YEAR 4 PAPER 3 FORMATIVE Qu1) A 26yr old female presents to her GP with a pigmented lesion on her face.

She admits to frequent use of sun beds and to sunbathing. She is concerned that the lesion might be cancer. 1. What 4 symptoms might suggest a melanoma? (2) Any change in size/shape/colour Itching Bleeding/discharge 2. What 4 clinical signs might increase your suspicion? (2) Asymm. Border Irregular border Diameter > 6mm Satellite lesions . 3. Give 2 benign differentials? (2) Melanocytic /naevus Seborrhoeic keratosis 4. You suspect the lesion is a melanoma. As her GP, what is your most appropriate management? (1) Refer using 2 week rule to dermatologist/ plastic surgeon 5. The lesion has a Breslow thickness of 0.7mm. What is Breslow thickness used for? (2) Used to determine prognosis Used for planning surgery 6. Give 2 effects of sun exposure on the skin? (2) Destruction of elastic tissue Loss of skin immune function Direct cellular damage of DNA Vit D production Premature ageing

Qu2) You see a 40yr old female who is 12wks pregnant. She is a smoker, has a history of hypertension and gestational diabetes. She has previously had a caesarean section for a breech presentation. 1. What feature in the Hx puts her at increased risk of having a baby with Downs? (1) Maternal age 2. What is the genetic abnormality in Downs? (1) Trisomy 21 3. Give 3 different screening tests for Downs and the gestation at which they are performed. (6) nuchal translucency scan 12 weeks triple test 15 weeks anomaly scan 20 weeks 4. What 2 invasive procedures are used to identify Downs? (2) Amniocentesis and CVS QU 3) You see a 24yr old, who is pregnant for the first time. She is 12/40. The USS shows mono-chorionic, diamniotic twins. 1. What 3 complications are these foetuses at higher risk of than singletons? (3) twin to twin transfusion/IUGR/ SUDDEN INTRAUTERINE DEATH/ placental abruption/ preterm delivery 2. What 3 complications is the mother at more risk of than in singleton pregnancies? (3) pre-eclampsia, PIH, PPH, thrombosis, fetal distress/ anaemia/ cholestasis

At 36/40 (24wks later), she is admitted with regular contraction 3mins apart. She is 4cm dilated, but membranes are still intact. The presenting twin is breech. 3. After weighing up the risks and benefits, would you give tocolytics? Why?

NO because risk of RDS low at 36 weeks 4. What is the safest mode of delivery for the twins? (1) C- section 5. What is the safest mode of delivery for the mother? (1) Vaginal delivery Quip 4) A 75yr old man was diagnosed with a non-small cell lung Ca 3months ago. He has a moderate performance status. He received 5 fractions of RT. He presents acutely with SOB. 1. Give 3 differentials for his SOB. Mass effect of lung cancer worsening of lung Ca PE Pleural effusion Pneumothorax Pneumonia 2. What 3 therapeutic options would you give him in A&E? O2, Abx, anxiolytics, Morphine, Reassurance, breathing exercises He improves with your treatment and is discharged. 6 weeks later, he presents with thoracic back pain and leg weakness. 3. Give 2 other symptoms you would want to check for. Loss of sensation in legs/body Urinary problems/faecal problems? 4. What is the possible cause? Spinal cord compression 5. What is your investigation of choice? MRI Qu 5) A 67yr old female with breast Ca diagnosed four yrs ago. She had a Left mastectomy and chemo, but has since deteriorated, developing brain and bone mets.

1. What 2 important medical interventions can be discontinued when a patient is dying? discontinue inappropriate blood tests interventions review unnecessary interventions

2. What 3 non-physical aspects of care must be considered when dealing with a dying patient? spiritual, psychological, social, religious 3. Give 2 symptoms that are common in the terminal phase of illness. State a medication that might be used to treat each. pain morphine N + V cyclizine/haloperiadol Sedation midazoloam Secretions hyoscine Dyspnoea morphine

4. Differentiate between certification and verification of death. certification is the documentation surrounding cause of death of patient. Can be issued by someone medically qualified verification ensuring patient is dead external examination only

QU 6) An 18yr old boy is shouting while alone in his room, becoming increasingly isolated, thinks things are referring specifically to him, may appear suspicious and his conversation is becoming difficult to follow. He has rapid changes in mood, and is becoming preoccupied with beliefs in occult & black magic. He is also smoking cannabis etc. 1. List 3 symptoms in the history that are suggestive of psychosis. Auditory hallucinations/ thought alienation / delusions/ persecutory ideas/ delusions of reference

2. Give a differential, stating your reasons. Drug induced psychosis Mental and behavioural disorders Substance abuse due to cannabis/multi drug use OCD Depressive psychosis

3. Give a common and clinically relevant side effect of olanzapine. Increase appetite/wgt gain/sedation/change in glucose 4. Give 2 risk factors for suicide in an 18yr old male who self harms. tolerance/ increase in diabetes, peripheral oedema final acts suicide note/putting finances in order planned as opposed to impulsive act / attempts of concealment Stated intent to die at time of overdose 5. He refuses admission, but you think he has a high suicide risk. Under which section of the MHA should you admit him? section 3 known to services / diagnosis of schizophrenia section 2 ONLY if assessed my medical emergency services with medical records not available QU 7) A 68yr old male is seen by his GP. He is a non-smoker who is usually fit&well. His GP makes an incidental diagnosis of hypertension (210/110 or something). His blood pressure was high 2yrs ago. Of note in his PMH, he has had 3 episodes of renal colic. 1. What is the most likely cause of his hypertension? (1) essential hypertension 2. What 2 blood tests would you use to estimate his 10yr CV risk? (2) fasting glucose, fasting lipids 3. What 2 investigations would you do to detect end-organ damage? (2) His bloods show raised calcium, and raised ALP with low phosphate. CXR, ECG, U + E, urinalysis, echo

4. Whats your diagnosis now? (1) Primary hyperparathyroidism 5. Give 2 surgically correctable causes of hypertension. (2) Phaeochromocytoma, coarctation of aorta, renal artery stenosis, cons syndrome (accept adrenal tumour) 6. List 2 drugs that aggravate/cause hypertension. (2) Oral pill Steroids Vasopressin NSAIDS

QU 8) A 50 yr old gentleman swallowed some bleach or something as a kid and now has an oesophageal stricture. He has a long history of indigestion and reflux for which he takes antacids and a PPI. He drinks 10units/day and smokes 20/day. He reports a 4mth Hx of decreased appetite, weight loss of 2st and dysphagia. A malignant lesion is seen in the lower oesophagus. He is going to have a thoracoabdominal oesophagogastrectomy. 1. What 4 pre-op investigations should he have? (2) CXR, Lung function tests, ECG, FBC, U + E, LFTS, plasma protein and calcium, blood glucose 2. What 2 pre-op treatments might optimise post-op respiratory function? (2) Chest physiotherapy with use of nebulisers and bronchodilators if necessary, ensure no acute respiratory infection if so treat with antibiotics 3. Which post-op analgesia regime would you discuss with him> Epidural V PCA 4. What special anaesthetic technique might be employed in order for the surgeon to operate optimally? (1)

One lung anaesthesia 5. What are the common post-op complications after such surgery? (2) Chest infection, lung collapse, pleural effusion, PE 6. Which arrhythmia might occur post-op? Why? (2) AF due to haematoma formation at operative site which is near the left atrium QU9) A 51yr old male has chest pain on exertion. He is unemployed, overweight, drinks several pints per night and smokes 20/day. 1. What 3 signs would indicate IHD risk factors? (3) hypertension, obesity, xanthelemata, tendon xanthomas, arcus senilus, gout, retinal changes, peripheral neuropathy 2. What 3 investigations would be done to check for IHD risk factors? (3) ECG, Blood glucose, plasma lipids, LFTS, CXR, TFTS A diagnosis of angina is made. 3. What 2 further tests might you do to confirm this diagnosis? (2) Exercise test, coronary angiogram He is started on aspirin, simvastatin and atenolol. 2weeks later he is complaining of swollen legs& feet, lethargy and is aching all over. 4. Which drugs might be responsible for which of these side-effects? (2) Atenolol Tiredness, swollen ankles, possibly heart failure Simvastatin aching all over (QU 10) A 76yr old female presents with weight gain and lethargy. She is 160cm tall, and weighs 90kg. She had thyrotoxicosis age 45 after the birth of a child. 1. Whats her BMI and comment on it? (2) BM1 = 35 = Obese

2. She has a hoarse voice and dry skin. What 3 other symptoms might she have? (3) She has high TSH and low T4 Cold intolerance, depression, constipation, angina, carpal tunnel syndrome 3. Whats the diagnosis? Hypothyroidism

4. Give 3 other diseases associated with this condition. (3) Pernicious anaemia, SLE, diabetes, hyperparathyroidism, prem. ovarian failure, Addisons, RA, Sjrogens syndrome, dementia 5. What are the dangers of starting thyroxine at too high a dose? Angina, acute MI, palpitations, cardiac arrhythmias