Question 1 A 26 y/o presents to you, her GP, as she has noticed a pigmented lesion on her face.

She admits to using sun beds frequently & every year has a beach holiday. She is worried she may have skin cancer. i) List 4 symptoms that would indicate a possible diagnosis of melanoma. (2m) ii) iii) iv) Any change in size/shape/colour? Does it itch? Any bleeding/discharge? Asymmetrical shape Irregular border Variegated appearance Diameter > 6 mm Satellite lesions Melonacytic naevus Seborrhoeic keratosis

List 4 clinical signs that would also raise your suspision. (2m)

2 benign deferential diagnosis

You examine this ladys lesion & you suspect a melanoma. As her GP, what is the most appropriate management? (1m) Refer using 2 weeks wait to dermatologist/plastic surgeon

The histology report shows a Breslow thickness of 0.7mm v) What is the Breslow thickness used for? (2m) vi) Used to determine prognosis Used when planning surgery Elastosis destruction of elastic tissue

List 2 effects that sun exposure has on the skin. (2m)

 Question 2 O+G

Loss of skin immune function Direct cellular damage to DNA Vitamin D production Increase melanin production by melanocytes

Mrs R attending antenatal clinic at 12 weeks gestation, known smoker with hypertension and gestation diabetes mellitus. She is 40 y o and her last pregnancy was caesarean section for breech presentation. I. What feature in her history increased her risk of Downs syndrome? (1m)

-Maternal age II. What genetic abnormality of Downs? (1m)

-- Trisomy 21/ extra chromosome 21 III. Give 3 screening test for Downs and State when in gestation if can be performed. (6m) Nuchal translucency scan- 12 weeks accept (11-13) Antenatal serum screening accept- HCG/ AFP/ estradiol / triple test 15 weeks (15-20 accepted) Anomaly scan 20 weeks (accept 18-22 weeks)

IV. Give 2 invasive test for Downs (2m) --Amniocentesis, Chorionic villous sampling

Question 3

Ms CM is a 24 y o women in her first pregnancy. At 12 weeks gestation an USS finds a mono-chorionic diamniotic twin pregnancy. I. Name 3 complication of pregnancy that these fetuses are at increased risk of compared with a singleton pregnancy. (3m) -- Twin to twin transfusion syndrome, IUGR, intrauterine death, placental abruption, preterm delivery.

II.

Name 3 complication of pregnancy that Catherine is at increased risk of compared with the risk associated with carrying a singleton pregnancy. (3m)

--Pre-elcampsia, post partum haemorrhage, hypertension, thrombosis, fetal distress, anaemic, cholestasis of pregnancy.

24 weeks later C arrives on delivery suite complaining of regular contraction occurring every 3 mins. The first tetus is breech presentation and on vaginal examination C is 4 con dilated and the membranes are intact. III. After balancing the risk vs benefits of tocolysis should this therapy be given and why is this? (2m) --nobecause risk of RDS is low at 36 week gestation IV. What is the safest mode of delivery for the twins (1m) --Caesarean section V. What is the safest mode of delivery for C? (1m)

--Vaginal delivery.

Question 4 Palliative Care J is a 75 y o man who was diagnosed as suffering from non-small cell carcinoma of the right upper lobe of the lung three months ago. As he had a moderate performance status he was treated with 5 fractions of radiotherapy to his right upper lobe. He is seen by you in A+E as he has become acutely breathless at hom and his family telephoned for an ambulance. I. What are 3 possible cause of his difficulty in breathing? (3m)

.-worsening lung cancer. Increased size of cancer/ metastases -chest infection/ pneumonia - pleural effusion -pulmonary effusion -Pneumothorax II. In A+E, give 3 therapeutic options that you would give to James in order to manage his distressing breathing difficulties. (3m) -Oxygen therapy - Anxiolyitcc- lorazepam/ diazepam - Morphine orally - Reassurance -breathing exercises -antibiotics His symptoms improve with management and his is discharged home. He returns to A+E 6 weeks later with new onset of Thoracic Back pain and leg weakness. III. What 2 other symptoms would you enquire about? (2m) - loss of sensation of legs/ body -Urinary problems

-Faecal problems IV. What is causing his symptoms? (1m) -spinal cord compression V. What is the investigation of choice? (1m)

-magnetic resonance imaging Question 5. Palliative care -Anne is a 67 year old lady who has been suffering from carcinoma of the breast for 4 years. She has been treated with a left mastectomy followed by chemotherapy. She has deteriorated considerably over the last 2 months and now has liver, bone and brain metastases. The team on the ward feel that she is now dying. I. Name 2 important medical interventions which may be discontinued when a patient is dying. -discontinue inappropriate blood tests -discontinue inappropriate interventions -review unnecessary interventions II. What are the 3 non-physical aspects of care to be considered when dealing with a dying patient? -spiritual/ psychological/ social/ religions Medication need to be prescribed in anticipation when a patient is entering the dying phase. III. Give 2 symptoms that are common in the terminal phase and suggest medications you would use for each in their management.

-Pain morphine/ diamorphine -Nausea + Vomiting Cyclizine/ Haloperidol -Sedation Midazolam -Secretions-Hyoscine hydrobromide/ Glycopyronium -Dyspnoea-Morphine IV. What is the difference between certification and verification of a death? -Certification is the documentation surrounding the cause of death of a patient. This can be issued if you are medically qualified. -Verification is ensuring the patient is died or confirming death that is externally examination. Question 6 David is 18 years old, recently he has been heard shouting in his bedroom while alone, become isolated, refers to items in the news as having special relevance to him, may appear suspicious and his conversation has been difficult to follow. His moos is rapidly changeable, he has been hoarding various objects. His parents believe he is smoking cannabis and possibly taking other illicit drugs 1. from the history give 3 possible psychiatric symptoms 3 auditory hallucination ,thought alienation, persecutory, delusion of reference 2. the family doctor see david. David symptoms have developed over the last 2 year and his college work has significantly deteriorated, he consider schizophrenia the most likely the diagnosis. List one other differential diagnosis with reason 2 drug induced psychosis, psychoactive substance- psychotic disorder, psychotic illness in context of possible illicit drug, obsessive compulsive disorder- hoarding, depressive psychosis, schizoaffective disorder 3 A psychiatrist confirm the diagnosis and start olanzapine 5mg at night, give one common and clinically relevant side effect of this drug 1

Increase appetite/weight gain, sedation, change in glucose tolerance, hyperglycaemia diabetes 4. one evening he is found,having taken an overdose in his car. With respect to the act of deliberate self harm give 2 factors that if present would indicate an increased risk of subsequent suicide for a single men of 18 2 final acts, planned , stated intend to die at a time of overdose 5. suicide risk is considered high but david refuses hospital admission and is detained under mental health act, which section? Section 2 and section 3 Question 7: General Practice A 68 year old gentleman attends surgery following an incidental finding of hypertension by a local pharmacist. He is currently fit and well, is a non smoker and takes no regular medication. He last attended 2 years ago and was seen by the Practice Nurse who noted a raised blood pressure and advised him to return in 2 weeks. You note a past history of 3 episodes of renal colic. Full clinical examination was unremarkable other than a blood pressure of 210 / 100. i) What is the most likely cause of this gentlemans hypertension? Essential Hypertension ii) Name 2 blood tests that would help estimate his 10 year cardiovascular risk? (2 marks) Fasting blood glucose Fasting lipid profile iii) Name 2 other investigations that would help detect end- organ damage.(2 marks) Chest X- Ray ECG Urea and Electrolytes (1 mark)

Urinalysis for protein Echocardiography His blood tests reveal an adjusted calcium of 3.4 mmol/l (1 -1.5), phosphate of 0.5 mmol/l (1.5 2.9) and alkaline phosphatase of 250 IU/l (50 200) iv) What is the diagnosis? Primary hyperparathyroidism v) List 2 other surgically correctable cause of hypertension? Phaechromocytoma Coarctation of the aorta Renal Artery Stenosis Conns Syndrome (accept adrenal tumour or hyperplasia) Question 8: Surgery Edward is a 50 yr old male. When he was 7 years old, he unintentionally drank some bleach and he has had a stricture ever since. He has a long history of indigestion and reflux, for which he takes antacids and a PPI. He drinks 10 units of alcohol/ day and smokes 20 cigarettes/day. In the last 4 months, he has lost his appetite, is losing weight (2 stone) and his food is sticking more than usual. Investigations reveal a malignant lesion at the lower end of his oesophagus and he is admitted for thoracoabdominal oesophagogastrectomy. (2 marks) (1 mark)

i)

Which 4 pre-op investigations does Edward need? (2 marks)

--Chest x-ray, lung function tests, full blood count, plasma urea and electrolytes, liver function tests, including plasma protein & Ca2+, blood glucose. ii) Which 2 pre-op treatments would optimize Edwards post-op respiratory function? (2 marks)

--Chest physiotherapy with use of nebulizers and bronchodilators if necessary. Ensure no acute respiratory infections. If present, treat with antibiotics if necessary.

iii)

Which post-op analgesic regimen would you discuss with Edward preoperatively? (1 mark)

--Epidural v. patient controlled analgesia.

iv)

Which special anaesthetic technique may be required for the surgeon to perform this operation optimally? (1 mark)

--One lung anaesthesia

v)

What are the common post-op respiratory problems after this operation? (2 marks)

--Chest infection, lung collapse, pleural effusion, pulmonary embolism.

vi)

Which cardiac arrhythmia may occur after this operation and why? (2 marks)

--Atrial fibrillation. Due to haematoma formation at the operative site, which is near the left atrium.

Question 9: Cardiology

Jim, a 51 year old male, wakes up 1 morning with intermittent central chest pain which is crushing, episodic and occurs on exertion. The pain is not present by the time hes at the GP. He had it several times before but they have all lasted less than 20 minutes and he is breathless during attacks. He is unemployed and overweight. He smokes 20/day and drinks several pints of beer most nights. His parents died some years ago, but he is unsure of the causes.

i)

List 3 physical signs of risk factors for ischaemic heart disease. (3 marks)

--Hypertension, obesity, xanthalesma, tendon xanthoma, arcus senilis, gout, peripheral neuropathy, retinal changes.

ii)

The GP refers him for the rapid access pain clinic. List 3 investigations to indicate risk factors for ischaemic heart disease. (3 marks)

--Blood glucose, plasma lipids, liver function tests, electrocardiogram, chest x-ray, thyroid function tests.

iii)

A diagnosis of angina is made. State 2 further tests to confirm this diagnosis. (2 marks)

--Treadmill test, coronary angiography.

Jim is started on aspirin, simvastatin and atenolol. 2 weeks later, he presents with a leaden feeling in his legs, swollen feet, tiredness and aching all over.

iv)

Which drugs could be responsible for which side effects? (2 marks) ankles.

--Atenolol tiredness, leaden feeling in legs, possible heart failure & swollen --Simvastatin aching all over.

Question 10: General practice Mavis, a 76 year old pensioner, during a routine check-up complains of weight gain and tiredness. She is 160cm tall and weighs 90kg. She is generally healthy. She suffered from thyrotoxicosis after the birth of her second child 45 years ago. She was treated successfully by partial thyroidectomy.

i)

Calculate her body mass index and comment on it. (2 marks)

--BMI = 35, obese.

ii)

She was found to have a hoarse voice and dry skin. Suggest 3 other symptoms to enquire about. (3 marks)

--Cold intolerance, depression, constipation, angina, carpal tunnel syndrome.

She had some blood tests done. These are the results: TSH 35.4 (0.3-5.0) iu/l. Free T4 3.0 (9.0-24.0) pmol/l, Hb 11.3 g/dl, MCV 105 femtolitre

iii)

What is her diagnosis? (1 mark)

--Hypothyroidism.

iv)

List 3 other diseases associated with this condition. (3 marks)

--Pernicious anaemia, SLE, diabetes, hypoparathyroidism, premature ovarian failure, Addisons disease, rheumatoid arthritis, Sjogrens syndrome, dementia.

v)

Her GP starts her on thyroxine low dose. What are the dangers of starting at too high a dose? (1 mark)

Angina, acute myocardial infarction, palpitations or cardiac arrhythmias.