PLABABLE EXPLANATIONS (Some of the explanations are not complete but they will be

complete at the end of the 15th of October 2023. As explanations will be updated on this
day too to better answer your questions during the discussion on the last day)
1. In a patient with a sudden onset, severe headache, and normal CT scan, SAH must still
be ruled out, as the CT scan may not detect biood if performed very early in the course of
SAH. Lumbar puncture is the next step to look for xanthochromia and red blood cells in the
cerebrospinal fluid. This will confirm or exclude the diagnosis of SAH Even if you were
thinking migraine, you still need to do an LP first because a CT scan was arranged (which
means that the clinicians originally thought it was a SAH) So commit to your suspected
diagnosis.

2.Beta blockers (Propranciol) should not be used in patients with asthma due the risk of
bronchospasm. Amitriptyline is second line. Topirimate should be avoided in women of
childbearing age as it is contraindicated in pregnancy.

3.The patient presents with symptoms suggestive of acute sinusitis and has a fever, which
suggests an inflammatory process. According to NICE CKS guidelines, the management of
acute sinusitis is primarily focused on symptomatic relief Oral paracetamol can be used to
relieve pain, reduce inflammation, and lower the fever. Nasal pseudoephedrine is a
decongestant, but there is insufficient evidence to recommend its use, and the same applies
to oral cetirizine, an antihistamine Nasal corticosteroids can reduce inlammation, but are not
recommended as firstline treatment by NICE CKS Nasal steroids should be considered if
the patient has been having symptoms

for 10 days or more.

4. Clopidogrel should be used as a second antiplatelet medication in the context of

anticoagulated patients (warfanin/DOAC). Usually patients will be started on aspinin and
ticagrelor post-MI.

5. The patient has salicylate poisoning, as indicated by the history of aspirin ingestion and
the elevated salicylate level Salicylate poisoning initially causes a respiratory alkalosis due
to direct stimulation of the respiratory centre in the medulla, leading to hyperventilation. This
is reflected in the ABG with a high pH and low PaCO2 Though salicylate poisoning can also
lead to a metabolic acidosis, in this case, the bicarbonate level is 22 mmolit, which does not
support a concurrent metabolic acidosis Therefore, the primary

acid-base disturbance is respiratory alkalosis

6. Large secondary pneumothorax requires chest drain

Initial management for someone who is overweight (BMI 25-29.9) is to provide detailed
advice on diet, physical activity, and behavioural changes. Referral to a dietician or
consideration of ather interventions might be appropriate if initial advice does not result in
weight loss or if there are other health issues involved.
7. Adult polycystic kidney disease is an autosomal dominant condition.

8. This syndrome is characterized by the repeated, effortless regurgitation of recently

ingested food. it is not preceded by retching, which differentiates it from conditions like
bulimia nervosa where vomiting is induced, The food can be re-chewed, re swallowed, or
spit out. Compensatory behaviours are only seen in anorexia and bulimia.

10. Neisseria gonorhoeae = G =Gram negative negative diplococci

11.The patient's presentation is typical for cluster headache, characterised by severe,

unilateral headache episodes lasting from 15 minutes to 3 hours, onand often associated
with ipsilateral ptosis, lacrimation, nasal congiestion, and restlesness. The attacks are
recurrent and can happen up to several times a day, typically at the same time each day,
and they are more frequent at night. Atypical facial pain would usually present with pain that
can be anywhere in the face, often described as deep, aching, or burning The pain is
usually continuous, lasting for hours to days, in contrast to cluster headache which can be
more episodic.

12. Rotavinus vaccine is a live attenuated vaccine It is given as 2 doses, 4 weeks apart.
Usually the first dose is given at 8 weeks, and the second dose at

13. Major bleed, PCC works the fastest Faster than FFP Faster than Vit K

14. 70kg x 3mg- 210mg

1% lidocaine is 10 mg/m

210/10=21 L
15. For a woman who presents wim a fixed breast lump and has a suspicious- next step to
cytological and histological details

16. This is Hirachsprung's disease, a denervated segment of farge bowel leading

obstruction

17.Performing changes based on audit findings and then re-auditing ensures the
discrepancies in care are addinessed and verifies that the implemented changes have
brought practices in line with NICE CKS recommendations.

Simply increasing the number of patients in the audit might provide a larger sample size, but
it does tome GP surgeries are very small and may not have the capacity to obtain a large
sample size

18. A normal CT scan can occur especially a delay in presentation. A puncture should be
performed >12 hours after headache onset looking for xanthocromia a hemoglobin
degradation product.

19. Morphine is known to provide immediate relief from sensation of breathlessness. It acts
centrally on the brain reduce the perception of dyspnea

Nebulized bronchodilator would be more appropriate if primary issue was bronchospasm,

such as in asthma or copd (or perhaps a tumor obstructing the airways)

21. You need something that Netwased adrenalize work fastest and is part of the treatment
for severe croup .Steroids take a lot longer to work

22. This pregnant woman has presented with symptoms of pulmonary embolism. Firstline
investigation include an ECG and Chest Xray. The next investigation would be v/q scan
(first choice over ctpa in pregnancy)

23.The boys presentation with barking cough, and symptoms worsening at night is
suggestive of croup. The most common viral cause of croup is Para influenza specifically
type 1 virus
24. She has missed more than two combined oral contraceptive pills (>48 since the last pill)
She should take one pill as soon as possible and take the next one on time (even if it
means taking two pills in one day).

She must use condoms/abstinence for the next seven days, She was in the third week of
the pill packet and therefore does not need emergency contraception but should omit the
pill-free interval (run the next pack back-to-back).

25. One condition that comes to mind given the systolic murmur at the left lower sternal
border and apex and his age is hypertrophic cardiomyopathy (HCM) HCM is one of the
leading causes of sudden cardiac death in young athletes. usually resulting from ventricular
arrhythmias, specifically ventricular tachycardia or ventricular fibrillation.

The most appropriate next step would be to refer urgently to a cardiologist. The cardiologist
would arrange an echocardiogram and possibly a cardiac MRI and exercise testing

26. HELLP Syndrome = Haemolysis (low haemoglobin), Elevated liver enzymes (raised
ALT) and Low platelets It is a severe form of pre-eclampsia. Acute fatty liver disease is
assoicated with jaundice and abnormal liver synthetic function (low albumin, raised INR)
and raised ammonia

27.The combination of severe headache, fever, and a progressively altered level of

consciousness in this young man raises concerns for meningitis. A lumbar puncture is
crucial for diagnosing and distinguishing between viral and bacterial meningitis

28 Metabolic acidosis

29. The murmur described is consistent with tricuspid regurgitation. Given the patient's drug
dependence, he is at risk for infective endocarditis, particularly of the right side of the heart.
A transthoracic echocardiogram (TTE) is often the initial investigation of choice to assess
valvular pathology and function

30. Pulled elbow occurs when a child (usually <4 years old) is abruptly lifted by their wrist or
arm. This leads to slippage of the annular ligament off the head of the radius, leading to
partial dislocation. Treatment is by reduction which leads to instant resolution of pain

31. IV morphine is part of the management. Oxygen here would only be given if his sats
were <94%. We do NOT give IV aspirin or IM opioids for acute Mi

32. No explanation

33.The patient's history and clinical presentation are consistent with a wound infection
following a human bite, given the contact with another person's teeth, Human bites are
considered polymicrobial and can be contaminated with both aerobic and anaerobic
bacteria. Co-amoxiclav is the drug of choice for treating human bite wound infections due to
its broad-spectrum activity against the common pathogens involved.

34.The initial test would be endoscopy, but the questions asks for DIAGNOSIS -
oesophageal manometry.

35. Given the sudden forceful pull and the popping sound described, it is important to first
rule out a fracture or any other bony injury. In children, especially around the age of 3, the
bones are still growing and can be prone to specific types of fractures, such as "greenstick"
or "buckle" fractures.

The mechanism of injury described - a sudden pulling of the arm - is a

common cause for a specific type of dislocation called a "nursemaid's elbow" or "pulled
elbow", This occurs when there is a partial dislocation (subluxation) of the radial head from
its usual position in the annular ligament. It is a common injury in children under the age of
5. "Manipulation under analgesia to realign any potential dislocation" is also a very relevant
choice, and in many cases, given the classic presentation, a clinician might opt for a
reduction manoeuvre before obtaining an X-ray However, always proceeding with caution
and considering the specific clinical presentation is crucial, so Xray is a better choice.
Especially since there is a popping sound which is not typical in a "pulled elbow".

36. This is SVT Valsalva manoeuvres and carotid massage are first line treatment, but
carotid massage should not be performed when carotid stenosis is suspected (auscultation
of a bruit)

37. A 2 week wait referral to gastroenterology would be the best management plan. It is
quicker than urgent referrals and are suitable for suspected cancers. The presence of a
palpable left supraclavicular lymph node (often called Virchow's node) is concerning for
malignancy, often of gastric origin. Gastric malignancies can manifest with signs of
unintentional weight loss and fullness.

38. This is winged scapula caused by damage to the long thoracic nerve

39. The clinical picture described is consistent with signs of both upper and lowe motor
neuron dysfunction. The presence of fasciculations (which are

spontaneous, often twitchy contractions of portions of muscles) is typically associated with

lower motor neuron damage. The exaggerated jaw jerk refle and the increased ankle jerk
reflex suggest hyperactivity of certain reflexes. indicative of upper motor neuron
dysfunction. Motor neuron disease is a group of diseases that primarily affect the neurons
responsible for controlling voluntary muscles. The most common form of MNL in adults is
amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. ALS affects both
upper and lower motor neurons, which fits the presented symptoms.

While multiple sclerosis can produce motor symptoms like muscle weakness and spasticity
(increased muscle tone), it does not typically cause the combination of both upper and
lower motor neuron signs as described in the patient's presentation.

40. His mental capacity needs to be assessed to determine if he has capacity to decline
treatment.

41. For those taking a contraceptive containing ethinylestradiol and levonorgestrel which is
combined oral contraception, if a tablet is missed, the general advice is to take the missed
tablet as soon as remembered. If it coincides with the time for the next dose, both tablets
can be taken simultaneously. The timely consumption of the pill ensures effective

contraceptive protection

42. To confirm the presence of sickle cell disease, an invasive test is required. An
amniocentesis can be performed after 14 weeks. CVS is performed before 14 weeks

Non-invasive prenatal testing is not DIAGNOSTIC.

The combined test is a screening test for Down's, Edwards and Patau syndrome

43. NICE CKS recommends nitrofurantoin as the first choice antibiotic for lower urinary tract
infections in pregnancy as long as it is not during term.
44. Migraine acute treatment includes the use of sumatriptan taken at the start a headache,
https://cks.nice org uk/topics/migraine/management/adults/

45. Clozapine, an atypical antipsychotic, is associated with a risk of QT prolongation on the

ECG, which can potentially lead to serious arrhythmias such as torsade de pointes. Regular
cardiac monitoring is crucial for patients on clozapine. While other ECG changes can occur
with various conditions, QT prolongation is the finding most specifically linked to clozapine.

46. This woman has gestational diabetes. Firstline treatment is with diet and lifestyle advice.
If no improvement in capillary glucose readings after 1-2 weeks then she should be offered
metformin.

Gestational diabetes is diagnosed on OGTT: - Fasting glucose >=5.6 - 2-hour glucose >=7.8

47. In paediatric life support, if a child is unresponsive and not breathing or breathing is
abnormal, it is recommended to give 5 initial rescue breaths.

48. As prevalence increases, positive predictive value increases.

Norovirus is a common cause of viral gastroenteritis, particularly in closed environments like

care homes, hospitals, and schools. The patient's symptoms, coupled with the similar
presentation in multiple residents and staff at her workplace, make a norovirus outbreak the
most likely scenario.

49. Clostridium difficile, one of the main contenders, is usually associated with recent
antibiotic use and causes pseudomembranous colitis.

50 This patient has Wernick's encephalopathy.

51. Ejection systolic murmur radiating to the carotids is the hallmark clinical finding in aortic
stenosis

52. Acute Lymphoblastic Leukaemia (ALL) - The commonest childhood leukaemia -

Depression of all three cell lineages - Peak age is 2-4 years old

53. This man appears to be experiencing a manic episode which are features of bipolar
disorder

According to NICE CKS, individuals newly diagnosed with bipolar disorder in the acute
phase may be recommended the following medications for the management of mania:
Haloperidol

Olanzapine

Quetiapine
Risperidone

Note: Aripiprazole and chlorpromazine are antipsychotics used for mania too but not
mentioned in NICE CKS.

54. An adjustment disorder is an emotional or behavioral reaction to a stressful event or

change in a person's life. The reaction is considered an unhealthy or excessive response to
the event or change within three months of it happening.

55. Fluclox to cover Staphylococcus aureus.

56. Bell's palsy is an acute, usually unilateral, lower motor neuron paralysis of cranial nerve
VII (facial nerve), It is a clinical diagnosis of exclusion. Peak incidence is around 20-40
years old.

Clinical features

- Preceding peri-auricular pain

- Acute unilateral weakness of the facial muscles (affecting the forehead)

- Unilateral decreased lacrimation

Unilateral hyperacusis (loss of innervation to the stapedius muscle) - Unilateral loss of taste
(anterior 2/3 of the tongue)

Management

- Prednisolone should be started within 72 hours of symptom onset - Antiviral treatment is

not recommended (never as monotherapy)

57. The patient's presentation is consistent with acute limb ischaemia, which is a surgical
emergency, The findings suggest that there may still be some collateral blood flow, given
the intact sensation and capillary refill, but the compromised strength indicates an
impending severe ischaemia. Immediate surgical consultation is essential to restore blood
flow.

58. Treatment of syphillis = Benzathine penicillin G.

59. Simple pneumothorax. People with Marfan syndrome are at an increased of

pneumothorax due to their underlying connective tissue abnormalities.

No evidence of tension pneumothorax. While individuals with Marfan syndrome are at an

increased risk for aortic dissection, the described presentation aligns more with a
pneumothorax
60. Scarlet fever is caused by group A streptococcus pyogenes. Strawberry tongue, cervical
lymphadenopathy and red, sandpaper-like rash.

61. The clinical features described are suggestive of Acromegaly In a typical individual
without Acromegaly, oral administration of glucose suppresses the secretion of growth
hormone. In patients with Acromegaly, however, this suppression does not occur, and
growth hormone levels remain inappropriately high after glucose ingestion

62. A homonymous supervior quadrantanopia occurs when there is damage to the inferior
optic radiations (temporal lobe).

63. Malaria. The most direct and conclusive method to diagnose malaria is to for the
parasite in the blood. This is achieved through microscopic examination of blood smears.

64. A dermoid cyst is a benign ovarian growth which can contain hair, sabaceous fluid, teeth
and thyroid tissue. The other ovarian cysts/tumours are beyond the scope of the PLAB
exam.

65. Seborrheic dermatitis can occur in adolescence, The key feature here is the nasolabial
fold involvement.

66.The pneumococcal vaccine should be administered around 4 weeks before surgery if

possible.

The patient should also receive the Haemophilus influenzae type b and Meningococcal
Group C conjugate vaccines if they have not been previously immunised

67. Symptoms consistent with hyperthyroidism. In primary hyperthyroidism, there is an

increased production of thyroid hormones, especially T3, which leads to a reduced level of
thyroid-stimulating hormone (TSH) due to negative feedback mechanisms.

68. NICE guidelines state that in the context of diabetes (regardless of age) - start an ACEi
But in Black/Afro-Carribean patients, use an angiotensin receptor blocker (ARB) rather than
ACE inhibitor. If the patient is not diabetic, then it is important to look at the age and
ethnicity.

69.The presence of wheezing suggests that air is still moving, but with difficulty. The child's
level of consciousness, while decreased, still shows he's responsive and alert. These
clinical details aim to guide the answer towards non invasive management with salbutamol
nebulisers as the next step, rather than moving directly to intubation.
In a clinical setting, it is important to prioritize salbutamol nebulisers over IV hydrocortisone.
The primary concern for the child in the provided scenario is acute bronchoconstriction,
leading to difficulty breathing and decreased oxygenation. Salbutamol is a bronchodilator
and acts rapidly to open up the airways. While steroids like hydrocortisone have a crucial
role in managing asthma exacerbations, their primary effects are anti-inflammatory and take
hours to become fully effective: In contrast, salbutamol's bronchodilating effects are
immediate, However, it's important to note that in a real-life clinical setting, many
interventions might happen simultaneously, depending on the resources and personnel
available. The child in this scenario would indeed be getting systemic steroids, either orally
or IV, in addition to bronchodilators, but the bronchodilators would be the immediate priority

70.This is functional hypothalamic amenorrhoea She is underweight and there is evidence

of a forced vomiting (Russel's sign) and low potassium. Treatment would include support,
referral to eating disorder clinic and gradual weight gain The prolactin level is only mildly
raised and likely not significant.

71. The woman's presentation of tachycardia and low blood pressure suggests she may be
in a state of shock, potentially from causes like sepsis, bleeding. or heart conditions. Given
her relatively normal oxygen saturation at 95% on room air, her primary need is not oxygen
supplementation, The immediate priority in her management is to address her
haemodynamic instability by giving IV fluids.

An ECG would be essential to determine the cause of her tachycardia, but this can be done
later (or simultaneously).

72.First test (screening) = insulin like growth factor 1. Diagnostic test = OGTT with serial
growth hormone measurements. Once acromegally is confirmed, an MRI head is performed
to characterise the lesion.

73.The hallmark of GBS is acute onset of ascending muscle weakness, In the vignette, the
woman has a rapidly progressing difficulty in walking, which aligns with the typical
presentation of GBS, Additionally, the absent deep tendon reflexes in the lower limbs further
support this diagnosis.

Diabetic neuropathy most commonly presents as a sensory polyneuropathy with symptoms

like tingling, pain, or numbness. Sensory tends to be before motor loss.

MG -> Normal tendon reflexes

MS -> Increased tendon reflexes

74.This patient has autoimmune hypothyroidism (TPO antibodies TSH, low T4). Treatment
is with levothyroxine.

positive, raised

75.. This patient presents with nephrotic syndrome: Albumin is important here as it is part of
the definition of nephrotic syndrome. 24 hour uninary protein collection is important but we
already can get that information when we do a urine protein to creatinine ratio

76, This woman is immunocompromised. The findings of a dendritic ulcer is typical of

herpes simplex

77. Zollinger-Ellison syndrome (ZES)

Once an endoscopy is done, it is quite pointless to do a H.pylori breath test!

H. pylori is always tested during an endoscopy if one finds ulcers. A biopsy is done for
histology and a CLO test to identify h pylori

78. A chest x-ray should be performed to rule out other differential diagnoses such as
pneumonia, pulmonary oedema and pneumothorax. This should be performed prior to
CTPA or VQ scan, Only perform a leg uitrasound Doppler there are symptoms or signs of a
DVT

79. A Colles fracture is a type of distal radial fracture occurring just above the wrist. Dinner
fork deformity! You can see this on the X-ray

80. Non-specific urethritis is inflammation of the male urethra not caused by gonorrhoea
Treat is emprical - ts likely chlamydia, but mycoplasma and other organisms may also be
the cause.

81. The symptoms of heavy menstrual bleeding and tiredness are both associated with
hypothyroidism Additionally, a lowered heart rate (as indicated by the 59 bpm in the stem)
can also be a sign of hypothyroidism. Given the symptomatology and the subtle signs of
bradycardia, hypothyroidism is a strong potential diagnosis
82. Lost coil -> speculum -> TVUSS -> Abdominal x-ray

83. In the context of a known alcoholic who has had a seizure and is postictal and confused,
there is a concern about Wernicke's encephalopathy, a potentially life threatening condition
associated with thiamine (vitamin B1) deficiency. Administering thiamine urgently can help
prevent or treat Wernicke's encephalopathy.

Lorazepam is also important for managing alcohol withdrawal seizures, but preventing or
treating Wernicke's encephalopathy with thiamine is a more immediate priority given the risk
of irreversible neurological damage. Lorazepam also has a role in managing seizures in the
context of alcohol withdrawal. However, in the scenario presented, the man has already had
a seizure and is now postictal. There is not an ongoing seizure to manage immediately.

If someone is suspected of having Wernicke's encephalopathy, thiamine should be

administered immediately, even before the diagnosis is confirmed. The potential benefits of
early treatment far outweigh the risks, and the treatment itself (thiamine administration) is
relatively safe

84. Cushings syndrome is associated with proximal muscle weakness, hisuitism and
hypertension. PCOS does not cause muscle weakness or hypertension.

85. High arm sling is recommended as it supports the arm, elbow, and wrist above the level
of the heart, which can help reduce swelling

86. Coeliac symptoms with travel history = Giardiasis

87. Amongst all the medications here, prednisolone is the only one that may result in
thrombocytosis
88. Hepatitis B surface antigen (HBsAg) = ACTIVE INFECTION (acute or (This is used in
the vaccinel)

Hepatitis B surface antibody (anti-HBs) = IMMUNITY (acquired or vaccine)

Hepatitis B core antibody (anti-HBc) = EXPOSURE TO VIRUS

Hepatitis B core IgM antibody (IgM anti-HBc) = ACUTE INFECTION (<6 months)

89.Act in the patient's best interests, especially when they lack the capacity make an
informed decision for themselves

Pericarditis following myocardial infarction: - Post-myocardial infarction (2-7 days post-MI)

- Dressier's syndrome (2-4 weeks post-MI)

91. A meeting to address the patient's best interest would be the best step. If agreed that
the best interest is to give antibiotics, then that should be given.

92. Itchy, jaundiced woman with hypercholesterolaemia, derranged liver function and
ant-mitochondrial M2 antibody (AMA-M2) = Primary biliary cirrhosis. Staging is with a liver
biopsy and treatment is with ursodeoxycholic acid Autoimmune hepatitis is a diagnosis of
exclusion - usually associated with other autoimmune conditions and negative
anti-mitochondrial antibodies

93. Given the woman's history of PID, her occupation which might increase the risk of
sexually transmitted infections, and her current symptoms of lower abdominal pain and
increased vaginal discharge, it is prudent to reswab to ensure an accurate sample and to
start antibiotics. Waiting for cuiture results before initiating treatment might delay care in a
potentially high-risk patient

94. Crohn's flare = steroids. Mesalazine is used in UC not crohns

95. Sinusitis, haematuria, purpura on lower limbs and ANCA + are all part of Wegener's.
Oral ulcers can be seen in both Wegener's and Behcet's

96.Do not use amoxicillin in penicillin allergy Cephalosporins can be used if only a penicillin
induced rash (note 10% cross reactivity so caution if anaphylaxis). Nitrofurantoin should be
avoided in G6PD Gentamicin should not be used for a simple lower urinary tract infection
unless no other sensitivities.

97. localized pain, morning stiffness less than 30 mins, pain worsening after periods of
inactivity and during weight-bearing are all features of OA

98. Pemphigus = superficial blisters (that burst) and oral involvement. The skin biopsy is
also typical. Pemphigoid usually has tense blisters that have no rubbed off due to deeper
skin involvement (and therefore thicker skin).

Joint pain, increased warmth, fever are all consistent with septic arthritis.

Avascular necrosis of femoral head does not usually present with fever or elevated
inflammatory markers

100. No bleeding and INR <8 = hold warfarin

No bleeding and INR >8 = oral vitamin K (and hold warfarin)

Minor bleeding and IN <8 = Tranexamic acid (IV vitamin Kif'risk factors - not clarified in
guideline) (and hold warfarin)
Minor bleeding and INR >8 = IV vitamin K (and hold warfarin)

Major bleeding (regardless of INR) = Prothrombin Complex Concentrate and IV vitamin K

(and hold warfann)

101. Osteomyelitis - haematogenous spread MRI spine is the best investigation

for this

102. Hiatus hernias occur when there is herniation of abdominal contents through

the oesophageal hiatus of the diaphragm into the thoracic cavity

103. Mental capacity assessment is appropriate here. Before any medical intervention
concerning the patient, especially when they have expressed refusal regarding treatment, it
is essential to assess their mental capacity

104. Acamprosate is used to reduce cravings of alcohol

105. The most common organism responsible for mastitis, especially in lactating

women, is Staphylococcus aureus

106.. Breast cancer is the most common malignancies to metastasise to bone in women

107. Glycerol suppositories (stool softoner) usually tried first as it is more gentle compared
to bisacodyl which is a stimulant laxative

108. Hodgkin's lymphoma is characterised by Reed Sternberg cells (giant leated cells, 'owl
eves') and alcohol-induced lymphadenopathy pain
109. Hypercalcaemia is the only correct answer. Indapamide which is a diuretic results in -

Hypokalaemia

Hyponatraemia

Hypomagnesaemia

Hypercalcaemia (due to hypocalciuria)

110. No explanation

111.She died from a pulmonary embolism! Lung cancer may be present but it was not the
cause of death.

112.Behcet's disease is a systemic illness associated with mouth and uicers. Anterior uveitis
and HLA B51 are clinchers here
113.Sleep hygiene is most appropriate. This should be tried first above all Adjusting timing
is not suitable since it is already given in the morning

114.Acute gout crystals = Monosodium urate crystals which are needle and demonstrate a
negative befringement reaction

115. Sitagliptin is weight neutral and fine to use with low eGFR. Reduced only needed if
eGFR is less than 45.

Gliclazide would result in weight gain,

Pio is contraindicated in heart failure.

116.This is a forest plot used in a meta-analysis to pool results of similar studies to establish
whether there is statistical significance (usually when there are studies that have conflicting
results).

117.Thiazide diuretic can result in hyponatraemia ACE i rarely cause hyponatraemia

118.Complete molar pregnancy (contains no fetal tissue) is characterised by hyperemesis,

raised bHCG and snowstorm/bunch of grapes appearence on ultrasound Treatment is with
suction removal

119. Confirmed subclinical hypothyroidism + trying to conceive should be to endo

Referred

120. Streptococcus pneumoniae. Fever, confusion, and a raised white cell count in the
cerebrospinal fluid (CSF) suggests bacterial meningitis.

Elevated white cell count

Elevated protein level

Consistent with bacterial meningitis too

121. Central vision affected first -> AMD. Retinitis pigmentosa affects the peripheral vision
first

122. This is the most appropriate choice An infant presenting with new-onset jaundice after
the 2w needs an immediate assessment to rule out pathologic causes such as biliary
atresia.

123. This has classic features of Paget's disease of the breast Someties images
are not given and you just have to go with the description.

124.MCV low MCHC low normal ferritin All features of thalassemia trait

125.Taking a collateral history from the patient's daughter (or even calling her brother) is the
appropriate next step to gather additional information about the patient's condition.

126. CT scans are quick, Readily available, Used in suspected AAA rupture Portable US is
helpful but he is hemodynamically stable so no need for a FAST scan here

127. The history and clinical features are one of sarcoidosis of which the common
dermatological manifestation is erythema nodosum

128. This gentleman presents with symptoms of progressive dysphagia on a background of

GORD whichis a risk factors for Barrett's oesophagus The most common type of cancer
which affects the lower third of the oesophagus is adenocarcinoma

129.Cough and coryza can be seen in Kawasaki's disease too although not part of the
diagnostic criteria, WHen one sees cough and coryza with a rash, they often think measles
but this is not a case of measles because of the presence of strawberry tongue and cervical
lymphadenopathy This fits better with Kawasak's disease. Again, the idea here is to give
you questions that challenge yourself because in the exam it will not be very straightforward

130. Stopping amlodipine could be an option as ED is s/e even though considerec an

uncommon side effect. But given his BP his on the higher side of normal and he has been
taking amlodipine for years without ED effects, better to try sildenafil first If ED happened
around the same time he took the meds, it is reasonable to change the meds first.

131. 100% because 1 defective gene comes from him and the other from the mother

132. Sodium bicarb is important for TCA overdose, Helps correct metabolic acidosis and
enhances drug elimination by alkalinization of urine 8.4% is the number to remember.

133. Amlodipine makes the most sense: It is safe for breastfeeding mothers, It is a
once-a-day dose, so compliance is better. Labetalol is mostly TDS/QDS (BD also can be
done). There is also no reason to pick labetalol over amlodipine. Ramipril not safe for breast
feeding

Best way to remember this is ==> For postnatal breastfeeding moms -> Pick enalapril first
(if not there, pick amlodipine/nifedipine)
134. He is eating and drinking well There is no need to start a syringe driver unless he is
unable to eat/drink or we need to titrate up the dose of medications

135. Second trimester - Pick carbimazole. if first trimester, use PTU, There is a small risk of
maternal hepatotixicity with PTU in second and third trimester. PTU is still considered safe if
carbimazole is not an option

Carbimazole + levothyroxine (block and replace) is never the answer in pregnancy! We

want the lowest dose of antithyroid medication during pregnancy

136. Psychiatric evaluation is crucial before discharge.

137. Nitro is the safest. NICE CKS also recommends this in pregrancy unless term

138. The most obvious and very treatable issue here is hypercalcaemia which intravenous
fluids can help.

139. Second degree heartblock (Morbitz type I) = Gradually increasing PR interva followed
by a dropped QRS complex. Atropine - This can be used to increase the heart rate by
blocking parasympathetic activity on the heart. It is effective in AV nodal blocks like Mobitz
type l, especially if the patient is symptomatic. If asymptomatic, then no treatment is
required.

140. "Lorazepam is the safest to give to this patient for rapid tranquillisation. Halopendol
would worsen his prolonged QT intervals Quetiapine can also worsen his prolonged QT
intervals. It is also not a drug used for rapid tranquillisation."

141.Suspected testicular cancer - refer urgently to urology (under 2 ww)

142. Leptospirosis. Serology is the best.

143.SSRis such as sertraline would be considered one of the safest for depression in a
breast feeding mother

144. Sickle cell anaemia is autosomal recessive 1 4 chance of affected child, 1 2 chance of
child being a carrier. 1:4 chance of child not affected. The fact she has one effected child
dose NOT change the risk for the next child.

145. Her features are ones of lithium toxicity. It may be that it was brought about

because of renal impairment (or dehydration) that resulted in the lithium build up

While both alcohol and lithium can cause tremors, the descriptor "coarse" more classically
associated with lithium toxicity.
This is also supported by the elevated urea and creatinine levels indicate a decline in kidney
function, which can reduce the clearance of lithium from the body

146. Raised intracranial pressure + nausea = use cyclizine

147.Acute sinusitis - likely bacterial in origin given fever - phenoxymethylpenicillin

is first line.

148. He has stage 2 hypertension -> (2150/95), Start antihypertensive because he is aged
55 and older -> CCB No need for statins as there is no QRISK

score here

149.The difference in risk between the two treatments is 12% - 8% = 4%. Therefore, the
NNT is 1/0.04 = 25.

150. Nausea, vomiting. + irregular pupil are all features of glaucoma

151. Oral antihistamines - treatment for urticaria. No point doing IgE test at this stage - this
is acute (not chronic)

152. A palliative stoma would allow the patient to bypass the obstructed segment of the
bowel, providing relief from symptoms and improving her quality of life, especially
considering the extensive pentoneal and mesenteric metastases which make surgical
debulking not feasible: NG tube is a useful one to perform first (in the acute setting) but it is
not the most definitive management.

153. Vitiligo - Well demarcated and can appear anywhere on the body, common sites
include the face, hands, and other areas frequently exposed to the sun.

This absence of other symptoms such as itching, and scales helps to differentiate vitiligo
from other skin conditions like psoriasis, lichen sclerosus, or tinea

154. Warfarin, alcohol, fall, elderly -> these are all key words for subdural

haematoma (likely chronic subdural haematoma) which occurs after a minor head injury.

155. Cracked heal Urea-containing emollients is a good way to start. Can apply 3 times a
day to really soften the skin

156. PMR ESR is one to get

157. Spirometry is a good test to begin, FENO is also a good test in adults (or anyone 17
years old and above), but if below 17, start with spirometry first. FENO can still be done
under 17 for those with normal spirometry, where asthma is still likely
158. Subtle pneumothorax is seen in the apical part of the left thoracic cavity

159. Referring to gynae would be most suitable. They can consider a speculum for a
cervical smear and examination under GA

160.A mid-systolic click followed by a late systolic murmur is characteristic of MVP

161. 17-hydroxyprogesterone. Elevated levels would suggest 21-hydroxylase deficiency, a

form of congenital adrenal hyperplasia.

In girls, it can lead to the development of male secondary sexual characteristics, such as
clitoromegaly (an enlarged clitoris) and the early appearance of pubic hair

Hyponatraemia, -> Due to decreased aldosterone, the kidneys do not reabsorb sodium as
efficiently, leading to its loss in unine and reduced levels

in the blood.

Hyperkalemia -> Reduced aldosterone also means the kidneys are not excreting potassium
properly, leading to elevated levels in the blood.

While aldosterone deficiency is associated with 21-hydroxylase deficiency, the actual levels
of aldosterone can be vanable in CAH patients. So best to do 21-hydroxyprogesterone

YWe get asked this quite a lot because candidates often use other question banks or
revision notes from elsewhere (which are not written by UK doctors) that say aldosterone is
useful in children. We do not prefer aldosterone levels in children. We still prefer
17-hydroxyprogesterone (17-OHP) It is advisable to check the sources of where you study
and ensure that a UK medical/surgical team is drafting it up: You can read more about our
team here: https //plabable com/aboutus

162.Resp acidosis, Likely from not breathing well due to respiratory depression CNS
depressants such as alcohol, opioids or benzodiazepines can result in

163. Legionella. Potential source (rooftop hot tub in a hotel), Hyponatraemia and x-

ray findings also suggest this .

164. Offering support and guidance, while ensuring the doctor's well-being is important. The
hospital's occupational health service is equipped to handle such situations and can provide
necessary resources and counselling to him
165. Should not go to work for 48 hours after diarrhoea. She does not need a fit note
because it will only be 2 days. A fit note is not required nor appropriate if she is ill for 7
calendar days or less. She can self-certify

166.Specifically, borderline personality disorder, Intense emotional reactions, impulsivity,

potential self-harm (as suggested by the scars on the wrists), and rapidly shifting
perceptions towards others (initial anger followed by gratitude)

167. Stop simvastatin while on clarithromycin. Clarithromycin can alter the metabolism of
simvastatin leading to an increase in plasma levels and therefore increasing the risk of
myopathy and rhabdomyolysis. No need to stop ramipril because he does not show signs of
dehydration. One eGFR of 80 does not really say much of anything because his baseline
could be around there too. His creatine and urea are within the normal levels anwyay.

168.Pyloric stenosis Blood test to check renal profile to look at potassium levels is important
because hypokalemia needs to be corrected immediately

169. The external oblique aponeurosis is the first structure to be pierced. After that. we go
through the internal oblique muscle then to the transversus abdominis

170. I've purposely put the liver cancer and "no liver cancer" column the other way round to
test your knowledge. For those who got this right, you probably realised this Sensitivity is a /
(a+c) = 95/100

171.Bitemporal hemianopsia - pituitary adenoma

172.Pseudohypoparathyroidism is a disorder in which the body is resistant to the effects of

parathyroid hormone (PTH), Even though PTH is elevated, its actions are blunted, leading
to hypocalcaemia and hyperphosphataemia

Vit D would not explain elevated phosphate levels

Secondary hyperparathyroidism occurs mostly due to CKD Renal function

here is normal.

Primary hyperparathyroidism results in opposite findings -> high calcium, low phosphate

173.Bronchiectasis, The linear opacities represent the "tram tracks". CT chest is most
appropriate
174.Fibro more appropriate than ME The pain here is the predominant feature rather than
just fatigue.

175.Haemophilia Ais a sex-linked recessive disorder. This means it is carried on the X

chromosome. Males inhent an X chromosome from their mother and a Y chromosome from
their father (XY). This means that if a son inhents an X chromosome carrying haemophilia
from his mother, he will have haemophilia There is a 50% chance he could receive the
abnormal X gene from his mom and 50% chance he could get the normal X gene from his
mom.

176. The Doctrine of Double Effect is a principle in medical ethics that distinguishes
between the intended consequences and the unintended side effects of an action. It states
that, if certain criteria are met, it is ethically permissible to carry out an action that has both
a good effect and a bad effect.

The relief from pain (good effect) was intended, while the patient's death (bad effect) was an
unintended, but foreseeable, consequence.

The primary intention was pain relief, not to hasten the man's death

Beneficence refers to the ethical principle that a physician should act in the best interest of
the patient ensuring that all actions taken promote the wellbeing of the individual. While
beneficence justifies the intention to relieve pain, it does NOT directly address the moral
complexity of an action having both a positive intended effect and a negative unintended
consequence.

Non-maleficence is the ethical principle that captures the idea of "do no harm." But in this
stem, the clinician actually did do some harm. Just that the benefits might have outweighed
the potential possibility of death from morphine

177. In situations involving potential genetic conditions like Huntington's disease, it is

recommended to wait until the individual is old enough to make an informed decision
regarding testing This is particularly true in cases where there is no current treatment to
alter the course of the disease and the information can have significant psychosocial
implications.

178. The man is experiencing persistent pain despite being on a regular dose of
slow-release morphine and requiring frequent doses of immediate release morphine. When
a patient in a palliative care setting has uncontrolled pain despite maximum oral doses or if
they're unable to take oral medication, a common approach is to switch to continuous
subcutaneous infusions using a syringe driver

179. Autosomal dominant. Occurs in every generation. Usually, both sexes are affected in
somewhat of an equal manner. But in this one, only males are atfected (for some reason).
That being said, it is still autosomal dominant because it cannot be anything else.

If it is X-linked recessive, the male who is affected cannot pass it down to another male
because he is only passing down his y chromosome

180. The transferrin saturation (TS) test measures the percentage of transferrin that is
saturated with iron, In individuals with haemochromatosis, the TS is typically elevated
because they absorb more iron from their diet than is normal Therefore, a high transferrin
saturation is suggestive of haemochromatosis, especially when seen in conjunction with an
elevated serum ferntin level