Theme: Abnormalities of water and electrolyte balance

Options
A Addison's disease
B Conn's syndrome
C Diabetes insipidus
D Renal tubular acidosis
E Salmonella enteritis
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all.

Q#
1.
2.
3.
4.
5.

K+
2.8
2.6
5.6
2.5
5.6

Na
136
1498
128
130
160

HCO3
18
30
22
8
18

Theme: Abnormalities of acid-base balance

Options
A Acute metabolic acidosis
B Acute metabolic alkalosis
C Acute respiratory acidosis
D Acute respiratory alkalosis
E Chronic respiratory acidosis
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all

Q#
6.
7.
8.
9.
10.

pH
7.20
7.64
7.20
7.62
7.28

pCO2
2.2
5.4
8
1.8
7.8

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pO2
11.8
12
5.8
13
6.2

HCO3
12
38
24
19
33

Answer: Abnormalities of wafer and electrolyte balance.

1. D
The hallmark of renal tubular acidosis is a mild metabolic acidosis with hyperkalemia.. The
normal range for serum bicarbonate concentration is 22 to 28 mmol/l. The low level suggests
acidosis. The Clinical picture is common after therapy with acetazolamide
2. B
Conn's syndrome or primary hyperaldosteronism is a rare condition, but it is important as a
cause of secondary arterial hypertension. The main clinical feature is hypertension without
edema and the combination of mild hypernatremia with hypokalemia.
3. A
Addison's disease or adrenal failure is characterized by low blood pressure, skin and buccal
pigmentation and the combination of hyponatremia and mild Hypercalcemia.
4. E
Severe diarrhea results in metabolic acidosis due to bicarbonate loss arid hypokalemia
(Remember: The bicarbonate content of bowel is approximately 80 mmol/l).
5. C
Diabetes insipidus is due to ADH deficiency or lack/loss of renal ADH responsiveness. These
patients lose predominately free water and present with predominately free and water and
present with polyuria and dehydration. Other causes of such electrolyte constellation are poor
fluid intake or water loss due to fever/ hyperventilation.
6. A
Remember the normal values of blood gas analysis pH 7.36-7.44 pO 2 > 11 kPa; pCO2 4.6-5.5
kPa, Bicarbonate 22-28 mmol/l. The differential diagnosis follows a simple two step approach: if
pH less, than 7.36 diagnose acidosis. if pCO2 normal or low = diagnose metabolic acidosis.
7. B
Firs step: pH > 7.44
Second step: pCO2 normal or high
8. C
First step: pH < 7.36
Second step: pCO2 high

= alkalosis
= metabolic alkalosis

= acidosis
= respiratory acidosis. The normal bicarbonate
concentration makes an acute respiratory acidosis likely.

9. D
First step: pH > 7.44
Second step: pCO2 low

= alkalosis
= respiratory alkalosis.

10. E
First step: pH < 7.36
Second step: pCO2 > 5.5 kPa
Third step: bicarbonate > 30 mmol/l

= acidosis
= respiratory acidosis
= chronic respiratory alkalosis likely.

NB. In real life mixed acid-base disturbances are common which are best tackled with a
nomogram (see OHCM listed in the Recommended Reading list page xi).
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Theme: Shortness of breath

Options
A Anticoagulation
B Chest drainage
C Correction of acidosis with intravenous bicarbonate
D Intravenous antibiotics (in combination with corticosteroids)
E Intravenous insulin
F Pain relief e.g. with non-steroidal anti-inflammatory drugs (NSAIDs)
G Rapid dehydration with normal saline
H Re-breathing or sedation with benzodiazepine
I Thrombolysis with e.g. Streptokinase
J Treatment with anti malarial drugs (e.g. quinine)
For each presentation below choose the SINGLE most appropriate treatment from the
above list of options. Each option may be used once, more than once, or not at all.

11. A 34-year-old man has suddenly developed dyspnea (respiratory rate 42

breaths per minute) after return from a prolonged holiday in Thailand. His
pulse oximetry reading is 80%, but you are not able to detect any
abnormalities over the lungs.
12. A50-year-old man has developed mild dyspnea and positional chest pain,
mainly lying flat. His electrocardiogram shows ST-segment elevations, in
most leads.
13. A 23-year-old woman is admitted with severe shortness of breath. Her
respiratory rate is 48 breaths per minute. (Blood gases results: pH-7.52,
pO2-14 kPa, pCO2-2.0 kPa).
14. A 20-year-old patient with non-insulin dependent diabetes has become
progressively breathless over the last 24-hours. His pH is 7.2 and his pCO 2
2.2 kPa. The blood glucose concentration is 34 mmol/l.
15. A 26-year-old drug addict complains about severe shortness of breath for
three days. The symptoms have developed gradually. Physical examination
of his chest is normal, but his pulse oximetry readings are low (65-70% on
air).

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Answer: Shortness of breath

11. A
The likely diagnosis is pulmonary embolism. Anticoagulation with a
heparin is the accepted treatment.

12. F
The description is suggestive of pericarditis. Anticoagulation or
thrombolysis
is
contraindicated,
because
it
might
cause
hemopericardium and cardiac tamponade.

13. H
The diagnosis is hyperventilation syndrome. Re-breathing into a plastic
bag is in most instances sufficient to relief the symptoms. The underlying
problem is commonly an acute-anxiety-state and sedation with a
benzodiazepine might be necessary.

14. G
Rehydration with normal saline has priority in diabetic ketoacidosis. The
estimated fluid deficit in decompensated ketoacidosis is approximately
10% of body weight. Insulin treatment is the next step correction with
bicarbonate solution is not necessary and might be harmful.

15. D
Drug addicts are a high-risk group for contracting HIV. Pneumocystis
carinii pneumonia is a common first manifestation of immunodeficiency.
The treatment of this type of pneumonia consists of high dose cotrimoxazole and in severe cases corticosteroids are added.

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Theme: Findings on physical examination

Options
A Cardiomyopathy
B Holmes-Adie syndrome
C Infectious polyneuritis
D Intra-thoracic malignancy
E Multiple sclerosis
F Myasthenia gravis
G Pericardial disease.
H Pulmonary valve stenosis
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all.

16. Increasing swelling of the face and neck.

17. The jugular venous pressure increases with inspiration.
18. Weakness in both legs with absent reflexes
19. Pulsating liver.
20. Dilated right pupil with poor light reaction and missing ankle jerks.

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Answer: Findings on physical examination

16. D
The patient has superior vena-cava syndrome. The most common cause
is bronchial carcinoma. Metastatic spread into the mediastinal lymph
glands causes mechanical flow obstruction of the superior vena cava.
The clinical syndrome is characterized by swelling of the neck, head and
arms.

17. G
This clinical presentation is known as Kussmaul's sign it is caused by
pericardial tamponade or construction.

18. C
Infectious polyneuritis is the likely diagnosis from the option list.

19. A
A pulsating liver is mostly due to tricuspid valve insufficiency. In dilated
cardiomyopathy this is a common finding.

20. B
Holmes-Adie syndrome is the correct answer, The exact pathology of the
peripheral reflex loss is not known; the pupillary malfunction might be
due to a defect in the ciliary ganglion.

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Theme: Basic differential diagnosis and treatment of emergencies

Options
A Acute myocardial infarction
B Acute pulmonary edema
C Cardiogenic shock
D Epileptic fit
E Occult internal hemorrhage
F Pneumonia
G Pneumothorax
H Pulmonary embolism
I Septic shock
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all

21. A 30-year-old woman has been unwell for six-hours. Her vital signs are:
pulse 130/min, BP 100/60-mmHg, temperature 40 oC, respiratory rate 44
breaths/min.
22. A 76-year old man has collapsed in the street. His vital signs are: pulse
180/min, BP 60/?-mmHg, temperature 36oC, respiratory rate 29
breaths/min.
23. A 50-year-old builder develops severe dyspnea and chest pain. His vital
signs are: pulse 100/min, BP 240/160-mmHg, temperature 36 oC respiratory
rate 32 breaths/min.
24. An 18-year-old nanny has become increasingly drowsy and deliriant, She
was well the day before admission. Her vital signs are pulse 100/min, BP
50/?-mmHg, temperature 39.5oC, respiratory rate 26 breaths/min. There is a
rash over her lower legs.
25. A 63-year-old heavy smoker has suddenly collapsed at home. His vital
signs are, pulse 130/min, BP 40/?-mmHg, temperature 36 oC, respiratory
rate 30 breaths/min. There are no neurological deficits; electrocardiogram
and chest X-ray are normal.

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Answer Basic differential diagnosis and treatment of emergencies

21. F
The most likely diagnosis is pneumonia. The combination of fever and
high respiratory rate is the typical clinical finding.

22. C
This gentleman has cardiogenic shock due to tachyarrhythmia, e.g. fast
atrial fibrillation.

23. B
Acute pulmonary edema due to hypertensive crisis is the correct
diagnosis.

24. I
The young woman is in septic shock. The rash suggests meningococcal
disease.

25. E
The normal electrocardiogram and chest X-ray makes a cardiac cause
of shock unlikely. Consider a sudden internal hemorrhage e.g. from
leaking aortic aneurysm or perforated peptic ulcer.

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Theme: Causes of headache

Options
A Cluster headache
B Extradural hemorrhage
C Giant cell arteritis
D Glioblastoma multiforme
E Meningeoma
F Meningitis
G Metastatic disease
H Migraine
I Subarachnoid hemorrhage
J Subdural hematoma
K Tension headache
L Trigeminal neuralgia
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all

26. An elderly man complains of headache and progressive confusion over the
past four months. CT scan of the brain reveals an irregularly enhancing
mass in the left parietal lobe.
27. A previously fit and healthy 29-year-old man complains of sudden onset of
severe headache, associated with nausea and vomiting. On examination
he is drowsy Glasgow Coma Scale (GCS) 9/15 and he has neck stiffness.
28. A 78-year-old man complains of headache and pain on chewing for three
weeks. He has lost 10-kg in weight. His investigation results show a mild
anemia (Hb 11-g/dl) and an ESR of 100 mm after one hour.
29. An 11-year-old girl is complaining of sudden-onset headache, nausea and
vomiting. Her temperature is 40oC.
30. A 36-year-old businessman has suffered from recurrent headaches for the
last 4 months. He describes the headache to be like a very tight band
around the head.

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Answer: Causes of headache

26. D
27. I
28. C
29. F
30. K
These are the classical description of the various headache types. The most
common forms are tension and migrainous headaches. Clinically a stepdown
approach is necessary. First exclude potentiality serious diseases such, as
meningitis (fever and rash) and subarachnoid hemorrhages (sudden onset of
severe headache in previously well person). The commonest type of
intracranial malignancy is metastatic disease. However, single irregular lesions
(such as in question 26) are mostly aggressive gliomas. Do not forget other
causes of headaches' such as sinusitis, osteoarthritis of the temporomandibular
joint, tooth abscess and cluster headaches. The latter present mainly in middleaged men with profuse lacrimation and pain around the eye.

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Theme Hematuria in children

Options
A Acute glomerulonephritis
B Benign recurrent hematuria
C Hemolytic uremic syndrome
D Nephroblastoma
E Renal venous thrombosis
F Urinary tract infection

For each presentation below choose the SINGLE most likely cause from the above list
of options. Each option may be used once, more than once, or not at all

31. A four-year-old child has an upper respiratory tract infection followed two
weeks later by hematuria associated with oliguria and Periorbital edema.
32. A three-year-old girl has itching, frequency and pain on urination.
33. A child of four months presents with an abdominal mass and investigation
shows displacement of the right kidney and there is microscopic hematuria.
34. A six-year-old has a number of episodes of painless macroscopic hematuria
with no evidence of a UTI and a normal IVU.

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Answer: Hematuria In children

31. A
In children acute glomerulonephritis often follows a sore throat or Upper
Respiratory tract infection and the causative organism is normally a
Group A Streptococcus. The combination of hematuria, oliguria, and
periorbital edema suggests nephritis. A raised ASOT would suggest that
a streptococcal infection was the cause.

32. F
This describes the common features of a urinary tract infection (UTI).
Diagnosis is made by examination and culture of the urine.

33. D
Nephroblastoma usually presents with abdominal distension and the
finding of mass in the abdomen. Hematuria is an uncommon but well
recognized finding.

34. B
The lack of infection, a normal urinary tract and repeated episodes
suggest a benign recurrent hematuria. The etiology of this condition is
unclear.

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Theme: Electrocardiography
Options
A Dominant QRS deflection negative in lead I
B Dominant QRS deflection positive in lead l and
negative in leads II and Ill.
C Dominant QRS deflection positive in leads I and II.
D High T-waves (more than 2/3rd of corresponding R
waves)
E Loss of R waves in leads V1
F QT time prolonged
G QT time shortened

For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all

35. Left axis deviation

36. Right axis deviation
37. Normal electrocardiographic axis
38. Hypokalemia
39. Hypocalcemia
40. Hyperkalemia

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Answer: Electrocardiography

35. B
The electrocardiographic axis is easily determined from leads II and I. If
the major QRS deflection is positive (upwards, R-wave) in lead II, and I
the axis is normal. If it is only positive in lead I the diagnosis is left axis
deviation and if it is negative in lead I the diagnosis is right axis
deviation.

36. A
See answer 35

37. C
See answer 35.

38. F
Hypokalemia and Hypocalcemia prolong the QT-interval.

39. F

40. D
Hypercalcemia can produce high T waves in electrocardiographic
recordings. Other conditions are hyperacute myocardial infarction and it
may also be found as a normal variant in young, fit adults.

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Theme: Utero-vaginal prolapse

Options
A Complete / III degree uterovaginal prolapse
B Manchester repair
C No option applies
D Ring or Smiths shelf and shaft pessary
E This is a common complication after hysterectomy
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all

41. Associated with urinary incontinence.

42. Method of choice in women has not completed their family.
43. Procidentia
44. Ideal for elderly women with high anesthetic risk
45. Vault prolapse

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Answer: Utero-vaginal prolapse

41. C
42. B
43. A
44. D
45. E
The incidence of utero-vaginal prolapse is rising due to ageing of our
population. However, it is occasionally seen in young women and in these
cases a Manchester repair is performed. Vault prolapse is common after a
hysterectomy. The term procidentia means complete utero-vaginal prolapse.
Ring or Smith shelf and shaft pessary is the preferred method of management
in women who are a poor anesthetic risk or who do not want an operation.

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Theme Investigation of trauma

Options
A Chest X-Ray
B CT head scan
C Lateral cervical spine X-Ray
D Lumbar spine X-Ray
E MRI thoracolumbar spine
F Shoulder X-Ray
G Skull X-Ray
H Ultrasound abdomen

Match the following symptoms and signs, below to the SINGLE most helpful
investigation from the above list. Each option may be used once, more than once, or
not at all.

46. A 32-year-old boxer who complains of left-sided weakness 24-hours after a

boxing match.
47. A 19-year-old man who have sustained stab wounds to his abdomen and
trunk. His respiratory rate is 23 breaths/min, appear normal but his pulse is
142/min and his BP is only 80/40-mmHg.
48. A 47-year-old woman complains of left shoulder and neck pain after having
fallen off her bicycle. She has a graze on her forehead and also complains
of tingling in her left ring and little fingers (digits IV and V).
49. A 27-year-old motorcyclist has been involved in an accident and complains
of loss of sensation below the umbilicus and paralysis of both legs. His BP
is 80/50-mmHg with a pulse rat of 72/min.
50. A 54-year-old roofer complains of lower back pain radiating into the right leg
having fallen from a scaffold. He has no loss power or sensation when
examined.

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Answer: Investigation of trauma

46. B
This man probably has a subdural hemorrhage. A history of blows to the
head and delayed onset of neurological symptoms should arouse
suspicion. Considerable delay of clinical presentation in this condition is
not unusual, as the bleeding is venous in origin.

47. H
This man is in circulatory shock. The likely cause is blood loss into the
abdominal cavity. An ultrasound scan is a rapid and accurate way of
identifying intra-peritoneal fluid. Peritoneal lavage as often quoted in
older textbooks but is rarely indicated.

48. C
This lady's frontal graze is evidence of an axial compression injury to the
neck. A cervical spine lateral X-ray will detect an abnormality with a
sensitivity of 90%.

49. E
This man has spinal injuries with neurogenic shock ie. Hypotension in
the presence of a normal pulse rate. The sensory deficit suggests a
lower thoracic spine injury (umbilicus = T10).

50. D
A fracture of a lumbar vertebra is the most likely diagnosis. In the
absence of any neurological deficit a plain X-ray should be the first
investigation. This will allow identification of the level of injury.
Subsequently a CT scan or MRI may be required to assess the stability
of the injured vertebra and integrity of the spinal canal.

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Theme: The painful red eye

Options
A Acute cellulitis
B Chronic open angle glaucoma
C Closed angle glaucoma
D Foreign body
E Intra-ocular tumour
F Subconjunctival hemorrhage
G Ulcerative keratitis
H Urgent referral to eye surgeon
I Uveitis
J Viral conjunctivitis
K Vitreous hemorrhage
For each presentation below choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all

51. A 36-year-old man complains about sudden-onset pain in the right eye,
blurred vision and profuse lacrimation. On examination the eye is red and
his visual acuity is not significantly reduced. Additionally, complains about
back pain and stiffness in his lower spine.
52. After a prolonged and difficult labour a 26-year-old woman has successfully
delivered a large baby (4330 grams) per vaginam. The midwife is
concerned that the mother has developed red eyes.
53. A 24-year-old man presents to his GP complaining of burning, itching eyes,
and lacrimation. On examination you find mild erythema in both eyes, but
visual acuity is normal. He is also complaining about painful eye
movements.
54. A 65-year-old man complains about sudden-onset left eye pain, which
started while driving his car. On examination the eye is red and his visual
acuity is reduced. He claims to see a 'halo' around lights and. describes his
visual loss as 'looking through frosted glass'.
55. A newborn baby (12-days-old) has developed a red left eye with purulent
discharge.
56. A 48-year-old man with a recent injury of his left cheek was admitted with
marked left-sided periorbital swelling, red eye and blurred vision. He has
high fever and is drowsy.

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Answer: The painful red eye

51. I
This is the classical description of a patient with ankylosing Spondylitis.
The X-ray of his lumbar spine is often unremarkable in the early stages
of the disease. Bone scanning or special views of the iliosacral joints are
methods, to detect early disease.
52. F
Not an uncommon situation. Due to the high venous pressure when
pushing down to expel the small vessels burst in the conjunctiva. No
treatment is needed, but warn the mother that it might take a week or
two before the redness in the eye clears up.
53.J
A viral conjunctivitis is the correct diagnosis. Viral infections often cause
diffuse myalgia pain with extreme eye movements is a common finding.

54. C
This is the classical description of acute closed angle glaucoma.

55. H
The diagnosis is ophthalmia neonatorum and an emergency. The child
has to be admitted under the care of an eye surgeon and the disease
has to be notified. A bacterial infection (especially sexually transmitted
diseases such as Gonorrhea, chlamydia and staphylococcus) must be
considered.
56. A
Periorbital cellulitis is again an emergency. Anti-staphylococcal
antibiotics, such as flucloxacillin in combination with penicillin are the
recommended treatment

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Theme Childhood investigation

Options
A Bone marrow aspirate
B Brain biopsy
C Cardiac biopsy
D Jejunal biopsy
E Liver biopsy
F Lung biopsy
G Muscle biopsy
H Rectal biopsy
I Splenic aspirate
Which, biopsy investigation from the options listed above would you use to diagnose
the following condition? Each option may be used once, more than once or not at all.

57. Duchennes muscular dystrophy

58. Leishmaniasis
59. Subacute Sclerosing Panencephalitis (SSPE)
60. Hirschsprung disease

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Answer: Childhood investigations

57. G
Duchennes muscular dystrophy can be diagnosed by muscle biopsy.
The specimen will display the characteristic histological changes.

58. I
Visceral leishmaniasis results in massively enlarged liver and Spleen
and marrow infiltration. Splenic aspiration to confirm the presence of
Donovan bodies is the most commonly used investigation in the
developing world, although there is now a tendency to use bone marrow
aspiration since it is considered safer.

59. B
SSPE is a late compaction of measles (occurring some 10 years after
primary infection). It is characterized by an elevated measles specific
IgG in the CSF and by characteristic changes brain biopsy.

60. H
Developmental deficit of ganglions in the myenteric plexus of the colon
results in Hirschsprung's disease. The histological diagnosis can be
made by rectal biopsy.

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Theme: Multiple trauma

Options
A Fractured os calcis and thoracolumbar vertebrae
B Fracture pelvis, femur and cervical spine
C Fractured right humerus, right femur and pelvis
D Head/facial injury, fractured sternum, tibial fractures
E Respiratory distress and facial burns

Mark the following patients to the SINGLE most likely pattern of injury from the options
listed above. Each may be used once, more than once, or not at all.

61. A 37-year-old driver of a car struck by a van on the drivers side.

62. A 25-year-old roofer falling 7-meters to the ground, landing feet first.
63. A 43-year-old man involved in an explosion at a petrochemical plant.
64. The driver of a car in an head-on-collision whilst not wearing a seat belt.
65. A19-year-old motorcyclist, thrown 19-meters from his motorbike.

PASTEST book-Two

Answer: Multiple trauma

61. C
All this patient's injuries are right sided, indicating the direction of the
impact.

62. A
Os calcis and vertebral fractures are typical consequences of a fall from
a height Pelvic fractures may also be caused by this mechanism.

63. E
Explosions may cause inhalation/respiratory injuries as well as fractures
resulting from the blast. A high index of suspicion is required (continuous
pulse oximeter surveillance) with smoke inhalation. The threshold for
endotracheal intubation should be low as progressive upper airway
edema could make this option impossible at a later stage. Do not forget
additional CO and CN poisoning.
64. D
This patient has sustained a head-injury from striking the windscreen a
fractured sternum from hitting the steering wheel and tibial injuries from
dashboard disintegration. He also requires neck immobilization as he
has a cervical spine injury until proven otherwise.

65. B
High velocity accidents often result in long bone and pelvic fractures.
Motorcyclists are also at severe risk of cervical spine injuries and the
helmet should be removed with great care as spinal damage may be
aggravated.

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Theme: The painful hip in children

Options
A Developmental dysplasia of the hip (CDH)
B Irritable hip syndrome
C Osteomyelitis
D Perthes disease
E Septic arthritis
F Slipped upper femoral epiphysis (SUFE)
Match the following symptoms and sign listed below with SINGLE most likely condition
from the options above. Each option may be used once, more than once, or not at all.

66. A six-year-old boy complains of intermittent hip-pain for several months.

Hematological investigations are normal. X-rays show flattening of the
femoral head.
67. A two-year-old girl with a one-day history of increasing hip pain has become
unable to weight bear. Her WCC is 22 /fl, with an ESR of 88 mm/hour and
CRP of 300-mg/l. A radiograph of the hip shows a widened joint space.
68. A 12-year-boy with left groin pain for 6 week is noticed to stand with the left
leg externally rotated. Examination reveals negligible internal rotation of the
hip.
69. A four-year-old boy complains of right hip pain a few days following an
Upper respiratory trac infection. Blood tests are follows: WCC 12 /fl, ESR 10mm/ hour and CRP 2 mg/l.
70. A five-year-old girl complains of progressively increasing severe pain in her
left hip and upper leg for 6-days. She is able to walk but limps visibly. Blood
tests are as follows: WCC 19/fl, ESR 72 mm/hour and CRP 94 mg/l. X-rays
and ultrasound scan of the hip are normal.

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Answer: The painful hip in children

66.D
Perthes disease commonly presents in the 4-9 years age group. It is
more common in boys, often with a strong family history. The symptoms
tend to be relatively minor in the early stages. At a later stage, X-rays
may show flattening of the femoral head caused by localized
osteonecrosis.
67. E
This girl has septic arthritis; this condition is characterized by severe
pain usually rapid in onset and the child is unable to walk. It occurs most
commonly below the age of four years. The commonest organism
isolated is S. aureus. High inflammatory markers, along with fluid in the
hip joint, suggest the diagnosis that is confirmed with joint aspiration.
The basis of treatment is surgical drainage with adjuvant antibiotic
therapy.
68. F
SUFE is found in older children (boys > girls), up to the age of puberty.
Classically symptoms are insidious in onset, as the displacement
gradual. External rotation of the limb at rest is pathognomic. A special
lateral X-ray view will show the posterior displacement of the upper
femoral epiphysis.
69. B
Irritable hip often follows an upper respiratory tract infection. The
pathophysiology is still unknown. The children develop a form of reactive
synovitis in the hip with pain and a sterile effusion. Blood tests are
usually normal and the children are not systemically ill. Aspiration of the
hip joint will reveal fluid containing white blood cells but no organisms.
Aspiration is also therapeutic as it reduces pain.
70.C
Osteomyelitis can be difficult to differentiate clinically from septic
arthritis. The pain tends to be more chronic in onset and less severe in
osteomyelitis the child may still be able to walk which is not the case
with septic arthritis

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Theme: Cervical disc prolapse

Options
A C5 nerve root
B C6 nerve root
C C7 nerve root
D C8 nerve root
E T1 nerve root

Altered sensation or paraesthesia over the following areas listed below suggests
involvement of which of the nerve roots from the above list of option? Each option may
be used once, more than once, or not at all.

71. Thumb
72. Outer forearm
73. Upper outer arm
74. Middle finger
75. Little finger

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Answer: Cervical disc prolapse

71. B
72. B
73. A
74. C
75. D
Remember the following landmarks for the upper limb dermatome distribution:

Thumb and radial forearm segment C6

Middle finger (D3) segment C7
Little finger (D5) and ulnar border of hand segment C8
Ulnar forearm segment Th1
Outer upper arms and shoulder segment C5
Inner upper arm and axilla segment Th2 and Th3
The clavicular area (sub- & supraclavicular fossa) is supplied by segments C3 and C4.

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Theme: Jaundice in childhood

Options
A ABO incompatibility
B Biliary atresia
C Breast milk jaundice
D Congenital toxoplasma infection
E Crigler-Najjar syndrome
F Galactosemia
G Gilberts syndrome
H Glucose-6-phospho-diesterase deficiency
I Hereditary spherocytosis
For the list of scenarios below select the correct cause from options above. Each
option may be used once, more than once, or not at all.

76. A newborn develops an unconjugated hyperbilirubinemia 12-hours after

birth associated with a severe metabolic acidosis.
77. An infant is jaundiced at birth and is found on examination to have a
distended abdomen with organomegaly. The infant also has convulsions.
78. A newborn develops a progressive conjugated hyperbilirubinemia with pale
stools and dark urine.
79. A full-term infant develops jaundice on day three, which continues for two
weeks. The hyperbilirubinemia is unconjugated, there is no derangement of
other liver function tests and the child remains clinically well.

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Answer: Jaundice in childhood

76. A
Jaundice appearing within the first 24-hours of Life is nearly always due
to hemolytic disease. With the awareness of rhesus incompatibility, ABO
incompatibility is now the commonest cause in the UK.

77. D
These signs are suggestive of a congenital infection. Congenital
toxoplasmosis results in hepatosplenomegaly, thrombocytopenia, and
cerebral calcifications. The children often suffer convulsions.

78. B
Biliary atresia is a congenital defect in which there are variable degrees
of abnormality of the biliary tract resulting in progressive obstructive
jaundice. Surgical intervention is invariably necessary.

79. C
This scenario is very suggestive of breast milk jaundice especially since
LFTs and clinical condition are normal.

PASTEST book-Two

Theme: Treatment of femoral fracture

Options
A Dynamic hip screw (DHS)
B Gallows traction
C Hemiarthroplasty
D Intramedullary nailing
E Multiple cannulated hip screws
F Open reduction and internal fixation (ORIF)
G Skeletal traction
H. Total hip replacement (THR)

Choose the MOST appropriate form treatment from the above list of option for each of
the following fractures option may be used once, more than once, or not at all.

80. A 78-year-old lady in A&E with a displaced subcapital (Garden-IV) fracture

of the femoral neck.
81. A 24-year-old motorcyclist after an RTA came with a closed fracture of the
right femoral shaft.
82. A nine-month-old child brought with a spiral fracture of the femoral shaft.
83. A-57-year-old lady with an undisplaced fracture of the right femoral neck
84. An 8-year-old girl with a displaced intertrochanteric fracture

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Answer: Treatment of femoral fractures

80. C
In displaced subcapital fractures the blood supply to the femoral head
has been damaged. Fixation of these is therefore likely to fail (avascular
necrosis of the femoral head) and should only be considered in young
patients accepting the chance that further surgery maybe required. In
elderly patients the treatment of choice is to replace the femoral head
with a hemiarthroplasty.
81.D
Intramedullary nailing is the best treatment as it stabilizes the fracture,
promotes union, & allows early mobilization and rehabilitation of patient.

82. B
Below the age of one, Gallows-traction is very effective.

83. E
In this case the femoral head may be preserved, as the blood supply
was probably not interrupted, as there has been no displacement of the
fragments. Fixation with cannulated screws should be undertaken within
12-hours of the fracture occurrence as the risk of avascular necrosis of
the femoral head increases with later surgery.
84. A
These are extra- capsular fractures and the blood supply to the femoral
head has therefore not been damaged. Fixation with a screw and plate
device such as the Dynamic Hip Screw (DHS) provides much better
stability than with screws alone.

PASTEST book-Two

Theme: Management of infertility

Options
A Bacteriological examination of urine
B Day-21 progesterone
C Semen analysis
D Tubal patency test
E Wait and see
For each presentation below, choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all.

85. A couple aged 25-years have been trying for a baby for six-months.
86. Useful in determining ovulation.
87. An essential investigation for all heterosexual infertile couples.
88. This investigation is of little value
89. This is an essential investigation of the female partner.

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Answer: Management of infertility

85. E
86. B
87. C
88. A
89. D
Infertility is a symptom and not a diagnosis. It is often mismanaged with
protracted and fragmented investigations. In healthy couples of
childbearing age with regular sexual intercourse and without contraception,
80% will achieve a pregnancy after 12 months and 90% after two years. It
is therefore not necessary to initiate investigations before one year. Semen
analysis is an essential investigation and can be performed in a primal care
setting. Two samples one month apart should be investigated
Hysterosalpingogram, Laparoscopy and dye test or high contrast
ultrasonography will confirm tubal patency. .

PASTEST book-Two

Theme: Back Pain

Options
A Bony metastasis
B Central disc prolapse
C Dissecting abdominal aortic aneurysm
D L1-L2 disc prolapse
E L4-L5 disc prolapse
F Mechanical back pain
G Osteoporotic vertebral body crush fracture
H Spinal stenosis
I Spinal tuberculosis
For each of the following clinical pictures choose the MOST likely diagnosis from the
above list of options. Each option may be used once, more than once, or not all.

90. A33-year-old male company director complains of intermittent lower back

pain in the absence of any neurological symptoms or signs. Radiographs
are normal.
91. A 43-year-old woman complains of sudden onset lower back pain radiating
down the left leg as far as the heel. She has paraesthesia over the lateral
aspect of the left lower leg and foot. Examination reveals straight leg raising
(SLR) limited to 20 degrees with altered sensation in the above distribution.
92. A 68-year-old woman complains of bilateral buttock and thigh pain
associated with back pain after walking 200 meters; sitting down relieves
the pain. She does not experience any symptoms at rest. Examination of
the back is unremarkable.
93. A 28-year-old woman has severe lower back pain; she is incontinent of
urine. Examination reveals loss of sensation over the perineum and straight
leg raise is limited bilaterally.
94. A 72-year-old man complains of severe back pain not responding to rest.
He is unable to sleep and has lost 6 Kg in weight over the last two months.
Examination reveals some tenderness in the lumbar region but no
neurological abnormalities.

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Answer: Bake pain

90.F
A sedentary lifestyle is the usual cause of mechanical back pain. The
absence of any neurological abnormalities is necessary for the
diagnosis. Physiotherapy with back strengthening exercises and postural
advice is the mainstay of treatment

91.E
This lady has sciatica. The distribution of her leg symptoms suggests
compression of the L5 nerve root, which is usually caused by an L 4-L5
disc prolapse.

92. H
Spinal stenosis causes claudication. The symptoms subside within,
minutes of sitting down. Assessment of the peripheral circulation is
mandatory to exclude any vascular causes. Surgical treatment is by
spinal decompression.

93. B
This is an emergency Urgent decompression is required in order to
prevent any irreversible damage. The diagnosis is central disc prolapse.

94. A
Intractable back pain (ie. persisting at rest) in an elderly person is
unusual. It suggests a malignant-process, particularly if associated with
systemic symptoms such as weight loss. Spinal tuberculosis is rare in
the United Kingdom.

PASTEST book-Two

Theme: Short stature in children

Options
A. Achondroplasia
B Congential hypothyroidism
C Downs syndrome
D Growth hormone deficiency
E Hypopituitarism
F Klinefelters syndrome
G Noonan's syndrome
H Russel Silver syndrome
I Turners syndrome
For each child listed below choose the MOST likely cause of short stature form the
options listed above. Each option may be used once, more than once, or not at all.

95. A child with an abnormally sized head, predominant-shortening of the

proximal upper and lower limbs.
96. A six-year-old boy with webbing of the neck, cubitus valgus and congential
heart disease.
97. A seven-year-old boy previously treated with cranial irradiation for a brain
tumour has recurrent episodes of hypoglycemia.
98. A two-year-old baby with poor motor and speech development, large tongue
and umbilical hernia.

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Answer: Short stature in Children

95. A
Disproportionately shortened limbs would point to a skeleton dysplasia
such as achondroplasia. This is an autosomal dominant condition.

96. G
Noonan's syndrome in boys mimics many of the features of Turner's
syndrome however. Turners can only be found in girls due to the
chromosomal abnormality (XO).
NB. XO is the type of chromosomal defect.

97. D
Cranial irradiation especially it a young age can lead to hypopituitarism
with loss of growth hormone production and resulting in short stature
and hypoglycemia.

98. B
The child has congenital hypothyroidism.

PASTEST book-Two

Theme urinary incontinence

Options
A Detrusor instability
B Genuine stress incontinence
C None of the above
D Retention with over flow
E Urinary fistula
From each presentation below choose the SINGLE most likely diagnosis from the
above list of options. Each option may be used once, more than once, or not at all.

99. History of dysuria, frequency and foul smelling urine.

100. History of urgency and frequency of micturition and inability to hold urine
as soon as the urge to pass urine is felt.
101. History of leakage of small amounts of urine following an operation for
stress incontinence.
102. Urinary incontinence when intra-abdominal pressure is raised, e.g. on
coughing and sneezing.
103. Continuous leak of small quantity of urine following Wertheims
hysterectomy for stage-Ib carcinoma of the cervix.

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Answer: Urinary incontinence

99. C
100. A
101. D
102. B
103. E
There are several types of urinary incontinence and the clinic presentation
might suggest the correct diagnosis and help to chose appropriate treatment.
Urinary fistulae should be suspected after radical surgery or radiotherapy for
gynecological cancers, whereas retention with over flow is common after
difficult vaginal delivery (normal or instrumental). Urinary tract infection often
presents with urgency and frequency of micturition and must be distinguished
from Detrusor instability.

PASTEST book-Two

Theme: Chest trauma

Options
A Abdominal ultrasound
B Chest drain
C Chest radiograph
D Computed tomography
E MRI scan chest
F MRI scanning
G Needle thoracocentesis
H Pericardiocentesis
For each of the following, scenarios choose the MOST appropriate investigation from
the above fist of options. Each option may be used once, more than once, or not at all.

104. A 35-year-old has been stabbed in the left lower chest from behind with a
5-centimeter long blade. His BP is 80/60-mmHg with a pulse of l10/min. He
has normal breath sounds and no evidence of pneumothorax on X-ray.
105. A 20-year-old horse rider has sustained a crush injury to the chest when
her horse landed on her during a fall. On examination you find tenderness
on the right side of her chest with decreased breath sounds and dullness to
percussion. Her vital signs are; pulse of 110/min and BP is 100180-mmHg.
106. A 32-year-old driver of a car involved in a head on collision has, evidence
of blunt chest trauma to the sternum area. His BP is 90/60-mmHg with a
pulse of 120/min. He has prominent neck veins and muffled heart sounds.
Chest X-ray is normal.
107. A 27-year-old motorcyclist involved in a road traffic accident (RTA)
complains of difficulty in breathing. He has a respiratory rate of 40
breaths/min, decreased chest movements and air entry on the right along
with hyper-resonance on percussion. His pulse oximeter readings are
around 80% on oxygen.
108. A 37-year-old man was involved in a high speed RTA. He is unconscious
with evidence of bruising across his chest. Despite intravenous fluid
replacement with 4-liters of Hartmann's Solution, he remains hypotensive.
His X-ray shows a widened mediastinum.

PASTEST book-Two

Answer: Chest trauma

104. A
Penetrating injuries to the left lower chest may involve the spleen as this
lies under the 9th -11th ribs. Having excluded a pneumothorax on X-ray
this patient requires an abdominal ultrasound to confirm the presence of
intraabdominal bleeding.

105. C
Clinically, this lady has a hemothorax. She is hemodynamically stable
and an X-ray is appropriate to confirm the diagnosis.

106. H
This man exhibits the hallmarks of a Pericardial tamponade Cardiac
ultrasound will confirm the diagnosis. Needle pericardiocentesis is
required treatment

107. G
This man is shocked due to a tension pneumothorax. Needle
thoracocentesis (second intercostal space in medioclavicular line) will
release the pressure and buy time for insertion of it chest drain set.

108. D
This man has a thoracic aortic aneurysm. A computed tomogram
followed by angiography will confirm the diagnosis.

PASTEST book-Two

Theme: Developmental milestones of children

Options
A 6 week
B 6 months
C 1 year
D 2 years
E 3 years
F 5 years

From the above options select the age at which you would expect a normal child to
achieve the following development stages listed below? Each Option may be used
once, more than once, or not at all.

109. Sitting unaided

110. Smiling
111. Walks up stairs
112. Dry by day
113. Cruising around furniture

PASTEST book-Two

Answer: Development milestones of children

109. B
110. A
111. D
112. E
113. C
In chronological order most normal children smile at six weeks, sit at six
months, cruise around furniture at one year; walk upstairs by two years, and
are, dry by day at approximately three years. All these stages have ranges but
in this question there is only one normal age available for each milestone e.g.
cruising around furniture is delayed at two years and incredibly precocious at
six months so one year is the only possible answer. Major development
milestones at 6, 12, 18, 24, 36 and 48 months should be learnt for the purposes
of the exam. These should be split into gross arid fine motor, hearing and
speech, social behavior and play.

PASTEST book-Two

Theme: Vaccines
Options
A Hib
B Mantoux
C Pneumovax
D Rubella
E Salk polio
F Tetanus
For each description of vaccine type given below, choose the MOST likely vaccine
from the above list. Each may be used, more than once, or not at all.

114. Killed
115. Conjugate
116. Live
117. Polysaccharide

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Answer: Vaccines
114. E
115. A
116. D
117. C
The UK vaccination schedule should be known for the PLAB exam. The nature
of the vaccines is also important for parent information. At present Hib and
Meningococcal vaccines are the only conjugate vaccines (a polysaccharide
conjugated to a protein carrier) to be used. A simple polysaccharide vaccine in
the form of Pneumovax is used for special indications including post
splenectomy and immunosuppressed patients Measles, mumps and rubella are
live attenuated vaccines and although the usual Sabin polio vaccine is a live
virus, the killed inactivated Salk vaccine is used for certain patients.
IMMUNIZATION SCHEDULE
Vaccine
BCG
Triple
(pertussis, tetanus, diphtheria)
Repeat triple Hib and polio
MMR
(measles, mumps rubella)
Polio, Tetanus
Diptheria (Td) booster
Flu vaccine

Age
Neonatal or at 6 weeks 10-14
years
2 months
3 and 4 months
12-15 months
15-18 years
65 years (consider yearly)

PASTEST book-Two

Theme: Congenital infections in childhood

Options
A Congenital CMV infection
B Congenital Herpes simplex infection
C Congenital parvovirus
D Congenital rubella
E Congenital syphilis
F Congenita toxoplasmosis

Which congenital infection listed in the option above is MOST likely in the following
clinical cases? Each option may be used once, more than once, or not at all.

118. A newborn child with thrombocytopenia, hepatosplenomegaly. CT scan of

the head reveals retinitis and periventricular calcification.
119. A newborn girl with hepatosplenomegaly, Chorioretinitis, and tram-like
calcifications on CT scan of the head.
120. A newborn boy with skeletal changes suggestive of recurrent periostitis, a
bony prominence of the head and a saddle nose.
121. A stillborn child with non-immune (ie. compatible rhesus constellation)
hydrops fetalis.

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Answer: Congenital infections in childhood

118. A
119. F
120. E
121. C
Congenital infections in children can be very similar in presentation, especially
congenital rubella, toxoplasmosis and CMV. They are best differentiated on the
basis of eye involvement and the type of calcifications observed. Congenital
syphilis results in chronic inflammation of the bones and a bony prominence of
the head congenital parvoviral infection must be considered in all cases of
nonimmune hydrops.

PASTEST book-Two

Theme: Abnormal smear

Options
A Colposcopy is indicated
B Cytobrush technique is indicated
C Dyskaryosis
D Dysplasia
E May be a false positive result

For each presentation below, choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all.

122. Must be used in a woman in whom previous colposcopy was incomplete.

123. Repeat smear test necessary in the first instance.
124. Within three months from the end of pregnancy
125. This is a histological diagnosis.
126. With two or more inadequate smears

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Answer: Abnormal smear

122. B
123. C
124. E
125. D
126. A
The terminology is often confusing. Dysplasia is a histological diagnosis
whereas dyskaryosis is a cytological diagnosis. Mild, moderate and severe in
both cases equates to CIN I, II and III respectively. A smear during pregnancy
and within three months from the end of pregnancy can be misleading and
should be avoided unless indicated, e.g. previous severe abnormality. In
postmenopausal women and in women who have had a loop biopsy a
cytobrush must be used to obtain cells from the squama columnar junction.

PASTEST book-Two

Theme: Increased susceptibility to infection

Options
A Bruton's agammaglobulinemia
B Chediak-Higashi syndrome
C Chronic granulomatous disease
D Complement deficiency
E Hyper IgE syndrome
F IgA deficiency
G Severe combined immunodeficiency
Susceptibility to which infections listed below is MOST characteristic of the above
immunodeficiency syndromes. Each option may be used once, more than once or not
all.

127. Recurrent Neisseria meningitidis infection

128. Pneumocystis carinii pneumonitis
129. Aspergillus infection
130. Staphylococcal skin abscesses

PASTEST book-Two

Answer: Increased susceptibility 10 infection

127.D
In repeated Neisseria infections, complement deficiency especially
deficiency of properdin, a positive regulator of the alternative pathway of
complement activation, should be considered.

128.G
Opportunistic infections such as PCP are associated with severe T cell
defects. All forms of severe combined immunodeficiency have a defect
of T cell function and affected individuals are susceptible to PCP.

129. C
Although principally conferring susceptibility to bacterial infection chronic
granulomatous disease is also associated with aggressive aspergillus
infections and this is one of the main causes of death in this condition.

130. E
Although the mechanism is not known, Hyper IgE syndrome (also known
as Jobs syndrome) is associated with Staphylococcus aureus infections.
The hallmarks of this condition are severe eczema and high IgE levels.

PASTEST book-Two

Theme: Complications of total hip replacement (THR)

Options
A Anterior dislocation
B Cellulitis
C Chest infection
D Deep infection
E Deep vein thrombosis (DVT)
F Hematoma
G Posterior dislocation
H Pulmonary embolism (PE)
Choose the MOST likely diagnosis from the above list of options for each of the
following clinical presentations. Each option may be used once, more than once, or not
at all.

131. A 73-year-old man complains of swelling and discoloration of the right leg
seven days after a right THR. He has tenderness behind the right knee on
palpation.
132. An 81-year-old lady develops a pyrexia of 38 oC three weeks after her left
THR. Her wound is oozing and her blood tests reveal a CRP of 150 mg/l
and an ESR of 96 mm/hour.
133. A 67-year-old lady develops swelling and bruising of the left thigh, four
days after her left THR. Blood tests are normal.
134. A 77-year-old man develops sudden chest pain and breathlessness five
days after his left THR. His pulse oximetry readings are 82% on air.
135. A 75-year-old lady develops sudden severe pain in her right hip whilst
sitting down three weeks after her right THR. She is unable to stand and her
right leg is internally rotated, flexed and adducted at the hip.

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Answer: Completion of total hip replacement (THR)

131. E
Post-operative swelling in the operated leg is common following THR.
Calf tenderness is indicative of deep vein thrombosis. A Doppler U/S
scan or a venogram will confirm the diagnosis.

132. D
High inflammatory markers and oozing from a hip wound are hallmarks
of a deep infection, such as an abscess. The treatment is aggressive
surgical debridement and adjuvant antibiotic therapy in the hope of
salvaging the THR.

133. F
Bruising and swelling suggest a hematoma occasionally a low-grade
pyrexia and mild elevation of the inflammatory markers may accompany
these. Treatment is usually non-operative

134. H
Pulmonary embolism is more likely than chest infection in view of the
sudden onset of symptoms spiral CT or a V/Q scan will confirm the
diagnosis.

135.G
Internal rotation, adduction and flexion at the hip are signs of posterior
dislocation. This is commonly caused by sitting in low chairs or bending
over to pick objects from the floor. In anterior dislocation, the leg is
extended and externally rotated at the hip.

PASTEST book-Two

Theme: Skin disease in children

Options
A Erythema chronicum migrans
B Erythema infectiosum
C Erythema multiforme
D Erythema nodosum
E Exanthema subitum
F Purpura fulminans
G Tinea corporis
For the clinical scenarios listed below choose the condition MOST associated from the
above list of options. Each option may be used once, more than once or not at all.

136. A nine-month-old child is non-specifically unwell for three days with a

fever. The rash subsides and the child breaks out in a maculopapular rash
over its body.
137. Following a course of Septrin for a bacterial infection, a five-year-old child
breaks out in a widespread macular rash with target lesions.
138. A four-year-old boy has runny nose and mild fever and develops bright red
cheeks and reticular rash on the forearms.
139. Following a tick bite on holiday in a forested area, a seven-rear-old boy
develops an erythematous macule at the site of the bite, which then spreads
into an annular lesion with a clear central area.

PASTEST book-Two

Answer: Skin disease in children.

136. E
This pattern is characteristic of roseola infantum and the rash is
exanthema subitum. The causative agent is most commonly HH-V6
(Human Herpes Virus 6) infection.

137. C
Erythema multiforme has a multitude of precipitating factors including
bacterial infection (e.g. mycoplasma) viral infections (e.g. HSV infection)
and drugs, the most common of which are sulfonamides. The target on
is characteristic of the condition.

138. B
This is slapped cheek syndrome or erythema infectiosum. It is due to
parvovirus B-19 infection and is usually a benign condition. In certain
cases, especially in individuals with underlying hematological
abnormalities it can result in aplastic crises.

139. A
A tick bite from areas inhabited by deer can resulted in Borrelia infection
(Lyme disease). The disease progresses in stages but initially leads to
the characteristic rash of chronicum migrans. It may progress to
meningoencephalitis at this stage.

PASTEST book-Two

Theme: Drugs in childhood

Options
A. Aminophylline
B Aspirin
C Azithromycin
D Benzylpenicillin
E Brufen
F Cefotaxime
G Cisapride
H Isoniazid
I Tetracycline
For the list of scenarios below select the correct drug from the options above. Each
option may be used once, more than once, or not at all.

140. Is recommended as first line empirical therapy in bacterial meningitis

where the cause of infection is not known.
141. Is not recommended for analgesic or antipyretic use in children under 12years of age due to the risk of Reye's syndrome.
142. Causes arrhythmias in association with antifungal agents.
143. Should not be given to children under 12 years of age as it can cause
staining and malformation of teeth.

PASTEST book-Two

Answer: Drugs in childhood

140. F
Cefotaxime is now recommended by both the UK and US academic
panels as the drug of choice for empirical therapy in bacterial meningitis.
Ceftriaxone is an alternative in younger age groups amoxicillin should be
added to cover against Listeria infection.

141. B
Reyes syndrome is fatty necrosis of the liver that can lead to fulminant
liver failure and encephalopathy and is thought to be caused by certain
drugs especially aspirin.

142. G
Cisapride has now been withdrawn form the market due to the concern
over arrhythmias especially in association with the conazole drugs e.g
ketoconazole /fluconazole.

143. I
Tetracyclines have long been associated with the staining and
malformation of teeth and are not recommended for younger children.

PASTEST book-Two

Theme: Genetic defects

Options
A Angelman's syndrome
B Beckwith-Wiedemann syndrome
C Down's syndrome
D Edward's syndrome
E Klinefelter's syndrome
F Noonan's syndrome
G Russell-Silver syndrome
H Turner's syndrome
Choose the MOST likely genetic: defect from the list of options above for each clinical
scenario listed below. Each option may be used once, more than once, or not at all.

144. A new-born-male who is hypotonic and noted to have brachycephaly and

recurrent vomiting due to duodenal atresia.
145. A 14-year-old girl of normal intelligence who is short for her age and has
not yet started to menstruate.
146. A small for dates newborn with small chin, severe mental retardation and
abnormally shaped soles of the feet.
147. A five-year-old girl with short stature, hypertrophy of her left-sided limbs
and mild mental retardation.

PASTEST book-Two

Answer: Genetic defects

144. C
Downs syndrome can be difficult to diagnose in the neonatal period
although hypotonia is very common. The presence of duodenal atresia is
also very suggestive.

145. H
Short stature and amenorrhoea are the two hallmarks of Turner's
syndrome both arise from ovarian dysgenesis and can be treated with
oestrogen replacement.

146. D
Edward's syndrome (Trisomy 18) is a devastating condition and children
usually die in the first months of life. The rocker bottom feet are
characteristic of this condition.

147. G
Russell-Silver dwarfism is associated with hemi-hypertrophy and an elfin
like face and is the most likely candidate on the list. Noonan's syndrome
affects boys.

PASTEST book-Two

Theme: Intra-uterine contraceptive device (IUCD)

Options
A Antibiotic therapy and remove IUCD
B Contraindicated
C IUCD should be inserted after the next period
D Remove IUCD and offer alternative contraception
E Suspect ectopic pregnancy refer to early
pregnancy assessment unit
For each patient below choose the MOST appropriate option from the list above. Each
option may be used once, more than once, or not at all.

148. A 25-year-old woman is complaining of persistent lower abdominal pain

and irregular vaginal bleeding since the insertion of an IUCD six months
ago.
149. A 32-Year-old woman who had an IUCD inserted three weeks ago is
complaining of severe abdominal pain. On examination pulse 92/min, temp
37.7oC, the abdomen is tender but there is no rigidity or guarding.
150. A 27-year-old woman has come to your family planning clinic requesting
insertion of an IUCD. Her last menstrual period was three weeks ago.
151. A woman in her early twenties presents with left iliac fossa pain and
vaginal bleeding for three days. An IUCD was inserted three months ago
and her last normal period was five weeks ago.
152. A Woman in her late twenties with a history of pelvic inflammatory disease
was reported to have pelvic adhesions at laparoscopy six months ago and
is requesting and IUCD for contraception.

PASTEST book-Two

Answer: Intra- uterine contraceptive device (IUCD)

148. D
149. A
150. C
151. E
152. B
An intrauterine contraceptive device is a reliable method of contraception
particularly for women in whom oral contraceptives are contraindicated or
where there is poor compliance. It should be inserted soon after beginning of
the menstrual bleed as the procedure is easier through the slightly soft and
dilated cervix and additionally, pre-existing pregnancy is ruled out. Commonest
complications are pelvic inflammatory disease, ectopic pregnancy and irregular
bleedings.

PASTEST book-Two

Theme: Ankle injuries

Options
A Elastic bandage and physiotherapy
B External fixation
C External fixation and wound debridement
D Manipulation under anesthesia (MUA) and POP application
E Open reduction and internal fixation (ORIF)
F Plaster of Paris (POP) immobilization
G Suture repair
Choose the MOST appropriate from or treatment from the list of options above for
each of following clinical condition. Each option may be used once, more than once, or
net at all.

153. A 26-year-old man complains of sudden onset pain at the back of his heel
and calf whilst playing squash. He has calf tenderness and is unable to
stand on his toes; X-rays are normal.
154. A 54-year-old woman sustains a twisting injury to the left ankle whilst
stepping off a kitchen ladder. He has swelling and tenderness over the
lateral aspect of the ankle. X-rays shows an undisplaced fracture of the
distal fibula.
155. A 23-year-old motorcyclist involved in a RTA has a compound (open)
fracture of the left tibia with extension into the ankle joint.
156. A 31-year-old footballer sustains an injury to the right ankle in a tackle.
There is swelling and tenderness over both medial and lateral aspects of
the ankle. X-rays show a displaced fracture of the distal fibula (weber type
C) with evidence of talar shift.
157. A 4-Year-old window cleaner falls off a ladder injuring his left heel. X-rays
confirm an extra-articular fracture of the calcaneum.

PASTEST book-Two

Answer: Ankle injuries

153. G
This man has a tendon Achilles rupture. The best results in young
patients are achieved by open repair of the ruptured tendon. Plaster
immobilization results in weakening of the calf musculature and an
increased re-rupture rate.

154. F
Undisplaced fractures of the distal fibula do not require surgical fixation
and may be simply treated in plaster.

155. C
Compound fractures require urgent and extensive wound debridement in
order to prevent subsequent infection. The use of external fixators after
debridement preferable to internal fixation, techniques because of the
lower infection risk.

156. E
Displaced ankle fractures require accurate anatomical reduction if
function is to be restored.

157. F
Calcaneal fractures are mostly treated, conservatively because of the
high risk of wound healing problems and subsequent infections. Only
fractures with severe joint involvement are considered for surgical
fixation.

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Theme: Investigations of postmenopausal bleeding

Options
A Full blood count
B None of the above
C Pipelle biopsy
D Referral to gynecology clinic
E Transvaginal ultrasound scan
F Vulval biopsy
For each presentation below, choose the SINGLE most likely diagnosis from the above
list of options each option may be used once, more than, or not at all.

158. Post menopausal woman complaining of pruritus vulvae.

159. A 50-year-old woman on cyclical hormone replacement therapy complains
of irregular vaginal bleeding.
160. An episode of vaginal bleeding ten years after the menopause.
161. A 60-year-old woman complaining of labial ulceration and bleeding.
162. Is of little value in the management of postmenopausal bleeding.

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Answer: Investigations of postmenopausal bleeding

158. B
159. D
160. D
161. F
162. A
A gynecologist should urgently investigate postmenopausal bleeding. Any of
the gynecological malignancies may be the underlying cause however they
would be unusual symptoms of ovarian cancer.

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Theme: Contraception
Options
A Associated with pelvic pain
B Break through bleeding is a common side-effect
C Consider ectopic pregnancy
D Is associated with irregular bleeding
E Suitable in a stable relationship
For each presentation below, choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, or not at all.

163. Progesterone contraceptives

164. Intrauterine contraceptive devices
165. Biphasic pill
166. History of irregular period and pelvic pain
167. Rhythm method

PASTEST book-Two

Answer: Contraception
163.D
164. A
165. B
166. C
167. E
Most women will go the family planning clinic for contraceptive advice but a
proportion will consult their General Practitioner. Progestogen only
contraceptives (pill or injection) often cause irregular bleeding but this is
minimal. In women with IUCD and a history of pelvic pain and irregular bleeding
ectopic pregnancy should always be suspected. Biphasic pills (combined
oestrogen and progesterone pill with varying dose of oestrogen through the cycle)

may cause break through bleeding and in these cases a normal combined pill
should be considered. Rhythm method, ie. avoiding sexual intercourse during
the peri-ovulatory phase has a high failure rate and good compliance requires a
high degree of motivation. It is suitable for couples in a stable relationship as
failure (ie. pregnancy) is usually accepted

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Theme: Investigations for Pruritus vulva

Options
A. Creatinine clearance
B. Glucose tolerance test
C. High vaginal swab
D. None of the listed options
E. Vulval biopsy
For each presentation below, choose the SINGLE most likely diagnosis from the above
list of options. Each Option may be used once, more than once, or not at all.

168. Must be done in a woman with associated history of vaginal discharge.

169. A woman with a history of postmenopausal bleeding.
170. This investigation is unnecessary.
171. A 45-year-old woman with associated vulval ulceration.
172. In a 38-year-old woman with gestational diabetes mellitus in her three
pregnancies.

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Answer: Investigation of pruritus vulvae

168. C
169. D
170. A
171. E
172. B
In most cases of pruritus vulvae there is an underlying gynecological cause.
However in a proportion of cases systemic disorders are etiological factors
such as diabetes mellitus or dermatological conditions. Poor hygiene, use of
talcum powders, deodorant, baths salts, synthetic underwear, tight jeans and
biological washing powders contribute to the symptoms and these should be
recognized in the history. In older women with a localized lesion a biopsy is
essential.

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Theme Causes of amenorrhoea

Options
A. Drug side-effect
B. Imperforate hymen
C. Likely to be premature menopause
D. Post pill amenorrhoea
E. Primary .amenorrhoea

For each presentation below, choose the SINGLE most likely diagnosis from the above
list of options. Each option may be used once, more than once, or not at all.

173. A 34-year-old woman being treated for endometriosis.

174. A 32-year-old woman with a history of hot flushes
175. A 14-year-old girl who is experiencing cyclical pelvic and vaginal pain but,
no period
176. A 17-year-old girl who has had only withdrawal bleeds.
177. A 24-year-old woman has recently discontinued contraceptive precaution.

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Answer: Causes of amenorrhoea

173. A
The object of medical treatment of endometriosis is suppression of
menstruation e.g. with the contraceptive pill continuous progesterone
therapy or danazol, GnRH etc.

174. C
Premature menopause (ie. menopause before, the age of 45 years)
occurs in about 1% of all women; it needs investigation. Possible
underlying causes are genetic factors (family history), chronic infections,
metabolic disease (e.g. diabetes mellitus and other endocrine disease),
drug treatment (e.g. chemotherapy) or autoimmune disease
175 B
Amenorrhea in a teenage girl with normal sexual development but
intermittent abdominal pain palpable lower abdominal swelling and
occasionally problems with micturition should make you suspect vaginal
atresia or more commonly imperforate hymen. Colposcopy will show a
bulging bluish membrane at the lower end of the vagina.
176. E
Primary amenorrhoea is the correct diagnosis. It has a considerable
differential diagnosis, e.g, chromosomal abnormalities (e.g. 45 X C),
hormonal disease (e.g. hypothyroidism) and anatomical defects.

177 D
Post pill amenorrhoea is not physiological and if the normal menstruation
has not restarted after 2-3 cycles further investigations are necessary.
Often the underlying problems are hyperprolactinemia or other chronic
medical disease.

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Theme: Vaginal discharge

Options
A. Common cause in pre-pubertal girls
B. Can be diagnosed clinically
C. Is more common with systemic
antibiotic treatment, diabetes and in
pregnancy
D. This has no diagnostic value
E. Treat with diathermy

For each presentation below. choose the SINGLE most likely diagnosis or treatment
from the above list of options. Each option may be used once, more once, or not at all.

178. Persistent vaginal discharge with cervical erosion

179. Candidiasis
180. Trichomonas
181. Foreign body in the vagina
182. Liver function test

PASTEST book-Two

Answer: Vaginal discharge

178. E
179. C
180. B
181. A
182. D
History and biochemical examination is often sufficient for diagnosis and
bacteriological investigations will confirm the diagnosis. Systemic causes and
foreign bodies including retained tampons are often the underlying cause.
Asymptomatic cervical erosion needs to be treated.

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Theme : The painful knee

Options
A. Anterior knee pain in a 15-year-old
gymnast with no history of trauma
B. Giving way and intermittent swelling
C. Intermittent locking and swelling in a
patient with osteochondritis dissecans
D. Pain along the medial joint line swelling
and inability to extend the joint fully
E. Pain over the proximal tibia associated
with a tender swelling
Match the conditions listed, below to SINGLE most likely clinical picture from the
options above. Each option may be used once, more than once, or not at all.

183. Anterior cruciate ligament rupture

184. Loose body
185. Chondromalacia patellae
186. Medial meniscus tear
187. Osgood Schlatter's disease

PASTEST book-Two

Answer: The painful knee

183. B
The anterior cruciate ligament prevents forward subluxation of the tibia
on the femur under normal conditions its rupture results in instability that
is usually associated with a joint effusion.

184. C
Loose bodies most commonly arise in knees of patients with
osteochondritis dissecans. In this condition there is necrosis of the
subchondral bone with subsequent detachment of a fragment of bone
and its overlying cartilage. It most commonly affects the lateral surface
of the medial femoral condyle.

185. A
Atraumatic anterior knee pain in a teenager is almost invariably due to
chondromalacia. More commonly found in girls who exercise regularly.

186. D
A bucket handle meniscal tear can cause locking (ie. inability to fully
extend the joint). Medial joint pain suggests a medial meniscus problem

187. E
This is traction osteochondritis of the tibial tuberosity at the union of the
patellar tendon. It tends to occur in active boys and is characterized by
anterior knee pain and tender swelling of the tibial tuberosity.

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Theme: Viral infections in childhood

Options
A. Adenovirus
B. Cytomegalovirus
C. ECHO virus
D. Enterovirus
E. Epstein-Barr virus
F. Molluscum contagiosum
G. Mumps
H. Rotavirus
For each group of symptoms listed below, select the MOST likely causative agent
from the list of options above. Each option may be used once, more than once, or not
at all.

188. A four-month-old child of an HIV positive mother is perfectly well until he

develops a cough and tachypnea. He soon requires ventilation and the
chest X-ray shows bilateral pneumonitis.
189. A ten-year-old boy develops high fever with generalized lymphadenopathy
and hepatosplenomegaly four weeks after he has a liver transplant.
190. An 18-month-old boy from a traveling family is admitted with unilateral
parotid swelling and has signs of meningism.
191. A three-year-old has a crop of raised discrete lesions with umbilicated
centres on his abdomen. They persist for several months but the child
remains well.

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Answer: Viral infection in childhood

188. B
One has to assume that the child has maternally transmitted HIV and is
therefore susceptible to opportunistic infection. Although PCP would be
the most common cause, CMV infection can prove equally devastating.

189. E
Post organ transplant patients are immunosuppressed and are
especially susceptible to viral infections. This scenario with
organomegaly and lymphadenopathy is suggestive of Epstein-Barr
related lymphoproliferative disease, which can affect up to 20% of solid
organ recipients.

190. G
This child is unlikely to have been immunized and is presenting with an
acute mumps infection. Meningoencephalitis represents the most severe
complication of mumps infection

191. F
The umbilicated centre implies that this is molluscum, a benign condition
in childhood although lesions may take months to disappear.

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Theme: Causes of dementia

Options
A. Alzheimer's disease
B. Creutzfeldt-Jacob disease
C. Depression
D. Huntington's disease
E. Hypothyroidism
F. Post-ictal confusion
G. Wernicke's encephalopathy
For each Patient with memory loss below, select the MOST likely diagnosis from the
above list of options. Each option may be used once, more than once or not at all.

192. A 43-year-old unmarried woman has had poor memory and sleep
disturbance for the last three weeks. She has been living alone after
recently moving to the United Kingdom. Neurologic examination is normal.
193. A 65-year-old man gives a six-month history of forgetfulness and
progressively mislaying items around the home. His wife reports he
occasionally gets lost when out walking around their neighborhood.
Neurological examination is otherwise unremarkable.
194. A 36-year-old woman is brought to hospital having being found
unconscious at home after falling down the stairs. She cannot remember
anything about the episode is mildly disoriented and has broken her wrist.
Neurologic examination is otherwise unremarkable.
195. A 32-year-old homeless woman is brought to hospital complaining of
memory loss. She is disoriented in space and time has gait ataxia and a
right sixth nerve palsy. A CT (head) is normal.
196. A 24-year-old man complains of low mood and-sleep disturbance for the
last two months. In the last two weeks he reports difficulty remembering
the names of familiar objects and difficulty writing. Myoclonus in the upper
limbs is noted on examination.

PASTEST book-Two

Answer: Causes of dementia

192: C
Pseudodementia due to affective disorder may be difficult, to distinguish from
Alzheimers disease. In depression the cognitive deficit (if present) is typically acute
and recent. Whereas that associated with Alzheimer's disease is typically insidious.
The depressed patient will often communicate a sense of distress and agitation, and
the depression will be associated with are typical features e.g. positive diurnal mood
variation and early morning waking. Other clinic features favoring a diagnosis of
depression include family history previous episodes, and precipitating life events.

193. A
Dementia is a term that describes a progressive and pervasive the number of different
cognitive capabilities. A defect in memory the core deficit in Alzheimer's disease, the
commonest for it dementia in this age group. However, individuals with Alzheimers
disease will also show additional impairments either overtly or on examination in other
cognitive capabilities e.g. problem solving, word finding and speech, navigation,
arithmetic, writing or reading. Alzheimer's disease is caused by a progressive
degeneration of neurons in the entorhinal cortex hippocampus and higher order
association cortex, characterized neuropathologically by senile plaques (containing
amyloid) and neurofibrillary tangles.

194. F
Postictal confusion may produce memory loss, but the onset is acute and associated
with symptoms and signs strongly suggestive of all acute seizure.

195. G
Wernickes encephalopathy represents an acute neuropsychiatric reaction to severe
thiamine deficiency. Characteristically patients are globally confused with gait ataxia
and ophthalmoplegia (nystagmus, abducens palsy or conjugate gaze disorder all
typical). All three elements of this triad need not be present in order to make diagnosis
Thiamine deficiency may be secondary to alcoholism, vomiting during pregnancy,
dietary insufficiency or gastric carcinoma. Treatment is with urgent intravenous
thiamine, but the majority will develop a chronic Korsakoff syndrome.

196.B
Creutzfeldt-Jacob disease is characterized by a rapidly progressive dementia,
myoclonus and distinctive electroencephalographic and neuropathologic findings. The
infectious agent casing CJD is unique in being a conformationally abnormal prion
protein ie contains no genetic material. The dementia can be accompanied by signs of
involvement of any part of the central nervous system, but myoclonus is particularly
common. Although typically occurring sporadically in middle-aged adults, a family
history may be present in 8-1%. More recently, variant CJD in young adults has been
linked with exposure to beef infected with the bovine spongiform encephalopathy
agent. This new variant form often presents with an extended neuropsychiatric
prodrome with mood disturbance or other psychiatric symptomatology.

PASTEST book-Two

Theme: Drug management of psychiatric disease

Options
A. Amitriptyline
B. Atropine
C. Carbamazepine
D. Chlordiazepoxide
E. Chlorpromazine
F. Lithium carbonate
G. Lorazepam
For each patient below, select the MOST appropriate drug that should be
administered from the above list of options. Each option may be used once, more than
once, or not at all.

197. A 63-year-old man presents in an agitated state with confusion and visual
hallucinations that terrify him. He has pyrexia, tremor and tachycardia and
is sweating profusely. He has previously been admitted repeatedly with
symptoms associated with chronic alcoholism.
198. A 30-year-old woman is brought to Casualty in an agitated and distractible
state. She is in an expansive euphoric mood and will not stop talking. Her
friends report that her agitated and excitable behavior has recently
resulted in dismissal from her job.
199. An 83-year-old man gives a three-month history of increasing insomnia,
fatigue and difficulty concentrating. He has lost interest in daily activities
and feels a burden on his family.
200. The police bring a 45-year-old man to Casualty after threatening staff at a
nearby store. He has prominent third-person auditory hallucinations and
states that the Queen of England, via a radio transmitter implanted in his
teeth, controls his actions.

PASTEST book-Two

Answer: Drug management of psychiatric disease

197. D
Delirium tremens typically presents typically presents acutely after three to four
days of abstinence from alcohol. When fully developed the syndrome includes
visual hallucination, agitation and autonomic arousal (often including pyrexia).
While short lived (a few days) mortality can be up to 20%. Treatment is fluid
replacement and sedation with diazepam or chlordiazepoxide with close
monitoring for electrolyte imbalance (especially hypokalemia, but also
magnesemia)
198. G
Bipolar disorders consist of a marked change in mood that varies from major
depressive episodes to significant manic episode. A manic episode consists of
a sustained period (at least a week) when mood was abnormally and
persistently elevated, expansive or irritable. Symptoms include inflated selfesteem (which may be delusional), decreased need for sleep, talkativeness,
flight of ideas, distractibility, they typically cause marked impairment in
occupational functioning or relationships with other. The average age of onset
of bipolar disorder is about 30 years. Treatment of the acute manic phase is
often in hospital. Lithium is not useful in the acute manic of mania, with
benzodiazepines (especially lorazepam) being used instead. If possible to use
ECT to control the manic excitement.
199. A
Symptoms of depression are the commonest psychiatric symptoms in
community samples of elderly become more marked, particularly when
disturbing sleep or appetite, then antidepressant medications should be used.
In patients who present sedating effects, particularly given at bedtime.
200. E
Schizophrenia is characterized by psychotic symptoms during the active phase
of the illness. Symptoms include delusions (e.g. involving a phenomenon that
the individuals culture would regard as totally implausible e.g. thoughts being
individuals out loud), prominent hallucinations (often a voice commenting on
the individuals behavior or thoughts, incoherent speech, catatonic behavior
and flat or inappropriate affect. During the course of the illness, there is
significant deterioration in social functioning and self-care. The goal of
treatment initially is to decrease symptom occurrence. Medication dosage is
increased as long as hallucinations, delusions and disorganized thinking
continues: the most frequent limiting factor is the appearance of extrapyramidal
side- effects.

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