • C.• A 55 year old female has been on long-term steroids for chronic obstructive pulmonary disease. there is decreased range of movement especially flexion. abduction and internal rotation.

MRI is the most sensitive and specific technique and is useful for early diagnosis before collapse of bone occurs. • In a patient on long term steroids presenting with groin pains radiating to the thigh associated with an antalgic gait and decreased range of movement of the hip.• Answer: d) avascular necrosis of the femoral head. the most likely diagnosis is avascular necrosis of the femoral head. CT scan and x-ray are useful to rule out advanced disease if duration is not clear. Bone scanning is more sensitive than x-ray but is non-specific. • In this condition. • • MRI showing avascular necrosis of the femoral head .

Thyroid adenoma • E. Grave's disease • D. Which of these diagnoses is most likely? • A. Colloid goitre . Her Free T4 is 20 pmol/l and TSH is 5 mU/l. Multinodular goitre • C.• A patient who is 8 months pregnant has a thyroid function test because she has a smooth palpable goitre. Medullary thyroid carcinoma • B.

0 mU/l) and normal free T4. Presentation is with mildly elevated TSH (0.3-4. Mild iodine deficiency or a pregnancy can cause the goitre to become more noticeable.• Answer: e) colloid goitre. A colloid goitre is most likely. • • Colloid Goitre -increased size of follicles and flattening of follicular epithelial cells .

Which of the following is a feature of diabetic neuropathy to watch out for? A. Loss of vibration sense E. E. Cervical myelopathy B. Muscle hypertrophy D. D. Brisk reflexes C. Myotonia . B.A 55 year old patient with type 2 diabetes is reviewed in the diabetic clinic. C.

• Answer: d) loss of vibration sense. A 3rd nerve mononeuropathy can occur. and sensory neuropathy causes vibration sensory loss. . prolonged contraction of muscle fibres associated with muscle dystrophy is due to genetic causes of muscle protein abnormality and is not neurologically dependent. Autonomic neuropathy to the gut. bladder and sexual organs (impotence) can occur. With myotonia. Motor neuropathy can cause muscle wasting.

Mitral stenosis • B. Atrial septal defect • D. Dilated cardiomyopathy • E.• A 40 year old lady has a pulmonary systolic murmur which is louder on inspiration. Hypertrophic cardiomyopathy . What is the likely diagnosis? • A. She also has a right ventricular heave. Aortic stenosis • C. The second heart sound is wide and fixed with splitting.

whilst Secundum causes RBBB and RAD on the ECG. • In Atrial Septal Defect (ASD). A systolic murmur is heard in the pulmonary area because of increased pulmonary valve flow due to pulmonary hypertension. a left parasternal heave is present due to RVH. Similarly. • ECG showing RBBB and LAD .• Answer: c) atrial septal defect. a Primum defect causes RBBB and LAD.

Displaced apex beat C. Breathlessness . Which of the following features would indicate poor prognosis without urgent treatment? A. Pulmonary oedema D. Aortic valve calcification seen on X ray E.Early diastolic murmur B.A 75 year old man with known moderate to severe aortic stenosis presents to hospital with breathlessness.

Pulmonary oedema and angina can occur with aortic stenosis.Answer: c) pulmonary oedema. these are symptoms which indicate urgent assessment should be made with a view towards surgery. .

His calcium is 2. Low urinary phosphate excretion • E. Serum alkaline phosphatase is increased • B. Arthritis • D. Normal skull • C. Low urinary cAMP . Which one of the following would suggest that he has primary hyperparathyroidism? • A.8 mmol/l and PTH 12 pmol/l.• A 45 year old man has polyuria and abdominal pains. phosphate 0.9 mmol/l.

• Salt and pepper changes on the skull can be a hallmark. • Primary hyperparathyroidism does not respond to steroids. .Answer: a) serum alkaline phosphatase is increased. Serum alkaline phosphatase is usually increased in primary hyperparathyroidism. • Gout. is worsened by hyperparathyroidism. • High urinary phosphate excretion leads to serum phosphate and a high cAMP in the urine suggests active excretion. rather than arthritis.

• E. She is embarassed about having to shave her chin and also her chest. Polycystic ovarian syndrome. • C. Congenital adrenal hyperplasia. What is the most likely diagnosis? • A. . • B. Adrenal tumour. Her voice is becoming deeper. Ovarian carcinoma . • D. Drug induced hirsutism .• A 40 year old lady has increasing hirsutism.

• • MRI showing an adrenal tumour .• Answer: c) adrenal tumour. There are high testosterone or DHEA levels in the plasma. Rapid development of hirsutism is usually caused by an adrenal tumour.

B. Subchondral cysts E. Hairline fracture . He has spinal and hip X rays for assessment. Fibrosis D.• A 60 year old man has worsening joint stiffness. Which one of the following is a recognised X ray change of osteoarthritis? A.Lytic lesions C. hip and back pains. Osteitis fibrosaB.

subchondral sclerosis and subchondral cysts are common in osteoarthritis. .• Answer: d) subchondral cysts. loss of joint space. Osteophytes.

She has polyuria and polydipsia. Diabetes E.0 mU/l. Subclinical hypothyroidism B. Renal tubular acidosis C. Primary hyperparathyroidism . MEN 1 D. Her free T4 is 16 pmol/l and TSH is 3.• A 55 year old lady has abdominal pains. Which of the following is most likely? A.

polyuria and polydipsia. .• Answer: e) primary hyperparathyroidism. hence MEN is unlikely. phaeochromocytoma or medullary thyroid involvement. There are no features suggestive of pituitary tumour. Hypercalcaemia can cause abdominal pain.

Involvement of one or two large joints only E.A 10 year old child with joint pains is suspected of having juvenile chronic arthritis. A full rheumatological history is taken. Low grade fever B. Transient purpuric rash C. Which of the following is a recognised presenting feature of juvenile chronic arthritis? A. Ulcerative colitis . Haematuria D.

Juvenile chronic arthritis is rheumatoid factor negative. A high swinging fever is typical. pauciarticular and polyarticular. . Peaks of disease are about 5 years and 15 years of age. There is no relation with ulcerative colitis. Different classifications are systemic. An erythematous rash can occur. but it is non purpuric. Commonest type is Still’s disease. Haematuria is not typical. Certain forms can involve only one or two large joints only.• Answer: d) involvement of one or two large joints only.

Laboratory testing now reveals the following: Serum electrolytes (meq/L): Na+ 150. Na+ 144. HCO3– 25 BUN: 6.4 mmol/L. HCO3 – 25 BUN: 7. K+ 32 Urine osmolality: 195 mosmol/kg water After 12 h of fluid deprivation. K+ 30 Urine osmolality: 199 mosm The likely diagnosis is • A. gl: 5. Bl.1 mmol/L (20 mg/dL) (98 mg/dL) Urine electrolyte : Na+ 24.1. Cl– 109. nephrogenic diabetes insipidus • B. osmotic diuresis • C.La boratory evaluation of a 19-year-old male who is being worked up for polyuria and polydipsia yields the following results: • S.7 mmol/L . none of the above . psychogenic polydipsia • E. body weight has fallen by 5%. Urine electrolytes (mmol/L): Na+ 28. Cl– 107. salt-losing nephropathy • D. K+ 4.0. K+ 35 Urine osmolality: 200 mosmol/kg water One hour after the subcutaneous administration of 5 units of arginine vasopressin urine values are as follows: Urine electrolytes (meq/L): Na+ 30. K+ 4.

What is her condition. She experienced several attacks of hematuria recenly. 1. Proteinuria was less thn 1gm/24hrs and her RFTs were normal.Slide no 6 This female patient sufferred convuslions in childhood. 2. What is the most likely lesion of her CT scan .

sodium 134 mmol/l. Frusemide D. creatinine 80μmol/l. Diarrhoea E. Alcoholism C. serum magnesium of 0. He has frequent nonsustained ventricular tachycardia on the ECG and cardiac monitor.0 g/dl. potassium 3. Poor diet B. WCC 7 x 10^9/l.6 mmol/l (0. Hyperphosphataemia .2 mmol/l. platelets 230 x 10^9/l.A 50 year man presents with lightheadness.75). Which one of following is likely to be responsible for his arrhythmias? A. His bloods show a Hb 13. urea 11mol/l.

.• Answer: c) frusemide. which is most commonly associated with diuretic use. The likely cause of the arrhythmias is hypomagnesaemia and hypokalaemia.

E.A 38 year old lady presents with myalgia and lethargy. Mixed connective tissue disease. Extranuclear antigen tests show a negative Ro and negative La. negative Scl70 and positive ribonuclear protein antibody at 160 units. Polymyositis. Systemic lupus erythematosus . Her blood tests show a positive ANA with a titre of 1:1024 and rheumatoid factor is negative. B. Scleroderma. D. C. The CK is raised at 360 U/l.Polymyalgia rheumatica. . What is the likely diagnosis? A.

raised CK and positive anti RNP antibody suggests mixed connective tissue disease. . A positive ANA (speckled pattern).• Answer: e) mixed connective tissue disease.

fever chills. but he has since developed severe headache. It was warm but not painful. The macule is disappearing. mild neck stiffness. • What is the most probable diagnosis? • Infective endocarditis • Lyme disease • Meningococcal meningitis • Q fever • Rheumatic fever . He also has malaise and fatigue. pains which were once in the knees but are now in the ankles and elbows. He reports having developed a skin rash around the groin area. It began as a papule but went on to become a macule with a bright outer border and a clear centre.• A 29-year-old banker is said to have gone camping three weeks ago.

Receding hair line C. his GP suspects Behcet's syndrome and is referred to the rheumatologist.A 40 year old man has genital ulceration and uveitis. Hirsutism D. Which one of the following is a feature of Behcet’s syndrome? A. Facial asymmetry B. Arterial thrombosis . Malignant melanoma E.

CNS vasculitis involvement may lead to TIA. vasculitis (thrombophlebitis) and thrombosis. retinal vein occlusion). .• Answer: e) arterial thrombosis. parkinson’s and dementia. meningoencephalitis. Behcet's syndrome is an inflammatory disorder (associated with certain HLA B and DR types) causing mouth ulceration. arthritis. eyes (anterior uveitis.

On examination he has painful limitation of internal rotation but can abduct right arm only 90 degrees.• A 42-year-old male a 15 year history of type 1 diabetes presents a two month history of deteriorating pain & stiffness of the right shoulder. Flexion is relatively unimpaired. • Which of following is likely diagnosis? 1 )Adhesive capsulitis 2 )Brachial plexopathy 3 )Calcium pyrophosphate arthropathy 4 )Diabetic arthropathy 5 )Rheumatoid arthritis . There some weakness of movement of shoulder slight wasting of shoulder muscles. He has some reduced vibration sensation in both hands.

Fibromyalgia • B. Supraspinatus tendinitis • C. Polymyalgia rheumatica • D. What is the likely diagnosis? • A. She also feels constantly lethargic. Cushing's syndrome . Her ESR is 105 mm/hour. Temporal arteritis • E.A 70 year old lady presents with bilateral shoulder and neck pains which have been present for several years.

With a raised ESR. Temporal arteritis should always be considered especially if a headache is present. polymyalgia rheumatica is far more likely than fibromyalgia. .• Answer: c) Polymyalgia rheumatica.

He reports thirst and has had a urine output of approximately 5 L per day. Measurement of serum vasopressin level • C.but his sodium is noted to rise from 140 to 154 meq/L over 2 days. 24-h measurement of urinary sodium • D. Which of the following is the most appropriate next step to evaluate the patient’s disorder? • A. Trial of arginine vasopressin • E. He does well after the administration of antibiotics. Measurement of serum osmolality • B. Trial of free water restriction .A 50-year-old male is admitted to the hospital with pneumonia.

On examination. Which of the following is the likely diagnosis? A.5 g/dl WCC 7. Ischaemic cardiomyopathy E. The blood pressure is 135/80 mmHg. the ventricles are stiff and systolic function is mildly impaired. Pulmonary embolus . Dilated cardiomyopathy C.Restrictive cardiomyopathy B.5 mmol/l creatinine 140 µmol/l urea 6 µmol/l ECG shows poor R wave progression. Blood tests reveal Hb 10.A 55 year old patient presented with breathlessness and ankle oedema.5 x 10^9/l Platelets 150x 10^9/l sodium 136 mmol/l potassium 3. her JVP rises with inspiration. An echocardiogram shows no pericardial effusion. She has a soft systolic murmur and a third heart sound. Constrictive pericarditis D.

The rise in JVP with inspiration suggests either constrictive or restrictive cardiomyopathy. The transmitral dopplers on the echo may show E/A wave reversal and high velocities which may suggest restrictive picture. lymphoma or connective tissue disease. there symptoms can be caused by any form of cardiomyopathy. . endomyocardial fibrosis.• Answer: a) restrictive cardiomyopathy. In this scenario. This may be due to infiltration due to haemochromatosis. sarcoidosis. myeloma. Echocardiography showing no pericardial effusion and stiffness suggests restrictive rather than constrictive cardiomyopathy.

01mU/l. Grave's disease C. FT3 3. Examination reveals a exopthalmos and a goitre. Hashimoto's thyroiditis B. FT4 35 pmol/l. tremors and palpitations.A 35 year old female presents with sweatiness. She has positive antithyroid antibodies. What is the likely diagnosis? A.1 nmol/l. Papillary thyroid carcinoma . Post radioiodine treatment E. Iodine deficiency D. Her GP requests TFT’s which show a TSH of 0.

• Answer: b) Grave's disease. • • Exopthalmos in Grave's disease . • Graves disease is the diagnosis . There will be increased uptake on the thyroid radioisotope scan. Almost 80% of patients have exopthalmos. Medical treatment such as carbimazole or radioiodine treatment are recommended rather than surgery.thyroid autoantibodies are increased.

• D : Amyloidosis. Echocardiography demonstrates thickened myocardium with impaired relaxation and a bright speckled appearance. • B : Cor pulmonale.A 68-year-old female is referred to outpatients with a three-month history of dyspnoea and significant peripheral oedema. • E : Secondary neoplastic myocardial deposition. . What is the likely diagnosis? • A : Hypertrophic cardiomyopathy. • C : Sarcoidosis. Clinical findings are solely of the oedema.

She has attended the GP on a number of occasions during the past year for sinusitis and is now concerned that the bridge of her nose has collapsed and that she may require cosmetic surgery. Cyclophosphamide 3. 4. Chest X-ray is abnormal and reveals multiple nodules. Corticosteroids 2. Routine blood testing reveals a creatinine of 205 μmol/l. Renal biopsy reveals a necrotising microvascular glomerulonephritis. Which of the following is the best initial treatment for this condition? 1. Methotrexate . Azathioprine 5.A 44-year-old woman presents to her GP for review. Corticosteroids and cyclophosphamide.

Often patients present with severe rhinorrhoea. Treatment is with cyclophosphamide in combination with corticosteroids in patients with severe disease. complicated by nasal ulceration and later cough with haemoptysis. The clinical history is highly suggestive of Wegener’s Granulomatosis. Chest X-ray reveals nodular changes +/– pneumonic features.True 3. Renal involvement is characterised by microvascular glomerulonephritis. .

Methotrexate 2. On examination rheumatoid nodules on the elbows and symmetrical soft tissue swelling over the PIP and MCP joints were noted. leflunomide . Which of the following is best avoided if possible? 1. Effusions of both wrists were also noted. Her GP has commenced her on NSAIDs and she been referred to a rheumatologist for consideration of DMARD. Radiological examination of the wrist and hands showed erosions and bony decalcification. Chloroquine 3. Maximal stiffness occurs on waking and eases after an hour. She has a past history of TB. She is rheumatoid factor positive. Sulfasalazine 4. Infliximab 5.A 45-year-old woman presented with a 1-year history of intermittent swelling and pain in the small joints of her hands.

Anti-TNF-a is an effective treatment for rheumatoid arthritis (RA). .True 4. However. it can reactivate old TB and should be used with caution in these patients. It has been shown to give a sustained clinical response over 2 years.

The most likely diagnosis is • A. urine studies show a pH of 6. type I renal tubular acidosis (RTA) • B. sodium of 15 meq/L.0 meq/L. type IV RTA • E. and chloride of 12 meq/L. chloride 112 meq/L. and potassium 3. potassium of 10 meq/L. chronic diarrhea .A patient with a history of Sjِgren’s syndrome has the following laboratory findings: plasma sodium 139 meq/L.0. type II RTA • C. bicarbonate 15 meq/L. type III RTA • D.

Examination reveals a BMI of 24.5 kg/m2 a pressure of 186/100 mmHg. There are no abnormalities on sensory examination.• 72-year-old male presents a 2 month history of weight loss & weakness. He is unable to rise from squatting position. Examination of lower limbs reveals a bilateral weakness of knee extension. • Which of following tests may be diagnostic? 1 )Vitamin B12 concentration 2 )Thyroid function test 3 )Oral glucose tolerance test 4 )Urine free cortisol concentration 5 )Vitamin D concentration . There absence of knee reflex but ankle reflexes are preserved both plantars are flexor.

• Which of the following would be correct in keeping with a diagnosis of ploymyalgia rheumatica? 1 )raised creatinine kinase 2 )increased alkaline phosphatase 3 )sudden loss of vision in one eye 4 )shoulder & pelvic girdle pain in 35-yearold man 5 )erythema nodosum .

• Correct answer 2 .

• A 45-year-old woman admitted a spiking temperature sweats. . She unwell last 3 weeks flitting arthralgia lethargy. Her recent transthoracic echocardiogram normal. 3 )rheumatoid arthritis 4 )adult onset Stills disease . Autoimmune screen negative. Her ferritin elevated at 6000(g/l. ESR 56mm/hour. 2 )systemic lupus erythematosus . 5 )meningitis . 1 )bacterial endocarditis. Blood cultures are sterile. There a rash over her trunk which prevalent in mornings.

Subsequent investigations show: Free T4 of 40 pmol/L (9-23) Free T3 ofs 9.8 nmol/L (3.0 mU/L (0.5-5) She is clinically thyrotoxic a diffuse goitre & commenced on Propranolol & Carbimazole.• A 52-year-old schoolteacher attends for weight loss & sweats. What is appropriate test this patient? 1 )FNA of thyroid gland ]2 )MRI scan pituitary gland 3 )Radio-isotope uptake scan of thyroid gland 4 )Repeat TFT 5 )Thyroid auto antibodies .5-6) TSH of 7.

5 tds of sinemet.A 75-year-old man presents with 12 months history of cognitive impairment. intermittent confusion and generalised myoclonus. In the following 2 months he was started experiencing visual hallucinations. He was started on 62. parkinsonism. The most likely diagnosis is: 1) Idiopathic Parkinson's disease 2) Alzheimer's disease 3) Diffuse Lewy body disease 4) Multiple system atrophy 5) Progressive supranuclear palsy .

myoclonus and marked sensitivity to neuroleptic treatment. intermittent confusion. . Visual hallucinations in parkinson's disease treated with L-dopa usually appear late (>2 years after initiation of treatment). parkinsonism.The answer is 3 Diffuse lewy body disease presents with cognitive impairment. visual hallucinations. Visual hallucinations are not features of multiple system atrophy or progressive supranuclear palsy.

EMG showed evidence of myopathy. There is no family history.A female patient aged 30 has a 5 years history of difficulty getting upstairs and out of a low chair and mild upper limb weakness but no pain. The most likely diagnosis is: 1) Polymyositis 2) Inclusion body myositis 3) Acid Maltase Deficiency 4) Miller-Fisher Syndrome 5) Lambert-Eaton Myasthenic Syndrome . She presented with severe type 2 respiratory failure.

is characterised by ophthalmoplegia. inclusion body myositis) and limb girdle muscular dystrophy is rare. dermatomyositis. autonomic symptoms and fatiguability. Miller-Fisher Syndrome. ataxia and areflexia. a variant of GBS. is associated with hyporeflexia which returns after exercise. Muscle biopsy shows vacuolation in muscle fibres.The answer is 3 Acid maltase deficiency typically presents with insidious onset of proximal myopathy and early respiratory muscle weakness. . Respiratory failure in inflammatory myopathies (polymyositis. often a paraneoplastic phenomenon. Lambert-Eaton Myasthenic Syndrome.

Which statement is true regarding Gabapentin? 1) is a potent hepatic enzyme inducer 2) side effects typically include visual field defects with long-term use 3) therapy is best monitored through measuring plasma concentrations 4) is of particular value as monotherapy in absence attacks (petit mal) 5) requires dose adjustment in renal disease .

which may be irreversible.The answer is 5 Gabapentin does not induce cytochrome P450 unlike other anticonvulsants such as phenytoin and phenobarbitone. . Vigabatrin may cause visual field defects. No use in Petit Mal and is used for add-on therapy in partial or generalised seizures. Rarely have visual disturbances been associated with gabapentin.

Which of the following clinical manifestations suggests Guillain Barré Syndrome? 1) Weakness beginning in the arms 2) Asymmetrical involvement of distal muscles 3) Bulbar involvement in about 50% of cases 4) Brisk tendon reflexes 5) Normal CSF protein .

Campylobacter and mycoplasma are recognised causes. CSF protein is elevated to more than twice the upper limit of normal. Clinical symptoms usually improve within 2-3 weeks. though a chronic relapsing form is recognised. Asymmetry is present in only 9% of patients. In 20% of cases there is urinary incontinence of retention. Usually there is painless progression over days or weeks. with normal glucose and no pleocytosis. ataxia and areflexia. Bulbar involvement occurs in 50%. It usually follows a non-specific viral infection. upper limbs and finally the bulbar muscles (Landry's ascending paralysis).The answer is 3 GB is a post-infectious polyneuropathy causing demyelination in mainly motor but also sensory nerves. Weakness begins in the legs and progressively ascends to involve the trunk. there may be tenderness or muscle pain. with symmetrical involvement being typical. but in cases of abrupt onset. with a risk of aspiration and respiratory insufficiency can be problematic. Bacterial cultures are negative and viral cultures rarely isolate anything. The dissociation between a high CSF protein and a lack of cellular response in a person with an acute or subacute polyneuropathy is diagnostic of Guillain Barré Syndrome . In the Miller Fisher Syndrome there is external ophthalmoplegia.

A 72-year-old lady has 4 months of memory loss. Muscle tone is normal and both plantar reflexes are downgoing. What is the likely diagnosis? 1) Alzheimer's disease 2) Frontal lobe dementia 3) Mulit-infarct dementia 4) Normal-pressure hydrocephalus 5) Parkinson's disease . urinary incontinence and falls. slow gait. On examination she has mild memory loss and a broad-based.

because it is a potentially reversible cause of dementia. urinary incontinence. It is important to distinguish it from Parkinson's Disease. and dementia. The onset of gait disturbance and urinary symptoms is unusual so early in dementia. Frontal lobe dementia is characterised by loss of 'executive' functions and multi-infarct state usually has a step-wise history. It is an important clinical diagnosis.The answer is 4 Normal pressure hydrocephalus characterized by abnormal gait. .

Which of the following nerve lesion is most likely? • A. on examination. L4 nerve root • C. He also is unable to tiptoe on the same foot. Ankle jerk is absent.• A patient has. Tibial nerve • D. Femoral nerve . Sciatic nerve • E. Common peroneal nerve • B. weakness in plantar flexion and foot inversion on the left.

Tibial nerve supplies the gastrocnemius muscle and leads to the above findings. The common peroneal nerve causes weakness of eversion and dorsiflexion. .• Answer: c) tibial nerve.

• A 25 year old secretary has had several episodes of brief jerking of the right arm over the past few weeks. Which is the best medication to commence? A. Carbamazepine B. Diazepam E. There is no loss of consciousness. Phenytoin C. Lorazepam D. A CT scan of the head is unremarkable. Levodopa • .

• Answer: a) carbamazepine. . Brief episodes of jerking suggests simple partial seizures. Carbamazepine is first line therapy for this.

Clinically he has a systolic murmur heard loudest in the right upper sternal edge. He has a diagnosis of hypertrophic obstructive cardiomyopathy. His ECG shows grossly large QRS complexes with LVH strain pattern. Tricuspid regurgitation • C.• A 40 year old patient has a transthoracic echocardiogram as a follow up. Interventricular septal thickness of 4 cm . ECG showing ventricular ectopics • E. Systolic anterior motion of mitral valve • D. Which of the following suggests highest risk for sudden death? • A left ventricular outflow tract gradient of 20 mmHg • B.

this may vary with exercise. The LV outflow tract gradient is not significantly high in this patient.3 cm) suggests very hypertrophic myocardium and high risk of outflow tract obstruction with exertion. . however. The large interventricular septal thickness of 4 cm (normal <1.• Answer: e) interventricular septal thickness of 4 cm.

Marfan's syndrome • D. Down's syndrome • E. Which of the following is an association? • A. Coarctation of aorta . Mitral valve prolapse • C. This reveals a bicuspid aortic valve.A 18 year old man is referred for an echocardiogram for further investigation of a systolic murmur. Mitral stenosis • B.

5% of cases demonstrate significant association with coarctation of the aorta. • • Coarctation of Aorta .• Answer: e) coarctation of aorta. Bicuspic aortic valve can be congenital.

Sacroilitis • C.• A 50 year old woman with rheumatoid arthritis has hand and spine X rays due to worsening joint and back pains. Marginal erosions • E. Tendon swelling • D. Calcification of entheses . Juxta-articular osteosclerosis • B. Which of the following is a recognised X ray change of rheumatoid arthritis? • A.

• • Marginal Erosions of the first MTP joint . Calcification of entheses also occurs in seronegative arthritis.• Answer: d) marginal erosions. Marginal erosions are seen at the articular cartilage and attachment of synovium. Juxta-articular osteoporosis or osteosclerosis occurs in OA. There is associated loss of joint space. Sacroilitis is seen in seronegative arthritis.

Rheumatoid arthritis • B. and has a butterfly shaped rash on her face. Perthe's disease . 1 year later she presents with hip pain limiting her mobility. Which one of the following is the likely cause? • A. Her physician makes a diagnosis of SLE. Septic arthritis • C.• A 35 year old lady has positive ANA. Avascular necrosis • E. Juvenile chronic arthritis • D. She has flare ups of joint swellings and pains requiring several months treatment with prednisolone.

Nephritis. vasculitis and long term steroid use predispose to avascular necrosis. Collapse of the femoral head due to avascular necrosis . 15% of patients with SLE develop avascular necrosis of the bone.• Answer: d) avascular necrosis.

an enlarged skull vault. Disseminated intravascular coagulation . Venous varicosities • E. Hypercalcaemia • C. In this patient. one of the complications of immobilisation would be: • A. Osteoarthritis • B. Peripheral vascular disease • D.A 65 year old man has impaired hearing in his left ear. bowing of the left tibia which is warm to touch.

Other complications are gout. high output cardiac failure and coincidental hyperparathyroidism. In this condition immobilisation is likely to cause hypercalcaemia.• Answer: b) hypercalcaemia. • • Bowed tibia in Paget's disease . The patient has the clinical features of Paget’s disease of bone.

Pulmonary AV malformation • C. Oesophageal dysmotility • B. Aortic aneurysm . Hiatus hernia • E. Pulmonary fibrosis • D.A 60 year old lady has an autosomal dominant condition. In view of the likely diagnosis. She has been on ferrous sulphate tablets for chronic iron deficiency anaemia. which feature may be associated? • A. She small red lesions on her face and mouth.

Oesophageal dysmotility is seen in scleroderma.• Answer: b) pulmonary AV malformation. She has hereditary haemorrhagic telangiectasia (OslerRendu-Weber syndrome). 10% of patients have pulmonary AV malformation. • • Telangiectatic lesions in HHT . Patients have a chronic problem with recurrent GI bleeding and require multiple transfusions and iron supplementation.

Saphenous vein graft • B.• A cardiothoracic surgeon is planning for surgery in a 60 year old man with coronary artery disease. which of the following vessels should be considered for grafting to the Left anterior descending artery? • A. Right internal mammary • D. In coronary artery bypass grafting. Radial artery • E. Brachial artery . Left internal mammary • C.

• Answer: b) left internal mammary. It has been shown to be superior to saphenous vein grafts (from aorta to LAD) in staying patent and hence is now the choice artery (LIMA to LAD) graft. The left internal mammary artery supplies the anterior chest wall. RIMA arteries are sometimes used to graft the RCA. Although circumflex and right coronary arteries are usually grafted with veins. .

Which medical condition predisposes to this? Behcet's disease B. He has limited wrist movements and clubbing. Diabetes E. Hyperthyroidism .A 45 year old man has developed pains and swelling over his wrist joints bilaterally over 3 months. Crohn's disease C. Amyloidosis D. X rays show periosteal reaction at the ends of the radius and ulnar bones suggestive of periostitis.

• Answer: b) Crohn's disease. ulcerative colitis. whipple's disease and crohn's disease. Hypertrophic osteoarthropathy (or hypertrophic pulmonary osteoarthropathy when there is mesothelioma or bronchogenic carcinoma associated) is associated with conditions such as liver cirrhosis. • • Hypertrophic osteoarthropathy .

A 30-year-old woman complains of severe headache. predominantly in the wrist and knees. ESR 88 mm/1st hr. and is now finding it extremely difficult to cope with her work and household activities. Cardiovascular. Her temperature is 38oC. ANA positive. Joint examination is remarkable for tenderness in the wrists and knees. ALT 50 IU/l. she looks unwell.7 g/dl WBC3. as well as irritability. AST 44 IU/l. Cranial angitis . Viral meningitis 3. she is pale and there is an erythematous rash on her face.L0.8 x 10 9/l. Lupus glomerulonephritis 4. low mood and lack of energy. She works as a secretary.1 x 10 9/l. On examination. and joint pains. PLT88 x 10 9/l. She and her husband are requesting sick leave. N2. Her husband informs you that he has noted her to be withdrawn and short tempered. She also gives a history of a recent increase in hair loss. Respiratory and abdominal examination are unrevealing.8 x 10 9/l. Neuropsychiatric lupus 2. Neurological examination does not show focal neurologic signs or neck stiffness. but no swelling. Antiphospholipid antibody syndrome 5. She has had amenorrhoea for the last 3 months. CRP8 mg/l. mainly in the occipital region. Laboratory results were returned as follows: Hb 9. DNA and ENA awaited. ALK-P156 IU/l. Urine dipstick protein+ What is the most likely clinical problem that may explain the above? 1.

. Lupus glomerulonephritis cannot be completely excluded but active urinary sediment with proteinuria of ++ on dipstick will be more suggestive. The above clinical findings and investigation results are suggestive of systemic lupus erythematosus (SLE).True 1. relatively harmless migraine headache. However. lymphocytosis rather than lymphopenia would be more consistent with APS. the symptoms of headache and mood changes point towards the possibility of neuropsychiatric lupus. Features of neurological disease in lupus range from the common. Antiphospholipid antibody syndrome (APS) is unlikely even though the patient has thrombocytopenia. recognised in some lupus patients. to major psychotic episodes and grand mal seizures.

He is an ex smoker and drinks 15 units of alcohol in a week. He has an ataxic gait. more in the cerebellar region than the cerebrum. CSF for anti Hu and anti Yo antibodies • C. His wife mentions that he is confused. his MMSE score is 20/30. An MRI scan of the head shows diffuse white matter changes. CSF for oligoclonal bands • B. CSF for TB culture • D. On examination. Routine blood tests are normal.• A 65 year old man is assessed on the ward for weakness in his legs. EEG E. There is bilateral pyramidal weakness and coordination is impaired. EMG . Which of these tests would help most in confirming the diagnosis? • A.

Anti Hu and anti Yo antibodies would help confirm a diagnosis of paraneoplastic syndrome. . Multiple sclerosis is unlikely in view of late presentation and is not commonly associated with dementia.• Answer: b) CSF for Anti Hu and anti Yo antibodies.

A 36 year old female gave a recent history of
sensory impairment and imbalance in left
half of the body. She also complained of
tingling .She had recurrent episodes of
ataxia in last year – each episode resolved
spontaneously. What is the likely diagnosis
of this episode?
A. Transient ischaemic attack
B. Intracranial space occupying lesion
C. Multiple sclerosis
D. Cerebellar haemorrhage

• Answer: C) Multiple sclerosis.
• History of patchy sensory loss, and ataxia
which improves on occasion is suggestive
of an inflammatory disorder, in this case
most likely multiple sclerosis.

Which of the following diseases is
associated with an increased frequency
of HLA -DR4 on the cell membranes?
A. Ankylosing spondylitis
B. B. Rheumatoid arthritis
C. C. Porphyria
D. D. Congenital adrenal hyperplasia
E. E. Narcolepsy

• Answer: b) rheumatoid arthritis. Lack of
HLA DR2 is associated with narcolepsy,
and increased HLA DR4 is associated with
rheumatoid arthritis.

11.Anti-neutrophilic cytoplasmic autoantibodies:
A positive only in Wegener’s syndrome associated with
renal disease .
B cause neutropenia in SLE .
C present in inflammatory bowel disease .
D is invariably associated with Polyarteritis Nodosa.
E ANCA positive glomerulonephritis characteristically
causes nephrotic syndrome.

Migraine C. Cluster headache B. Tension headache D. Cavernous sinus thrombosis .25 year old lady complains of unilateral throbbing headache for 10 months. What is the diagnosis? A. Each time she has headaches. CT head was normal. she also complains of unilateral weakness in the arm which resolve spontaneously when the headaches improve. Somatoform disorder E.

The headache usually precedes the weakness by a day or more. . The limbs gradually return to normal over several days. Hemiplegic migraine is a term used to describe the migraine syndrome that is associated with a weakness or sensory loss of the limbs on one side of the body.• Answer: B) migraine.

• 31 yrs old female coming for infertility. Metformin . Rosiglitazone • E. clomiphene • C. Testosterone • B. PCO by US . what is the most appropriate drug? • A. BMI 35. Finasteride • D.

The reduction of hormonal imbalance and treating insulin resistance helps to restore the ovulatory cycles and fertility. but not in the options).• Answer: clomiphene Both metformin and clomiphene has been shown to be effective in stimulating ovulation in patients with PCOS (clomiphene is more effective. .

• A 65 year old lady is seen in the rhematology clinic with the results of a DEXA scan. Oestrogen replacement • C. Phosphate replacement . The T score of the hip is -2. Calcium and vitamin D • B. Which of the following medications does NOT improve bone mineral density? • A.5 SD.8 SD and in the spine is -2. Selective oestrogen receptor modulator (SERM) • D. Bisphosphonates • E.

What is the diagnosis? 1) Alcohol withdrawal. 2) Hepatic encephalopathy. 5) Wernicke's encephalopathy. One hour after admission. 4) Subdural haematoma.59.50-year-old old man is admitted to hospital unconsious. . 3) Hypoglycaemia. and smelling of alcohol. he becomes suddenly sweaty with a regular tachycardia of 110 bpm and a BP of 100/50.

.The answer is 3 This is a bit early for alcohol withdrawal particularly as the patient is admitted smelling of alcohol. We do not have any clinical findings to suggest any of the other alternativies. The most likely diagnosis is hypoglycaemia.

Periarticular erosions • E. Loss of joint space .A 45 year old lady has had long standing arthritis of her hands and feet. Which of the following X ray changes suggests rheumatoid arthritis instead of a seronegative arthropathy? • A. Osteosclerosis • B. Osteoporotic changes • D. Osteophytes • C.

Periarticular erosions are suggestive of rheumatoid arthritis.• Answer: d) periarticular erosions. and can also be found in rheumatoid arthritis. Osteophytes and loss of joint space are commonly found in osteoarthritis. • • Periarticular Erosions .

Right internal capsule infarct • E. Pontine haemorrhage • B. There was no loss of consciousness. Which is the likely diagnosis? • A.• A 60 year old man is brought to hospital having collapsed to the ground suddenly and was unable to move his left leg or arm. Primary epilepsy • C. Examination reveals a mild hemiparesis of the left arm and leg. He has a past medical history of hypertension only. The episode lasted a few seconds and he has been relatively well. Left internal capsule infarct . Medullary haemorrhage • D.

causing transient contralateral hemiparesis.• Answer: d) right internal capsule infarct. This patient is likely to have a lacunar infarct involving the internal capsule. .

A 35 year old man presents acutely with urethritis. Circinate balanitis D. C. B. D. Myocardial infarction B. which one of the following features is associated? A. Rheumatoid factor is negative and he has raised inflammatory markers. Calcinosis . Pulmonary embolus C. nail dystrophyE. In view of the likely diagnosis. conjunctivitis and arthritis.

• Other features are anterior uveitis. .• Answer: c) circinate balanitis. cannot climb a tree). circinate balanitis (painless rash) and aortic incompetence. The arthritis may relapse or remain chronic. seronegative arthritis (cannot see. Reiter’s syndrome is urethritis. Management is usually with rest and NSAIDs. cannot pee. keratoderma blenorrhagica (brown abscesses on palms and soles). conjunctivitis. The seronegative arthritis is usually a mono or oligoarthritis. mouth ulcers. The diagnosis is Reiter's syndrome. plantar fasciitis and archilles tendinitis (enthesopathy). The typical patient is a young man with recent urethritis or dysentery.

A demyelinating polyneuropathy is typically caused by: 1) Diabetes 2) Excessive alcohol 3) Hereditary motor-sensory neuropathy 4) Renal failure 5) Vitamin B12 deficiency .

Amiodarone. chronic inflammatory demyelinating polyneuropathy (CIDP). paraprotein-related disorder. Guillain-Barre syndrome. leukodystrophies.The answer is 3 The differential diagnosis of demyelinating neuropathy includes: hereditary motor-sensory neuropathy (Charcot-Marie Tooth disease). . alcohol. Diabetes. Refsum's Disease. Vitamin deficiencies and renal failure cause an axonal polyneuropathy.

Papillary thyroid carcinoma • B. A short synacthen test shows a rise in cortisol from 100 to 140 μg/ml. hypotension. Hepatocellular carcinoma • E. Which one of the following conditions is associated? • A. Phaeochromocytoma • D. hyponatraemia.• A 35 year old lady has skin pigmentation. Pernicious anaemia . Ovarian fibroids • C.

primary ovarian failure and pernicious anaemia.g. Many autoimmune diseases are associated e. vitiligo. diabetes. Addison's disease is described.• Answer: e) pernicious anaemia. .

Which of the following is the most likely cause? 1) Alzheimer type dementia 2) chronic sub-dural haematoma 3) Creutzfeldt-Jacob disease 4) depressive stupor 5) normal pressure hydrocephalus .A 70-year-old woman presented with episodic impairment of consciousness.

Similarly Normal Pressure Hydrocephalus. .The answer is 2 This is quite a grey question. Of all those listed subdural haematoma is classically associated with fluctuating level of consciousness. Alzheimer's disease would be expected to have a continous impairment of consciousness in its advanced stages but could be episodic if there were variation in drugs therapy or concurrent illnesses. The clinical scenario is very brief with no mention of any neurological signs so a logical deduction must be made. This would make it the most likely. Creutzfeld-Jacob and depression would present with dementia (or apparent dementia) but not fluctuant.

Temporal lobe lesions cause: 1) Apraxia 2) 2) Astereogenesis 3) Primitive reflexes 4) Visuospatial neglect 5) Wernike's (receptive) aphasia .

Lesions of the temporal lobe cause visual field defects (typically homonymous superior quadrantanopia).it is different to neglect since in agnosia the objects are seen and followed but cannot be named). Wernike's (receptive) aphasia. anosmia and changes in personality.The answer is 5 Lesions of the frontal lobe include difficulties with task sequencing and executive skills. and visual agnosia (seeing but not percieving objects . homonymous hemianopia. astereognosis (unable to recognise an object by feeling it) and visual field defects (typically homonymous inferior quadrantanopia). and memory impairment. neglect. . primitive reflexes. Expressive aphasia (receptive aphasias a temporal lobe lesion). auditory agnosia. They may also cause alcalculia (inability to perform mental arithmetic). perseveration (repeatedly asking the same question or performing the same task). Occipital lobe lesions include cortical blindness (blindness due to damage to the visual cortex and may present as Anton syndrome where there is blindness but the patient is unaware or denies blindness). Lesions of the parietal lobe include apraxias.

urinary incontinence and falls. slow gait. What is the likely diagnosis? 1) Alzheimer's disease 2) Frontal lobe dementia 3) Mulit-infarct dementia 4) Normal-pressure hydrocephalus 5) Parkinson's disease . On examination she has mild memory loss and a broad-based. Muscle tone is normal and both plantar reflexes are downgoing.A 72-year-old lady has 4 months of memory loss.

It is an important clinical diagnosis. It is important to distinguish it from Parkinson's Disease. and dementia. . because it is a potentially reversible cause of dementia. Frontal lobe dementia is characterised by loss of 'executive' functions and multi-infarct state usually has a step-wise history.The answer is 4 Normal pressure hydrocephalus characterized by abnormal gait. The onset of gait disturbance and urinary symptoms is unusual so early in dementia. urinary incontinence.

What is the diagnosis of the patient whose hand on the right and suffers hyponatremia Slide no 10 Normal hand .

very cyanotic child lying on a stretcher with her knees drawn up against her chest. Physical examination shows a small. Her respirations are rapid and deep. Which of the following is the most appropriate general treatment strategy for this patient? • • • • • Decrease systemic vascular resistance to increase right-to-left shunting Decrease pulmonary vascular resistance to decrease left-to-right shunting Decrease systemic vascular resistance to decrease right-to-left shunting Increase pulmonary vascular resistance to increase left-to-right shunting Increase systemic vascular resistance to decrease right-to-left shunting . Auscultation of the heart discloses tachycardia but no murmur. Pulse oximetry shows an oxygen saturation of 58% in room air.• A 2 year old girl with unrepaired tetralogy of Fallot presents to the emergency department with increased cyanosis.

Decreasing pulmonary vascular resistance (as in choice B) is a good idea. • • • • • • • • •   .to pass through the stenotic pulmonary valve and enter the lungs. or to pass through the VSD and into the left ventricle (and on to the systemic circulation) without ever getting oxygenated? Remember. it is easier for blood to pass through the pulmonary outflow tract obstruction and into the lungs. then goes to the lungs via the pulmonary artery. the RBC enters the right ventricle. Thus. This leads to severe right-to-left shunting. then the right ventricle. and a large VSD) but only two of them are necessary for understanding the pathophysiology of the lesion: the pulmonary outflow tract obstruction and the VSD. Here. Increasing pulmonary vascular resistance (choice D) would cause increased right-to-left shunting. which is not what this patient needs. called a "Tet spell. right ventricular hypertrophy. Alternately. then the right-to-left shunt should decrease . not the left-to-right. The red blood cell returns to the heart via the vena cava. Imagine now a single red blood cell returning to the heart in a patient with Tetralogy of Fallot. blood flows to the path of least resistance. When the pulmonary vascular resistance is high and the systemic vascular resistance is low. Decreasing systemic vascular resistance (choice C) will lead to more right-to-left shunting." and is what is happening to the patient in the vignette. an overriding aorta. then enters the left ventricle.• Explanation • • The correct answer is Choice E. After getting oxygenated in the pulmonary capillaries.but the goal is to decrease the right-to-left shunt. but this will cause more cyanosis and would not be the goal of treatment. it is much more difficult for blood to get into the lungs than it is for it to pass through the VSD and out to the circulation without being oxygenated. deoxygenated. where it can be oxygenated. Understanding the anatomy of patients with congenital heart disease is crucial for understanding their care. it returns to the left atrium via a pulmonary vein. as it would allow more blood to enter the lungs . and thus how much blood goes to the lungs versus how much goes to the body without being oxygenated depends on the balance between the pulmonary vascular resistance and the systemic vascular resistance. the correct answer is choice E . if the systemic vascular resistance is high and the pulmonary vascular resistance is low. For example. It then enters the right atrium. which as described previously. This is the goal of treatment for a Tet spell.which will reduce the patient's cyanosis. would be very bad in this situation. the best way to think about the anatomy for a patient with congenital heart disease is to imagine the path of lesion: the pulmonary outflow obstruction the VSD. imagine a single red tract blood cell in aand normal patient. Patients with Tetralogy of Fallot have four distinct lesions ("PROVe": pulmonary outflow tract obstruction.                                                                                                        Decreasing the systemic vascular resistance would lead to increased right-to-left shunting (choice A). After leaving the vena cava and the right atrium.if the systemic vascular resistance increases. the cell must make a "choice" . Often.  blood flow. then moves out to the body to deliver its oxygen to the tissues.