Practice MCQ Mscaa Questions For Year 4 2

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Practice MCQ Mscaa Questions for Year 4-2
Senior Medicine and Surgery (University of Bristol)
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Practice MCQ’s for Year 4 Exam (Revision Tool)

This document contains 54 MCQ single best answer questions that are relevant to year 4
modules, and the synoptic component of early years and year 3.
These questions are released from the MSCAA database and reflect the exact style and
content you may encounter in the year 4 exam, and the final year MCQ paper. The spread of
questions across the different modules is not representative of what will appear in the exam.
The pass mark for these questions has not been calculated formally, but generally a pass mark
is around the 60% mark if you are using this tool as a self-assessment measure. This paper
does also not contain the full number of questions you would usually have in an exam, so
allow around 72 seconds per question on average.
You are allowed to use a calculator.
The answers are on a separate page at the end. The justification for the answers is what is
provided by the MSCAA and question author.
The questions are copyright of the Medical School Council, but permission has been granted
to release these.

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1. A 73 year old man collapses on the surgical ward 24 hours after having a sigmoid
volvulus reduced by sigmoidoscopy.
He has no pulse and an ECG shows asystole. Chest compressions and

ventilation are started. The cardiac arrest team are with the patient.
Which is the most appropriate next step in management?
A. Cardiac defibrillation
B. Intravenous 0.9% sodium chloride
C. Intravenous adrenaline/epinephrine
D. Intravenous atropine sulfate
E. Transcutaneous pacing
2. A 78 year old woman has pain in both shoulders, hips and thighs. She is very stiff
on waking in the morning and takes 2–3 hours to loosen up. She finds getting
dressed difficult.
Investigations:
Erythrocyte sedimentation rate 67 mm/hr (<20)
CRP 87 mg/L (<5)
What is the most appropriate initial treatment?
A. Co-codamol
B. Leflunomide
C. Methotrexate
D. Naproxen
E. Prednisolone
3. A 36 year old man is rescued from a housefire.
He is alert and talking but has a dull headache. His pulse rate is 98 bpm, BP
139/86 mmHg, respiratory rate 22 breaths per minute and oxygen saturation
100% breathing 15 L/min oxygen via a non-rebreather mask.
Which is the most appropriate parameter to measure?
A. Bicarbonate
B. Carboxyhaemoglobin
C. Haemoglobin
D. Lactate
E. Methaemoglobin

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4. The association between maternal smoking during pregnancy and low birthweight
can be studied by obtaining smoking histories from pregnant women at the time
of first prenatal visit, then assessing birthweight at delivery and analysing the
data according to the smoking histories.
Which is the best description of this type of study?
A. Case–control
B. Cross-sectional
C. Prospective cohort
D. Randomised clinical trial
E. Retrospective cohort
5. An 18 year old woman has had a chronic skin condition for several years. She
has noticed that she gets well-defined areas of scale formation at the sites of
minor skin injuries, such as scratches or insect bites, typically when the injuries
are healing. The scaling can persist for several weeks or months.
What is the most likely underlying skin condition?
A. Acne vulgaris
B. Eczema
C. Psoriasis
D. Seborrhoeic dermatitis
E. Vitiligo
6. A 30 year old woman has irregular periods, decreased libido and galactorrhoea.
Visual field examination is normal.
Investigations:
Prolactin 5000 mU/L (100–500)
Pregnancy test: negative
MR scan of pituitary shows a 4-mm mass in the sella turcica.
Which is the most appropriate management?
A. Cabergoline
B. Dexamethasone
C. Octreotide
D. Radiotherapy
E. Transsphenoidal surgery

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7. A 23 year old man is admitted to the acute surgical ward with appendicitis and is
prepared for theatre. Although he has not eaten for 24 hours, he has been
vomiting on and off all day.
Which airway device provides protection for the lungs from regurgitated stomach
contents?
A. Guedel (oral) airway

B. i-gel ® (supraglottic) airway
C. Laryngeal mask airway
D. Nasopharyngeal airway
E. Tracheal tube
8. A 30 year old woman has severe headache 24 hours after a spinal anaesthetic.
Her temperature is 37.1°C, pulse rate 90 bpm and BP 120/80 mmHg.
Which is the most likely diagnosis?
A. Low pressure headache

B. Meningitis
C. Migraine
D. Subarachnoid haemorrhage
E. Subdural haemorrhage
9. A 27 year old man is brought to the Emergency Department with left-sided chest
pain of sudden onset that is worse on taking a deep breath.
His temperature is 36.8°C, pulse rate 126 bpm, BP 108/60 mmHg, respiratory
rate 28 breaths per minute and oxygen saturation 94% breathing air.
Investigations:
ECG: sinus tachycardia
Which is the most appropriate next investigation?
A. Chest X-ray
B. CT pulmonary angiography
C. D dimers
D. Echocardiography
E. Ventilation/perfusion isotope lung scan

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10. A healthy 23 year old man is scheduled to undergo an elective arthroscopy of his
knee. He is to have a general anaesthetic for the operation and asks the pre-
operative assessment nurse how long he needs to fast beforehand.
Which are the most appropriate fasting times for clear liquids and solids
respectively?
A. 2 h for clear liquids, 2 h for solids

B. 2 h for clear liquids, 6 h for solids
C. 2 h for clear liquids, 12 h for solids
D. 6 h for both clear liquids and solids
E. 6 h for clear liquids, 12 h for solids
11. A 28 year old woman presents to her GP with a neck lump that she noticed
incidentally when rubbing her neck.
There is a smooth, non-tender 1.5 cm mobile lump within the thyroid gland.
Investigations:
TSH 2.3 mU/L (0.3–4.2)
Free T4 17 pmol/L (9–25)
Which is the most appropriate next investigation?
A. CT of neck
B. No further investigations
C. Thyroid antibodies
D. Thyroid scintigraphy
E. Ultrasonography of neck
12. A 78 year old man has type 2 diabetes. His clinician does not invite him to join an
internet-based self-monitoring programme because she considers him to be too
old to engage with it effectively.
What is the most appropriate description of the clinician's approach?
A. Bias
B. Discrimination
C. Inequity
D. Prejudice
E. Stereotyping

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13. A 27 year old man has severe central chest pain. He admits to using cocaine
shortly before the onset of the chest pain, but says that he had used it on only
two previous occasions.
He is distressed and sweating. His pulse rate is 115 bpm and BP 118/68 mmHg.
An ECG shows sinus tachycardia with ST elevation in the lateral leads, and
several ventricular ectopics.
Which is the mechanism by which cocaine has caused this acute episode?
A. Blockade of myocyte repolarisation

B. Coronary artery spasm
C. Enhanced platelet aggregation
D. Increased systemic vascular resistance
E. Rupture of pre-existing arterial plaques
14. A 31 year old man visits his GP with a painless lump in his scrotum.
There is a well-defined, non-tender spherical 1 cm mass on the right side of the

scrotum. It is superior to the testis and transilluminates.
A. Abscess
B. Epididymal cyst
C. Hydrocoele
D. Inguinal hernia
E. Testicular tumour
15. A 78 year old patient is admitted with chronic oropharyngeal dysphagia. He has
left ventricular systolic dysfunction from ischaemic heart disease. He is
breathless on exertion, particularly when climbing stairs. He is being prepared for
a percutaneous endoscopic gastrostomy feeding tube. The passage of a
nasogastric tube has been unsuccessful, and he is having nil by mouth.
He weighs 70 kg. His pulse rate is 72 bpm and BP 132/80 mmHg.
Which is the correct volume of maintenance fluids (in mL) to prescribe for the
next 24 hours?
A. 1750
B. 2450
C. 2800
D. 3000
E. 3250

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16. A 75 year old woman is reviewed 4 days after a fractured neck of femur repair.
She has been agitated and upset, particularly at night. She has punched nurses
and keeps trying to leave the ward. She has seen strange men in black capes
entering the ward and believes that they are controlling the hospital. When she
was seen in the memory clinic 6 months ago, she was found to have mild
cognitive impairment.
What is the most appropriate treatment?
A. Chlordiazepoxide hydrochloride
B. Chlorpromazine hydrochloride
C. Donepezil hydrochloride
D. Haloperidol
E. Memantine hydrochloride
17. A 62 year old man has acute breathlessness with a weak cough, following a
recent viral upper respiratory infection. Over the past 4 months, he has
had double vision, limb weakness and slurred speech when tired.
His respiratory rate is 18 breaths per minute and oxygen saturation 96%
breathing air. He is sweating and using his accessory muscles of inspiration.
Which is the most appropriate test to monitor his respiratory function?
A. Arterial blood gas

B. FEV1
C. FVC
D. Peak expiratory flow rate
E. Ratio of FEV1 to FVC
18. A 19 year old man has 2 days of right-sided chest pain and breathlessness on
exertion. He smokes cannabis and takes cocaine.
His temperature is 36.4°C, pulse rate 108 bpm, BP 112/80 mmHg, respiratory
rate 24 breaths per minute and oxygen saturation 94% breathing air. His trachea
is central. He has reduced breath sounds at the right apex.
What is the most likely diagnosis?
A. Acute coronary syndrome

B. Coronary artery spasm
C. Pneumonia
D. Pneumothorax
E. Pulmonary embolism

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19. An 80 year old woman is admitted to the Emergency Department after being
found collapsed at home. She has central chest pain.
Her pulse rate is 30 bpm, BP 70/40 mmHg and respiratory rate 26 breaths per
minute. Her 12-lead ECG shows sinus bradycardia with no evidence of
myocardial ischaemia.
Which is the most appropriate initial treatment?
A. Adrenaline/epinephrine
B. Atropine sulfate
C. Dobutamine
D. Normal saline
E. Permanent cardiac pacemaker
20. A previously healthy 10 year old boy has deafness of new onset. He has a history
of a recent respiratory tract infection.
Tuning fork tests show:

a) when the tuning fork is placed in the middle of his forehead he hears the tone
loudest in his right ear;
b) when the tuning fork is held in front of his right external auditory meatus it is
quieter than when it is placed on the bone behind the same ear;
c) when the tuning fork is held in front of the left external auditory meatus the
sound is louder than when it is placed on the bone behind the same ear.
Which ear(s) is/are affected and which type of hearing loss is this?
A. Bilateral mixed deafness

B. Left conductive deafness
C. Left sensorineural deafness
D. Right conductive deafness
E. Right sensorineural deafness

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21. A 64 year old woman is due to undergo an arthroscopy of her knee. She has type
2 diabetes and takes metformin (500 mg twice daily) and gliclazide (80 mg each
morning).
Her glycated haemoglobin is 54 mmol/mol (20–42). She is scheduled first on the

morning day case list and is asked to fast from midnight the previous night.
Which is the most appropriate plan for managing her diabetic medication?
A. Continue both drugs and start a variable-rate insulin infusion

B. No change to usual medication
C. Omit both drugs and start a variable-rate insulin infusion
D. Omit gliclazide and continue metformin
E. Omit metformin and continue gliclazide
22. A 70 year old man has a brief episode of twitching that starts in his left hand and
spreads up the arm over 2 minutes, then stops. His arm feels weak for an hour
afterwards. He had an ischaemic stroke affecting his left side 6 months ago with
good functional recovery. He has a history of type 2 diabetes mellitus and is
taking clopidogrel, metformin, ramipril and simvastatin. He is anxious about a
further stroke.
There is no weakness on neurological examination.
A. Functional episode
B. Hypoglycaemia
C. Migraine
D. Partial seizure
E. Right hemisphere transient ischaemic attack
23. A 56 year old woman develops vertigo, nausea, vomiting and intense occipital
headache of sudden onset. She is unable to walk without falling. She has a
history of hypertension treated with ramipril.
Her temperature is 37.4°C, pulse rate 94 bpm, BP 146/92 mmHg, respiratory rate
12 breaths per minute and oxygen saturation 96% breathing air. She has
multidirectional nystagmus and some clumsiness of her right arm.
A. Acute labyrinthitis
B. Benign paroxysmal positional vertigo
C. Cerebellar stroke
D. Ménière's disease
E. Multiple sclerosis

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24. A 79 year old woman has 3 months of a left leg venous ulcer that is slowly
healing.
Ankle–brachial pressure Indices are 0.9 on the left side and 1.1 on the right side
(0.8–1.2).
Which is the most appropriate management?
A. Compression stockings
B. Diagnostic biopsy
C. Full-length graduated compression bandaging
D. No further management required
E. Repeat ankle–brachial pressure indices in 3 months
25. A 26 year old woman sustains a head injury in a motorcycle accident. Her eyes
are closed, but she opens them when asked to do. She is confused about what
happened and about where she is, but attempts to talk about it. She is repeatedly
attempting to remove the cannula from her right wrist.
What is her GCS?
A. 3
B. 7
C. 9
D. 12
E. 14
26. A 65 year old man has sudden pain and redness in his right eye. He also has a
headache and nausea.
Visual acuity is 6/60 in the right eye. The eye is congested, with a hazy cornea
and mid-dilated pupil.
A. Acute glaucoma
B. Conjunctivitis
C. Corneal ulcer
D. Scleritis
E. Uveitis

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27. A 45 year old woman attends her GP surgery with symptoms of vaginal soreness,
itching and discharge. She has had recurrent episodes of vaginal candidiasis
over the past 4 months.
The labia minora are red and swollen. A diagnosis of vaginal candidiasis is made.
What is the most appropriate investigation at this stage?
A. Glycated haemoglobin
B. HIV test
C. Sexually transmitted infection screen
D. Test her partner for candidiasis
E. Vaginal pH testing
28. A 25 year old man sustains 40% full-thickness burns in a house fire. Despite
intensive treatment, he becomes breathless and hypotensive. He develops a
petechial rash.
His temperature is 38°C, pulse rate 110 bpm, BP 80/50 mmHg and oxygen
saturation 96% breathing 40% oxygen.
Investigations:
Haemoglobin 110 g/L (130–175)
White cell count 4.2 × 109/L (3.8–10.0)
Platelets 15 × 109/L (150–400)
APTT 75 seconds (22–41)
PT 25 seconds (10–12)
Firbinogen 0.7 g/dL (1.5–4.0)
Fibrinogen degradation products 137 mg/mL (<8)
A. Anaphylactic reaction to antibiotics

B. Disseminated intravascular coagulation
C. Fat embolism
D. Immune thrombocytopenic purpura

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29. A 67 year old woman suddenly loses the vision in her left eye. She is in good
health with no history of eye disease and is not taking any medication.
Her right eye is normal. The left has vision reduced to hand movements only. The
left pupil reacts sluggishly to light. Her fundal photograph is shown (see image).
Which is the cause of her sudden loss of vision?
A. Branch retinal artery occlusion

B. Branch retinal vein occlusion
C. Central retinal artery occlusion
D. Central retinal vein occlusion
E. Cilioretinal vein occlusion

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30. A 78 year old man develops increasing confusion on the ward at night. He is
wandering around naked asking for his wife, shouting, and threatening staff and
patients. He was admitted this morning with 1 week of productive cough and
temperature. He has a history of idiopathic Parkinson's disease.
His temperature is 37.6°C, pulse rate 100 bpm, BP 132/71 mmHg and oxygen
saturation 95% breathing air. His capillary blood glucose is 5 mmol/L.
Attempts to calm him with nursing measures do not improve the situation, and he
begins hitting staff.
Which is the most appropriate treatment?
A. Amitriptyline
B. Haloperidol
C. Immediate release carbidopa-levodopa
D. Lorazepam
E. Risperidone
31. A 78 year old woman has back pain and bilateral leg weakness. She had surgery
for breast cancer 14 years ago. She had a minor fall at home a few days ago.
She has weakness of hip flexion bilaterally.
A. Lumbar disc prolapse

B. Mechanical back pain
C. Osteomalacia
D. Osteoporotic vertebral collapse
E. Spinal cord compression
32. A 65 year old woman had a stroke 2 weeks ago causing right arm weakness and
dysphasia. CT scan of head showed a left parietal lobe infarct. Her medication
since the stroke includes aspirin and simvastatin.
Her pulse rate is 82 bpm and irregular.
Investigations:
ECG: atrial fibrillation, rate 68 bpm.
Which is the most appropriate long-term plan for secondary stroke prevention?
A. Apixaban
B. Aspirin
C. Aspirin and dipyridamole
D. Clopidogrel
E. Ticagrelor

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33. A 49 year old man has 3 days of cough and fever. He undergoes haemodialysis
three times per week.
His temperature is 38.6°C, pulse rate 90 bpm, BP 122/80 mmHg, respiratory rate
30 breaths per minute and oxygen saturation 95% breathing 15 L/min oxygen via
a non-rebreather mask. His JVP is 4 cm above the sternal angle. He has
inspiratory crackles in the right mid and lower zone and left upper zone. His blood
capillary glucose is 12 mmol/L.
Investigations:
Sodium 131 mmol/L (135–146)
Potassium 5.7 mmol/L (3.5–5.3)
Urea 16.7 mmol/L (2.5–7.8)
Creatinine 327 μmol/L (60–120)
Chest X-ray: see image
Which is the most appropriate initial treatment?
A. Haemodialysis
B. Intravenous 10 mL 10% calcium gluconate
C. Intravenous 1000 mL 0.9% sodium chloride over 1 h
D. Intravenous co-amoxiclav and clarithromycin
E. Intravenous furosemide

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34. A 78 year old woman is admitted after been found collapsed at home. She has
been lying on the floor overnight. She has a history of hypertension and takes
amlodipine.
Her temperature is 35.8°C, pulse rate 88 bpm and irregular, and BP 102/60
mmHg.
Investigations:
Sodium 136 mmol/L (135–146)
Potassium 5.8 mmol/L (3.5–5.3)
Urea 20.9 mmol/L (2.5–7.8)
Creatinine 180 μmol/L (60–120)
Creatine kinase 870 U/L (25–175)
Urinalysis: glucose negative, ketones negative, blood 2+, protein 1+, leucocytes
positive (catheter sample).
She has passed 60 mL of urine over the past 2 hours.
Which is the most likely cause for her acute kidney injury?
A. Glomerulonephritis
B. Hypovolaemia
C. Renal arterial emboli
D. Rhabdomyolysis
E. Ureteric obstruction
35. A 64 year old woman develops an acutely painful right knee 3 weeks after a
prosthetic right knee replacement. Her temperature is 38.2°C and pulse rate 103
bpm. Her right knee is inflamed, with serous fluid discharging from the lower end
of the wound.
Which is the most likely causative organism?
A. Corynebacterium species
B. Enterococcus species
C. Pseudomonas aeruginosa
D. Staphylococcus aureus
E. Streptococcus pyogenes

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36. A 65 year old woman has an infective exacerbation of COPD.
Her temperature is 37.8°C, pulse rate 108 bpm, BP 100/75mmHg, respiratory

rate 26 breaths per minute and oxygen saturation 88% breathing 15 L/minute
oxygen via a non-rebreather mask. She is alert.
Investigations:
Arterial blood gas on 15 L/min oxygen
pH 7.28 (7.35–7.45)
PO2 7.2 kPa (11–15)
PCO2 8.9 kPa (4.6–6.4)
Bicarbonate 31.3 mmol/L (22 – 30)
Lactate 1.2 mmol/L (1 – 2)
Which is the most appropriate next management option?
A. Continuous positive airway pressure

B. Invasive ventilation
C. Nasal high flow oxygen
D. Nasopharyngeal airway
E. Non-invasive ventilation
37. A 79 year old man attends the Emergency Department with 2 hours of chest pain
and light headedness.
His ECG is shown (see image).
Which is the most likely explanation for the ECG findings?
A. Aortic dissection
B. Hyperkalaemia
C. Myocardial infarction
D. Pericarditis

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38. A 50 year old woman has acute onset of shortness of breath. She underwent a
laparoscopic cholecystectomy 10 days ago. Her temperature is 37.4°C, pulse
rate 104 bpm, BP 122/80 mmHg, respiratory rate 24 breaths per minute and
oxygen saturation 94% breathing air. Her chest is clear. She has minimal
tenderness over the right hypochondrium.
A. Myocardial infarction
B. Pancreatitis
C. Pneumonia
D. Pulmonary embolus
E. Subphrenic abscess
39. A 16 year old girl presents to the Emergency Department after an episode of loss
of consciousness following a fall. She had consumed an excessive amount of
alcohol at a party before the fall. She has a dirty scalp wound and cannot
remember recent events. Her pulse rate is 68 bpm, BP 110/80 mmHg and
oxygen saturation 98% breathing air. She opens her eyes to command and is
confused. Her capillary blood glucose is 6.0 mmol/L.
Her wound is cleaned and sutured.
Which is the most appropriate immediate management plan?
A. Admit and observe for 24 h

B. CT scan of head
C. Discharge with head injury instructions
D. Refer to neurosurgeon
E. X-ray of skull
40. A 47 year old woman has 1 year of increased urinary frequency, urgency and
nocturia. She finds that she leaks urine if she is unable to get to the toilet
promptly. She had three normal pregnancies with no complications. The
perineum appears normal and there is no uterine prolapse. Incontinence is not
provoked by coughing or straining. Urinalysis is negative. A postmicturition
ultrasound scan of bladder shows minimal residual urine volume.
Which is the most appropriate initial management plan?
A. Botulinum toxin type A injection into bladder wall

B. Oral duloxetine
C. Oral oxybutynin
D. Percutaneous sacral nerve stimulation
E. Topical oestrogen

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41. An 80 year old man presents to the Emergency Department with 2 hours of
epistaxis that has not stopped despite compression. He has a history of
hypertension. A bleeding site is visible in the anterior nasal cavity. His BP is
160/95 mmHg.
Which is the most appropriate initial management option?
A. Anterior pack
B. Antihypertensive medication
C. Cautery
D. Cryotherapy
E. Ice pack
42. A 23 year old man attends the sexual health clinic with a painful swelling in his
groin and pain when opening his bowels. He had unprotected anal sex with a
new male partner 4 weeks ago. He has a perianal ulcer and tender inguinal
lymphadenopathy.
A. Genital herpes
B. Gonorrhoea
C. HIV seroconversion
D. Lymphogranuloma venereum
E. Secondary syphilis
43. A 25 year old man presents to the Emergency Department after vomiting a large
quantity of blood. At endoscopy, a deep ulcer is identified in the posterior wall at
the junction of the first and second parts of the duodenum. There is a bleeding
vessel in the base.
From which artery is the bleeding most likely to be arising?
A. Gastroduodenal artery
B. Left gastric artery
C. Short gastric artery
D. Splenic artery
E. Superior mesenteric artery

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44. A 63 year old man with COPD has had an increase in cough for 2 days. He now
has pain of sudden onset in the right side of his chest radiating to the right
shoulder, and increasing breathlessness.
Chest X-ray: see image.
Which is the most likely cause of his acute deterioration?
A. Acute myocardial infarction

B. Diaphragmatic hernia
C. Lobar pneumonia
D. Pneumothorax
E. Pulmonary embolus

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45. A 27 year old woman has a long history of irregular menstruation. She does not
take any medication. Her BMI is 29.4 kg/m2.
Investigations:
LH (pre-menopausal female) 15 U/L (follicular) (1–11)
FSH 6 U/L (follicular) (2–8)
Testosterone 3.5 nmol/L (0.2–2.9)
Cortisol post 1 mg dexamethasone 40 nmol/L (<50)
Prolactin 425 U/L (100–500)
A. Androgen secreting tumour

B. Cushing's syndrome
C. Polycystic ovary syndrome
D. Premature ovarian failure
E. Prolactinoma
46. An 18 year old man is in the intensive care unit with septic shock as a result of a
compound fracture of his leg. His urine output has been <30 mL for the past 2
hours.
His pulse rate is 125 bpm, BP 85/40 mmHg and JVP 4 cm above the sternal
angle. There are basal crackles on auscultation of the chest.
Investigations:
ECG shows sinus rhythm, 125 bpm.
He is being treated with intravenous 0.9% sodium chloride at 125 mL/h and
antibiotics.
Which is the most appropriate additional intravenous treatment?
A. 500 mL 0.9% sodium chloride over 15 min

B. 500 mL Hartmann's solution over 15 min
C. Dopamine hydrochloride
D. Furosemide
E. Noradrenaline/norepinephrine

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47. A 80 year old man has progressive memory loss over 2 years.
He scores 20/30 on the Montreal Cognitive Assessment, and he requires an MR

scan of brain.
In which part of the brain are changes most likely to be found in early Alzheimer’s
disease?
A. Basal ganglia
B. Frontal lobe
C. Medulla oblongata
D. Parietal lobe
E. Temporal lobe
48. A 43 year old woman is admitted to hospital with an overdose of amitriptyline

hydrochloride taken 4 hours previously. She has a history of chronic headache.
Her pulse rate is 105 bpm and BP 95/40 mmHg. She is drowsy and her pupils are
dilated. ECG shows significant QRS prolongation.
Which is the most appropriate immediate management option?
A. Activated charcoal
B. Intravenous amiodarone hydrochloride
C. Intravenous atropine sulfate
D. Intravenous magnesium
E. Intravenous sodium bicarbonate
49. A 76 year old man undergoes an abdominoperineal resection for a low rectal
carcinoma. He has a history of severe COPD and hypertension.
Which is the most appropriate method for providing analgesia during the early
postoperative period?
A. Epidural anaesthesia
B. Intramuscular opioid
C. Oral non-steroidal analgesia
D. Patient controlled intravenous analgesia
E. Spinal anaesthesia

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50. A researcher is seeking to examine whether long-term mobile phone use is linked
to acoustic neuroma risk. The information on mobile phone usage is collected
from participants with acoustic neuroma and a comparable group of participants
without acoustic neuroma, selected from the general practice register.
Which type of study design is being used?
A. Case–control study
B. Case series
C. Cohort study
D. Cross-sectional study
E. Ecological study
51. A 56 year old woman has home blood pressure readings averaging 160/90
mmHg. Hypertension is confirmed on 24-hour ambulatory monitoring. She has
type 1 diabetes mellitus.
Investigations:
Urinary albumin: creatinine ratio 42 mg/mmol (<3.5)
eGFR 43 mL/min/1.73 m2 (>60)
Which type of antihypertensive is most appropriate?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Calcium channel blocker
E. Thiazide-like diuretic
52. A 31 year old woman is admitted with 24 hours of confusion. She is having visual
hallucinations of snakes and mice on the floor. Her partner says that she often
drinks 80 units of alcohol per week. He has not seen her for the past week. She
has a history of depression and takes fluoxetine. Her temperature is 37.6°C,
pulse rate 100 bpm and BP 162/98 mmHg. She is disorientated in time and
place. She has no focal neurological deficit.
A. Delirium tremens
B. Fluoxetine overdose
C. Hepatic encephalopathy
D. Korsakoff's psychosis
E. Wernicke's encephalopathy

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53. A 43 year old woman has a sudden severe headache that started 24 hours ago.
She has a history of autosomal dominant polycystic kidney disease. Her
temperature is 36.8°C, pulse rate 92 bpm and BP 140/100 mmHg. Neurological
examination is normal. CT scan of head is normal.
Which is the most appropriate next step in management?
A. Erythrocyte sedimentation rate

B. Lumbar puncture
C. MR scan of brain
D. Refer to outpatient headache clinic
E. Start amlodipine
54. A 74 year old man has progressively worsening muscle aches that are now
causing him to struggle to get up from a chair or raise his arms above his head.
He has a history of oesophageal cancer treated surgically and ischaemic heart
disease. He is taking bisoprolol, clopidogrel, ramipril and simvastatin.
Investigations:
Haemoglobin 125 g/L (130–175)
White cell count 7.8 x 109/L (3.0–10.0)
Platelets 391 x 109/L (150–400)
Erythrocyte sedimentation rate 105 mm/hr (<20)
Which is the most appropriate therapeutic change?
A. Start co-codamol
B. Start ibuprofen
C. Start prednisolone
D. Stop bisoprolol
E. Stop simvastatin

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Answers:
1. Correct Answer(s): C
Justification for correct answer
Epinephrine the only recommended treatment for asystole. Atropine no longer
recommended.
2. Correct Answer(s): E
The scenario describes typical features of polymyalgia rheumatica, which responds
well to prednisolone and poorly to analgesics such as Naproxen or cocodamol. No
features to suggest inflammatory arthritis
3. Correct Answer(s): B
Carbon monoxide inhalation likely. Will not show on pulse oximeter as is read as
oxyhaemoglobin
This is a prospective cohort study where a group of individuals who differ with
respect to one or more factors are followed, to determine how these factors affect
outcomes. A case-control study finds individuals with a given outcome along with a
suitable control group and looks back retrospectively at how many individuals from
both groups had the exposure(s) of interest. A cross-sectional study measures
prevalence in a population at a given point in time. A randomised clinical trial tests
the effects of a specific intervention or interventions against a control group. A
retrospective cohort begins after the outcome has occurred and looks back at the
exposure of interest.
This is typical of Koebnerisation. Psoriasis is by far the commonest underlying cause,
though it can also occur in vitiligo.
6. Correct Answer(s): A
Cabergoline (a dopamine agonist) is the first-line treatment for a micro- and
macroprolatinomas.
i-gels are often used in cardiac arrest situations as they are easier to place than
tracheal tubes. However, only the tracheal tube can seal the trachea off and protect
against aspiration.
Most likely cause in this setting - common phenomenon.
CXR to rule out other pathology before Well’s score and then CTPA (or V/Q) if PE
likely or D-dimer if PE unlikely. (NICE CG144) Diagnostic investigations for

lOMoARcPSD|1492543
25
pulmonary embolism 1.1.7 If a patient presents with signs or symptoms of pulmonary

embolism (PE), carry out an assessment of their general medical history, a physical
examination and a chest X ray to exclude other causes. [2012]

http://www.aagbi.org/sites/default/files/Perioperative_fasting_in_adults_and_children
__.4 .pdf Standard national guidelines for elective patients with no problems affecting
gastric emptying. Too long a period of fasting is unnecessary whilst residual solid
food in the stomach poses a big risk of aspiration/asphyxiation.

This is a non-functional thyroid nodule so needs ultrasound to classify - FNA may
then be indicated.

Discrimination is the unjust or prejudicial treatment of different categories of people.

Cocaine-induced ACS.

Separate and can get above mass which is cystic is an epididymal cyst
(spermatocele) which is benign and usually asymptomatic and managed
conservatively. Although a hydrocele trans illuminates it would surround the testis.

Maintenance fluid requirements for someone with underlying cardiac disease is
recommended as 20-25 mL/kg. This gives an upper volume of 25 x 70= 1750. This
conforms to current NICE guideline CG 174 (2013).
16. Correct Answer(s): D

This woman has delirium. Therefore, low dose haloperidol would be the best option,
according to NICE guidelines.

Myasthenic crisis is an acute respiratory failure characterised by forced vital capacity
(FVC) below 1 L, negative inspiratory force (NIF) of 20 cm H2O or less, and the need
for ventilatory support. The use of accessory muscles indicates significant inspiratory
weakness. Weak cough indicates weakness of expiratory muscles. Arterial blood gas
analysis commonly shows hypercapnia before hypoxia. There should be a low
threshold for endotracheal intubation due to rapid deterioration of bulbar and
respiratory muscles.


lOMoARcPSD|1492543
26
Pneumothoraces are more commonly encountered in young, tall men who smoke.
There is no past medical history provided in the vignette confirming the presence of
existing lung disease - this excludes secondary pneumothorax as a diagnosis.

Atropine is the first line initial treatment for sinus bradycardia.

The combination of lateralisation of Weber’s test to the right and a negative Rinne’s
test on the right (i.e. bone conduction louder than air conduction) occurs with right
conductive deafness. This also fits with the clinical history of a recent respiratory tract
infection.

Joint British Diabetes Societies' 2016 guidelines - Management of adults with
diabetes undergoing surgery and elective procedures: Improving standards.
Principles are to minimise fasting times (hence first on list) and disruption to usual
medication. In this setting where the procedure is fairly minor, patient should be
eating again at lunchtime and hence there is no call for insulin in any form. Specifics
are in Appendix 2 of document. https://www.diabetes.org.uk/resources-s3/2017-
09/Surgical%20guidelines%202015%20-
%20full%20FINAL%20amended%20Mar%202016_0.pdf

The description fits with partial seizure affecting his right hemisphere as a result of a
previous stroke.

Triad of headache, nausea/vomitting and ataxia. Profound imbalance, sudden onset
and prominent headache suggest cerebellar stroke.

Despite gradual improvement this venous ulcer would be best managed with
stockings, which would also help prevent further lesions.

Opens eyes in response to voice = 3 Confused, disoriented = 4 Localizes painful
stimuli = 5.

All the symptoms and signs described can occur with acute glaucoma. Uveitis whilst
causing red eye, headache and visual disturbance is associated with a small pupil.
Scleritis, corneal ulcer and conjunctivitis are not generally associated with headache
and nausea or a significant drop in visual acuity.

lOMoARcPSD|1492543
27

Recurrent candidiasis indicates the need to test for diabetes mellitus.

The history, signs and investigations are all most indicative of DIC.
29. Correct Answer: B (No justification provided)
30. Correct Answer: D

Whilst anti-psychotics are first-line to manage delirium where medication required,
they are contra-indicated in Parkinson’s disease. (NICE CG103 Delirium: prevention,
diagnosis and management).
31. Correct Answer: E (No justification provided)
32. Correct Answer: A

For patients with a stroke and AF should start anticoagulation as secondary
prevention. This can be with either warfarin or with a factor Xa inhibitor such as
apixaban. This is covered in both NICE AF guidelines
(https://pathways.nice.org.uk/pathways/atrial-
fibrillation#path=view%3A/pathways/atrial-fibrillation/preventing-stroke-in-people-
with- atrial-fibrillation.xml&content=view-node%3Anodes-anticoagulation-treatment )
and the most recently updated stroke guidance (2016)
(https://www.rcplondon.ac.uk/guidelines- policy/stroke-guidelines ). This version
reflects increasing use of the novel oral anticoagulants, which FY doctors need to be
aware of.

This patient has severe pneumonia with evidence of multifocal consolidation on the
chest X-ray. He requires treatment with antibiotics first. The other interventions are
not indicated.
34. Correct Answer: B

This patient is hypovolaemic due to long lie without hydration and the probably
sepsis. The level of CK is compatible with minor soft tissue injury. Rhabdomyolysis
would give a CK of >10,000. There is no indicators of glomerulonephritis and the
urinalysis abnormalities are compatible with a catheter sample +/- urosepsis. Renal
emboli are rare and would give loin pain. Ureteric obstruction is unlikely as the
patient is still passing some urine.

Staphylococcus is responsible for 20-25% of prosthetic joint infections, with
coagulase negative staph next (not included on list). The other bacterial causes
would be rare. Candida is also very uncommon.

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28
36. Correct Answer: E

Respiratory acidosis needs to be corrected with ventilation in an alert patient.
37. Correct Answer: C

Classic STEMI

This is because she is most likely to have suffered pulmonary embolus after period of
surgery.

Current guidelines. Safety issue. A child of 16 doesn't need a tetanus booster.

Immediate release anticholinergics are the first line treatment for overactive bladder
with urge incontinence in the NICE 2013 guidelines.

Minor bleeding from an accessible site can be treated with cautery using a silver
nitrate stick or electrocautery. Anterior pack is for profuse bleeding with site difficult to
localise. Anti hypertensives will only prevent further attacks of epistaxis. Cryotherapy
and ice pace of little advantage and secondary.

Proctitis and lymphadenopathy make LGV the most likely - and is endemic in MSM
population in UK.

The gastroduodenal artery runs posterior to the first and second parts of the
duodenum and may be a source of major haemorrhage in peptic ulcer disease.
44. Correct Answer: D (No justification provided)

The increased ratio of LH:FSH along with oligomenorrhoea and BMI in the
overweight range indicates PCOS is most likely. A mild elevation in prolactin is
sometimes seen in PCOS.

Description of adequate (if not over) hydration. Needs vasoconstriction.
47. Correct Answer: E (No justification provided)

lOMoARcPSD|1492543
29

Bicarbonate is the treatment of the choice in patients with prolonged QRS complexes
following a tricyclic antidepressant overdose.

This is because for major abdominal surgery in respiratory disease opioid, by
whatever route, should be avoided. Epidural is best because it can be topped up and
titrated; spinal anaesthesia cannot. Transcutaneous electrical nerve stimulation has
been used for postoperative pain, but trial results are contradictory. Intramuscular
injection is difficult to titrate.
50. Correct Answer: A (No justification provided)

There is good evidence for renal function protection in diabetic nephropathy with
ACE-1 in addition to its hypertensive properties.

The patient has typical features of delerium tremens with confusion, visual
hallucinations, tachycardia and pyrexia on the background of heavy alcohol use. This
normally occurs on reduction or abstinence, which may not be clear from the history.

This is because APKD is associated with subarachnoid haemorrhage. A lumbar
puncture should be performed. MRA would be reasonable, but not MRI.

Classical PMR history, presentation and raised inflammatory markers.

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Practice MCQ Mscaa Questions for Year 4-2

Senior Medicine and Surgery (University of Bristol)

Studocu is not sponsored or endorsed by any college or university

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He has no pulse and an ECG shows asystole. Chest compressions and

Which is the most appropriate next step in management?

What is the most appropriate initial treatment?

3. A 36 year old man is rescued from a housefire.

Which is the most appropriate parameter to measure?

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Which is the best description of this type of study?

What is the most likely underlying skin condition?

Visual field examination is normal.

MR scan of pituitary shows a 4-mm mass in the sella turcica.

Which is the most appropriate management?

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A. Guedel (oral) airway

Her temperature is 37.1°C, pulse rate 90 bpm and BP 120/80 mmHg.

Which is the most likely diagnosis?

A. Low pressure headache

Which is the most appropriate next investigation?

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A. 2 h for clear liquids, 2 h for solids

Which is the most appropriate next investigation?

What is the most appropriate description of the clinician's approach?

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A. Blockade of myocyte repolarisation

There is a well-defined, non-tender spherical 1 cm mass on the right side of the

Which is the most likely diagnosis?

He weighs 70 kg. His pulse rate is 72 bpm and BP 132/80 mmHg.

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What is the most appropriate treatment?

Which is the most appropriate test to monitor his respiratory function?

A. Arterial blood gas

What is the most likely diagnosis?

A. Acute coronary syndrome

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Which is the most appropriate initial treatment?

Tuning fork tests show:

A. Bilateral mixed deafness

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Her glycated haemoglobin is 54 mmol/mol (20–42). She is scheduled first on the

A. Continue both drugs and start a variable-rate insulin infusion

There is no weakness on neurological examination.

Which is the most likely diagnosis?

Which is the most likely diagnosis?

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Which is the most appropriate management?

What is her GCS?

Which is the most likely diagnosis?

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What is the most appropriate investigation at this stage?

Which is the most likely diagnosis?

A. Anaphylactic reaction to antibiotics