Question 1

A 34 Year old woman falls off her horse and is brought by ambulance to the emergency
department. She reports that she cannot move her arms and legs.
Initial observations are:
Pulse 48 BP 80/50 Sats 97% on air GCS 15

Her ABC primary survey shows no further abnormalities. On examination she is unable to
move her arms and legs with associated loss of sensation

1. What is the likely cause of her hypotension and what is the physiological mechanism
for this? (2 marks)

Neurogenic shock
Loss of background sympathetic stimulation to vessels causing vasodilation

2. Name two ways her hypotension could be managed? (2 marks)

Intravenous fluids
Inotropes/vasopressors

3. Name two radiological tests she requires in the resuscitation room? (2 marks)

CXR
Pelvis xray
FAST Scan

4. Her CT Scan shows a displaced spinal fracture at the level of C5. What worrying sign
are you worried she may develop? (1 mark)

Inability to breath
Hypoxia
 5. She remains tetraplegic. Name three other aspects of her treatment in the
emergency department. (3 marks)

LMWH
Anti-thrombotic socks
PPI
Urinary catheter
Question 2

A 72 year old patient presents to the receiving unit with collapse. He has been feeling dizzy
for 2 days but has been having no other symptoms. His initial observations are:
Pulse 38 BP 120/80 Sats 98% on air

An ECG is awaited .

1. Name an initial bedside test you would check? (1 mark)

BM/capillary glucose

2. He has an intravenous cannula inserted. Name three blood tests you would want to
check giving a rationale for each. (3 marks)

FBC/Hb – May have anaemia

Mg+ - Can cause arrhythymias
Troponin – Ischaemia and ACS can cause collapse
U=Es/Potassium – Can cause rhythm disturbance
Calcium – Can cause rhythm disturbance
Glucose – Hypo can cause collapse

3. He now has an ECG performed which is shown below. What is the diagnosis and
name one other abnormality. (2 marks)

Compete/third degree heart block

Wide QRS
ST depression laterally
T wave inversion laterally
 4. What immediate treatment should he receive giving the route of administration? (1
mark)

Intravenous atropine

5. This has no effect. He becomes more unwell 10 minutes later and his BP is now
70/40. Name three ways his condition could be treated (3 marks)

External pacing
Isoprenaline/adrenaline
Temporary pacing wire
Additional atropine
Question 3

You are called by the ward nurse to see a 68 year old patient who is an inpatient in the
ward. He already has intravenous access. He has become more unwell today and the ward
has just had his morning blood results phoned to the ward. The results are:

Na 132 K+ 8.2 Cl 88 HCO3 16 Urea 42 Creat 500

1. Name three aspects of your immediate treatment in the ward. For medications give
the route of administration. (3 marks)

Intravenous calcium gluconate

Intravenous Actrapid (soluble insulin) in glucose
Nebulised salbutamol
Intravenous fluids (saline)

2. What investigation in the ward does he need urgently and what abnormality are you
most likely to see? (2 marks)

ECG
Tenting of the T waves
The patients’ blood results improve over the next couple of days but you are then called
back to the ward as the patient has become confused. He is now breathless and you order a
CXR which is shown below.

3. What is the most obvious abnormality? Name one organism that could cause this
appearance. (2 marks)

Cavitating mass L lower zone

Consolidation L lower zone

TB
Klebsellia
Staph aureus
Aspergillus
Haemophilus influenza
Strep pneumonia
 4. What is the most likely cause of his confusion and what treatment does he require?
(2 marks)

Delirium
Intravenous antibiotics
Intravenous fluids.

5. You repeat his U+Es which show Urea 48 and Creatinine 950. What intervention is
he likely to require? (1 mark)

Dialysis
Question 4 Marks

A 47-year old male presents following the gradual onset of involuntary

hyperkinetic movement affecting all 4 limbs. Clinical examination
demonstrates generalised chorea. There is a family history of Huntington’s
disease.

1. Name 3 causes of chorea other than Huntington’s disease. 3

Drug-induced / tardive (eg dopamine antagonist prescription)

L-dopa induced chorea in Parkinson’s disease
Sydenham’s chorea
Wilson’s disease
SLE
Paraneoplastic disorder
Benign hereditary chorea

2. What is the pattern of inheritance seen in Huntington’s disease? 1

Autosomal dominant

3. In addition to chorea name 2 other clinical features of Huntington’s 2

disease.

Dementia
Mood disturbance
Personality change / impulsivity
Eye movement difficulties 2
Ataxia

4. Huntington’s disease can clinically manifest at an earlier in

successive generations of an affected kindred. What is this
phenomenon called and why does it happen in Huntington’s
disease?

Genetic anticipation
Progressive generation inherit larger numbers of CAG / triplet repeats of
Huntingtin gene

Genetic testing confirms that the patient has Huntington’s disease. He has
a daughter aged 24 years.
 1
5. What medication could be prescribed to improve his chorea?

Tetrabenazine
1

6. What should his daughter be offered?

Pre-symptomatic genetic counselling

QUESTION 5

Marks
A 30-year-old woman is sent by her GP to gynaecological outpatients
complaining of vaginal bleeding after intercourse. She has never had
a cervical smear.

(1) List 3 clinical signs you would look for on your initial clinical 3
examination.

Any abnormality of the introitus and vagina

Presence of cervical ectopy
Presence of local abnormality eg. Cervical polyp
Irregularity of cervix suggestive of cervical cancer

(2) The cervix looks frankly abnormal with blood stained discharge. 2
Colposcopic examination and biopsy are arranged and the
histopathology confirms a malignancy. List the two most common
histological types of cervical cancer.

Squamous cell carcinoma

Adenocarcinoma.

(3) The most common type of malignant tumour is often preceded by a 3

premalignant condition. What abnormality may be seen on cervical
cytology and how is it classified?

Dyskariosis (1) which is labelled mild, moderate and severe.(2)

(4) What single factor is most important in causing the above 1

premalignant condition?

Infection with human papillomavirus

(5) Name one way the incidence of cervical cancer may be most 1
effectively reduced.

HPV vaccination programmes

Also accept regular cervical smears or HPV screening
QUESTION 6

A 28-year-old man visits his GP surgery having received a verbal warning at his
work which is in a bank. He gives a year long history of worries that his receipts Marks
will not balance each day, to the extent that he has to check each transaction at
least six times. Customers have complained about his excessive slowness

(a) What name is given to these symptoms?

1
Obsessions or compulsive rituals

(b) List 5 characteristic features of such symptoms 5

Recurrent
Intrusive
Unpleasant
Recognised as silly/irrational
Effort made to resist thoughts
Recognised as own thoughts

(c) Name two possible diagnoses 2

Obsessional compulsive disorder

Depressive episode/major depressive disorder

(d) What neurotransmitter system is thought to be most relevant in the 1

genesis of these symptoms?

Serotonin/5HT

(e) What drug treatment is most effective? 1

SSRIs or Clomipramine
Accept – Fluoxetine/Sertraline/Paroxetine/Citalopram
QUESTION 7

A 75-year-old man is admitted as an emergency under your care with a Marks

one-day history of severe generalised abdominal pain. He has no
previous relevant history. On examination he is shocked and
distressed. His abdomen is rigid, diffusely tender and silent and a
chest Xray suggests free intraperitoneal air.

(1) What is the most likely diagnosis? 1

Perforated intra-abdominal viscus

(2) Name 2 common causes of this condition? 2

Diverticulitis
Peptic ulcer
Appendicitis

(3) What 3 initial therapeutic measures that should be instituted 3

Intravenous fluids- crystalloid fluids

parenteral or effective analgesics
Broad spectrum antibiotics

(4) Give 2 other measures which you would consider at this stage, 2
explaining how these would help with your investigation/assessment of
the patient’s progress?

Measure How they would aid investigation/assessment

U&E fluid balance, dehydration, renal function
Urinary fluid balance, renal function
catheter
Regular Assess stability of patient including response to
monitoring of treatment
vital signs
(BP, pulse,
resp rate,
temperature)

(5) The patient underwent a laparotomy. Name 2 aims the surgery attempt 2
to achieve?

Diagnosis
Peritoneal lavage
Prevent further peritoneal contamination (eg.appendicectomy, omental
patch or Hartmann’s procedure)
Question 8

You are the FY working in the neonatal unit and are called to review a baby who has had a
bilious vomit, he was born at 27+2 weeks gestation and is now at day 3 of life. He weighs
800g (2nd centile) and has had an uncomplicated admission so far. You discuss him with your
seniors who are concerned he may have necrotising enterocolitis (NEC).
MARKS
1. Give two other differentials for bilious vomiting in neonates? 2

Malrotation
volvulus,
duodenal atresia OR Small bowel atresia,
meconium ileus/plug

2. What two other signs would you look for in this baby that could suggest NEC? 2

Abdominal distention,
pyrexia,
blood in stool,
tachycardia,
feed intolerance,
increased requirement for respiratory support,
jaundice.

3. You decide to get an abdominal film to assist with your diagnosis, what feature of 1
NEC can be seen on this abdominal film?

dilated loops of bowel,

bowel wall oedema, MARKS
4. What two other common conditions of extreme prematurity might this baby be at 2
risk of?

Retinopathy of prematurity,
intraventicular haemorrhage,
respiratory distress syndrome OR chronic lung disease of prematurity,
patent ductus arteriosus

5. What management should be considered? 1

Withhold feeds
Fluid bolus
Antibiotics

6. Name two complications of NEC? 2

Death
Sepsis
Short bowel
Respiratory compromise from distended abdomen
Peritonitis
Intestinal perforation
Intestinal stricture
Liver problems secondary to long-term parenteral feeding.
QUESTION 9

A 70-year-old woman attends the emergency department with a Marks

complaint of loss of vision in the left eye, unaccompanied by pain.
She thinks she may have had previous episodes that recovered and
that the symptoms came on over a period of less than 30 minutes.
She has not experienced associated headaches. She is known to
have atrial fibrillation.

(1) What is the most likely cause of these symptoms? 1

Embolic occlusion of the Central Retinal Artery

Ophthalmic arterial occlusion

(2) Name 2 other causes of painless loss of vision 2

Central retinal vein occlusion

Ischaemic optic neuropathy – secondary to giant cell arteritis
Retinal detachment
Demyelinating optic neuropathy
Vitreous haemorrhage
(embolic occlusion of the central retinal artery – only if not given as the
answer to part (a))

(3) What 2 points from the history, as given above, help you to distinguish 2
between the possible causes of vision loss in this patient?

Transient episodes
Atrial fibrillation
Lack of headache
Age of patient

(4) Name 4 features of the ophthalmic examination would be important for 4

you to note in this patient?

Visual acuity
Visual fields
Pupillary reflex – direct and consensual
Pupillary – afferent defect
Red reflex
Fundoscopy (would get up to 2 marks if they give details of
fundoscopy)
(5) What investigation would you perform with regard to the carotid 1
artery?

Carotid ultrasound scan

Question 10

You are a GP trainee and Mrs J, a 24 year old lady, presents to the clinic. She has
just registered at the practice, her notes haven’t arrived at the surgery and she is
complaining of tiredness. She doesn’t wish to be fully examined but clinically you
suspect anaemia and you arrange a full blood count, results of which are shown
below.

Haemoglobin 9.3 g/dl Reference range 11.5 – 13.5

White cell count 8.9 x 109/litre Reference range 4 – 11 x 109/litre
Platelets 304 x 109/litre Reference range 150 – 400 x 109/litre
MCV 104 fls Reference range 80 – 96 fls

She returns to the health centre and this time you notice that she is also slightly
icteric. Urine analysis shows urobilinogen but no bilirubin. There is no glycosuria,
haematuria or pyuria. The serum bilirubin concentration is 65 µmols/l (normal range
15 – 22 µmols/litre).

(a) Apart from investigations for haemolysis, list 2 other investigations, explaining
your reason for doing the test, to help elucidate the cause of the increased MCV.
(2 marks)

B12 level, pernicious anaemia can lead to increased MCV and haemolysis
(Schillings test not acceptable)
Serum folate level – folic acid deficiency can cause a raised MCV and haemolysis
Thyroid function tests – myxoedema can be associated with a raised MCV
Liver function tests. (Liver disease, particularly related to alcohol (raised Gamma
GT), can produce raised MCV.

(b) Apart from results given above, list two biochemical or haematological
abnormalities that may occur in haemolysis.
(2 mark)
Raised LDH
Raised reticulocyte count
Reduced Haptoglobin
Urinary Haemosiderin
Positive Coomb’s test
Spherocytes or red cell abnormalities on blood film examination

No marks for raised bilirubin or low haemoglobin!

(c) Explain (in less than 50 words) why in haemolysis increased serum bilirubin
may not lead to increased renal excretion of bilirubin. (1 marks)

Liver metabolism produces bilirubin which is not water soluble, if produced in excess
it remains in the circulation, and may be protein bound and therefore does not
become excreted in the urine.

(d) Apart from haemoglobinopathies, list 2 defects in the red cells that can cause
haemolysis and give one example of each.
(2 marks)
Red cell membrane defects – Spherocytosis, Elliptocytosis,
Red cell enzyme deficiencies – G-6-phosphate dehydrogenase deficiency
Pyruvate kinase deficiency.
Increased sensitivity to complement mediated lysis - PNH

It transpires, when the notes arrive, that Mrs J had a splenectomy for this problem as
a child and that she has subsequently had no follow up or treatment after this
procedure.

(e) What organism you would wish to vaccinate against. (1 mark)

Vaccinate against Pneumococcus, Haemophilus and Meningococcus, influenza

vaccine (1 mark for any of these)

(f) List 2 other pieces of advice you would wish to give her
(2 marks)

She should carry a card explaining that she has had a splenectomy and when
vaccinations were undertaken (1 mark)
( tell doctor she’s had a splenectomy not accepted because this does not allow for
accidents)
Life long penicillin therapy should be initiated
Seek medical attention urgently if infection is suspected
Anti-malarial prophylaxis if travelling to endemic area
 Question 11 - Short note question

Q1. Describe what is shown in the above figure (4 marks)

Bar chart of UK treatment outcomes at 12 months in 2011 for TB cases by presence or

absence of social risk factors e.g. alcoholism, homelessness etc.
High completion rate overall but less with known social risk factors – ~85% in no known risk
factors and 75% in known Those with known risk factors more likely to die, lost to follow up,
stopped treatment, or still on treatment
Demonstrates impact of social factors on TB treatment
Q2. In the UK, discuss the main risk factors for tuberculosis infection (students may wish to
use a social determinants health model to help structure their answer) (6 marks)

The main risk factor for TB infection in the UK, is being non-UK born or spending prolonged
time in high risk country.
Age – usually older in UK born but young age also a risk
Aside from place of birth, the other main risk factor for TB is problem alcohol use. The
incidence of TB is also influenced by – and associated with – adverse social circumstances
such as poverty, poor nutrition, reduced access to healthcare, homelessness, problem drug
use and imprisonment (although TB is not a significant problem in Scottish prisons, with very
few cases in the last ten years).
HIV co-infection and other immune system conditions/situations
The main risk factor for TB infection in Scotland, excluding place of birth, is problem alcohol
use. However incidence of TB is influenced by – and associated with – other social risk
factors as well. These include poor nutrition, poor access to healthcare, homelessness,
problem drug use and imprisonment. Overcrowding can also be an issue.
It is of note that some of these groups are almost hidden within the community and unlikely
to register with GPs to access primary care (therefore, access to healthcare is an issue). They
may present late and adhere poorly to treatment, increasing the risk of spread of TB and
emerging drug resistance.
TB is one of a number of diseases that contributes to the continuing inequality in health
experienced by those living in deprived communities relative to those in affluent
communities
Contacts of cases

Q3. Discuss the public health activities that can be undertaken for prevention and control of
tuberculosis. (10 marks)
Prompt identification and treatment of people with TB
Community TB nursing and DOTS (direct observation of treatment supervision/short-course)
– reduces risk of MDR. Reduces risk of onward transmission.
Quarantining of active respiratory TB in appropriate accommodation i.e. negative pressure
rooms – can come under the The Public Health (Scotland) Act 2008 - the ability to restrict or
exclude an individual from places or activities which put others at significant risk. It also
includes the power to detain and individual in hospital.
Public and health professional education – signs symptoms, high risk groups, eligibility for
screening and vaccination
Contact tracing, screening, and preventative management of contacts e.g. using anti-TB
drugs or vaccination
TB surveillance – systems to monitor cases, contact tracing activities, early identification of
outbreaks, and MDR
New entrant screening – ports, immigration, and at healthcare services
Vaccination – BCG –no data on the protection afforded by BCG when give >35 years. For
high risk groups e.g. born in high risk country, parent or grandparent from high risk country,
contacts of cases etc.
Occupational health screening, clearance, and vaccination e.g. healthcare workers, prison
staff, homelessness shelter staff, vets, abattoir workers, laboratory staff.
Primary prevention activities in high risk groups e.g. availability of affordable housing
Marks awarded on balance of interpretation and discussion to the max awarded for each
section.