PassTest

1) A 74 ylo female attends her GP for a routine checkup. O/E, she appears tired and breathless.
Her pulse is 74/min and irregularly irregular and BP is 124/76 mmHg. There is no significant
medical history. What is the most likely cause of the lady’s atrial fibrillation?
Thyrotoxicosis
Ischaemic heart disease
Hypertension
Alcohol excess
Lone atrial fibrillation
Atrial fibrillation is the most common sustained arrhythmia worldwide. Its incidence increases with
age and it is found in approximately 5% of the population aged >70 years. It can be classified as
paroxysmal, persistent or permanent according to the need and response to treatment.
 Paroxysmal AF reverts to sinus rhythm spontaneously
 Permanent AF remains despite treatment
A range of conditions is associated with AF, the most common being hypertension, valvular heart
disease, ischaemic heart disease and cardiac failure. Other causes include thyrotoxicosis, pulmonary
disease, sepsis and alcohol excess.
Approximately 50% of patients with paroxysmal AF and 20% of patients with permanent AF have
otherwise normal hearts however, in which case the diagnosis is termed lone AF.
This is the most likely cause of this lady’s symptoms, as she has no other relevant medical history or
examination findings, which would indicate a cardiovascular or pulmonary cause. Alcohol excess may
still be a cause, although less common, and should be enquired about with a thorough history.
Investigations should be tailored according to the differential diagnosis. All investigations should
include an ECG, which would show no p waves, an irregular baseline and variable ventricular response
rate. Management of atrial fibrillation is dependent upon the classification, i.e. permanent, persistent
or paroxysmal and can be classified into rate control, rhythm control and anticoagulation. Patients
with atrial fibrillation carry an increased risk of thromboembolic disease and therefore, in high-risk
patients, where the benefit of anticoagulation outweighs the risk of haemorrhage, anticoagulation
should be considered. Treatment options aimed at rate and rhythm control include pharmacological
agents, DC cardioversion and electrical device therapy

2) A 78 y/o man complains of severe epigastric pain and nausea. He has not opened his bowels in
3 days, however prior to this, they were opening normally. He has a past history of coronary
stents inserted after a myocardial infarction 8 yrs ago. He has been asymptomatic since. He
 takes aspirin for his cardiac condition and NSAIDs for knee arthritis. He has not consumed any
alcohol over the last 2 yrs following his episode of acute gastritis.
Examination reveals some mild tenderness over the epigastrium but no guarding. Bowel
sounds are normal. An erect CXR and abdominal X-ray do not reveal any abnormality. Blood
gases taken are unremarkable with a normal lactate. Routine blood tests (FBC, U&E, LFT) are
unremarkable with a normal amylase. Upper GI endoscopy is performed and some gastric
erosions are seen.
Which of the following diagnoses is most likely?
Acute gastritis
Duodenal ulcer
Pancreatitis
Ischaemic bowel
Myocardial infarction
An upper GI endoscopy revealed some gastric erosions which is not uncommon with aspirin
and NSAID consumption. This is not the same as an acute gastritis. Duodenal ulcer would also
have been seen at OGD and would present more as hunger pains. A normal erect chest X-ray
and the absence of peritonitis exclude a perforated duodenal ulcer. Pancreatitis is unlikely
given the normal amylase although on occasion this can be normal in cases depending on the
timing of the blood test or whether the pancreas has had previous chronic inflammation.
Ischaemic bowel would present with more generalised abdominal pain and a metabolic lactic
acidosis on blood gas. Myocardial infarction would seem like the most likely diagnosis given
the options. An ECG and ultrasound scan or CT should be performed early to treat any existing
cardiac condition without delay.

3) A 67 y/o man visits his GP complaining of lethargy and light-headedness whenever he gets up
from the lying/ sitting position. His relatives are concerned because he has developed a
change in his facial features. Investigations included the following results:

These results are consistent with:

Adrenal metastases
Conn’s syndrome
 Abrupt withdrawal of corticosteroid therapy
Hypopituitarism
Cushing’s disease
The commonest cause of adrenal hypofunction is suppression of the pituitary-adrenal axis by
therapeutic corticosteroid therapy. During therapy, patients present with Cushing’s syndrome
that typically causes a “moon” face (although synthetic glucocorticoids do not have
mineralocorticoid activity and so Na+ retention and K+ wasting is not seen).
However, if therapy is withdrawn abruptly or demand for cortisol increases without a
concomitant dosage increase (e.g. following surgery), symptoms and signs of adrenal
hypofunction can occur. Thus, Na+ is lost and K+ retained, as in adrenal metastases and
hypopituitarism.
However, in the case of adrenal metastases, ACTH levels would be expected to be high, owing
to lack of negative feedback.
In the case of hypopituitarism and abrupt withdrawal of corticosteroid therapy, ACTH levels
are low due to primary hypofunction of pituitary and suppression respectively. The response
to low dose ACTH differentiates between the two:
 In cases of hypopituitarism, the adrenals would respond with an increased cortisol
output (the primary problem is at the level of the pituitary)
 In cases of abrupt withdrawal of corticosteroid therapy, the prolonged suppression of
the adrenals means that output of cortisol cannot increase, until function has
recovered.

4) A 77y/o man is brought to see his GP by his friend who has noticed he is becoming
increasingly forgetful and unsteady on his feet. Unfortunately his friend doesn’t know
anything about his previous medical history or if he takes any medications. Routine
investigations reveal:

Given these results, which is the likeliest cause of his symptoms?

Hypothyroidism
B12 deficiency
Myelodysplasia
Alcohol excess
Phenytoin toxicity
The blood results are consistent with a diagnosis of alcohol excess. His confusion may be due
to a chronic (Wernicke’s) encephalopathy, alcohol associated dementia or another underlying
dementia exacerbated by his alcohol excess. This group of patients often suffers recurrent
 falls and is therefore at risk of subdural haematoma. These need to be excluded by a CT or
MRI brain scan.
He has a macrocytosis, thrombocytopaenia, mild hyponatraemia, and a low urea that are all
consistent with excess alcohol.
 Hypothyroidism can cause a macrocytosis and hyponatraemia but does not cause the
thrombocytopaenia or low urea.
 B12 may cause a pancytopaenia, classically causing a marked macrocytosis.
 Phenytoin may cause a macrocytosis by its own effects or through causing a folate
deficiency.
 In its early phase, myelodysplasia may be seen to cause a macrocytosis with no other
haematological effects

5) A 54 y/o woman is admitted with left loin pain and haematuria. O/E she has a tender left loin.
A CT scan of the kidneys, ureters and bladder (CT-KUB) is performed. A left renal tract calculus
is observed.
What is the most common location of renal tract calculus?
Renal pelvis
Mid-ureter
Vesicoureteric junction
Pelvi-ureteric junction
Bladder
CT-KUB is the first line imaging modality in most centers for patients with renal colic, although
intravenous urography is still used. A plain abdominal radiograph is of limited use in acute
renal colic, but may be used to monitor a known radio-opaque calculus. Renal calculi come in
various types:
 Calcium oxalate (majority)
 Triple phosphate
 Uric acid
 Cystine
 Xanthine
The three most common locations (from proximal to distal) within the renal tract are:
 Pelvi-ureteric junction
 Within the ureter at the pelvic brim
 Vesicoureteric junction (the commonest site)

6) A 25 y/o man complains of scratchy sensation in the eyes as the day progresses. He
simultaneously feels tiredness in the eyes. He only has these symptoms during weekdays
when he works as a computer programmer in a local company. O/E, aside from mild
conjunctival hyperaemia, the rest of the ocular exam is normal.
Stimulation of which of the following nerves is associated with tear formation?
Oculomotor nerve
Intermediate nerve
Glossopharyngeal nerve
Vagus nerve
Chorda tympani
 This patient’s symptoms are suggestive of dry eye, which may occur in those who use
computers, study, watch TV or drive for long hours. In such circumstances, the rate of blinking
comes down, interfering with tear replenishment that is normally evaporated. Tears are
secreted by the lacrimal gland. Patients with dry eye complain of ocular sandy or scratchy
sensation as the day progresses, ocular fatigue, and conjunctival erythema. In severe cases,
changes in the conjunctiva and cornea happen. The intermediate nerve (minor portion of
facial nerve) supplies the secretomotor innervation for:
 The lacrimal gland
 Submandibular and sublingual gland
through two different pathways:
 The lacrimatory, preganglionic parasympathetic fibers originate from the geniculate
ganglion of the facial nerve as the greater petrosal nerve. The greater petrosal nerve
joins the deep petrosal nerve (derived from the carotic sympathetic plexus) to form
the Vidian nerve, which then reaches the pterygopalatine ganglion. The postganglionic
parasympathetic fibres travel through the maxillary nerve and its zygomatic branch,
and ultimately reach the lacrimal gland.
 The salivatory pathway is mediated via the chorda tympani branch
 The oculomotor nerve provides parasympathetic innervation to the ciliary muscle and
sphincter pupillae muscle of the iris. Its stimulation results in pupillary constriction.
 The glossopharyngeal nerve provides the secretomotor innervation for the parotid gland. The
preganglionic parasympathetic fibres travel through the tympanic branch of the
glossopharyngeal nerve to tympanic plexus and reach the otic ganglion via the lesser petrosal
nerve. The postganglionic parasympathetic fibres then reach the parotid gland via the
auriculotemporal nerve, a branch of the mandibular nerve.
 The vagus nerve provides parasympathetic innervation to the heart, lung and gastrointestinal
tract.
 Chorda tympani is a branch of the facial nerve, which joins the lingual nerve within the
infratemporal fossa. In addition to the gustatory afferent fibres from the anterior two-thirds
of the tongue, this nerve contains preganglionic parasympathetic fibres, which synapse at the
submandibular ganglion attached to the lingual nerve. The postganglionic parasympathetic
fibres reach the submandibular and sublingual glands via the branches of the lingual nerve.